rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
14071,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,431,D,,,M4JO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to date a medication when opened and failed to discard expired supplies in three of five supply cabinets. The findings included: Observation on [DATE], at 10:30 a.m., with Licensed Practical Nurse (LPN) #2, of the 2 North supply cabinet revealed the following: Four, vacutainer tubes (used for blood specimens) available for resident use, with an expiration date of February, 2009. Two vacutainer tubes available for resident use, with an expiration date of November, 2009. Nine packages of suction swabs (active ingredient hydrogen peroxide 1.5%) available for resident use, with an expiration date of 2007. One 20 milliliter container of Lidocaine 1%, opened and undated. Interview on [DATE], at 10:30 a.m., with LPN #2, on the 2 North Hall confirmed the supplies had expired and the Lidocaine was opened and undated. Observation on [DATE], at 11:10 a.m., with LPN #3, of the 3rd floor supply cabinet revealed the following: Sixteen 40 milliliter containers of Bact/Alert (used for arterial blood gases) available for resident use with an expiration date of [DATE], and sixteen 40 milliliter containers of Bact/Alert available for resident use, with an expiration date of [DATE]. Interview on [DATE], at 11:10 a.m., with LPN #3, on the 3rd floor, confirmed the supplies had expired. Observation on [DATE], at 12:45 p.m., with LPN #4, of the 100 South supply cabinet revealed the following: Five vacutainer tubes available for resident use, with an expiration date of November, 2009. Interview on [DATE]. at 12:45 p.m., with LPN #4, on the 100 South Hall, confirmed the supplies had expired.",2014-04-01
14072,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,314,D,,,M4JO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, manufacture recommendations, observation and interview, the facility failed to ensure the specialty mattress was set accurately for two residents (#11, #1) of twenty- five residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the residents weight dated May 3, 2010, was131 lbs (pounds). Medical record review of the physician's orders [REDACTED]. Review of the name brand manufacture recommendations revealed ""...The comfort control LED displays the patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure levels depending on the patient weight..."" Observation and interview with the Wound Care Nurse on May 5, 2010, at 11.00 a.m., revealed the resident lying supine in the bed on the specialty mattress. Continued observation revealed the control panel set on 5 (for weight of 175 to 210 lbs). Interview with the Wound Care Nurse at the time, confirmed the specialty mattress is set depending on the resident's weight, and the current setting of 5 was not accurate for the resident's current weight. Resident #1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Medical record review of the care plan dated March 25, 2010, revealed ""...apply air mattress to bed..."" related to the risk of impaired skin integrity due to impaired mobility and [MEDICAL CONDITION]. Medical record review of the Weight Chart dated May 1, 2010, revealed the resident's weight of one hundred seventy-six pounds. Observation on May 3, 2010, at 10:30 a.m., May 4, 2010, at 8:00 a.m., and May 5, 2010, at 7:45 a.m., revealed the resident lying in a bed equipped with a Low Air Loss and Alternating Pressure Mattress. Continued observation revealed a control pump, with a pressure adjust knob and markings to indicate the resident's weight in pounds. Further observation revealed the pressure adjust knob set at two hundred fifty pounds. Interview on May 5, 2010, at 8:35 a.m., in the resident's room with the Central Supply employee revealed ""...mattress should be set by resident's weight, if weight loss or weight gain it should be adjusted accordingly..."" Further interview with the Central Supply employee at 1 South Nurse's Station confirmed the resident's weight of hundred seventy-six pounds. Interview on May 5, 2010, at 8:45 a.m., in the resident's room with LPN (licensed practical nurse) #4 and the Central Supply employee confirmed the facility failed to set the pressure adjust knob according to the resident's weight.",2014-04-01
14073,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,281,D,,,M4JO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to follow a Physician's order for one resident (#16) of twenty five residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's order dated April 21, 2010, revealed clean skin tear area on top of L (left) forearm with normal saline and pat dry. Apply dressing and cover with gauze and change every other day. Medical record review of the Physician's order dated April 25, 2010, revealed clean skin tear on right forearm with normal saline cover with dressing and cover with gauze, change every other day. Observation on May 3, 2010, at 9:10 a.m. revealed the resident seated on the bed. Continued observation revealed dressings to the right and left forearm dated April 29, 2010. Both dressings had been in place for 5 days. Interview with the Wound Care Nurse on May 3, 2010, at 9:15 a.m., confirmed the dressings were dated April 29, 2010, and the Physician's order to change the dressings every other day had not been followed.",2014-04-01
14074,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,166,D,,,M4JO11,"Based on review of the resident council minutes, and interviews, the facility failed to resolve grievances in a timely manner for three of three months reviewed. The findings included: Review of the resident council minutes dated February 5, 2010, March 5, 2010, and April 2, 2010, revealed ""...doesn't receive meds in timely manner...once in awhile late on giving medications...medication/timing issue with shots...medicine is sometimes late...when I ask for pain pill I don't get them..."" Further review, revealed no documentation of follow up addressing the grievances. Interview with the resident council on May 3, 2010, at 2:30 p.m., in the one-south dayroom, revealed three residents voiced grievances of medication not given in a timely manner. Interview on May 5, 2010, at 1:30 p.m., with the Director of Social Services in the ground level in-service room, confirmed, ""...I agree. We need to be more proactive with follow ups...I understand we need something on paper stating how the grievances have been addressed..."" Interview with the DON (Director of Nursing), on May 5, 2010 at 9:30 a.m., in the DON's office confirmed the facility failed to resolve grievances in a timely manner.",2014-04-01
14075,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,502,D,,,M4JO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of medical record review, and interview, the facility failed to obtain laboratory services for one resident (#1) of twenty-five reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]."" Medical record review of lab results revealed no documentation for a PT/INR completed on April 26, 2010, as ordered by the physician. Interview on May 5, 2010, at 8:30 a.m., with LPN (Licensed Practical Nurse) #4, at the nurse's station on one south, confirmed the facility failed to obtain the PT/INR as ordered by the physician.",2014-04-01
14076,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2010-07-21,441,D,,,CKRK11,"Based on observation and interview, the facility staff failed to wash the hands during a dressing change for one (#12) of twenty-five residents reviewed. The findings included: Observation on July 20, 2010, at 2:02 p.m., revealed Licensed Practical Nurse (LPN) #1 providing wound care to resident #12. Observation revealed LPN #1 removed a dressing from resident #12's right hand, and described the wound on the right wrist as a Stage III pressure area with a small amount of serous drainage. Observation revealed LPN #1 cleansed the wound with wound cleanser, and without changing the gloves or washing the hands, applied ointment and a dressing to the wound. Interview on July 20, 2010, at 3:15 p.m., with the Director of Nursing, at the nursing station, revealed the hands were to be washed after cleansing a wound prior to applying ointment or a clean dressing. Interview on July 20, 2010, at 2:25 p.m., with LPN #1, in the hallway, confirmed the gloves were not changed and the hands were not washed after cleansing the wound prior to applying ointment and a clean dressing.",2014-04-01
14077,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2010-07-21,280,D,,,CKRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to revise the care plan for one resident (#9) with a history of falls of twenty-five residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no problems with memory, required moderate assistance with decision making, and extensive assistance with transfers. Review of the medical record revealed the resident had a history of [REDACTED]. Review of the facility's documentation dated September 22, 2009, revealed, ""PT (Resident) found lying in the floor beside of bed on fall mat...Intervention...Low Bed..."" Review of the facility's documentation dated April 8, 2010, revealed.""PT (Resident) was found lying on floor in room...Intervention...Up in Geri-chair as tolerated."" Review of the current care plan dated November 4, 2009, revealed no documentation for the use of a Geri- chair or a low bed. Observation on July 19, 2010, at 9:30 a.m., 10:30 a.m., and on July 20, 2010, at 8:30 a.m., revealed the resident sitting in a Geri-chair, in the resident's room. Continued observation revealed a low bed in the resident's room. Interview with the unit one risk manager on July 20, 2010, at 10:05 a.m., in the conference room, confirmed the care plan had not been revised until July 19, 2010, to reflect the use of a low bed and a Geri-chair.",2014-04-01
14078,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,323,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one (#20) resident of thirty-one residents reviewed. The findings included: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, moderately impaired cognitive skills for daily decision making, and required extensive assistance for transfers. Medical record review of the High Risk Patient Selection Form dated March 11, 2010, and May 27, 2010, revealed the resident had fallen in the past 30 days and the past 31-180 days. Medical record review of the post falls nursing assessment dated [DATE], revealed, ""...fell from wheelchair...on floor with WC (wheelchair) on top of (resident) safety belt still hooked to (resident) ...What immediate interventions were initiated to prevent future falls?...Anti Tipper Bars to WC..."" Medical record review of the post falls investigation dated April 19, 2010, revealed, ""...Type of injury: Bruise Head...Anti Tip Bars ordered for w/c..."" Observation with LPN #1 (Licensed Practical Nurse), in the resident's room, on June 15, 2010, at 9:25 a.m., revealed the resident seated in the wheelchair without the antitipper bars on the wheelchair. Interview with LPN #1, on June 15, 2010, at 9:30 a.m., in the nursing station, confirmed the anti tippers are to be on the wheelchair.",2014-04-01
14079,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,425,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the pharmacy delivery record and interview, the facility failed to ensure medication was available to meet the needs for one (#4) resident and failed to document the administration of three doses of a narcotic for one resident (#15) of thirty-one residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's progress note dated April 21, 2010, revealed, "" ...recurrent cystitis...resistant pseudomonas...Tx (treat) (with) Aztreonam (antibiotic) 1 gram IM (intramuscular) q (every) 12 (hours) x 7 days..."" Medical record review of a physician's orders [REDACTED]. Medical record review of the MAR (Medication Administration Record) dated April 2010, revealed the Aztreonam was circled as not administered on April 22, 2010, at 9 a.m., and 9 p.m., April 23, 2010, at 9:00 a.m., April 24, 2010, at 9:00 a.m., and 9:00 p.m., April 29, 2010, at 9:00 p.m., and April 30, 2010, at 9:00 p.m. Medical record review of the Nurse's Medication Notes (back of MAR) revealed, ""...4/22/10 9 p Aztreonam 1 g IM (not) available from pharmacy...4/23/10 9 A Aztreonam...(not) available from pharmacy ...4/24/10 9 pm Aztreonam...(not) available from pharmacy...4/29/10 9 pm Aztreonam...not available...4/30/10 9 pm Aztreonam...not available ..."" Review of the pharmacy delivery record dated April 24, 2010, revealed the Aztreonam 1 Gram was delivered on April 24, 2010. Interview on June 14, 2010, with RN #1 (Registered Nurse) at 10:30 a.m., in the Charge Nurse's office, confirmed the medication was not available for the resident. Review of the Narcotic Tracking/Destruction Log for June 2010, for resident #15, revealed four doses of Oxycodone 5 mg. was signed out for June 6, 2010. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. signed out on June 6, 2010. Interview with head nurse #2 on June 15, 2010, at 9:00 a.m., in the Head Nurse's office, confirmed the documentation showed the resident did not receive three of the four doses of Oxycodone as documented.",2014-04-01
14080,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,322,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to properly position the head of bed for resident (#7); failed to provide nutritional support as ordered for resident (#27); and failed to ensure assigned responsible staff administered nutritional support for resident (#9) of thirty one residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated June 1, 2010, to June 30, 2010, revealed, ""...GLUCERNA 1.5...75ML/HR (milliliters per hour) X (times)21 HRS...OFF AT 1PM - ON AT 4PM...ASPIRATION PRECAUTIONS: HOB (head of bed) > (greater than) 30 DEGREES WHILE TF (tube feeding) IN PROGRESS..."" Observation in the resident's room on June 13, 2010, at 10:15 a.m., revealed the resident lying on a Clinitron bed with the tube feeding in progress and the head of the bed elevated 20 degrees. Continued observation on June 14, 2010, at 8:40 a.m., revealed the resident lying on the Clinitron bed with the tube feeding in progress and the head of the bed elevated 19 degrees. Interview with Registered Nurse (RN) #2 in the resident's room on June 14, 2010, at 9:00 a.m., confirmed the facility failed to properly elevate the head of the bed greater than 30 degrees as ordered. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated June 1, 2010, to June 30, 2010, revealed, ""[MEDICATION NAME] 1.5 @ (at) 70ML/HR X 20 HR...(OFF 10AM-2PM)..."" Observation in the resident's room on June 14, 2010, at 3:05 p.m., and 3:50 p.m., revealed the resident sitting in a recliner with the tube feeding pump positioned directly behind the resident and was not turned on. Interview with RN #2 in the resident's room on June 14, 2010, at 3:50 p.m., confirmed the facility failed to ensure the feeding pump was turned on as ordered. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had persistent vegetative state, was dependant for activities of daily living and required tube feed for nutritional support. Observation on June 13, 2010, at 10:00 a.m., revealed CNA #1 (Certified Nursing Assistant) had provided bath care. Continued observation revealed the feeding tube was disconnected and the pump was in the hold position. Further observation revealed the CNA connected the tube and started the feeding pump at the rate to be delivered. Interview with the CNA at the time of observation confirmed had reconnected the tubing and started the pump at the prescribed rate. Continued interview revealed the CNA's practice was to place feeding pump on hold and to disconnect prior to providing care. Review of the Nurse Aid Handbook for the State of Tennessee, Version 4.5, October 1, 2009, revealed no evidence of training for operation and safety or regulating flow rates of the tube feeding pumps. Interview with the DON (Director of Nursing) on June 14, 2010, at 4:15 p.m., in the DON's office, confirmed the CNA's are not to disconnect the feeding tube or to start the feeding pumps.",2014-04-01
14081,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,250,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure resident's needs were met by providing social services for one resident (#6) of thirty one residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge summary dated November 19, 2009, revealed the resident was fifty years old, had a bilateral below the knee amputation. Continued review revealed the resident had left hand digit amputation (2-5), and on April 28, 2010, had a revision of the bilateral above the knee revision. Observation of the resident on June 13, 2010, at 3:25 p.m., revealed the resident sitting. Interview with the resident at the time of observation revealed the resident explained the removal of both legs, and partial removal of the digits on both hands. Medical record review of the social services notes revealed no documentation the social services had addressed the loss of the lower extremities and the digits (fingers). Interview with the Master Social Worker on June 14, 2010, at 11:30 a.m., in the unit manager's office, confirmed the issue of the amputations had not been addressed. .",2014-04-01
14082,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,280,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to develop a care plan that addressed the psychosocial needs for one resident (#6) of thirty one residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge summary dated November 19, 2009, revealed the resident was fifty years old, had a bilateral [MEDICAL CONDITION]. Continued review revealed the resident had left hand digit amputation (2-5), and on April 28, 2010, had a revision of the bilateral above the knee revision. Observation of the resident on June 13, 2010, at 3:25 p.m., revealed the resident sitting in a wheel chair. Interview with the resident at time of observation revealed the resident explaining the removal of both legs, and partial removal of the digits on both hands. Medical record review of the care plan dated May 5, 2010, revealed the psychosocial needs following amputations had not been addressed. Interview with the Unit Manager of 500 Hall, on June 14, 2010, at 11:30 a.m., confirmed the care plan had not addressed the psychosocial needs of the resident have bilateral leg amputation and partial removal of fingers on both hands.",2014-04-01
14083,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,281,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to provide medication requested by one (hospice) resident (#15), of thirty-one residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had difficulty with long and short term memory, moderate difficulty with decision making skills, usually understood, and usually understands verbal information content. Continued review of the MDS revealed the resident had [MEDICAL CONDITION]/change in usual sleep pattern, no verbal or social behaviors, no difficulty with perception or awareness of surroundings, and no problems with mental function over the course of the day. Continued review of the MDS revealed the resident required assistance of staff with all activities of daily living Interview with the resident on June 14, 2010, at 9:15 a.m., in the resident's room, revealed the resident alert and oriented x three (person, place and time), responded appropriately to questions and statements. Continued interview with the resident revealed a request was made at approximately 10:00 p.m., on June 13, 2010, for an [MEDICATION NAME], for complaints of anxiety/anxiousness. Continued interview revealed the resident stated, ""I felt awful, I thought I would come out of my skin, and I woke up hurting."" When asked if the resident received it, stated ""no, I never received it all night."" When asked if the resident received an explanation why it was not given then or later, the resident stated, ""no"". Continued interview with the resident revealed the understanding the night medication had been given earlier; however, the resident stated was having anxiety/anxiousness. Medical record review revealed physician's orders [REDACTED]. by mouth every 2 hours as needed for severe anxiety"". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued review of the MAR indicated [REDACTED]. Review of the nurse's notes revealed no documentation the resident received the PRN [MEDICATION NAME], or that the resident was having difficulty with anxiety. Interview with Head Nurse #2 on June 14, 2010, at 9:00 a.m., in the Head Nurse's office, confirmed the resident was able to make needs known, and could communicate appropriately. Continued interview with the Head Nurse confirmed the resident did not receive the [MEDICATION NAME] as requested; confirmed no explanation was given to the resident, and confirmed no alternate treatment or support was given.",2014-04-01
14084,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,221,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to assess for the use of a restraint for one (#8) resident, and failed to ensure the restraint for one (#20) resident was secured according to the manufacturer's recommendation, of thirty-one residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had difficulty with long and short term memory and difficulty with decision making skills. Continued review of the MDS revealed the resident was dependent on staff for all activities of daily living, including feeding. Observation on June 13, 2010, at 2:45, and 4:00 p.m., revealed the resident in the day room, on 2-E, seated in a Geri Chair with a lap tray attached. Observation on June 13, 2010, at 3:30 p.m., revealed the resident at the Nurses Station on 2-E, seated in a Geri Chair with a lap tray attached. Medical record review of the physician's orders [REDACTED]. Pt. (patient) non-ambulatory. Check q (every) 30 min. Release. Reposition q 2hrs. and toilet as needed."" Review of the Physical Therapy notes dated June 2, and June 9, 2010, revealed the resident continues to receive Therapy, noting the resident was able to ambulate 300 - 800 feet with minimal to moderate assist and three sit and rests. Interview with Physical Therapy Assistant #1 on June 15, 2010, at 10:10 a.m., by phone, revealed the resident received Physical Therapy and confirmed the resident is transported to and from the Therapy Department by Geri Chair with the lap tray attached. Interview with Head Nurse #2, on June 14, 2010, at 8:55 a.m., in the resident's room, confirmed the resident's Geri Chair was used because the resident attempted to get out of the Geri Chair and confirmed the lap tray had not been assessed for use as a restraint. Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had impairment with long and short term memory, and moderately impaired decision making skills. Continued review of the MDS revealed the resident was non ambulatory, and had a history of [REDACTED]. Review of the physician's orders [REDACTED]. Check q (every) 30 m. (minutes). Release, toilet and reposition q 2 hrs & PRN (as needed)."" Observation on June 13, 2010, at 2:40 p.m., revealed the resident in the day room on 2-West, seated in a wheel chair, with a soft belt restraint applied across the resident's abdomen, and the ties draped around the back of the wheel chair. (Not down the sides and crossed at the lower back of the wheelchair). Interview with Licensed Practical Nurse #3at this time confirmed the restraint was not secured correctly. Observation on June 13, 2010, at 3:25 p.m., in the resident's room with Head Nurse #1 revealed the resident's soft belt restraint was applied across the resident's upper body (breast area) and under the arms, with the ties attached to the loops and tied straight across the upper part, of the back of the wheel chair. Continued observation and interview at 3:27 p.m., revealed the Head Nurse retied the restraint with the soft belt across the lap down the sides of the wheel chair, crossed behind the wheel chair and tied to the kick spurs, and confirmed the restraint had not been tied correctly. Review of the Manufacturer's Instructions for Application of the Soft Belt revealed the following: Position the patient as far back in the seat as possible, with the buttocks against the back of the chair...Lay the lap belt across the patient's thighs with the foam facing in...Bring the ends of the connecting straps down at a 45 degree angle between the seat and the wheel chair sides...Criss-cross the straps behind the chair and draw them around the opposite side kick spurs...There is a risk of chest compression or suffocation if the patient's body weight is suspended off the...chair seat...STOP USE AT ONCE: If the patient has a tendency to slide forward or down in the device; or is able to self-release."" Interview with Head Nurse #1 on June 13, 2010, at 3:30 p.m., in the resident's room, confirmed the restraint was not secured according to manufacturer's instructions.",2014-04-01
14085,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,514,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to maintain documentation of services provided for one resident (#30); and ensure accurate sliding scale orders were obtained for one resident (#19) of thirty one residents reviewed. The findings included: Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed no documentation resident had received a shower three times per week as per care plan. Interview with the DON (Director of Nursing) on June 14, 2010, at 10:20 a.m., in the conference room, confirmed no documentation to show resident received a shower as planned. Resident # 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the referring facility's physician's orders [REDACTED]. (patient) from...(referring facility) to (current facility)...Continue current MAR (Medication Administration Record) see Discharge MAR. Check BG (blood glucose) AC (before meals) & HS (at bedtime). Pt is on [MEDICATION NAME] Sliding (sliding scale insulin) see MAR..."" Review of the referring facility's Medication Status record dated May 29, 2010, and faxed to the facility June 1, 2010 at 1:47 p.m., revealed, ""[MEDICATION NAME] Subcutaneous Solution 100 Units/ML (milliliter) SS (sliding scale) coverage unit qid (four times per day) subcut.(subcutaneously). [MEDICATION NAME] per sliding scale: BG 111-150 I unit, BG 151-200 2 units, BG 201-250 3 units, BG 251-300 4 units, BG 301-350 6 units, BG 351-400 9 units, BG >(greater than) 400 9 units and call hospice MD; <(less than) 70 call hospice MD and titrate hypoglycemic protocol..."" Review of the physician's orders [REDACTED].S. BID (two times per day): 111-150= 1U (unit); 151-200=2U; 201-250=3U; 251-300=4U; 301-350=6U; 351-400=9U; >400=9U and call MD..."" Review of the facility Medication Record for June, 2010, revealed, ""[MEDICATION NAME] 100U/1 ML Vial for Humalog-[MEDICATION NAME] Insulin S.S. BID (two times per day): 111-150= 1U (unit); 151-200=2U; 201-250=3U; 251-300=4U; 301-350=6U; 351-400=9U; >400=9U and call MD..."" Review of the Sliding Scale Diabetic Monitoring Log dated June, 2010 revealed the blood glucose being checked and recorded four times per day. Interview with Head Nurse #2, on June 15, 2010, at 9:30 a.m., in the 3 West Head Nurse's office, confirmed the June 1, 2010, Admission Orders were inaccurately transcribed to the resident's June 2010, physician's orders [REDACTED]. Complaint #",2014-04-01
14086,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2010-12-02,226,D,,,0P9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility policies and investigations, and interview, the facility failed to implement policies and procedures to ensure freedom from abuse for one resident (#2) of six residents reviewed and for seven of nine sitters. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired memory and cognition, and required total assistance with all activities of daily living. Observation of the resident on November 23, 2010, at 9:00 a.m., revealed the resident was sitting in a chair in the hallway and made brief eye contact, but did not attempt any verbalizations. Medical record review of a Nursing Progress Note dated October 4, 2010, at 5:00 p.m., revealed, ""CNA (certified nurse aide) came to nurse and said that volunteer was 'hitting (resident #2).' This nurse went immediately to res (resident) & took over feeding. Res had no obvious injury or emotional distress. CNA states that vol (volunteer) 'smacked (resident #2's) hand and that (resident #2) attempted to hit (volunteer) back.' When (resident #2) swung at vol...again 'smacked (resident #2's) hand' and said if you hit me, I will hit you back...RN (registered nurse) was immediately called and volunteer was removed from room. Res hands had no marks and were not red."" Medical record review of a Nursing Progress Note dated October 5, 2010, at 11:00 a.m., revealed, ""...Res continues to show no S&S (signs and symptoms) of any type distress related to the incident."" Medical record review revealed documentation the resident was not showing any signs of distress on October 6, 2010, at 6:00 p.m., October 7, 2010, at 5:00 p.m., and October 8, 2010, at 8:30 a.m. Medical record review of the Quality of Life Progress Notes revealed: ""10-5-10 SW (social worker) notified of situation that occurred on 10/4 with volunteer slapping resident's hand...Resident does not show any signs or symptoms of distress...""10-6-10 Resident has not displayed any emotional distress resulting from the incident that occurred on 10/4...10-7-10 SW observed resident...did not display any changes in mood or behavior. No signs of distress relating to incident occurring earlier in the week...10-8-10 SW approach resident and rubbed resident's arm...did not appear to be fearful. Staff reported that (resident) has not displayed any changes in behavior since the incident...10/15/10 SW observed resident and spoke to several staff members. Resident does not appear to have suffered any ill effects from the incident that occurred on 10/4 with a volunteer. Staff has not observed any changes in the resident's mood or behavior. SW spoke with resident. Resident does not appear fearful...reached around SW's neck and pulled down and kissed SW on cheek and asked what are doing..."" Review of a facility investigation statement undated revealed, ""Record of conversation with (named family member of another resident)...happened to be in the dining room and witnessed the incident...stated...saw (AP-Alleged Perpetrator) strike (named resident) twice...called them 'light slaps...did not rear back or wind up before slapping occurred'...heard (AP) say 'you don't slap me like this'...commented that a charge nurse came and finished feeding (resident #2) while the RN (Registered Nurse) supervisor talked to (AP)."" Review of the facility's ""Volunteer Services Manual"" revealed the manual contained a section on abuse education, including ""Definitions and Examples of Abuse...Slapping..."" and the manual contained the facility's Resident Abuse Policy. Continued review revealed the manual included a Pledge to be signed by the volunteer and stated, ""...I pledge that I have read this manual in its entirety...and will follow all policies and procedures to the best of my ability."" Continued review of the manual revealed a Volunteer Service Agreement & Release, to be signed by the volunteer, stated, ""...In consideration of being allowed to participate in the volunteer service...I do hereby agree that...As a volunteer I will receive training to ensure that I am competent to perform my duties...I understand that I am expected to abide by all (named facility) policies and procedures and external regulations that govern my actions, including but not limited to those relating to ethical behavior, safety..."" Telephone interview with the AP on November 24, 2010, at 9:20 a.m., revealed the AP was in the dining room feeding two residents and talking with another family member when resident #2 was reaching for another resident's food. Continued interview revealed the AP gave resident #2 ""a light tap on the hand..."" Continued interview revealed ""(resident #2) always reaches for other people's food and I just lightly tapped (resident #2) hand to keep...from grabbing food...probably did not even feel it..."" Continued interview confirmed the AP had not received any education or training on abuse from the facility before or during any time as a volunteer at the facility. Telephone interview with CNA (certified nurse aide) #4 on November 24, 2010, at 2:20 p.m., revealed the CNA had seen the AP in the facility many times assisting in feeding the residents. Continued interview confirmed the AP was in the dining room feeding resident #2 on October 4, 2010, while CNA #4 and CNA #5 were present. Continued interview revealed resident #2 had to be monitored at meal times and would grab food off any other resident's tray in close range. Continued interview confirmed CNA #4 heard resident #2 say ""Don't hit me"" and the AP stated ""Don't hit me or I'll hit you back"" and CNA #4 heard a loud ""smack."" Continued interview revealed CNA #4 turned to look at what had occurred and ""...the look on the volunteer's face told me (AP) kne ...did wrong, but I think it was reactionary...don't think (AP) meant to hit (resident #2), just reacted."" Continued interview confirmed CNA #4 stayed with the resident while CNA #5 reported to the charge nurse. Telephone interview with RN (registered nurse) #2 on November 24, 2010, at 2:30 p.m., confirmed the RN was the house supervisor on October 4, 2010, and was called to the unit after the incident occurred. Continued interview confirmed the volunteer was known by all the staff at the facility and had assisted with residents before. Continued interview confirmed it was reported to the RN a CNA had witnessed the AP slap resident #2's hand and the RN took the AP aside and talked with the AP. Continued interview confirmed the AP admitted to the RN resident #2 had hit the AP and the AP hit resident #2 back. Continued interview revealed, ""I...explained (resident #2) has severe dementia and may do those things, but we are never to retaliate or strike a resident and (AP) became tearful. AP did not seem to think (his/her) reaction was inappropriate..."" Continued interview revealed the resident was assessed by the RN and did not have any visible marks and continued to eat with the assistance of a staff member, showing no behavioral changes immediately after the incident. Telephone interview with CNA #5 on November 24, 2010, at 2:40 p.m., revealed the CNA had the most experience with resident #2 and knew the resident well. Continued interview revealed, on October 4, 2010, the AP was feeding resident #2 and talking with another family member, ""when you feed (resident #2) you have to stick with (him/her) because (he/she) gets aggressive. (AP) gave (resident #2) a bite and then another resident and (resident #2) got impatient and reached out for food. (Resident #2) reached for food, (AP) pushed hand away and (resident #2) hit at (AP) and (AP) slapped (resident #2) hand...Don't think (AP) meant to hit (resident #2) or hurt (resident #2) - reacted. I think (AP) thought (resident #2) was trying to hurt (AP)..."" Continued interview confirmed the CNA did not see any marks on resident #2 and the resident did not exhibit any behavioral changes from normal and continued to eat dinner. Interviews with the Administrator on November 23, 2010, at 11:45 a.m., in the conference room, and with the Activities Director on November 23, 2010, at 11:45 a.m., and 1:40 p.m., in the conference room, and at 1:55 p.m., at the seventh floor elevators, revealed the facility had substantiated the alleged abuse and the AP was no longer a volunteer in the facility. Continued interviews revealed the AP had been an intermittent volunteer in the facility, occasionally coming in and assisting with feeding the residents, for approximately two or three years. Continued interviews confirmed the AP had never been in-serviced on abuse and the facility did not have a signed volunteer agreement or Pledge from the AP in accordance with the volunteer manual. Observations on November 22, 2010, at 2:20 p.m., and 2:35 p.m., and on November 23, 2010, at 8:45 a.m., revealed three residents in the facility were observed in their rooms and the dining room with three different sitters. Interview with the Director of Nursing on November 22, 2010, at 3:00 p.m., and 4:00 p.m., at the front desk, revealed many of the facility's residents preferred having private sitters and the facility had a policy and procedure to address private sitters. Continued interview revealed the facility had a list of eleven residents who used private sitters and nine sitters from three different sitter agencies were providing services to those residents. Review of the facility's Companion/Sitter Policies/Guidelines revealed, ""...All private companions/sitters must comply with the following guidelines...All Companions/Sitters must have on file with (facility), a criminal background check from the local Sheriff's Department for each state they have resided in during the past five years...(Facility) will check Abuse Registry and the State Sexual Offender Registry...upon registration of each private Companion/Sitter..."" Interview with the Director of Quality and review of abuse registry checks and criminal background checks for the nine sitters on November 23, 2010, at 1:48 p.m., and 2:15 p.m., in the Administrator's office, confirmed the security department was responsible for obtaining and keeping on file all abuse and criminal background checks for the Companion/Sitters. Review of the criminal background and abuse registry checks revealed the facility had records for seven of the nine sitters. Continued interviews confirmed the Director of Quality had obtained the criminal and background checks from the security department via fax on November 23, 2010. Continued interviews confirmed six of the seven obtained from the security department had headings indicating the faxes had been received from the individual sitter agencies on November 23, 2010, the date requested. Continued interviews confirmed the security department had not been maintaining records of the criminal background and abuse registry checks on all agency sitters as was indicated in the facility's policy and procedure. Self-reported incident #",2014-04-01
14087,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2010-08-19,221,D,,,RVKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure one resident (#1) of twenty two residents remained restraint free. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physical Restraints RAP Narrative dated March 22, 2010, revealed ""Resident will use side rail on left side of bed to pull and hold to."" Medical record review of the comprehensive care plan dated May 6, 2010, revealed ""...risk for falls...I have a history of attempting transfer unassisted...Assist me with my current task when I am attempting to transfer unassisted."" Medical record review of the certified nurse assistant Patient Specific Information revealed, ""...siderails...x1 (times one) to left side-fall risk."" Medical record review of the quarterly minimun data set (MDS) dated [DATE], revealed no side rail of any type in use. Observation on August 18, 2010, at 7:30 a.m., revealed resident in bed with full side rails up on both sides of the bed. Interview on August 18, 2010 at 9:30 a.m., with the 300 Unit Manager revealed only one side rail should be up on the back (left side) of the resident's bed.",2014-04-01
14088,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2010-08-19,250,D,,,RVKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide medically related social services needed for two residents (#4 & #16) of twenty-two residents reviewed. The findings included: Resident #4 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated July 7, 2010, revealed the resident had a short term memory problem and had modified independence for decision making. Medical record review revealed the resident had received Speech Therapy from readmission, had a Modified Barium Swallow Study on June 10, 2010, and afterwards had the diet upgraded to Mechanical Soft with chopped meat, no straws. Medical record review of the physician's progress note of August 5, 2010, revealed, ""...resident wanting PEG (percutaneous feeding tube) removed..."" Medical record review of the physician's orders [REDACTED]. Medical record review of the social services notes dated August 12, 2010, revealed ""Pt. will be staying long term...unable to go home because friends state...no where to go."" Observation and interview of the resident at 1:30 p.m., in the resident's room on August 18, 2010, revealed the resident had finished eating lunch in bed. Interview revealed the resident was reluctant to be interviewed, but the resident verified a plan to eventually leave the nursing home and stated, ""First, I need to get this tube out...I don't know how it got there..."" Interview with the social services assistant (SSA) verified resident #4 would not be able to return to previous home due to it being sold. Interview revealed the SSA stated the resident was followed by ""a psych nurse"" and a licensed counselor/social worker (LCSW). Interview verified the SSA had not spoke with the resident, LCSW, or the psych nurse since the information in the social services note of August 12, 2010, was given to the SSA by the resident's friend. During interview, the SSA stated the psych nurse mainly saw the residents for medication needs and the SSA stated it was not unusual the psych NP (nurse practitioner) had not seen the resident since June 17, 2010. Interview confirmed the SSA was unaware of the NP'S plan in June that stated the resident would only be seen PRN (as needed) in the future. Interview confirmed the SSA had not been aware the LCSW (consulting with the resident for counseling needs) had not seen the resident since May 2010. Interview with the Admissions Coordinator/Social Worker on August 18, 2010, at 9:30 a.m., in the conference room, revealed the LCSW was not seeing the resident. Interview confirmed this was an oversight. During interview, the Admissions Coordinator/Social Worker confirmed the SSA had not shared the information related to the resident's house being sold and stated, ""(SSA's name) doesn't share everything with me."" Interview with the Administrator, in the conference room at 4:50 p.m., on August 18, 2010, verified the resident had a lack of an effective family/support system and a continued need for emotional support and stated ""...(resident) needs to continue with psych services."" Medical record review revealed resident #16 was a sixty-two year old, admitted to the facility on [DATE], following a Hemicolectomy for Ischemic Bowel with creation of an Ileostomy, and the post-op complication of an Abdominal Wound Infection. Medical record review revealed the resident had a poor history of any medical care and additional [DIAGNOSES REDACTED]. Medical record review of the Physical Therapy note from August 9, 2010, revealed, ""...surgery for [REDACTED]. Now both ostomies are infected, with necrotic tissue present that needs selective debridement..."" Review of the MDS (Minimum Data Set) dated August 1, 2010, revealed the resident had insomnia and a deteriorated mood assessed, was unable to ambulate, and had daily moderate pain. Review of the ""Resident Mood Interview"" completed by the Social Worker Assistant (SSA) on August 2, 2010, revealed the resident was, ""feeling down, depressed, or hopeless for two to six days"" and the total score of the ""Mood Interview"" tool was ""4."" Review of the physician orders [REDACTED]. Interview with the Admissions Coordinator/Social Worker on August 18, 2010, at 9:30 a.m., in the conference room, revealed the Social Worker stated consults with the LCSW and the Psych NP were the facility's method used to address residents who experienced medically related social issues such as an inability to cope with loss of previous body functions, chronic pain, depression, and/or were in need of emotional support. Interview with resident #16's physician, on August 19, 2010, at 11:10 a.m., by telephone, verified the facility's staff had not spoke with the physician about the resident having medically related social services needs prior to August 18, 2010. Interview revealed the physician stated the resident had not wanted to see anyone from psych services when the physician had previously brought up the subject with the resident. Observation and interview of the resident on August 19, 2010, at 1:50 p.m., revealed the resident in the bed, lying on back. During interview, resident #16 was asked about willingness to be seen by a Psych Nurse Practitioner or a counseling Social Worker to have someone to talk with and the resident stated, ""No....I don't believe in psychiatrist...I just need to be able to stand on my feet and walk..."" Interview with the Administrator on August 19, 2010, at 2:10 p.m., in the conference room, verified the SSA does not proceed with a referral to psych services or the LCSW unless a resident scores a ""5"" or above on the ""Resident Mood Interview."" During the interview, the Administrator verified the interview tool had limitations and confirmed the SSA had not included the resident's loss of function (with the need for ileostomy), the chronic disabling medical condition, and chronic pain when assessing resident #16's need for referral to the Psych NP and/or the LCSW. Interview revealed the Administrator had entered into a conversation with the resident's girlfriend on August 18, 2010, related to the continued chronic pain the resident was experiencing. Interview with the Administrator continued and revealed neither the Administrator or the Admissions Coordinator/Social Worker had spoken with the resident prior to the order for a psych consult being obtained on August 18, 2010.",2014-04-01
14089,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2010-08-19,441,E,,,RVKN11,"Based on observation and interview the facility failed to store linen in a manner to prevent the spread of infection. The findings included: Observation on August 17, 2010, at 9:30 a.m.; August 18, 2010, at 2 p.m.; and August 19, 2010, at 9:00 a.m., revealed linen on the floor in the 100 unit clean linen closet and on the floor in the 200 unit clean linen closet. Observation revealed those items to include blankets, sheets, and one Hoyer lift pad. Interview on August 19, 2010, at 9:00 a.m., with the maintance staff confirmed the linen should be stored off the floor.",2014-04-01
14090,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2010-08-19,253,E,,,RVKN11,"Based on observation and interview the facility failed to maintain a clean environment during the initial tour of the facility. The findings included: Observation during the initial tour of the facility on August 19, 2010, at 9:00 a.m., in the presence of maintenance staff, the following was revealed: 1. Air conditioner covering and vent dirty in room 210. 2. Personal fan dusty in room 223. 3. Over the bed tables soiled with dried substance in rooms 222, 223, 305, 317. 4. Feeding tube pole with dried substance on the pole bases in room 105 and room 218. Interview with the maintenance staff on August 19, 2010, at 9:30 a.m., confirmed the facility failed to maintain a clean resident environment.",2014-04-01
14091,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2010-08-19,356,D,,,RVKN11,"Based on observation and interview the facility failed to post the daily staffing in a prominent place, in a clear and readable format. The findings included: Observation on August 17, 2010, from 9:15 a.m., to 4:30 p.m., August 18, 2010, from 7:15 a.m., to 5:15 p.m., and on August 19, 2010, from 7:15 a.m., to 8:45 a.m., of the three main entrances to the facility revealed no posting of the daily staffing for the facility's three units. Interview on August 18, 2010, at 8:50 a.m., in the conference room with the administrator, revealed the administrator was unsure where the staffing was posted but believed it was on station 2. Observation and interview on August 19, 2010, at 8:55 a.m., with the administrator and the director of nursing on station 2 revealed a white piece of paper with the staffing printed, in a clear plastic sleeve taped to the medication room window. Interview with the administrator and the director of nursing at the time of the observation confirmed the public could not easily find and read the staffing posted on the medication room window.",2014-04-01
14092,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2010-08-19,371,F,,,RVKN11,"Based on observation and interview the facility failed to store, prepare and serve food under sanitary conditions in the main kitchen and on the 300 unit. The findings included: The following observations were made in the kitchen on August 18, 2010, at 11:00 a.m.: 1. Heavy dark substance build up on the dish rack caddy in the dishroom. 2. Dark substance around the opening of the ice machine. 3. Food Spillage in the reach in cooler. 4. Dried food spillage around the base of the steam table. 5. Dried food spillage on the condiment cart. 6. Grease and dust buildup on the exaust hood. 7. Grease and dust buildup between the convection oven and the range. Continued observation at 11:22 a.m., during the noon meal service on the 300 unit revealed the following: 1. Regular cottage cheese served at 49 degrees. 2. Pureed cottage cheese served at 54 degrees. 3. Mixed fruit served at 54 degrees. Interview with the dietary manager on August 18, 2010, at 2:00 p.m., confirmed the cold food was not served at the proper temperature of 40 degrees and that areas of the kitchen were not clean. Observation on August 17, 2010, at 9:35 a.m., of the unit three nutrition room revealed the ice machine had several areas of a dark substance on the serving area, water from the ice machine running onto the floor, around the rusting metal doorpost out onto the floor in the hallway, and dark substances on the shelf and wall near the ice machine. Observation and interview on August 19, 2010, at 1:30 p.m., of the unit three nutrition room with the unit three manager revealed the ice machine had several areas of a dark substance on the serving area, water from the ice machine running onto the floor and around the rusting metal doorpost out onto the floor in the hallway, and dark substances on the shelf and wall near the ice machine. Interview with the unit three manager confirmed the ice machine/nutrition room was not sanitary.",2014-04-01
14093,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2010-08-19,279,D,,,RVKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to develop a comprehensive care plan for one (#17) resident's AICD (automatic implantable cardio-defibrillator) of twenty-two residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's [DIAGNOSES REDACTED]. Observation and interview with the resident on August 17, 2010, in the resident's room at 9:40 a.m., revealed the resident was alert, oriented, and able to converse and share recent medical history. Observation of the resident at 9:20 a.m., on August 19, 2010, revealed the resident up in the hall ambulating independently with a walker. Interview with LPN #1 on August 19, 2010, at 9:10 a.m., at the Station 1 nursing desk verified the resident's chart was not marked with an alert for the presence of an AICD. Interview confirmed LPN #1 had not previously been aware the resident had an implanted defibrillator. Interview confirmed the medical record did not define safety precautions due to the presence of the AICD and did not define whether the AICD included a pacemaker. Medical record review of the care plan with LPN #1 verified the AICD was not included in the resident's plan of care. Interview with LPN #1 at 10:00 a.m., on August 19, 2010, in the conference room, revealed the resident's cardiologist had been contacted within the last hour and LPN #1 was informed the resident had an appointment to see the heart doctor in September to have the AICD and pacemaker checked. During interview, LPN #1 stated the facility didn't have a defined procedure or protocol to address residents with an AICD and the LPN confirmed the assessment and care planning of the resident by the nursing staff had not included the AICD.",2014-04-01
14094,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2010-08-19,246,D,,,RVKN11,"Based on observation and interview the facility failed to provide a comfortable shower room for one shower room (unit 3) of three units in the facility. The findings included: Observation on August 19, 2010, at 9:00 a.m., in the unit 3 shower room revealed Certified Nurse Assistant (CNA) #1 assisted resident #6 with a shower. Observation revealed the room had no source of heat and the room was cool with cold air flowing from the vent in the ceiling, the resident complained frequently of being ""cold"", and the resident's hands and feet were a light blue color. Interview on August 19, 2010, at 9:05 a.m., with CNA #1 confirmed the shower room was cool with the cold air flowing from the ceiling vent; the staff had no means of warming the room for the resident's comfort; and the staff ""just tries to hurry."" Interview on August 19, 2010, at 10:15 a.m., in the conference room with the administrator confirmed the shower room on unit 3 was cool with the air conditioning in use and no source of heat for residents comfort during a shower.",2014-04-01
14095,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-08-10,431,D,,,BD4V11,"Based on observation, and interview, the facility failed to discard expired medications and failed to date medications when opened in one of four medication rooms. The findings included: Observation on August 10, 2010, at 9:40 a.m., of the second floor medication room, with LPN (Licensed Practical Nurse) # 1 revealed the following in the medication refrigerator: three, ten milliliter bottles of Humalog Insulin, one approximately ? full, and two approximately 3/4 full, available for resident use, opened, and undated; two, ten milliliter bottles of Lantus Insulin, one approximately ? full, one approximately ? full, available for resident use, opened and undated; One, ten milliliter bottle of Novolin R Insulin, approximately1/2 full, with an opened date of July 3, 2010, and an expiration date of August 2, 2010; One, ten milliliter bottle of Novolin R Insulin, approximately ? full, with an opened date of July 2, 2010, and an expiration date of August 1, 2010. Interview on August 10, 2010, at 9:40 a.m., with LPN #1, in the second floor medication room, confirmed the insulin was available for resident use, the Humalog and Lantus Insulin was not dated when opened, and the Novolin R Insulin had expired.",2014-04-01
14096,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-08-10,456,D,,,BD4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain equipment for one (#28) of thirty-seven residents reviewed. The findings included: Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on August 9, 2010, at 4:00 p.m., revealed the resident in the dining room, seated in a gerichair. Continued observation revealed the left arm on the gerichair was torn, with the wood and screws exposed. Observation with LPN (Licensed Practical Nurse) #1, on August 10, 2010, at 9:15 a.m., revealed the resident in the dining room, seated in a gerichair. Continued observation revealed the left arm of the gerichair torn, with the wood and screws exposed. Interview on August 10, 2010, at 9:15 a.m., with LPN #1, in the dining room, confirmed the gerichair was in need of repair.",2014-04-01
14097,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-08-10,157,D,,,BD4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility policy, and interview, the facility failed to notify the physician timely for a change in condition for one (#27) of thirty-seven residents reviewed. The findings included: Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nurse's note dated January 23, 2010, revealed, ""...P (pulse) 103...B/P (blood pressure) 76/40 5:30 A (a.m.) Resident unable to arouse to verbal stimuli-skin pale in color-resp (respirations) slow (and) shallow opens eyes to painful stimuli ...will continue to monitor...5:35 A Supervisor notified of (change) in condition...5:45 A Spoke (with) (named family member) (and) informed of decline in condition (named family member) request we send resident to (named hospital)...6:15 A T.O. (telephone order) received to transfer resident to...ER (emergency room )...6:30 A (ambulance) called to transport resident to...ER...4 p.m. Call placed to (hospital)-informed of admitting (diagnosis) MS (mental status) (change)[MEDICAL CONDITION]"" Review of the facility policy ""Change in a Resident's Condition or Status"", revealed, ""...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...Except in medical emergencies, notifications will be made within twenty-four...hours of a change occurring in the resident's medical/mental condition or status..."" Interview on August 10, 2010, at 12:45 p.m., in the lower level conference area, with the Director of Nursing, confirmed the physician was not notified timely of the change in the resident's status.",2014-04-01
14098,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-08-10,226,D,,,BD4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, a review of facility investigations, and a review of the facility policy on abuse and neglect, the facility failed to promptly report an allegation of abuse for one resident (#19) and failed to thoroughly investigate an allegation of neglect for one resident (#11) of thirty-seven residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS), dated [DATE], revealed the resident had no short or long term memory impairment; required extensive assistance with transfers and dressing; was total care for hygiene and bathing; and was continent of bowel. Review of facility policy ""Resident Abuse, Neglect and Misappropriation Prevention Program (RANMP)"" revealed ""Investigation--All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility...An immediate investigation into the alleged incident, during the shift it occurred on, is initiated as follows: 1. Interview the resident or other resident witnesses...The interview is to be dated, documented and signed by the nursing supervisor. A sampled 'Resident Interview Form' is attached...2. Interview the staff member implicated. Have the employee document their knowledge/version of the incident in a written narrative that is dated and signed. A (An) 'Employee/Witness Investigation Statement' is attached...3. Interview all staff on that unit, as well as other staff or other available witnesses. Witnesses are to document their knowledge of the incident in a written narrative, signed and dated, on the 'Employee/Witness Investigation Statement' form."" Review of facility grievances revealed a ""Concern/Comment Report"", dated March 8, 2010, for the resident ""Concern/Comment...only 1 sit to stand on floor, took 1 hour to take to bathroom and had BM (bowel movement) on self...Investigation Findings...There was only one sit to stand on floor, spoke to CNA's (certified nursing assistants) and nurses, did not realize length of time waiting."" Continued review of the March 8, 2010, ""Concern/Comment Report"", revealed no statement from the resident, no identification of the CNA responsible for assisting the resident to the bathroom, no witness statements from the responsible CNA or other staff working on the floor; and no conclusions drawn as to whether or not the allegation of neglect was substantiated. Interview with the Administrator on August 10, 2010, at 3:00 p.m., in the Administrator's office confirmed the investigation was not thoroughly investigated and the facility policy on the investigation of allegations of neglect was not correctly implemented. c/o # Resident #19 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 long-term memory problems, had moderately impaired decision-making skills, no mood or behavior problems, was independent with transfers and ambulation, and was continent of bowel and bladder. Medical record review of the Nurses Record and Progress Notes dated July 30, 2010, at 3:25 p.m., revealed, ""Resident stated that a CNA (Certified Nursing Assistant) hit (resident) on the bottom last night. Stated (CNA) hit (resident) hard c/ (with) (CNA's) open hand. Investigation initiated. Skin assessment completed c/ 0 (no) redness or bruising noted..."" Review of the facility's investigation revealed the facility began the investigation into the allegation of abuse on July 30, 2010. Review of the facility's investigation revealed the resident alleged the incident occurred on the evening shift of July 29, 2010, and the resident reported the allegation to a nurse the evening of the incident (July 29, 2010). Review of the nursing notes revealed no documentation of the allegation of abuse on July 29, 2010, and the first documentation of the allegation was on July 30, 2010, at 3:25 p.m., by the DON (Director of Nursing). Review of the facility's interviews revealed a statement from LPN #4 (Licensed Practical Nurse), dated July 30, 2010, and confirmed the resident reported to LPN #4 a CNA had ""smacked"" the resident ""on my butt."" Further review revealed LPN #4 felt the CNA was just teasing but the LPN would talk with the CNA and tell the CNA the action was inappropriate. Interview with the resident on August 10, 2010, at 8:15 a.m., in the resident's room, confirmed the resident felt the CNA had mistreated the resident and the resident had reported the incident to the nurse working the evening of the incident (July 29, 2010). Review of the facility's investigation and interviews with the team leader on August 10, 2010, at 8:30 a.m., in the dining room; with the Psychiatric Nurse Practitioner on August 10, 2010, at 8:35 a.m., at the nursing station; with the resident and the resident's roommate on August 10, 2010, at 8:55 a.m., in the resident's room; with the DON on August 10, 2010, at 9:48 a.m., in the lower level conference room; and with CNA #5 (present in the room at time of allegation) on August 10, 2010, at 1:40 p.m., by telephone, confirmed the abuse was unsubstantiated. Review of the facility's policy on Resident Abuse, Neglect, and Misappropriation Prevention Program, revealed, ""...Any complaint of, allegation of, observation of or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented in a uniform manner as detailed below. Procedures: Reporting - All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint of, allegation of, observation of 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. Nursing Staff duties: 1. An incident of abuse or suspected incident of abuse must be reported to the charge nurse who will examine the resident, document findings in the clinical records and immediately initiate the Investigation protocol. 2. The administrative or nursing supervisor assumes responsibility for immediate notification of the Administrator and the Director of Nursing, by phone if necessary, and also notification of the appropriate department head. 3. Nursing is to document on the resident's physical and emotional status every shift for 72 hours following the incident..."" Interview with the DON on August 10, 2010, at 9:45 a.m., in the lower level conference room, and at 2:30 p.m., in the DON's office, confirmed the DON was informed of the allegation of abuse from an Activities staff member, after the resident reported it to the Activities staff, on July 30, 2010. Further interview confirmed the resident had reported an allegation of abuse to LPN #4 on July 29, 2010, and LPN #4 had not followed facility policy on abuse and had not notified the DON or any other administrative or supervisory staff of the allegation of abuse. c/o #",2014-04-01
14099,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-08-10,323,D,,,BD4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure supervision while eating for one resident (#18) on aspiration precautions of thirty-seven residents reviewed. The findings included: Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the patient was sent to the hospital on July 31, 2010, and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Outpatient Modified Barium Swallow Study (MBSS) dated July 23, 2010, and signed by the Nurse Practitioner July 30, 2010, revealed, ""...Moderate pharyngeal dysphagia...Mechanical Soft diet with regular liquids. No straws. Chin tuck with all liquids. Pt (patient) will require supervision and/or assist with all intake in order to complete chin tuck with each liquid swallow 2* (secondary to) impaired cognition...Spoke c/ (with) pt's RN (registered nurse)...re:(regarding) need for chin tuck to prevent aspiration..."" Medical record review of a physician's orders [REDACTED]. Recommend nectar c/ chin tuck @ (at) this time..."" Medical record review of a physician's orders [REDACTED]. Recommend assist/supervision @ meals...cue chin tuck c/ swallow."" Medical record review of the hospital discharge orders dated August 5, 2010, revealed, ""...Feed pt. Aspiration Precautions."" Medical record review of the Care Plan dated January 18, 2010, and updated August 5, 2010, revealed, ""...Aspiration Precautions."" Medical record review of a physician's orders [REDACTED]. Medical record review of the Initial Care Plan dated August 5, 2010, revealed, ""...Pt to be fed, Institute Aspiration Precautions..."" Medical record review of the Initial Care Plan dated August 5, 2010, revealed a handwritten note, ""Diet (change) 8-8-10 Puree texture w/assist/supervision (with assist/supervision) Nectar thick liquids."" Observations of the resident, in the resident's room, on August 8, 2010, at 9:40 a.m., and on August 9, 2010, at 9:00 a.m., and 1:30 p.m., revealed the resident sitting in a wheelchair with a meal tray sitting on the over bed table, pulled in front of the resident, and the resident feeding self with no staff present. Observation on August 9, 2010, at 1:30 p.m., of the resident's meal ticket revealed, ""Supervision at meals."" Interview with LPN #2 (Licensed Practical Nurse) on August 9, 2010, at 9:07 a.m., outside the resident's room, revealed ""sometimes (resident) feeds self, sometimes not...fed (self) before left..."" Interview with the Speech Therapist on August 9, 2010, at 9:20 a.m., in the resident's room, confirmed the Speech Therapist had entered the resident's room and the resident was self feeding with no staff present. Further interview confirmed the resident needed cueing for the chin tuck to prevent aspiration and the resident needed staff supervision for safety while eating. Interview with CNA #1 (certified nursing assistant) and review of the CNA Assignment Sheet, on August 9, 2010l, at 1:38 p.m., outside the resident's room, revealed CNA #1 stated the resident fed self without staff assistance and the assignment sheet the CNAs used to inform them of any resident needs indicated the resident did not require assistance or supervision for feeding. Interview with ADON #1 (Assistant Director of Nursing) on August 9, 2010, at 1:36 p.m., outside the resident's room, confirmed the resident was to have assistance and supervision while eating for safety, and supervision had not been provided.",2014-04-01
14100,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-08-10,514,D,,,BD4V11,"**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 (#9) of thirty-seven residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated July 24, 2010, revealed, ""Sitting in W.C. (wheelchair) in front of A building in the visitors parking lot...states 'I've got to get away from that idiot in my room.' 'I can't even (expletive) without (roommate) looking at me.' 'I'll be as crazy as (roommate) if I don't get away.' Updated elopement assessment, and supervisor, and (family member) made aware. Picture of this resident placed c/ (with) switchboard operator. Brought back to floor and directed to dining room c/ magazine away from roommate for the moment. Communication form completed."" Medical record review, on August 8 and 9, 2010, of the Social Services notes and the Care Plan revealed no documentation Social Services had addressed the issues of attempted elopement or roommate conflict and compatibility. Medical record review, on August 10, 2010, at 10:30 a.m., revealed a Social Services note dated August 3, 2010, with the Social Services follow-up of the incident and ""...Care Plan updated..."" Further medical record review revealed the Care Plan had a handwritten update regarding the incident and was dated July 24, 2010. Medical record review and interview with Social Worker #1 on August 10, 2010, at 10:45 a.m., at the nursing station, confirmed the Social Worker had not documented in the medical record regarding the resident's attempted elopement and roommate conflict until the morning of August 10, 2010, and had inaccurately dated the Care Plan update as July 24, 2010, and the Social Services note as August 3, 2010.",2014-04-01
14101,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-08-10,281,D,,,BD4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain clarification of a physician's order and follow the physician's order for one resident (#9) of thirty-seven residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was sent to the hospital on April 27, 2010, and returned to the facility on [DATE], following a repair of a fractured left hip. Medical record review of a medication prescription dated May 3, 2010, revealed the resident was to receive [MEDICATION NAME] (pain medication) 5 mg (milligrams) every 6 hours as needed for pain, and the prescription was for 20 tablets. Medical record review of the MAR (Medication Administration Record) for May 3, 2010, revealed the resident received 29 tablets of [MEDICATION NAME] May 4 through May 30, 2010. Medical record review of the MAR for June and July, 2010, revealed the resident received the [MEDICATION NAME] June 4, 8, 9, 10, 15, 18, and July 29. Medical record review of the MAR for August, 2010, revealed the resident did not receive any [MEDICATION NAME]. Medical record review of a progress note dated July 16, 2010, revealed, ""[MEDICATION NAME] (pain medication) prescription was for 20 tab only & should have been dc'd (discontinued)..."" Medical record review of a physician's order dated July 16, 2010, revealed, ""...DC [MEDICATION NAME]"" Medical record review of the physician's orders and MAR for July, 2010, revealed the resident was not receiving [MEDICATION NAME], but was still receiving [MEDICATION NAME]. Interview with LPN #3 (Licensed Practical Nurse) and review of the resident's medical record on August 10, 2010, at 10:35 a.m., at the nursing station, confirmed the resident did not have an active order for [MEDICATION NAME] on July 16, 2010; the hospital had written the [MEDICATION NAME] prescription for only 20 tablets; the resident had continued to receive [MEDICATION NAME] because it was on the monthly recap orders; LPN #3 was not clear what medication was intended to be discontinued; and the facility had not called to obtain clarification from the Nurse Practitioner, who wrote the order July 16, 2010. Interview with ADON #2 (Assistant Director of Nursing) on August 10, 2010, at 12:45 p.m., in the ADON's office, confirmed ADON #2 had obtained clarification from the Nurse Practitioner on August 10, 2010; the resident was not on [MEDICATION NAME]; the intent of the order written July 16, 2010, was for the [MEDICATION NAME] to be discontinued and not [MEDICATION NAME]; and the facility had failed to obtain clarification of the physician's order written July 16, 2010.",2014-04-01
14102,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-08-10,246,E,,,BD4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to serve meals according to resident preferences for four (#20, #21, #26, #29) of thirty-seven residents reviewed. The findings included: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated May 17, 2010, revealed the resident had no memory or cognitive impairments. Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had some short term memory problems, and no long term or cognitive impairments. Resident #26 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had no memory or cognitive impairments. Observation of the breakfast tray delivery on August 8, 2010, revealed the breakfast trays were delivered to residents #20, #21, #26, and #29 between 9:30 a.m., and 9:50 a.m. Interview with resident #20 on August 8, 2010, at 9:15 a.m., in the resident's room, revealed the only complaint the resident had was eating too late at night. Further interview revealed the evening meal sometimes does not arrive until 8:00 p.m., and ""that is too late for old people."" Further interview revealed the resident had complained to the nursing assistants on multiple occasions and was told ""someone called off"" and was the reason the trays were late. Further interview revealed the resident did not feel the excuse was reasonable. Interview with resident #21 on August 8, 2010, at 9:28 a.m., in the resident's room, revealed the resident's only complaint was evening meal trays were delivered too late. Further interview revealed the evening meal was usually around 7:30 p.m. Further interview revealed the resident did not like to eat that late and if the facility served beans, the resident could not eat them because the beans would cause stomach problems and the resident could not sleep. Interviews with residents #26 and #29 on August 8, 2010, at 9:50 a.m., in the residents' room, revealed the residents had just received their breakfast trays. Further interviews revealed the residents did not receive their evening meal tray on August 7, 2010, until 8:00 p.m. Further interviews revealed resident #29 stated the meal tray being delivered at 8:00 p.m., did not allow enough time to completely empty the bladder before an 8:30 p.m., bedtime, which resulted in the first episode of incontinence the resident had experienced. Further interviews revealed resident #29 was very upset about the incontinence. Further interviews revealed resident #26 had been in the facility three and one half years, had attended almost every resident council meeting, and stated the residents complained often of the late meal trays, which had gotten worse the last six months. Observation of breakfast tray delivery on August 9, 2010, revealed the dining carts were delivered to the dining room at 8:30 a.m. Further observation revealed the breakfast trays were delivered to residents #18, #20, and #21, at 9:00 a.m. Interview with resident #21 on August 9, 2010, at 9:00 a.m., in the resident's room revealed the evening meal on August 8, 2010, was not delivered until 7:30 p.m., and the resident felt the time was too late. Interview with resident #20 on August 10, 2010, at 8:55 a.m., in the resident's room, revealed the evening meal on August 9, 2010, was not received until 7:20 p.m., and the resident did not finish eating until 8:00 p.m. Further interview revealed the resident thought the time was too late to eat. Interview with resident #21 on August 10, 2010, at 9:10 a.m., in the resident's room, revealed the evening meal on August 9, 2010, was delivered at 7:30 p.m., which was the usual time, and the resident would like to have the evening meal earlier. Interview with ADON (Assistant Director of Nursing) #1 on August 10, 2010, at 2:10 p.m., in the lower level conference room, confirmed the evening meal being delivered at 7:30 to 8:00 p.m., was too late to eat.",2014-04-01
14103,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-12-20,226,D,,,T7FZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation documentation, review of facility policy, and interview, the facility failed to implement the abuse policy for one resident (#1) of six sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility documentation dated October 23, 2010 revealed, ""At approximately 3 p (p.m.) today...talking with (certified nursing assistant - CNA #3)...(CNA #2) came up telling us about incident which occurred earlier in the day...As soon as I was relieved of my sitting job I reported this to my nurse (licensed practical nurse-LPN #1)."" Review of facility investigation documentation dated October 23, 2010 at 5:00 p.m. and authored by LPN #2 revealed, ""...physical/verbal contact...resident had brushed (certified nursing assistant- CNA#1's) breast with...hands...(CNA #1) knocked...hands away and said don't you grab my (breast) you sick (expletive deleted)...Both CNAs reported this to me..."" Review of facility investigation documentation dated October 24, 2010 revealed, ""...date of event 10-23-10 approximately 6:30 a.m..."" Review of the facility's abuse policy revealed, ""...Policy: Any complaint of, allegation of, observation of or suspicion of resident abuse...is to be thoroughly reported, investigated, and documented in a manner as detailed below...All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint...observation of, or suspicion of abuse...so that the resident's needs can be attended to immediately and investigation can be undertaken promptly..."" Interview with the director of nursing on December 20, 2010 at 12:35 p.m. in a lower level classroom revealed a report of abuse alleged to have occurred before 7:00 a.m. on October 23, 2010 was not reported until late afternoon on October 23, 2010. Continued interview confirmed the facility failed to implement the abuse policy for Resident #1. C/O: #",2014-04-01
14104,"BRIDGE AT ROCKWOOD, THE",445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2010-06-30,441,D,,,WPTM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medicial record review, observation, and interview, the facility failed to provide a sanitary environment for one resident (#5) of twenty-four residents reviewed. The findings included: Resident #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required total assistance with all activities of daily living, had limited movement in all four extremities, and received all food and fluids via gastric tube. Observation on June 28, 2010, at 10:45 a.m., and 1:37 p.m., in the resident's room revealed 5-6 flies on the resident's floor, and on the resident's bed linens. Continued observation revealed light green colored secretions on the resident's tracheostomy and a dust covered fan blowing on the resident. Observation and interview on June 28, 2010, at 2:10 p.m., in the resident's room with the Director of Nursing confirmed the presence of flies and the dust covered fan in the resident's room.",2014-04-01
14105,"BRIDGE AT ROCKWOOD, THE",445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2010-06-30,323,D,,,WPTM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were in place for one resident (#21) of twenty-four residents reviewed. The findings included: Resident #21 was readmitted to the facility November 21, 2007, with [DIAGNOSES REDACTED]. Medical record review of the Interdisciplinary Care Plan for Falls, dated May 15, 2010, revealed ""...Body Alarm at all X's (times)..."" Medical record review of a physician's orders [REDACTED].@ (at) all X's..."" Observation on June 28, 2010, at 10:20 a.m., revealed the resident in bed, asleep, without the body alarm attached. Continued observation on June 29, 2010, at 4:15 p.m., and 4:40 p.m., revealed the resident asleep in bed with the body alarm clip attached to the bottom bed sheet. Interview with LPN (Licensed Practical Nurse) #1, on June 29, 2010, at 4:45 p.m., at the resident's bedside, confirmed the resident's body alarm was not attached to the resident.",2014-04-01
14106,"BRIDGE AT ROCKWOOD, THE",445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2010-06-30,514,D,,,WPTM11,"**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 clinical record for three residents (#10, #11, #12) of twenty-four residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated April 26, 2010, revealed the resident required extensive assistance with transfers, dressing, personal hygiene, toileting, and bathing. Medical record review of the CNA (Certified Nursing Assistant) ADL (Activities of Daily Living) Tracking Form for May 2010, and June 2010, revealed no documentation of ADL's provided by the CNA on the following: 7 a.m.-3 p.m., shift on May 4, 10, 15, 23, 28, June 6, 20, 22, 24; 3 p.m.-11 p.m., shift on May 17, 18, 19, 23, 28, 31, June 1, 2, 3, 4, 8, 9, 20, 21; 11 p.m.-7 a.m., shift on May 5, 17, 18, 25, 29, June 5, and 9, 2010. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident required assistance with transfers, bed mobility, hygiene, bathing, and was incontinent of bowel and bladder. Medical record review of the CNA ADL Tracking Form for May 2010, and June 2010, revealed no documentation of ADL's provided by the CNA on the following: 7 a.m.-3 p.m., shift on May 4, 10, 15, 23, 28, and June 6, 20, 24; p.m.-11 p.m., shift on May 17, 18, 19, 23, 28, 31, and June 1, 2, 3, 4, 8, 9; 11 p.m.-7 a.m., shift on May 17, 18, 25, and June 5, and 9, 2010. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident required assistance with transfers, personal hygiene, bathing, dressing, toileting, and was incontinent of bowel and bladder. Medical record review of the CNA ADL Tracking Form for May 2010, and June 2010, revealed no documentation of ADL's being provided by the CNA on the following: 7 a.m.-3 p.m., shift on May 28, 30 and June 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 27; 3 p.m.-11 p.m. shift on May 18, 20, 22, 23, 28, 31, and June 1, 2, 3, 4, 5, 6, 8, 9, 14, 18, 19, 20, 21, 24, 26; the 11 p.m.-7 a.m., shift on May 17, 18, 25, and June 5, 9, 2010. Interview with ADON (Assistant Director of Nursing) #1, on June 29, 2010, at 9:30 a.m., in the 300 Hall Nurses Station, confirmed the facility failed to maintain complete and accurate clinical records.",2014-04-01
14107,MANOR HOUSE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2010-04-29,441,D,,,ZB4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #TN 454 Based on policy review, medical record review and interview, it was determined the facility failed to ensure respiratory isolation was implemented to prevent the transmission of infection for 1 of 14 (Resident #3) sampled residents. The findings included: 1. Review of the ""2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting"" policy documented ""...RESPIRATORY INFECTIONS... Potential Pathogens... M. ([DIAGNOSES REDACTED]) [DIAGNOSES REDACTED], Respiratory viruses, S. (Staphylococci) pneumoniae, S. aureus (MSSA (Methicillin-Susceptible Staphylococcus Aureus) or MRSA (Methicillin Resistant Staphylococcus Aureus))... Emperic Precautions... Airborne Precautions plus Contact precautions."" 2. Medical record review for Resident #3 documented an admission date of [DATE] at 7:20 PM with [DIAGNOSES REDACTED]. Review of the ""Patient Transfer Form"" dated 3/25/10 documented the resident was positive for MRSA of the sputum. Review of the hospital laboratory final report dated 3/25/10 for a sputum culture documented results of ""Staphylococcus Aureus ...Note Methicillin Resistance..."" Review of physician's orders [REDACTED]. During an interview in the conference room/office on 4/27/10 at 10:30 AM, the Director of Nursing stated the hospital staff had informed her 3 days prior to admission (3/22/10) to the facility that Resident #3 had MRSA in the nares and it had colonized. During an interview in the conference room/office on 4/27/10 at 11:00 AM, the Registered Nurse Unit Supervisor stated she had received the physician's orders [REDACTED]. During an interview in the conference room/office on 4/17/10 at 2:30 PM, Licensed Practical Nurse #3 stated the laboratory report for the positive MRSA culture of the sputum was found upon chart review on 3/29/10 and Resident #3 was placed in respiratory isolation. The facility failed to place Resident #3 in respiratory isolation on admission.",2014-04-01
14108,LAUREL MANOR HEALTH CARE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2010-06-23,332,D,,,SEOE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to administer medications correctly in three of forty opportunities observed. The facility's failure resulted in a seven percent medication error rate. The findings included: Observation on June 22, 2010, at 7:45 a.m., revealed licensed practical nurse (LPN #3) administered Multivitamin with minerals to resident #23. Medical record review revealed a physician's orders [REDACTED]. Interview with LPN #3 in the 200 hallway on June 22, 2010, at 8:00 a.m., confirmed the resident did not receive the correct vitamin as ordered by the physician. Observation on June 22, 2010, at 8:05 a.m., revealed LPN #2 administered Multivitamin with minerals to resident #24. Medical record review revealed a physician's orders [REDACTED]. Further review revealed a physician order [REDACTED]. Interview with LPN #2 on June 22, 2010, at 8:15 a.m., in the 200 hallway, confirmed the physician's orders [REDACTED].",2014-04-01
14109,LAUREL MANOR HEALTH CARE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2010-06-23,157,D,,,SEOE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to record and update the legal representative's phone number for one (#11) of twenty-four sampled residents. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes revealed on May 25, 2010, at 5:30 p.m., resident #21 entered resident #11's room. Continued medical record review revealed when resident #11 told resident #21 to leave the room, resident #21 hit resident #11 in the face, across the nose. Medical record review of nurse's notes dated May 25, 2010, at 5:30 p.m., revealed ""M.D. (medical doctor) notified and trying to reach (r/p--responsible party) (family member) (named). Phone number for (family member) states that the number is unavailable at this time. Will keep trying to reach r/p."" Interview with LPN (licensed practical nurse) #4 on June 23, 2010, at 2:30 p.m., in the conference room, revealed the LPN attempted to contact the responsible party on June 22, 2010, and the telephone message revealed ""the party was unavailable"". Continued interview with LPN #4 confirmed the LPN did not document any attempts to reach the second contact person listed in the medical record between June 22 and June 25, 2010, when the altercation occurred. Interview with the Administrator on June 23, 2010, at 2:35 p.m., in the conference room, confirmed when the licensed nurse was unable to contact the responsible party after the altercation on May 25, 2010, no other documented attempts were made to attempt to reach the second contact person listed in the medical record, to inform the family of the altercation and resident #11's transfer to the emergency room . c/o #",2014-04-01
14110,LAUREL MANOR HEALTH CARE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2010-06-23,280,D,,,SEOE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to make revisions to the current Care Plan indicating the advanced directives code status for one (# 6) of twenty-four residents reviewed. The findings included: Resident # 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's current Care Plan dated February 23, 2010, revealed ""...Do Not Resuscitate (DNR)..."" Medical record review revealed a Physician order [REDACTED]. Medical record review, on [DATE], at 4:40 p.m., revealed the resident's Care Plan for code status to resuscitate (CPR) was updated on [DATE]. Interview on [DATE], at 12:19 p.m., with the Director of Nursing (DON) and Registered Nurse (RN) # 1, in the resident's room, revealed ""...He's a DNR..."" Interview on [DATE], at 4:20 p.m., with the DON and RN # 1, in the 100 Hall, revealed ""...the resident is a full code...we were mistaken"" Continued interview revealed, RN # 1 pointed to a blue, circular sticker ""dot"", beside the resident's name on the door, indicated the resident is full code (CPR) status. Interview with the Care Plan Coordinator, on [DATE], at 11:00 a.m., in the Care Plan Coordinator's office, revealed the resident's POST code status was changed on February 23, 2010 and the Care Plan was updated on [DATE] but not placed in resident's chart. Interview on [DATE], at 1:50 p.m., with the Social Services Director, in the conference room, revealed the Social Services Director is responsible for immediately updating Care Plan changes for code status and confirmed the facility failed to update the resident's current advanced directives code status on the Care Plan.",2014-04-01
14111,LAUREL MANOR HEALTH CARE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2010-06-23,406,D,,,SEOE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a system of communication amongst staff to ensure the accurate evaluation of behaviors, and accurate development of the behavior management program for one (#5) of twenty four sampled residents. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the PASARR (Pre Admission Screening and Annual Resident Review), dated August 12, 2008, revealed ""...5. Developmental Needs:...History of uncooperativeness and disruptive behaviors...8. Rehabilitative Services (services of Lesser Intensity) Recommendations:..7. Behavior management (checked)...9. Recommendations and Rationale for Determination: Based on the information provided, (resident #5) continues to meet the target population definitions and needs DMRS (Division of Mental [MEDICAL CONDITION] Services) criteria for NF (nursing facility) placement due to (the resident's) dementia and multiple medical problems. While in the NF (the resident) will require a behavior management plan for (the resident's) uncooperativeness and disruptive behaviors..."" Medical record review of psychotherapy progress notes revealed: May 5, 2010 ""Focus of Session...We talked about how (the resident's) behaviors can affect how others respond to (the resident)...The patient has poor impulse control due to a mental handicap, however, (the resident) is able to acknowledge right from wrong and often engages in inappropriate behavior for attention. (The resident) should respond well to behavioral modification techniques."" May 12, 2010 ""The patient and I talked about an incident which occurred over the weekend which involved inappropriate touching...We also talked about the appropriate ways to interact with others and patient was encouraged to apologize for (the resident's) behavior."" May 26, 2010 ""The patient and I discussed (the resident's) recent changed behavior towards a staff member after being reprimanded two weeks ago."" Review of a facility provided undated document ""Behavior Management"" for resident #5, revealed ""Behavior: Altercation...Interventions:..6. Offer (the resident ) reward for appropriate behaviors i.e.: Trip To Walmart."" Continued review of the document revealed no specification or definition of ""appropriate behavior"" or specific criteria to be met, for the resident to be rewarded with a trip to Walmart. Medical record review of nurse's notes and social work notes revealed no documentation of the inappropriate behaviors documented in the psychotherapy notes on May 12 and 26, 2010. Observation on June 23, 2010, at 3:00 p.m., revealed the resident in the room, in a wheelchair, using a key to open a personal lock box. Interview with the Director of Nursing (DON), Risk Manager, and Social Worker, on June 23, 2010, at 9:00 a.m., in the conference room, revealed they were unaware of the behaviors noted in the May 12 and 26, 2010, psychotherapy notes. Continued interview with the Social Worker revealed ""the staff (CNA's) talk to (the therapist), not necessarily us (SW, DON, Risk Manager), about the behaviors they have seen."" Interview with the Social Worker on June 23, 2010, at 9:05 a.m., in the conference room, revealed the resident made one trip to Walmart as a reward, and had a second trip scheduled which was cancelled after (the resident) hit another resident. Continued interview with the Social Worker on June 23, 2010, at 9:05 a.m., in the conference room, revealed (the social worker) tracks the resident's behavior to determine if (the resident's) maladaptive behaviors are increasing or decreasing, and to determine the effectiveness of the reward system. Interview with the Social Worker, on June 23, 2010, at 9:15 a.m., in the conference room, confirmed the behavior management program was not set up with a specific definition of ""inappropriate behavior"" and criteria to be met, prior to initiation of the reward system. Continued interview with the Social Worker on June 23, 2010, at 9:15 a.m., in the conference room, confirmed there was no system in place to ensure (the social worker) was aware of all (the resident's) behaviors to aid in evaluation of the effectiveness of the behavior management program for resident #5.",2014-04-01
14112,LAUREL MANOR HEALTH CARE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2010-06-23,323,D,,,SEOE11,"**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 adequate supervision to prevent a fall for two residents (# 3, #5) of twenty-four residents reviewed. The findings included: Resident # 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility document, dated July 10, 2009, revealed on July 9, 2009, at 12:30 p.m., the resident fell out of the wheelchair, with no injury. Continued review of the facility document, dated July 10, 2009, revealed ""Additional Follow-Ups...Will use personal alarm both bed and chair to alert staff resd (resident) requires assistance."" Medical record review of a Nurse's Note dated November 28, 2009, at 9:10 p.m., revealed ""...Pt (patient) assisted to BR (bathroom) per CNA (Certified Nursing Assistant) et (and) instructed to pull call light. Pt up from toilet to bed, and fell on to tile floor...Noted approx 1 cm (centimeter) long superficial cut over right eye in eyebrow...sm (small) amt (amount) bleeding noted...noted 1 cm skin tear over right mid arm/elbow area and left hand noted less than 1 cm skin tear to 2 joint off middle finger...transport to ER (emergency room ) for evaluation..."" Review of a facility investigation dated November 28, 2009, at 9:10 p.m., revealed ""...Staff assisted resd (resident) to toilet and instructed resd to pull call light cord when finished. Resd did not pull cord, got up from toilet himself, attempted to walk back to bed and fell in floor hitting head..."" Continued review of the investigation document revealed the post-fall interventions, ""...Update fall program...Consult staff on not leaving a resd who is cognitively impaired in bathroom unattended..."" Observation on June 22, 2010, at 2:23 p.m., revealed resident in wheelchair with belt across the resident's waist. Interview on June 23, 2010, at 9:55 a.m., with the Director of Nursing, Care Plan Coordinator, Social Services Director, and Registered Nurse # 1, in the conference room, confirmed the facility failed to provide supervision for a resident on fall precautions who was cognitively impaired. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed resident #5 experienced a fall from the wheelchair on June 22, 2009. at 7:00 a.m. Review of facility documentation, dated June 22, 2009, revealed the resident fell forward from the wheelchair with the wheelchair falling on top of the resident. Further review revealed the post-fall intervention initiated was anti-tippers to the front of the wheelchair. Medical record review of nurse's notes and review of facility document, dated August 12, 2009, revealed on August 11, 2009, at 9:00 p.m., ""Pt. (patient) attempting to pick up pictures out of floor and slid from w/e (wheelchair) to floor...no injury noted..."" Medical record review of the care plan, revealed an intervention added on August 12, 2009 ""Will apply Dycem (sticky mat) to wheelchair (to prevent sliding)."" Medical record revew and review of facility documentation, dated January 21, 2010, revealed the resident fell from the wheelchair on January 21, 2010, at 10:30 p.m. Further review revealed the resident fell forward from the wheelchair with the wheelchair falling on top of the resident. Observation with CNA (Certified Nursing Assistant) # 3 on June 23, 2010, at 2:45 p.m., in the resident's room, revealed the resident seated in the wheelchair. Continued observation revealed CNA #3 assisted the resident to a standing position, and the dycem mat was not in the seat of the wheelchair. Interview with CNA #3 on June 23, 2010, at 2:50 p.m., confirmed there was no dycem mat in the seat of the resident's wheelchair. Interview with the RN Supervisor in the conference room, on June 23, 2010, at 3:15 p.m., confirmed there was no documentation the anti-tippers were in place on the wheelchair at the time of the fall. Observation with the RN Supervisor on June 23, 2010, at 3:20 p.m., in the 200 hallway revealed the resident sitting in a wheelchair with no anti-tippers in place. Interview with the RN Supervisor at that time confirmed the anti-tippers had not been applied to the wheelchair.",2014-04-01
14113,LAUREL MANOR HEALTH CARE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2010-06-23,441,D,,,SEOE11,"Based on observation, and interview the facility failed to assure the ice scoop was handled to prevent contamination and the spread of infection. The findings included: Observation of the ice pass on the secure unit on June 21, 2010, at 2:15 p.m., revealed Certified Nursing Assistant (CNA) #2, with gloved hands, removed the lid to a resident water pitcher; lifted the lid of the ice cooler; reached in the cooler and removed the ice scoop from the ice; filled the resident water pitcher from the ice cooler in the hall; deposited the scoop in the ice; entered the resident room; placed the water pitcher on the resident's over bed table; positioned the over bed table; and without removing the gloves or washing the hands, exited the resident room. Continued observation revealed the CNA, without removing the gloves or washing the hands, entered another resident room; retrieved two different residents water pitchers; opened the resident bathroom door; emptied the water pitchers; returned to the hall; lifted the lid to the ice cooler; retrieved the scoop from the ice; filled the water pitchers; deposited the scoop in the ice; returned to the residents room; placed the water pitchers on the resident's over bed tables; and without removing the gloves and washing the hands, the CNA returned to the ice cooler. Interview in the hall of the secure unit with CNA #2 on June 21, 2010, at 2:18 p.m., confirmed the ice scoop was to be placed in a separate container and not deposited in the ice cooler and this was not done. Interview at the secure unit nurses station with the Unit Manager on June 21, 2010, at 2:25 p.m., confirmed the ice scoop was to be placed in a separate container and not deposited in the ice cooler.",2014-04-01
14114,ASBURY PLACE AT JOHNSON CITY,445162,105 WEST MYTRLE AVENUE,JOHNSON CITY,TN,37604,2010-12-09,226,D,,,L0CL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and interview, the facility failed to implement the abuse policy in a timely manner for one resident (#3) of five residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had long and short term memory problems and had severely impaired cognitive skills for daily decision making, was totally dependent on staff for feeding. Medical record review of the facility investigation dated October 8, 2010, revealed Certified Nursing Assistant #1 (CNA) allegedly force fed resident #3 and treated the resident roughly. Continue review revealed the incident occurred on October 4 or October 5, 2010, and was reported to Registered Nurse (RN) #1 on October 8, 2010, by CNA #3. Further review revealed CNA #4 witnessed CNA #1 ""...trying to shove food in (resident's) mouth to make (resident) eat. (Resident) was begging (CNA #1) to stop ..."" Further review revealed CNA #2 and CNA #4 at different times observed CNA #1 handle the resident roughly. Review of the facility abuse policy revealed ""...all alleged violations involving abuse neglect, and injuries of unknown source (when both conditions are met) or misappropriation of resident's personal property will be reported to Nursing Supervisor or Director of Nursing immediately..."" Interview with CNA #2 on December 8, 2010, at 2:10 p.m., in the conference room confirmed on October 4, 2010, CNA #2 did not observe CNA #1 feed the resident; however CNA #1 ""bragged "" that (CNA #1) got the resident to eat everything on (resident's) plate. Further interview confirmed later that night observed CNA #1 holding the resident up with elbow in the residents back while the resident was vomiting. Interview with CNA #3 on December 8, 2010, at 3:00 p.m. in the conference room, confirmed on October 5, 2010, during the night shift, CNA #3 entered the resident's room and observed the resident vomiting and CNA #1(already in room) stated to the resident in harsh tone ""you are doing this because you think I am going to feed you"". Continued interview confirmed CNA #3 observed CNA #1 ""jerk the resident up in the bed"" Further interview revealed CNA #3 told CNA #1 to stop. CNA #3 stated ""having a bad day""; CNA #1 did leave the room resident's room. Continued interview confirmed CNA #3 reported this to RN #1 after 11 p.m. by phone until October 7, 2010. Interview with CNA #4 on December 8, 2010, at 3:50 p.m. in the conference room, confirmed on October 4, 2010, observed CNA #1 ""force feeding"" the resident the supper tray. Continued interview confirmed later observed CNA #1 handle the resident roughly and speak in a harsh tone while the resident was vomiting. Further interview confirmed this was not immediately reported. Interview with RN #1 on December 9, 2010, at 7:30 a.m., in the conference room, confirmed on October 7 (after 11 p.m.) RN #1 received a phone call from CNA #3 reporting the incident that occured on October 4, 2010. Continued interview confirmed an investigation was immediately started and the Director of Nursing was notified. Telephone interview with CNA #1 on December 9, 2010, at 9:15 a.m. revealed CNA #1 denied force feeding the resident and denied any mistreatment of [REDACTED]. Further interview revealed on October 4, 2010, the resident ate 100 % of magic cup and 4-5 bites of baked beans for supper. Interview with the Administrator, Director of Nursing and Assistant Director of Nursing on December 8, 2010, at 4:15 p.m., in the conference room confirmed the allegation of verbal and physical abuse was observed beginning October 4, 2010 on the 3:00 p.m. to 11:00 p.m, shift and on the 11:00 p.m. to 7:00 a.m. shift October 5, 2010, and was not reported to Administration until October 8, 2010, as stated in the facility abuse policy. C/O TN 929",2014-04-01
14115,KINDRED NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2010-06-23,431,D,,,RZXL11,"Based on observation, manufacturer's recommendations, and interview, the facility failed to assure biological are used or discarded prior to expiration for one of one medication rooms. The findings included: Observation of the refrigerator in the medication room on June 22, 2010, at 9:50 a.m., revealed one bottle of Tuberculin Purified Protein Derivative, ? full, opened and not dated. Review of the manufacturer's instructions revealed, ""Once entered, vial should be discarded after 30 days."" Interview with the Director of Nursing (DON) in the DON's office on June 23, 2010, at 9:30 a.m., confirmed the facility failed to discard or use the biological prior to expiration.",2014-04-01
14116,KINDRED NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2010-06-23,332,D,,,RZXL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of professional reference, and interview, the facility failed to appropriately administer medications in four of forty opportunities resulting in an error rate of ten percent. The findings included: Observation and interview of Licensed Practical Nurse (LPN #1) on hall 600 on June 22, at 8:45 a.m., 2010, revealed the nurse preparing medications at the medication cart. Observation included LPN #1 gathered the following oral medications for resident # 23: 1. [MEDICATION NAME] 20 mg (milligrams) (medication to decrease gastric acid secretion); 2. [MEDICATION NAME] 0.4 mg (to increase urination); 3. Multivitamin with Minerals (supplement); 4. [MEDICATION NAME] 100 mg (stool softener); 5. Potassium 20 millequivalents (replacement); 6. [MEDICATION NAME] 5 mg (steroid); 7. [MEDICATION NAME] 40 mg (diuretic); 8. [MEDICATION NAME] 25 mg (antihypertensive); and 9. [MEDICATION NAME] 40 mg (Anti-depressant). Continued observation revealed LPN #1 entered resident #23's room and placed the cup of medications on the table in front of the resident sitting in the chair. Continued observation and interview with resident #23 in the room on June 22, 2010, at 8:38 a.m., confirmed the breakfast meal had been served, consumed, and the tray had been removed from the room. Medical record review of the recapitulation of the Physician order [REDACTED]. Medical record review of the recapitulation of the Physician order [REDACTED]. Review of the medication book located at the nurses' station (2010 Pharmerica Specialized Long-term care nursing drug handbook) revealed the administration of [MEDICATION NAME] is ""Best if administered before breakfast."" Interview with LPN #1 at the nurses' station on June 22, 2010, at 9:00 a.m., verified the [MEDICATION NAME] was omitted and the [MEDICATION NAME] was administered after the meal. Observation on June 22, 2010, at 11:05 a.m., revealed Licensed Practical Nurse (LPN #2) preparing medications for administration to resident #22. Continued observation revealed the nurse prepared and gathered the medications and bolus feeding and entered the room. Continued observation revealed the nurse ascultated the abdomen via stethoscope; confirmed placement by positive ""air bubbles;"" and attached a syringe to the Gastrostomy tube to reveal no significant residual tube feeding. Continued observation revealed the nurse then administered the medications and bolus feeding via the [DEVICE]. Interview with LPN #2 in the hallway on June 22, 2010, at 11:20 a.m., confirmed the medications and bolus feeding were administered without flushing the [DEVICE] prior to administration. Review of the physician orders [REDACTED]. Interview with the Director of Nursing (DON) in the DON's office on June 23, 2010, at 9:30 a.m., confirmed the facility failed to follow the physician order [REDACTED]. Observation and interview of LPN #3 on hall 400 on June 22, at 4:45 p.m., 2010, revealed the nurse preparing medications at the medication cart. Continued observation revealed LPN #3 gathered the following oral medications for resident # 24: 1. [MEDICATION NAME] 325 mg (iron supplement); 2. [MEDICATION NAME] 20 mg (antihypertensive); 3. Requip 5 mg (antidepressant); and 4. [MEDICATION NAME] 40 mg (to treat ulcers). Continued observation revealed the medications were placed in a 30 cc (cubic centimeter) plastic medicine cup and two small spoonfuls of orange sherbet were placed on top of the medications. Continued observation revealed LPN #3 entered the room and administered the medications by two spoonfuls to the resident and then some water was consumed by the resident. Medical record review of the recapitulation of the Physician order [REDACTED]."" Interview in the conference room with the facility's Registered Dietician (RD #1) on June 23, 2010, at 8:35 a.m., revealed an order from the physician specifying a medication to be administered ""with food"" would indicate ""a protein and a carb (carbohydrate)"" to be given with the medication. Interview with the Director of Nursing (DON) in the DON's office on June 23, 2010, at 9:30 a.m., confirmed the facility failed to ensure a medication pass was performed with a medication error of less than 5 percent.",2014-04-01
14117,KINDRED NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2010-06-23,328,D,,,RZXL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview the facility failed to assure Nasal Cannula (type of oxygen delivery) tubing was changed timely for three resident's (#15, #16, #19) of twenty-seven residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Recapitulation Physician's Orders for June 2010, revealed, "" ...O2 (oxygen) at 2L/MIN (two liters per minute) VIA (by) NASAL CANNULA..."" Observation on June 21, 2010, at 9:35 a.m., in the resident room revealed, an oxygen concentrator in the on position delivering oxygen to the resident at 2L/MIN by nasal cannula. Continued observation at this time revealed no date on nasal cannula tubing. Interview with Charge Nurse # 1 on June 21, 2010, at 10:17 a.m., in the resident room confirmed, there was no date on the nasal cannula tubing to indicate when the tubing was last changed. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Medical record review of Recapitulation Physician's Orders for June 2010, revealed, "" ...O2 (oxygen) at 2L/MIN (two liters per minute) PER (by) N/C (nasal cannula)PRN (as needed)..."" Observation on June 21, 2010, at 9:48 a.m., in the resident room revealed, an oxygen concentrator in the on position delivering oxygen at 2L/MIN. Continued observation at this time revealed the nasal cannula tubing was dated June 11, 2010. Interview with Charge Nurse # 1 on June 21, 2010, at 10:15 a.m., in the resident room confirmed, the resident had recently received oxygen by nasal cannula (prior to breakfast this morning) and the nasal cannula tubing dated June 11, 2010, was not changed weekly as facility policy states. Resident # 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Recapitulation Physician's Orders for June 2010, revealed, "" ...O2 (oxygen) at 3L/MIN (three liters per minute) PER (by) N/C (nasal cannula) PRN (as needed)..."" Observation on June 21, 2010, at 9:52 a.m., in the resident room revealed, an oxygen concentrator in the on position delivering oxygen to the resident at 3L/MIN by nasal cannula. Continued observation at this time revealed the nasal cannula tubing was dated May 24, 2010. Interview with Charge Nurse # 1 on June 21, 2010, at 10:10 a.m., in the resident room confirmed the resident was receiving oxygen by nasal cannula and the nasal cannula tubing was dated May 24, 2010, and was not changed weekly as facility policy states. Review of the facility policy for Respiratory Equipment Change and Cleaning Guidelines revealed, "" ...Nasal Cannula...Equipment Change...Weekly...Label with date changed..."" Interview with the Director of Nursing (D.O.N.) in the facility business office on June 23, 2010, at 9:20 a.m., confirmed the facility policy for Respiratory Equipment Change was not followed.",2014-04-01
14118,KINDRED NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2010-06-23,441,D,,,RZXL11,"Based on observation and interview, the facility failed to change gloves during personal care for one (#2) of twenty-seven residents; and failed to administer medications in a sanitary manner. The findings included: Observation of resident #2 on June 21, 2010, at 2:10 p.m., included personal care performed by Certified Nursing Assistant (CNA #1). Continual observation revealed CNA #1 gathered supplies, manipulated the bed controls located on the upper side rail of the bed to lower the head of the bed, and applied gloves to both hands. CNA #1 removed the covers from the resident and pulled back the disposable brief; and wiped the front of the pubis and perineal area with a wet washcloth. CNA #1 assisted the resident to roll onto the right side and removed the disposable brief. CNA #1 cleaned the buttocks and rectal area with a wet washcloth removing a small amount of fecal material. CNA #1 walked from the bedside to the closet and without changing gloves opened the door and obtained a disposable brief and returned to the bedside. CNA #1 applied clean linen and the clean brief before assisting the resident to roll onto the left side. Without changing the gloves, CNA #1 positioned the clean brief, assisted the resident to lay on the back; secured the brief; pulled the covers from the foot of the bed up onto the resident; secured the nasal cannula into the nostrils; manipulated the bed controls to raise the head of the bed; left bedside and touched the interior door handle to open the door to get a plastic bag. With the same gloved hands, CNA #1 with one hand held the roll of plastic bags in the mounted basket and with the other hand pulled two plastic bags from the roll; touched the exterior door handle to open the door; pushed the door closed; and gathered the linens and garbage and placed in the plastic bags. Interview with CNA #1 in the hallway on June 21, 2010, at 2:21 p.m., verified the gloves were contaminated while performing personal care and were not changed before contaminating all the surfaces touched after personal care. Observation and interview of LPN #3 on hall 400 on June 22, at 4:45 p.m., 2010, revealed the nurse preparing medications at the medication cart for resident #24. Continued observation revealed LPN #3 dropped the medication Requip 5 mg (milligrams) (anti-depressant) onto the Medication Record page for resident #24. Continued observation revealed the LPN with bare fingers picked up the pill and placed it in the medicine cup with other medications. Continued observation revealed the LPN mixed the medications with orange sherbert and administered the medication to resident #24. Interview with the Director of Nursing (DON) in the DON's office on June 23, 2010, at 9:30 a.m., confirmed the facility failed to appropriately change gloves and failed to administer medications in a sanitary manner.",2014-04-01
14119,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2011-01-25,309,D,,,2KET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to catheterize one resident (#3) for residual urine as ordered by the physician of five residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with transfers, hygiene and bathing; required extensive assistance of two with toileting and was continent of bowel and bladder. Medical record review of a nurse's note dated October 7, 2010, revealed, "" ...extreme urinary urgency but voids very little when taken to bathroom ..."" Medical record review of a nurse's note dated November 21, 2010, revealed, "" ...continent of B&B (bowel and bladder) (with) episodes of incontinence ..."" Medical record review of a nurse's note dated December 7, 2010, revealed, ""Res (resident) used bed pan output 400 ml (milliliters) straight cath for residual yielded 150 ml ..."" Medical record review of a nurse's note dated January 5, 2011, revealed the resident was evaluated by a urologist on January 5, 2011. Medical record review of a urologist order dated January 5, 2011, revealed, ""Have (resident) void then catheterize ...to check for post void residual."" Medical record review of nurses' notes and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation on January 24, 2011, at 9:30 a.m., revealed the resident sitting in a chair at the bedside. The resident was alert and oriented and reported staff were ""good"" to take (resident) to the bathroom as needed. Interview on January 24, 2011, at 11:20 a.m., with Certified Nursing Assistant (CNA #1), who had been assigned to resident #3, confirmed the resident had urinary urgency. CNA #1 stated, ""...We'll take (resident) to the bathroom...go down the hall a room or two to take care of other residents...(resident) has...light on again and says 'I'm about to bust.' We'll take...to the bathroom and (resident) says, 'I can't do anything.' We'll put...back to bed and in 30 minutes...will say, 'I have to go.' We get...up again and (resident) will say, 'I can't do anything'..."" Telephone interview on January 24, 2011, at 1:20 p.m., with the Licensed Practical Nurse (LPN #1), who was assigned to the resident on the 6:00 a.m.-6:00 p.m., shift on January 5, 2011, confirmed the resident was not catheterized for residual urine on the 6:00 a.m.-6:00 p.m., shift on January 5, 2011. Telephone interview on January 24, 2011, at 2:05 p.m., with LPN #2, who was assigned to the resident on the 6:00 p.m.-6:00 a.m., shift on January 5, 2011, confirmed LPN #2 had not catheterized the resident for residual urine on the 6:00 p.m.-6:00 a.m., shift on January 5, 2011. Interview on January 24, 2011, at 3:05 p.m., with the Administrator, in the office, confirmed the resident had not been catheterized for residual urine as ordered by the urologist on January 5, 2011. C/O #",2014-04-01
14120,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2010-03-24,333,D,,,DJM011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation of medication administration, facility policy review, and interview, the facility failed to ensure residents are free of significant medication errors for one resident (#26) of twenty-eight residents reviewed. The findings included: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation orders dated March 1 - 31, 2010, revealed ""...K-Dur (potassium) 20 meq. (millequivalents) tablet SA (sustained action)...take one tablet by mouth daily...DO NOT CRUSH OR BREAK ABOVE MED..."" Observation of the medication administration pass on March 23, 2010, at 8:35 a.m., on the 300 hall, revealed Licensed Practical Nurse (LPN #1) removed the resident's medications including a K-Dur tablet, placed the medications in a clear plastic envelope, and crushed the medications. Continued observation revealed LPN #1 placed the crushed medications into a clear plastic medication administration cup mixed with applesauce and administered to the resident. Review of facility policy Crushing Medications revealed ""...The nursing staff and/or Consultant Pharmacist shall notify any Attending Physician who gives an order to crush a drug that the manufacturer states should not be crushed...The Attending Physician or Consultant Pharmacist must identify an alternative or the Attending Physician must document (or provide the nurses with a clinically pertinent reason to document) why crushing the medication will not adversely affect the resident..."" Interview with LPN #1 on March 23, 2010, at 12:15 p.m., at the Nurses Station located at the end of the 300 hallway, confirmed the facility had failed to follow the policy for crushing medications and the physician order [REDACTED].",2014-04-01
14121,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2010-03-24,314,D,,,DJM011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to apply heel protectors and float heels when in bed to prevent skin breakdown for one (#12) with a history of skin breakdown of twenty-eight residents reviewed. The findings included: Medical record review revealed resident #12 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on March 23, 2010, at 10:20 a.m., revealed resident #12 lying in bed without feet floating and no heel protectors were on. Further observation revealed the heel protectors were on the chair beside the resident's bed. Review of the nursing note dated January 9, 2010, revealed the resident was readmitted with ""...stage one or greater to both heels..."" Review of the Care Plan, with onset date on January 19, 2010, revealed the resident ""...has Stage 2 to...right heel..."" The care plan approaches included ""float heel while in bed and apply bunny boots"" (heel protectors). Review of the Skin Report dated March 22, 2010, revealed no open areas to the heel and the heel was slightly pink. Interview on March 23, 2010, at 10:23 a.m., in the resident's room with Certified Nurse Aide (CNA) #1 confirmed the resident was not wearing bunny boots and the heels were not floated. Interview with LPN #2, on March 23, 2010, at 2:49 p.m., in the hall outside of the Nursing Administration Office, revealed the heels were healed ""last week with no open areas."" Interview on March 23, 2010, at 3:00 p.m., with the Medicare Coordinator, in the Social Service Office, confirmed the facility failed to float the heels and apply the ""bunny boots"".",2014-04-01
14122,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2010-03-24,514,D,,,DJM011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure oxygen orders were accurate for one (#12) of twenty-eight residents reviewed. The findings included: Medical record review revealed resident #12 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital transfer orders dated January 9, 2010, revealed ""O2 (oxygen) @ (at) 2 L/M (liters per minute) via nasal cannula."" Review of the January 2010, February 2010, and March 2010, Recapitulation Orders revealed ""O2 @ 2 L/M via N/C (nasal cannula)."" Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the February 2010 through March 23, 2010, MAR indicated [REDACTED] Observation on March 23, 2010, at 10:20 a.m., revealed resident #12 lying in bed, no oxygen alert was posted on the resident's entrance way, no oxygen concentrator was in the room, and no nasal cannula was placed on the resident. Interview on March 23, 2010, at 10:23 a.m., in the resident's room, with Certified Nurse Aide (CNA) #1, revealed ""I think the O2 is PRN (as needed)."" Continued interview confirmed there was no oxygen equipment in the room. Interview with Licensed Practical Nurse (LPN) #5 and the Quality Assurance Nurse, at the 100 hall nursing station, on March 23, 2010, at 2:52 p.m., confirmed the January 2010, readmission physician orders [REDACTED]. Continued interview confirmed the last nursing note addressing oxygen was dated January 23, 2010 and that January was the last time they recalled the resident with oxygen. Interview with the Quality Assurance Nurse, at the 100 hall nursing station, on March 23, 2010, at 3:15 p.m., revealed the physician was called and informed the SAT (oxygen saturation rate) was 95 per cent without oxygen and oxygen had not been provided since January. Continued interview revealed the physician discontinued the oxygen due to the resident not needing the oxygen. Interview with the Director of Nursing, on March 24, 2010, at 7:25 a.m., in room [ROOM NUMBER], confirmed the physician orders [REDACTED].",2014-04-01
14123,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2009-03-24,363,E,,,8IYP11,"Complaint Investigation for TN 313 Based on review of the facility's menus, observation, and interview, it was determined the facility failed to follow the menu by serving smaller portions of pureed and ground meat for 31 of 83 diets served. The findings included: Review of the facility menu dated 2009, Week 4 Tuesday, documented, ""... Lunch Beef Tips in Gravy ... grd/grvy (ground/gravy) (#10 scoop) (#10 scoop equals 2/5 cups), pur (pureed) (#8 scoop) (#8 scoop equals 1/2 cup)..."" Observations in the kitchen on 3/24/09 at 11:15 AM, revealed the Cook served pureed meat with a #16 scoop and ground meat with a #16 scoop. A #16 scoop equals 1/4 cup. The Cook failed to follow the menu by not using #8 scoop for the pureed diet and not using the #10 scoop for ground meat. During an interview in the kitchen, on 3/24/09 at 12:15 PM, the Cook stated, ""I've been here so long. The old one (menu) said 2 ounces and it's just a habit. If you get a bigger scoop, the food runs together.""",2014-04-01
14124,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2009-03-24,517,F,,,8IYP11,"Based on review of the facility disaster menu plan, observation and interview, it was determined the facility failed to ensure there was an adequate food inventory for 3 of 3 days of the disaster menu. The findings included: Review of the facility's disaster menu plan, inventory needed for 100 beds, documented, ""Fruits and Fruit Juices Apple Sauce 6/#10 cans, Apricots 6/#10 cans, Fruit Mix 6/#10 cans, Peaches 6/#10 cans, pears 6/#10 cans, Apple Juice 12/46 oz (ounces), Cranberry juice 12/46 oz, prune juice 12/46 oz, Orange juice 12/46 oz; Puree Fruits Peach 12/15 oz, Pear 12/15 oz, Thickened Orange juice, Thickened Apple juice, Thickened Cranberry juice; Milk and Puddings Evaporated Milk 6/#10 cans, Dry Milk 6/5 lb (pounds), Thickened Milk 12/32 oz, Chocolate Pudding 6/#10 cans, Vanilla Pudding 6/#10 cans; Vegetables Green Beans 6/#10 cans, Carrots 6/#10 cans, 3 Bean Salad 6/#10 cans, Stewed Tomatoes 6/#10 cans, Mixed Vegetables 6#10 cans, Corn 6/#10 cans, Potatoes diced/sliced 6/#10 cans, Sweet Potatoes/Yams 6/#10 cans; Puree Vegetables Peas 12/15 oz, carrots 12/15 oz, Green Beans 12/15/oz; Soups Cream of Tomato 12/50 oz, Chicken Noodle 12/50 oz; Starches Pinto Beans 6/#10 cans, Kidney Beans 6/#10 cans, Bran Flakes 4/35 oz, Corn Flakes 4/35 oz, Crispy Rice 4/35 oz, Toasted Oats 4/35 oz, Sandwich Cookies 120/2 ct (count), Vanilla Wafers 6/13 oz, Graham Crackers 200/2 ct, Saltine Crackers 500/2 ct, Unsalted Crackers 500/2 ct, Bread loaves 30 loaves; Protein and Mix Protein Beef Stew 6/#10 cans, Macaroni and Cheese 6/#10 cans, Chilli with Beans 6/#10 cans, Ravioli w (with)/Beef 6/#10 cans, Corned Beef Hash 6/#10 cans, Sausage Gravy 6/#10 cans, Tuna 6/cans, Peanut Butter 200/.75 oz, Cheese Sauce 6/#10 cans, Eggs 15 dozen, Puree Beef 12/ 15 oz, Puree Chicken 12/15 oz, Med Pass 2.0 6/32 oz; Other Iced Tea Bags 1/96 ct, Drink Mix SF (sugar free) 12/pkgs (packages), Jelly 6/32 oz, Mayo (mayonnaise)/Salad Dressing 500ct, Sugar 2000 ct, Salt 3000 ct, Pepper 3000 ct, Sweet/Low 2000 ct, Margarine"". Observations in the food storage room on 3/24/09 at 3:00 PM, revealed there were only 2/#10 cans of Mixed Fruit, 6/5 pound (lb) bags of Dry Milk, 4/#10 cans of Chocolate Pudding, 1/14.75 oz can of Pureed Green Beans, 1/14.75 oz can of Pureed Carrots, 1/15 oz can of Pureed Chicken, 1/15 oz can oc Hot Chilli Beans, 4/15 oz cans of Black Eyed Peas, 3/35 oz Bran Flakes, 7/35 oz Corn Flakes, 3/35 oz Crispy Rice, 4/35 oz Toasted Oats, 2/#6 cans of Chilli with Beans, Salt, Pepper, 1 gallon Mustard, 28/42 oz packs of coffee, 2/#10 cans of Sliced Apples, and assorted paper products were observed on the emergency food supply shelves. During an interview in the food storage room on 3/24/09 at 3:30 PM, the Dietary Manager stated, ""This shelf is our emergency supply. We don't have it (all food listed on the required emergency inventory) all. We've been working on getting what's on the list.""",2014-04-01
14125,GREYSTONE HEALTH CARE CENTER,445242,181 DUNLAP ROAD,BLOUNTVILLE,TN,37617,2010-06-30,241,D,,,XE3911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to promote care that maintained or enhanced dignity during a meal for two residents (#26) and (#27) of twenty-seven residents reviewed. The findings included: Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident only required set up help for meals. Continued medical record review of the Care Plan dated May 13, 2010, revealed the resident feeds self with limited assistance. Observation in the 300 hall dining room on June 30, 2010, at 7:54 a.m., revealed resident sitting at a table with two other residents. Observation at this time revealed Certified Nursing Assistant (CNA) #1 feeding another resident #21 while resident # 26 watched. Continued observation in the 300 hall dining room on June 30, 2010, at 8:10 a.m., revealed facility staff setting up a tray for resident #26 (sixteen minutes) after resident #21 received tray. Interview with the Administrator on June 30, 2010, at 8:32 a.m., outside the administrator's office, confirmed the facility failed to maintain or enhance dignity during a meal for resident #26. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was total dependence for meals. Continued medical record review of the Care Plan dated March 25, 2010, revealed the resident is fed meals by staff. Observation in the 300 hall dining room on June 30, 2010, at 7:54 a.m., revealed resident sitting at a table with two other residents. Observation at this time revealed Certified Nursing Assistant (CNA) #1 feeding another resident #21 while resident # 27 watched. Continued observation in the 300 hall dining room on June 30, 2010, at 8:14 a.m., revealed facility staff setting up a tray to begin feeding resident #27 (twenty minutes) after resident #21 received tray. Interview with the Administrator on June 30, 2010, at 8:32 a.m., outside the administrator's office, confirmed the facility failed to maintain or enhance dignity during a meal for resident #27.",2014-04-01
14126,GREYSTONE HEALTH CARE CENTER,445242,181 DUNLAP ROAD,BLOUNTVILLE,TN,37617,2010-06-30,514,D,,,XE3911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain an accurate clinical record for one resident (#6) of twenty-seven residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Order dated May 31, 2010, revealed, ""[MEDICATION NAME] decreased to 375mg (milligrams) TID (three times daily)..."" Medical record review of the monthly Recapitulation physician's orders [REDACTED]. Order dated May 31, 2010, to decrease the [MEDICATION NAME] to 375mg TID. Medical record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 at the Nurse's Station on June 29, 2010, at 8:50 a.m., confirmed the Recapitulation physician's orders [REDACTED].",2014-04-01
14127,"SUMMIT VIEW OF LAKE CITY, LLC",445259,204 INDUSTRIAL PARK RD,LAKE CITY,TN,37769,2010-05-19,281,D,,,M9X511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interview, the facility failed to follow physician's orders for one (#2) of twenty-four residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated May 1, 2010, revealed ""...Chief Complaint: Congestion, progressive coughing, shortness of breath...Assessment and Plan: 1. Acute [MEDICAL CONDITION]...2. Pneumonia... "" Medical record review of the Pharmacy Orders for Surgery or Transfer Patients (medication orders) signed by the hospital physician on May 11, 2010, revealed the resident was to receive [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) and Atrovent ([MEDICATION NAME][MEDICATION NAME]) via nebulizer (inhalation) every four hours while awake upon return to the facility. Medical record review of the May 13-18, 2010, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the Nurse's Medication Notes (located on the reverse side of the May 2010, MAR) revealed no documentation of why the [MEDICATION NAME] and Atrovent were not administered. Review of the facility's policy Administering Medication Guidelines revealed ""...An explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at the scheduled time..."" Observation on May 18, 2010, at 2:20 p.m., with Licensed Practical Nurse (LPN) #1, of the medication cart, revealed there were twenty-five doses of [MEDICATION NAME] and Atrovent, dispensed by the pharmacy on May 12, 2010, available to be administered to the resident. Observation on May 17, 2010, at 6:40 a.m., revealed the resident lying on the bed receiving oxygen via a nasal cannula, with no respiratory distress. Telephone interview on May 18, 2010, at 3:25 p.m., with the facility's pharmacist, confirmed twenty-five doses of [MEDICATION NAME] and Atrovent were dispensed for the resident on May 12, 2010. Continued interview revealed there were no additional doses of the medications dispensed for the resident since May 12, 2010. Telephone interview on May 19, 2010, at 11:30 a.m., with the facility's pharmacist revealed there were no doses of [MEDICATION NAME] or Atrovent charged to the resident, from the emergency medication box from May 13-18, 2010. Interview on May 19, 2010, at 7:55 a.m., with Registered Nurse (RN) #1, (nurse responsible for the administration of the [MEDICATION NAME] and Atrovent on May 15-16, 2010, at 12:00 a.m., and 4:00 a.m.) in the nursing station, confirmed the [MEDICATION NAME] and Atrovent were not administered on May 15-16, 2010, at 12:00 a.m., and 4:00 a.m. Telephone interview on May 19, 2010, at 8:05 a.m., with Licensed Practical Nurse (LPN) #3, (nurse responsible for the administration of the [MEDICATION NAME] and Atrovent on May 13 and 15, 2010, at 12:00 a.m., and 4:00 a.m.) confirmed the [MEDICATION NAME] and Atrovent were not administered on May 13 and 15, 2010, at 12:00 a.m., and 4:00 a.m. Telephone interview on May 19, 2010, at 9:55 a.m., with LPN #2, (nurse responsible for the administration of the [MEDICATION NAME] and Atrovent on May 14, 15, and 16, 2010, at 8:00 a.m., 12:00 p.m., and 4:00 p.m.) confirmed the [MEDICATION NAME] and Atrovent were not administered on May 14, 15, and 16, 2010, at 8:00 a.m., 12:00 p.m., and 4:00 p.m. Telephone interview on May 19, 2010, at 8:13 a.m., with LPN #1, (nurse responsible for the administration of the [MEDICATION NAME] and Atrovent on May 13, 17, and 18, 2010, at 8:00 a.m., and 12:00 p.m.) confirmed the [MEDICATION NAME] and Atrovent were not administered on May 13, 17, and 18, 2010, at 8:00 a.m., and 12:00 p.m. Interview on May 18, 2010, at 2:30 p.m., with the Director of Nursing, in the nursing station confirmed the resident had not received [MEDICATION NAME] or Atrovent nebulizer treatments, and confirmed there was no documentation as to why the medications had not been administered.",2014-04-01
14128,"SUMMIT VIEW OF LAKE CITY, LLC",445259,204 INDUSTRIAL PARK RD,LAKE CITY,TN,37769,2010-05-19,157,D,,,M9X511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to notify the physician of medications not administered as ordered for one (#2) of twenty-four residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated May 1, 2010, revealed ""...Chief Complaint: Congestion, progressive coughing, shortness of breath...Assessment and Plan: 1. Acute [MEDICAL CONDITION]...2. Pneumonia... "" Medical record review of the Pharmacy Orders for Surgery or Transfer Patients (medication orders) signed by the hospital physician on May 11, 2010, revealed the resident was to receive [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) and Atrovent ([MEDICATION NAME][MEDICATION NAME]) via nebulizer (inhalation) every four hours while awake upon return to the facility. Medical record review of the May 13-18, 2010, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review revealed no documentation the physician was notified the [MEDICATION NAME] and Atrovent were not administered as ordered. Review of the facility's policy Administering Medication Guidelines revealed ""...Attending physician must be notified when two (2) consecutive doses of a medication are refused or withheld..."" Observation on May 18, 2010, at 2:20 p.m., with Licensed Practical Nurse (LPN) #1, of the medication cart, revealed there were twenty-five doses of [MEDICATION NAME] and Atrovent, dispensed by the pharmacy on May 12, 2010, available to be administered to the resident. Observation on May 17, 2010, at 6:40 a.m., revealed the resident lying on the bed, in no respiratory distress, receiving oxygen via a nasal cannula. Interview on May 19, 2010, at 7:55 a.m., with Registered Nurse (RN) #1, (nurse responsible for the administration of the [MEDICATION NAME] and Atrovent on May 15-16, 2010, at 12:00 a.m., and 4:00 a.m.) in the nursing station, confirmed the [MEDICATION NAME] and Atrovent were not administered on May 15-16, 2010, at 12:00 a.m., and 4:00 a.m. Telephone interview on May 19, 2010, at 8:05 a.m., with Licensed Practical Nurse (LPN) #3, (nurse responsible for the administration of the [MEDICATION NAME] and Atrovent on May 13 and 15, 2010, at 12:00 a.m., and 4:00 a.m.) confirmed the [MEDICATION NAME] and Atrovent were not administered on May 13 and 15, 2010, at 12:00 a.m., and 4:00 a.m. Telephone interview on May 19, 2010, at 9:55 a.m., with LPN #2, (nurse responsible for the administration of the [MEDICATION NAME] and Atrovent on May 14, 15, and 16, 2010, at 8:00 a.m., 12:00 p.m., and 4:00 p.m.) confirmed the [MEDICATION NAME] and Atrovent were not administered on May 14, 15, and 16, 2010, at 8:00 a.m., 12:00 p.m., and 4:00 p.m. Telephone interview on May 19, 2010, at 8:13 a.m., with LPN #1, (nurse responsible for the administration of the [MEDICATION NAME] and Atrovent on May 13, 17, and 18, 2010, at 8:00 a.m., and 12:00 p.m.) confirmed the [MEDICATION NAME] and Atrovent were not administered on May 13, 17, and 18, 2010, at 8:00 a.m., and 12:00 p.m. Interview on May 18, 2010, at 3:45 p.m., with the Director of Nursing, in the nursing station, confirmed the physician had not been notified the [MEDICATION NAME] and Atrovent were not administered.",2014-04-01
14129,"SUMMIT VIEW OF LAKE CITY, LLC",445259,204 INDUSTRIAL PARK RD,LAKE CITY,TN,37769,2010-05-19,371,F,,,M9X511,"Based on observation and interview, the facility failed to ensure the dietary employees working in the dish room properly cleaned and sanitized the dishes. The findings included: Observation on May 17, 2010, at 8:45 a.m., in the dish room, revealed one dietary employee on the clean side and one dietary employee on the dirty side of the dish machine. Further observation revealed the dietary employee from the clean side went to the dirty side, opened the dirty side of the dish machine door, pushed a rack of dirty dishes into the dish machine which came in contact with the rack of clean dishes inside the machine, and shoved the clean dishes out of the machine with the dirty dish rack, and shut the dirty side of the dish machine door. This employee then removed and disposed the gloves, went to the clean side of the dish machine, put on new gloves and started to store the dishes from the rack of dishes that had come in contact with the dirty dish rack. Interview on May 17, 2010, at 8:47 a.m., in the dish room, with the dietary employee on the clean side, confirmed the employee had gone from the clean side to the dirty side of the dish machine, opened the dirty side door of the dish machine, pushed a rack of dirty dishes into the rack of clean dishes inside the dish machine and shoved the rack of clean dishes out of the machine using the rack of dirty dishes. Further interview confirmed the employee had closed the dirty side door of the dish machine, took off and disposed the gloves, went to the clean side of the dish machine and put on new gloves and began storing dishes from the rack that had come in contact with the rack of dirty dishes. Further interview revealed ""That's the way I've always done it..."" Interview with the dietary supervisor on May 17, 2010, at 8:50 a.m., in the dish room, confirmed the observed process was the procedure in practice by the dietary department.",2014-04-01
14130,"SUMMIT VIEW OF LAKE CITY, LLC",445259,204 INDUSTRIAL PARK RD,LAKE CITY,TN,37769,2010-05-19,323,D,,,M9X511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place or provide adequate supervision for four (#2, #9, #15, and #20) of twenty-four residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory deficits and moderately impaired cognitive skills. Medical record review of a Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the Plan of Care dated April 15, 2010, revealed ""...Risk for falls...Safety alarm to alert staff to unassisted rising; check for functioning and placement..."" Medical record review of the Nurse Progress Notes dated May 16, 2010, at 10:30 a.m., revealed ""Called to resident room by CNA (Certified Nursing Assistant)...Resident laying on floor on left side of bed. Resident was laying on left side. Res (resident) voices no c/o (complaints of) pain at this time. R.O.M. (range of motion) WNL (within normal limits) for this resident. Neuro check WNL...red areas noted to left side & side of left knee. No bruising or swelling noted. Call light still attached to res blanket and within reach. Res. laying on blanket..."" Medical record review revealed no documentation the safety alarm was in place at the time of the resident's fall on May 16, 2010. Observations on May 17, 2010, at 6:40 a.m., 8:35 a.m., 11:50 a.m., and 2:36 p.m., and on May 18, 2010, at 7:30 a.m., 8:52 a.m., and 1:10 p.m., revealed the resident lying on the bed with no safety alarm in place. Observation and interview on May 18. 2010, at 2:38 p.m., with the Director of Nursing, revealed the resident lying on the bed, and confirmed the safety alarm was not in place. Interview with the Director of Nursing, in the nursing station on May 19, 2010, at 7:36 a.m., revealed the Director of Nursing had talked to Licensed Practical Nurse (LPN) #4, (LPN responsible for the resident's care on May 16, 2010, at the time of the resident's fall) and LPN #4 had confirmed the safety alarm was not in place at the time of the resident's fall on May 16, 2010. 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 impairment, moderately impaired cognitive skills, and had fallen in the past thirty days. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the May 2010, physician's recapitulation orders revealed the resident was to have a bed/chair alarm. Medical record review of the Plan of Care dated March 17, 2010, revealed ""...Resident is at risk for falls...pressure alarm...Monitor alarm for placement and functioning..."" Observation on May 18, 2010, at 10:00 a.m., revealed the resident seated in a wheelchair, in the dining room, and no alarm was present. Observation and interview on May 18, 2010, at 10:25 a.m., with the Director of Nursing, revealed the resident seated in a wheelchair in the dining room, and confirmed there was no safety alarm present on the resident's wheelchair. Resident #15 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 impairments, moderately impaired cognitive skills, and had fallen in the past thirty days. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the May 2010, physician's recapitulation orders revealed the resident was to have a low bed with a concave mattress, and a bed and chair safety alarm was to be used. Medical record review of the Nurse Progress Note dated May 17, 2010, at 12:00 a.m., revealed ""Heard resident yell for help. Upon entering room, resident was sitting in floor...Resident alarm was not intact & (and) bed was not lowered, like it was suppose to be...no injuries noted. Lowered resident's bed & put bed alarm on..."" Observation on May 19, 2010, at 8:30 a.m., revealed the resident lying on a concave mattress, with a safety alarm in place, and the bed in the lowest position. Interview on May 18, 2010, with the Director of Nursing, in the conference room, confirmed the bed was not in the lowest position and the safety alarm was not in place, at the time of the resident's fall on May 17, 2010.",2014-04-01
14131,"SUMMIT VIEW OF LAKE CITY, LLC",445259,204 INDUSTRIAL PARK RD,LAKE CITY,TN,37769,2010-05-19,514,D,,,M9X511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately document the administration of [MEDICATION NAME] for one (#18) of twenty-four resident reviewed. The findings included: Medical record review of resident #18 revealed facility admission on September 22, 2009, with [DIAGNOSES REDACTED]. Medical record review of a physician phone order dated October 16, 2009, revealed ""1) Hold [MEDICATION NAME] x (times) 3 days 2) Decrease [MEDICATION NAME] to 3.5 mg (milligrams) daily 3) Recheck PT/INR in 10 days."" Continued review of a physician phone order dated October 27, 2009, revealed ""Change [MEDICATION NAME] to 4 mg M W F (Monday, Wednesday, Friday) and 3 1/2 mg on Tu Th Sat Sun (Tuesday, Thursday, Saturday, Sunday)."" Review of the Medication Administration Record, [REDACTED]. Continued review revealed no documentation of the [MEDICATION NAME] was administered on October 19, 20, 22, 23, 24, 25 or 26, 2009. Review of the Emergency Box Record dated October 19, 2009, revealed two tablets of [MEDICATION NAME] 1 mg had been dispensed to resident #18. Interview with the pharmacist, on May 19, 2010, at 11:45 a.m., in the Director of Nursing Office, confirmed the pharmacy had dispensed, on October 19, 2009, fifteen doses of [MEDICATION NAME] 1.0 mg, and fifteen doses of [MEDICATION NAME] 2.5 mg with instruction of give one tab 1.0 mg with one tab 2.5 mg = 3.5 mg daily on October 19, 2009. Further interview revealed the resident had Medicare Part D insurance and the ""unused doses would have been destroyed."" Continued interview revealed the pharmacy would have no way of knowing if the medication had been administered since it had been destroyed and couldn't be counted for reimbursement. Interview with the Director of Nursing (DON), on May 19, 2010, at 10:30 a.m., in the DON Office, confirmed there was no documentation the [MEDICATION NAME] 3.5 mg was administered on October 19, 20, 22, 23, 24, 25, or 26, 2009.",2014-04-01
14132,"SUMMIT VIEW OF LAKE CITY, LLC",445259,204 INDUSTRIAL PARK RD,LAKE CITY,TN,37769,2010-05-19,502,D,,,M9X511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to obtain laboratory test as ordered by the physician for one (#13) of twenty-four residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapitulation orders dated August, September, October, November, December, 2009, and January, February, March, and April, 2010, revealed, ""...CBC (complete blood count)-BUN (blood, urea, nitrogen)-Creat (creatinine)-Na (sodium)-K (potassium)-ALT (liver test)-[MEDICATION NAME] every 4 months..."" Medical record review of the lab reports revealed the BUN, Creat, Sodium, Potassium, ALT, and [MEDICATION NAME] was obtained in August, 2009, and the Complete Blood Count had not been obtained since March 2009. Interview on May 19, 2010, at 8:25 a.m., with the Director of Nursing, in the conference room, confirmed the labs had not been obtained every 4 months as ordered.",2014-04-01
14133,BRIARCLIFF HEALTH CARE CENTER,445260,100 ELMHURST DR,OAK RIDGE,TN,37830,2011-01-21,514,D,,,UI8411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure the medical record was accurate for two residents (#1 #5) of eleven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Hospital discharge summary dated October 19, 2010, revealed the resident was admitted to the hospital on October 17, 2010 with a Urinary Tract Infection, and was discharged back to the facility on [DATE]. Medical record review of the Restorative Care Flow Record for the Month on October 2010, revealed ROM (range of motion) and application of braces to trunk and ankle were documented as provided on October 18, 2010. Interview with the Restorative Certified Nursing Assistant on January 19, 2011, at 2:00 p.m., in the conference room, confirmed services were documented on October 18, 2010 as provided, was not accurate and had intended to document on October 17, 2010 not on October 18, 2010. Interview with the Director of Nursing on January 19, 2011, at 3:00 p.m., in the conference room, confirmed the medical record was not accurate. Resident #5 was admitted to the facility on [DATE], and discharged on [DATE]. Medical record review of the Restorative Care Flow Sheet for the month of May 2010, revealed services were documented as provided on May 31, 2010 (after resident was discharged ). Interview with the Restorative Certified Nursing Assistant on January 19, 2011, at 2:00 p.m. in the conference room confirmed services were documented as provided on May 31, 2010, was not accurate and had intended to document on May 30, 2010, and not May 31, 2010. Interview with the Director of Nursing on January 19, 2011, at 3:00 p.m., in the conference room, confirmed the medical record was not accurate. c/o",2014-04-01
14134,BRIARCLIFF HEALTH CARE CENTER,445260,100 ELMHURST DR,OAK RIDGE,TN,37830,2011-01-21,314,D,,,UI8411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete weekly skin assessments for one resident #8 with an area of shearing on the coccyx of eleven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Assessment for Pressure Sore Potential revealed dated January 1, 2010, March 1, 2010, June 29, 2010 and October 11, 2010, revealed the resident was high risk for developing pressure sores. Medical record review of the Physician order [REDACTED]. Medical record review of the weekly skin assessment dated [DATE], and December 6, 2010, revealed no documented skin problems. Medical record review of the wound care treatment note dated December 2, 2010, revealed ""Coccyx intact cont (continue) (with) tx (treatment) as a precaution"" Medical record review of the wound care treatment note dated December 9, 2010, revealed ""Coccyx red yet blanchable cont (continue) (with) tx (treatment)."" Medical record review of the weekly skin assessment dated [DATE], revealed "" ...slight shearing pink area tx (treatment) in progress ..."" Medical record review of the wound care treatment note dated December 22, 2010, revealed ""Coccyx denuded abrasion noted cont (continue) (with) tx (treatment)."" Medical record review of the next weekly skin assessment dated [DATE], revealed "" ...shearing slight coccyx tx (treatment) in progress..."" Interview with LPN #1 on January 19, 2011, at 1:00 p.m. in the conference room confirmed the area described on the December 13, 2010, weekly skin assessment was the Coccyx/Buttocks area. Interview with the Director of Nursing on January 19, 2011, at 2:15 p.m., in the conference room, confirmed per the skin assessment dated [DATE], the resident was noted with a shearing area to the coccyx and, no skin assessment was completed between December 13, 2010, until December 30, 2010 (17 days). c/o",2014-04-01
14135,"BROOKEWOOD NURSING CENTER, INC",445278,332 RIVER ROAD,DECATUR,TN,37322,2011-01-27,226,D,,,BOSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation documentation, review of facility policy, personnel file review, and interview, the facility failed to implement the abuse policy for one resident (#5) of five sampled residents. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated August 30, 2010 at 10:30 p.m. revealed, ""Pt. (patient) c/o (complained of) pain to neck. No s/s (signs/symptoms) bruising. No redness noted. Administrator in building et (et) aware."" Medical record review revealed no nursing documentation dated August 30, 2010 before or after 10:30 p.m. Medical record review revealed the resident was discharged from the facility on September 1, 2010 and did not return to the facility. Review of facility investigation documentation dated August 30, 2010 revealed, ""...confused...Physical restraint involved CNA (certified nursing assistant)...(resident) had outburst on 3rd shift CNA allegedly placed arm around res neck in choke hold position..."" Continued review revealed no documentation regarding witnesses, location, or resident's condition. Review of facility documentation dated August 30, 2010 and signed by CNA #1 revealed, ""...(Resident) took...foot rest off and pulled back as if...was going to throw the footrest. (CNA #2) was behind the wheelchair and put (resident) in a choke hold...kept (resident) in this hold pulling (resident) up out of the chair a little even after I got the footrest away from (resident)...I told CNA #2 three or four times that was enough until...finally let resident go."" Review of facility investigation documentation dated August 30, 2010, and signed by licensed practical nurse (LPN) #1 revealed, ""Pt had been irate et (and) needing care...1 CNA had taken a foot rest off pt's w/c (wheelchair) CNA #2 was behind pt...After the foot rest was removed, pt. complained of CNA #2 hurting...neck from pulling it back. Soon after that CNA #1...told me that CNA #2 had pt. in choke hold and pt. had turned red. I then took CNA #2 aside...said did choke hold..."" Review of facility documentation (interview with resident) signed by Registered Nurse (RN) #1 revealed the alleged perpetrator was not identified by name of alleged perpetrator and included, ""...nearly choked me to death...still hurts...no apparent bruising...was short, black headed...nighttime...I deserved it."" Review of facility documentation dated September 1, 2010 and signed by by CNA #2 revealed, ""...foot rest...raised it back getting ready to throw it or hit (CNA #1) or (LPN #1). I reacted the same as anyone...seen it (A Dangerous situation)...)LPN #1) called me to the side said she would have to report it I said fine. Then I was trying to explain a choke hold from a head lock. I never applied a choke hold. A head lock maybe..."" Review of facility documentation dated September 2, 2010 and signed by CNA #3 revealed, ""...(CNA #2) was talking about how...couldn't stand (a male resident)...and how (CNA #2) told (male resident) the last time he was here (CNA #2) threaten to beat the (expletive deleted) out of him... It doesn't surprise me (CNA #2) did what (CNA #2) did because...had said once before if (resident) got out of hand...would just put (resident) in a head lock...There has been a few times I've heard (CNA #2) tell a resident to shut up or not to turn there (their) call light on cause...didn't have time to come in there..."" Review of facility documentation dated September 2, 2010 and signed by CNA #1 revealed, ""...I've saw (CNA #2) man handle patients..."" Review of a recorded message on the director of nursing's cell phone on January 24, 2011 at approximately 2:00 p.m. in the activity office, with the administrator and director of nursing (and identified by the director of nursing and the administrator as the voice of CNA #2) revealed, ""...I'm home...last night...I put (resident) in a choke hold but I didn't put...in a choke hold to put...to sleep. If I had (resident would have) been out..."" Review of CNA #2's personnel file revealed, ""...Employee Termination Notice...Date of Termination 9-1-10...Reason for Termination: Abuse, not eligible for rehire."" Review of facility policy ""Abuse Reporting and Investigation"" revealed, ""...all residents have the right to be free of verbal, sexual, physical...abuse...must report...must include...If someone has directly observed a particular incident, their names should be recorded on the report...Complete all information on the report form...Exact location...Vital Signs...brief assessment (presence/absence of pain, skin condition...and statement of care given...Chart documentation: Brief description of what happened...Resident complains including expressions of pain..."" Interview with the director of nursing on January 24, 2011 at 12:00 p.m. in the activity office revealed staff had failed to report allegations of CNA #2's rough physical treatment of [REDACTED].#5. C/O: #",2014-04-01
14136,KINDRED NURSING AND REHABILITATION- FAIRPARK,445286,307 N FIFTH ST BOX 5477,MARYVILLE,TN,37801,2010-09-09,312,D,,,T4N211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide ADL care for a dependent resident for one resident (#9) of seventeen residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, severely impaired cognitive skills for daily decision making, and was totally dependent for hygiene and bathing. Medical record review of the care plan dated August 4, 2010, revealed, ""...fingernail...care every Sunday..."" Observation on September 8, 2010, at 10:30 a.m., with the Staff Development Coordinator, revealed the resident lying in the bed, both hands contracted with the fingernails on both hands extending approximately ? inch beyond the tips of the nail bed. Further observation revealed an odor from the hands when the Staff Development Coordinator opened the hands. Interview on September 8, 2010, at 10:30 a.m., with the Staff Development Coordinator, in the resident's room, confirmed the nails were long and needed to be trimmed and confirmed an odor from the hands.",2014-04-01
14137,KINDRED NURSING AND REHABILITATION- FAIRPARK,445286,307 N FIFTH ST BOX 5477,MARYVILLE,TN,37801,2010-09-09,441,D,,,T4N211,"**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 follow infection control policies for one resident (#2) of seventeen residents reviewed. The findings included: Resident #2 was admitted to the facility June 18, 2010, with [DIAGNOSES REDACTED]. Medical record review of a Resident Progress Note dated September 4, 2010, at 9:25 a.m., revealed ""...1 cm (centimeter) X (times) 1 cm round open area found to pt's (patient) R (right) medial heel. Pt. has history of pressure ulcers to heels...Open area is draining a small amount of serosanguinous drainage..."" Medical record review of a Physician Telephone Order dated September 4, 2010, revealed ""...Cx (culture) open area R medial heel, [MEDICATION NAME] BID (2 times a day) X 1 week to R medial heel. Call MD if + (positive) Cx for abx (antibiotic)..."" Medical record review of a Laboratory Wound Culture Report dated September 6, 2010, revealed ""...Right Heel...3+ Pseudomonas Aeruginosa (type of bacteria)...4+ Methicillin Resistant Staphylococcus Aureus (MRSA type of bacteria)..."" Medical record review of a Physician Telephone Order dated September 6, 2010, revealed ""...Dc (discontinue) [MEDICATION NAME]. [MEDICATION NAME] 2% Cream topically to right heel TID (3 times per day)[MEDICATION NAME] (antibiotic) 600 mg (milligram) PO (by mouth) BID X 14 days..."" Observation on September 8, 2010, at 2:20 p.m., in the resident's room, with the Infection Control Nurse, revealed the right heel adhered to the bottom bed sheet. Continued observation revealed the nurse had to pull the sheet away from the heel. Further observation revealed yellow drainage on the bottom sheet, two open areas noted on the right medial and lateral heel. Review of a facility policy, Disease Specific Information (MRSA) revealed, ""...Infected draining lesions/pressure ulcers. Limited to one or two areas; drainage completely contained by a secure dressing. Standard precautions during dressing changes..."" Interview with the Infection Control Nurse on September 8, 2010, at 2:25 p.m., at the resident's bedside, confirmed the pressure ulcers had drainage and the drainage was not contained.",2014-04-01
14138,HUNTSVILLE MANOR,445288,287 BAKER STREET,HUNTSVILLE,TN,37756,2010-12-16,312,D,,,HRD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide oral care for one (#5) of twenty-eight residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required limited assistance with hygiene and received greater than 50% (percent) of nutrition through a feeding tube. Observation on December 7, 2010, at 1:30 p.m., revealed the resident lying in bed with tube feeding at 70 ml (milliliters) per hour. Observation revealed the resident's lips and mouth were dry and mucus streamed from the resident's upper lip to the lower lip. Observation of the resident and interview with the Licensed Practical Nurse (LPN #1) and Certified Nursing Assistants (CNA #1 and #2) on December 7, 2010, at 1:43 p.m., confirmed the resident was in need of oral care and confirmed oral care had not been provided on December 7, 2010. Observation of the resident and interview on December 7, 2010, at 1:47 p.m., with CNA #3 and at 1:50 p.m., with CNA #4 confirmed oral care had not been provided on December 7, 2010. CO #",2014-04-01
14139,HUNTSVILLE MANOR,445288,287 BAKER STREET,HUNTSVILLE,TN,37756,2010-12-16,278,D,,,HRD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess one resident (#17) with Pressure Ulcers of twenty-eight residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a ""Resident Admission (readmission) Body Audit"" dated June 24 and 25, 2010, revealed the resident had two stage 4 Pressure Ulcers on the heels and two stage 2 Pressure Ulcers on the buttocks. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had no Pressure Ulcers. Interview on December 9, 2010, at 10:20 a.m., in the conference room, with the Licensed Practical Nurse (Treatment Nurse) confirmed the resident had two stage 4 Pressure Ulcers on the heels and two stage 2 Pressure Ulcers on the buttocks at the time of the body assessment dated [DATE] (by the former Treatment Nurse). Continued interview with the Treatment Nurse confirmed the wounds did not heal prior to the resident's death (September 16, 2010). Medical record review and interview on December 9, 2010, at 10:40 a.m., in the conference room, with Licensed Practical Nurse #4/MDS Coordinator confirmed the MDS dated [DATE], was not correct and failed to reflect the stage 4 Pressure Ulcers to the heels and the stage 2 Pressure Ulcers to the buttocks. C/O # , #",2014-04-01
14140,HUNTSVILLE MANOR,445288,287 BAKER STREET,HUNTSVILLE,TN,37756,2010-12-16,456,E,,,HRD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident equipment was maintained for six (#22, #23, #24, #25, #26 and #27) of twenty-eight residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident required limited assistance with bed mobility and transfers and required extensive assistance with ambulation. Observation on December 8, 2010, at 11:35 a.m., revealed the resident was being transported in a wheelchair on the 100 hall by the Physical Therapy Technician (#1). Observation revealed the vinyl material on the right arm rest of the wheelchair was torn and had jagged edges with foam protruding from the armrest. Observation revealed the tear was four inches in length. Observation revealed the resident had no skin tears or reddened areas near the location of the torn armrest. Observation and interview on December 8, 2010, at 11:35 a.m., on the 100 hall, with the Physical Therapy Technician (#1) confirmed the armrest of the wheelchair was in need of repair. Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident was totally dependent on staff for all activities of daily living and was not ambulatory (able to walk). Observation on December 8, 2010, at 1:40 p.m., revealed the resident sitting in the wheelchair. Observation revealed the vinyl covering on both armrests was torn with foam exposed. Observation revealed the right armrest was missing one inch of foam padding with the metal frame exposed. Observation and interview on December 8, 2010, at 1:40 p.m., with Licensed Practical Nurse (LPN) #3 confirmed the wheelchair was in need of repair. Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident was totally dependent on staff for all activities of daily living and was not ambulatory. Observation on December 8, 2010, at 1:16 p.m., revealed the resident in a geri chair. Observation revealed the left arm of the padding on the geri chair was torn ? inch with padding exposed. Observation revealed three tears to the footrest with padding exposed. Observation revealed the resident had no skin tears to the arms or legs. Observation and interview on December 8, 2010, at 1:16 p.m., with LPN #3 confirmed the geri chair was in need of repair. Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident required extensive assistance with all activities of daily living. Observation on December 8, 2010, at 1:25 p.m., revealed the resident sitting in a wheelchair. Observation revealed the vinyl covering on the armrest was torn; the foam padding was missing; and the metal frame was exposed. Observation revealed duct tape had been placed on the armrest to within ? inch of the end of the armrest. Observation and interview on December 8, 2010, at 1:25 p.m., with LPN #3 confirmed the wheelchair was in need of repair. Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident required limited assistance with activities of daily living. Observation on December 8, 2010, at 1:20 p.m., revealed the resident sitting in a wheelchair. Observation revealed the vinyl padding on both armrests was frayed with the foam padding exposed. Observation revealed the resident had no skin tears or damage in the area of exposure to the worn armrests. Observation and interview on December 8, 2010, at 1:20 p.m., with LPN #3 confirmed the wheelchair was in need of repair. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident required extensive assistance with activities of daily living and did not ambulate. Observation on December 8, 2010, at 1:15 p.m., revealed the resident lying in bed. Observation revealed the right armrest of the wheelchair in the resident's room was torn with the foam padding exposed, and the covering of the left armrest was frayed. Observation revealed the resident had no skin tears in the area of the arms, which would rest on the armrests. Observation and interview on December 8, 2010, at 1:15 p.m., with LPN #3 confirmed the wheelchair was in need of repair. C/O # , #",2014-04-01
14141,ERWIN HEALTH CARE CENTER,445291,100 STALLING LANE,ERWIN,TN,37650,2010-12-02,160,F,,,P5CL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of resident fund records and interview, the facility failed to convey funds within thirty days of death for five (#1, #2, #3, #4, #5) of five residents with funds managed by the facility. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Record revealed the resident expired in the facility on [DATE]. Review of records related to the facility's management of the resident's personal funds revealed conveyance of the balance of the resident's funds in the amount of $301.58 was not issued to the family until [DATE], (two-and one-half months after the resident's death). Interview on [DATE], at 12:35 p.m., in the conference room, with the Assistant to the Administrator confirmed the resident expired in the facility on [DATE]. Continued interview with the Assistant to the Administrator confirmed the balance of the resident's funds in the amount of $301.58 was not conveyed to the family within thirty days of the resident's death and was not conveyed to the family until [DATE]. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Record revealed the resident expired in the facility on [DATE]. Review of records related to the facility's management of the resident's personal funds revealed conveyance to the estate of the balance of the resident's funds in the amount of $413.83 was not issued until [DATE]. Interview on [DATE], at 12:20 p.m., in the conference room, with the Assistant to the Administrator confirmed the resident expired in the facility on [DATE]. Continued interview with the Assistant to the Administrator confirmed the balance of the resident's funds in the amount of $413.83 was not conveyed to the resident's estate within thirty days of the resident's death and was not conveyed to the estate until [DATE]. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Record revealed the resident expired on [DATE]. Review of records related to the facility's management of the resident's personal funds revealed conveyance to the resident's estate of the balance of the resident's funds in the amount of $302.07 was issued on [DATE]. Continued review revealed the check was returned to the facility. Review of the returned check revealed the facility failed to sign the check when issued on [DATE]. Continued review of the financial records revealed a second check in the amount of $307.02 was issued to the estate on [DATE]. Interview on [DATE], at 12:40 p.m., in the conference room, with the Assistant to the Administrator confirmed the resident expired in the facility on [DATE]. Continued interview with the Assistant to the Administrator confirmed the balance of the resident's funds in the amount of $302.07 was not conveyed to the resident's estate within thirty days of the resident's death and the check issued on [DATE], had not been signed by facility staff. Continued interview with the Assistant to the Administrator confirmed a second check for the balance of the resident's funds to the resident's estate had not been issued until [DATE]. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Record revealed the resident expired on [DATE]. Review of records related to the facility's management of the resident's personal funds revealed conveyance to the resident's estate of the balance of the resident's funds in the amount of $50.01 was not issued until [DATE] (seven and one-half months). Interview on [DATE], at 12:30 p.m., in the conference room, with the Assistant to the Administrator confirmed the resident expired in the facility on February 18, 2010. Continued interview with the Assistant to the Administrator confirmed the balance of the resident's funds in the amount of $50.01 was not conveyed to the resident's estate within thirty days of the resident's death and was not conveyed to the estate until [DATE]. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Record revealed the resident expired on [DATE]. Review of records related to the facility's management of the resident's personal funds revealed conveyance to the resident's family of the balance of the resident's funds in the amount of $994.89 was not issued until [DATE]. Interview on [DATE], at 11:50 a.m., in the conference room, with the Assistant to the Administrator confirmed the resident expired in the facility on [DATE]. Continued interview with the Assistant to the Administrator confirmed the balance of the resident's funds in the amount of $994.89 was not conveyed to the resident's estate within thirty days of the resident's death and was not conveyed to the estate until [DATE]. C/O #",2014-04-01
14142,RIDGEVIEW TERRACE OF LIFE CARE,445300,PO BOX 26 COFFEY LANE,RUTLEDGE,TN,37861,2010-07-08,514,D,,,F7WP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain complete fluid intake/output documentations for two (#4 and #23) of twenty five residents reviewed. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Continued record review revealed a physician's admission order for ""[MEDICATION NAME] 1.2 by peg (feeding) tube per pump 115 ml (milliliters) 9:00 p.m. and stop at 5:00 a.m., flush with 30 ml water before and after feeding and flush peg tube with 300 ml each shift."" Review of comprehensive care plan dated May 7, 2010 revealed interventions for Nutrition/Hydration included ""Intake and Output"". Review of the facility Intake and Output Record for fluids for the month of May 2010, reveal documentation for the 300 ml water flush incomplete on 17 of 30 days and the ""24 hour totals"" incomplete on 28 of 30 days. Interview with the Director of Nursing on July 8, 2010, at 10:15 a.m., at the nurse's station confirmed the fluid intakes were incomplete. Resident # 23 was admitted to the facility February 19, 2010 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]."" Review of the facility Minimun data set dated [DATE], under special treatments/procedures and programs indicate Intake/Output to be monitored. Review of the facility Intake and Output Record for fluid from February 19, 2010, to discharge date on March 1, 2010, revealed the 100 ml water flushes, the 250 ml bolus feedings and the ""24 hour totals"" incomplete for 17 of 20 days. Interview with the Director of Nursing on July 8, 2010, at 10:15 a.m., at the nurse's station, confirmed the fluid intakes were incomplete.",2014-04-01
14143,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2010-06-09,332,D,,,V6Z311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility protocol review, and interview, the facility failed to maintain a medication error rate of less than five percent for two (#22, #23) of twenty-six residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the monthly recapitulation physician orders' dated June 2010, revealed ""[MEDICATION NAME] (blood pressure medication) 10 mg (milligrams) po (by mouth) qd (every day)...Hold for SBP (systolic blood pressure) less 105 and DBP (diastolic blood pressure) less than 65..."" Observation during the medication pass on June 8, 2010, at 8:48 a.m., revealed Charge Nurse # 1 obtained medications including [MEDICATION NAME] for the resident, entered the residents room and administered the medication to resident #22. Continued observation and record review of a Pulse and Blood Pressure document revealed the diastolic blood pressure of 58. Interview with charge nurse #1 at the 200 hall nurse's desk on June 8, 2010, at 10:42 a.m., confirmed the [MEDICATION NAME] had not been held for the resident's diastolic blood pressure of 58. Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the monthly recapitulation physician orders' dated June 2010, revealed ""[MEDICATION NAME] Diskus ([MEDICATION NAME][MEDICATION NAME]) 1 (one) puff bid (twice a day)[MEDICATION NAME] 18 mcg (micrograms) inhalation qd (every day)..."" Observation during medication pass inside the resident's room on June 8, 2010, at 7:40 a.m., revealed Charge Nurse #2 administered [MEDICATION NAME] Diskus one puff followed by [MEDICATION NAME] one puff and failed to wait one minute between each medication. Review of the facility's Inhaled Medication protocol for spacing and proper sequence revealed ""...If more than one inhaler is used...wait 1-2 (one to two) minutes before administering the next medication..."" Interview with Charge Nurse # 2, outside the resident's room, on June 8, 2010, at 7:45 a.m., confirmed the facility protocol for Inhaled Medications had not been followed.",2014-04-01
14144,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2010-06-09,281,D,,,V6Z311,"**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]. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated May 2010, revealed, ""[MEDICATION NAME] XL (medication used to decrease elevated blood pressure) 12.5 MG (milligrams) PO (by mouth) QD (every day) with Apical Pulse x (times) I (one) minute and B/P (blood pressure)***Hold for SBP (systolic blood pressure) < (less than) 105 or DBP (diastolic blood pressure) < 65 or pulse < [MEDICATION NAME] (medication used to decrease elevated blood pressure) 10 MG PO at 8 AM and 8 PM with B/P***Hold for SPB <105 or DBP <65..."" Medical record review of the MAR (Medication Administration Record) dated May 2010, revealed the following 8:00 a.m., diastolic blood pressures less than 65: May 4, 62; May 5, 60; May 6, 58; May 7, 60; May 8, 62; May 9, 62; May 10, 64; May 11, 64; May 12, 54; May 19, 56; May 20, 64; May 21, 60; May 24, 60. Continued review of the MAR indicated [REDACTED]. Further review of the MAR revealed the [MEDICATION NAME] XL and [MEDICATION NAME] had not been held on fifteen occasions when the diastolic blood pressure was below 65. Interview with the DON (Director of Nursing) on June 8, 2010 at 10:15 a.m., in the DON's office, confirmed the [MEDICATION NAME] and [MEDICATION NAME] were not held according to the parameters ordered by the Physician. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the May 2010, Physician Recapitulation Orders and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""[MEDICATION NAME] Monoitrate ([MEDICATION NAME]) 20mg PO (by mouth) QD (daily), hold for SBP (systolic blood pressure) < (less than) 105 or DBP (diastolic blood pressure) <[MEDICATION NAME] 50mg PO QD, hold for SBP (systolic blood pressure) < (less than) 105 or DBP (diastolic blood pressure) <[MEDICATION NAME] 6.25mg PO at 8 a.m. and 8 p.m. with apical pulse X (times) 1 (one) minute and B/P (blood pressure), hold for SBP (systolic blood pressure) < (less than) 105 or DBP (diastolic blood pressure) <65 or pulse <55..."" Continued review of the May 2010, Physician Recapitulation Orders and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""[MEDICATION NAME] 3.125mg PO Q (every) 8 (eight) hours (6:00 a.m., 2:00 p.m., 10:00 p.m.) with apical pulse X (times) 1 (one) minute and B/P (blood pressure), hold for SBP (systolic blood pressure) < (less than) 105 or DBP (diastolic blood pressure) <65 or pulse <55..."" Medical record review of the Vital Sign Flow Sheet dated May 2010, revealed the following diastolic blood pressures less than 65: May 4, 8:00 p.m., 62; May 5, 8:00 p.m., 64; May 4, 8:00 p.m., 62; May 11, 8:00 p.m., 60; May 14, 8:00 p.m., 54; May 15, 8:00 a.m., 64; May 17, 8:00 a.m., 60; May 19, 8:00 a.m., 60; May 24, 2:00 p.m., 50. Medical record review of the MAR's dated May 2010, revealed [MEDICATION NAME], or [MEDICATION NAME] were not held according to the parameters ordered by the Physician. Interview with the Director of Nursing (DON) in the DON's office on June 9, 2010, at 10:00 a.m., confirmed the [MEDICATION NAME], or [MEDICATION NAME] were not held according to the parameters ordered by the Physician.",2014-04-01
14145,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-12-02,356,D,,,DH0I11,"Based on observation and interview, the facility failed to post staffing data on a daily basis. The findings included: Observation on December 1, 2010, at 8:30 a.m., 11:30 a.m., and 12:35 p.m., revealed the facility had not posted the daily staffing data for December 1, 2010, including the resident census and the number of Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants on duty. Interview on December 1, 2010, at 12:35 p.m., with the Administrator, in the lobby, confirmed the staffing information for December 1, 2010, had not been posted. C/O #",2014-04-01
14146,HILLCREST HEALTHCARE CENTER,445316,111 E PEMBERTON STREET,ASHLAND CITY,TN,37015,2009-12-08,323,D,,,3VQT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 419 Based on medical record, observation and interview, it was determined the facility failed to follow interventions to prevent falls for 2 of 15 (Residents #8 and 12) sampled residents. The findings included: 1. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set ((MDS) dated [DATE] documented that Resident #8 was in need of full staff performance of daily activities. The significant change MDS dated [DATE] and the quarterly assessment of 6/15/09 documented Resident #8 was totally dependent for transfers for two person assist and totally dependent for ambulation requiring two person transfer. Review of Resident #8's care plan dated 3/5/09 documented the resident ""At risk for injury/falls... and assist with transfer of 2."" The care plan dated 4/1/09 documented ""At risk for injury/falls related to impaired mobility hx (history) of falls... Approach Assist with transfers 2."" An additional intervention included a body alarm on 12/6/09. Observation in Resident #8's room on 12/8/09 at 3:30 PM, revealed Resident #8 sitting in a wheelchair (w/c) with a body alarm clipped to the back of her shirt to the w/c. During an interview in Resident #8's room on 12/8/09 at 3:30 PM, Resident #8 stated, ""Told (Certified Nursing Assistant (CNA) #3) there suppose to be 2 persons. She just picked me up and put me in bed and the rail fell ."" The CNA failed to use two people for transfers as care planned. 2. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]."" Review of the care plan dated 11/11/09 documented under the heading of problems was: Potential for falls and or injuries secondary to shuffling gait, confusion and history of falls. Under the heading of interventions, #3 intervention was: bed/chair alarm at all times. Observations in Resident #12's room on 12/8/09 at 11:15 AM, revealed Resident #12 was seated in a w/c in her room. There was no chair alarm attached to the w/c nor was there a bed alarm attached to Resident #12's bed. During an interview in Resident #12's room on 12/8/09 at 11:17 AM, the Director of Nursing (DON) confirmed she did not know anything about Resident #12 having a chair or bed alarm, and confirmed there was not a chair alarm on the wheelchair Resident #12 was sitting in at this time. During an interview in Resident #12's room on 12/8/09 at 11:20 AM, Nurse #2 confirmed she was aware Resident #12 had a chair alarm, and also confirmed the alarm was not on the wheelchair. Nurse #2 and CNA #6, caring for Resident #12, stated after looking in the bed and in the drawers of the bedside table belonging to Resident #12 they did not find a bed or chair alarm.",2014-04-01
14147,WOOD PRESBYTERIAN HOME,445322,520 OLD HIGHWAY 68,SWEETWATER,TN,37874,2009-12-08,323,D,,,R02I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 306 Based on medical record review, observation, and interview, the facility failed to provide supervision to prevent a fall for one (#1) resident of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, modified independence in cognitive skills for daily decision making, required extensive assistance with one person physical assistance for transfers, toilet use, and was continent of bowel and bladder. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the care plan dated February 24, 2009, revealed, "" ...provide ext (extensive) assist x 1 for hygiene, dressing, toileting and bathing ..."" Medical record review of the Resident Assessment Protocol dated February 24, 2009, revealed, "" ...Most ADL's (activities of daily living) require the ext (extensive) assist of one ..."" Medical record review of the investigation of unusual occurrence dated April 2, 2009, revealed, "" ...Family reported CNA took ...to bathroom (and) left ...on toilet to use bathroom ...did not pull light and tried to get up without help and fell in floor ...Raised hematoma to back of head ...Changes to Care Plan: Staff to stay with ...when using bathroom ..."" Observation on December 7, 2009, at 10:15 a.m., in the resident's room, revealed the resident in the wheelchair with a pressure sensitive pad alarm on the wheelchair. Interview on December 7, 2009, at 12:20 p.m., in the conference room, with the Director of Nursing, confirmed the resident was not to be left alone in the bathroom.",2014-04-01
14148,WOOD PRESBYTERIAN HOME,445322,520 OLD HIGHWAY 68,SWEETWATER,TN,37874,2010-08-26,226,D,,,PUVW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation documentation, observation, and interview, the facility failed to implement the abuse policy for one resident (#1) of nine sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory impairment and was moderately impaired with decision-making skills. Continued review revealed the resident was frequently incontinent of bladder and needed extensive to total assistance with mobility, toileting, and hygiene/bathing. Medical record review of a nurse's note dated July 14, 2010, at 11:15 a.m., revealed, ""...was approached by CNA (certified nursing assistant #1)...yesterday @ (at) approx (approximately) 5 pm...when (CNA #1) went into (resident's) room...a young boy was @...bedside...(CNA #1) stated upon...arrival, the boy took his hand from elder's brief area et (hurriedly pulled covers up. He then left the room..."" Medical record review of a physician's progress note dated July 14, 2010, revealed, ""Allegedly sexually abused [MEDICAL CONDITION] (partial or total loss of the ability to express ideas, resulting from brain damage)...no obvious tears, sores, or bleeding..."" Review of facility investigation documentation (signed by CNA #1) dated July 13, 2010, revealed, ""Today I witnessed a young man in (resident's) room, he had his hand under...blanket on the lower half of...body...I then went and told the nurse..."" Review of facility policy revealed, ""Abuse Prevention Policy and Procedure...Employees will be trained...about...preventing abuse and intervention techniques for aggressive or catastrophic behaviors...will identify and intervene..."" Observation and interview with the resident on July 16, 2010, at 2:07 p.m., revealed the resident in bed in the room and requested the blinds be closed by use of gestures. Continued interview revealed the resident gave inconsistent information regarding prior acquaintance with the alleged perpetrator and whether the resident had informed anyone about the alleged inappropriate touching. Continued interview revealed contradictory information regarding the alleged perpetrator's physical description. Interview with CNA #1 on July 16, 2010, at 3:38 p.m., in a classroom, revealed the CNA saw a male in the resident's room on July 13, 2010, and included, ""I saw him with one hand under the blanket...I didn't really see him do anything but I went to the nurse...All I know for sure was (his) hand was under the blanket..."" Telephone interview with CNA #1 on July 21, 2010, at 2:45 p.m., revealed CNA #1 was unable to identify which of the male's hands was under the resident's blanket on July 13, 2010, and CNA #1 stated, ""(I) did not see his hand or what it was doing. Blanket was around (resident's) waist. Did not see resident's brief..."" Telephone interview with the administrator on August 9, 2010, at 10:30 a.m., revealed CNA #1 left the resident unattended by staff to report concerns regarding a man in the room with the resident. Continued interview confirmed the facility failed to implement the abuse policy for Resident #1 on July 13, 2010. C/O: #",2014-04-01
14149,WOOD PRESBYTERIAN HOME,445322,520 OLD HIGHWAY 68,SWEETWATER,TN,37874,2010-08-26,323,D,,,PUVW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation documentation, observation, and interview, the facility failed to provide adequate supervision to prevent falls for one resident (#8) of nine sampled residents. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was impaired with decision-making skills, was non-ambulatory, and depended on staff for transfers. Medical record review of a fall risk assessment dated [DATE], revealed the resident required assist of two people for ambulation. Medical record review of a care plan dated February 11, 2010, revealed the risk for falls was addressed, and included, ""...chooses not to ambulate and needs sit to stand lift to transfer at times...stay with...(resident) when...in toilet..."" Medical record review of a nurse's note dated April 3, 2010, at 6:15 a.m., revealed the resident was found in the floor in the room, and included, ""...thinks fell asleep in chair."" Review of facility investigation documentation dated April 3, 2010, revealed, ""...usually early riser...to sit in observable area when up early."" Medical record review of a mental health note dated June 20, 2010, revealed, ""O x 4 (oriented to person, place, time, situation) Insight impaired..."" Medical record review of a nurse's note dated July 8, 2010, at 4:15 a.m., revealed, ""...upon entering room...lying on floor in front of wheelchair...complaining of LUE (left upper extremity) pain...hematoma on the Lt. (left) side of...forehead..."" Medical record review of a nurse's note dated July 8, 2010, at 4:30 a.m., revealed the resident was transported to a hospital. Medical record review of a nurse's note dated July 8, 2010, at 6:55 a.m., revealed, ""return from ER (emergency room )...shoulder immobilizer to L (left) shoulder..."" Medical record review of a fax to the physician dated July 11, 2010, revealed, ""refuses to wear...L shoulder immobilizer (fractured shoulder)."" Observation on July 20, 2010, at 4:45 p.m., revealed the resident on a low bed (approximately four inches above floor), a mat on the floor, padded siderails raised on both sides of the bed, and a call light within reach. Continued observation revealed the resident moved both arms and shrugged shoulders without apparent discomfort, and the resident stated, ""I don't think it's broken."" Telephone interview with the administrator on August 26, 2010, at 3:15 p.m., revealed the resident required supervision while seated in the wheelchair in the resident's room, and confirmed the facility failed to provide adequate supervision to prevent falls for Resident #8 on July 8, 2010. C/O: #",2014-04-01
14150,HOLSTON HEALTH & REHABILITATION CENTER,445344,3916 BOYDS BRIDGE PIKE,KNOXVILLE,TN,37914,2010-09-09,441,D,,,YDLM11,"Based on observation, facility policy review, and interview, the facility failed to ensure hand hygiene and infection control practices were followed during ice pass on two of six halls, and failed to maintain infection control practices during incontinence care for one (#1) of eighteen residents reviewed. The findings included: Observation of the hydration aide on September 8, 2010, from 2:35 p.m., until 2:55 p.m., revealed the hydration aide dispensing ice to multiple residents from a rolling cart with a large cooler filled with ice, without gloves on the hands or available on the cart. Continued observation revealed the hydration aide entered one resident's room; returned to the ice cooler in the hall with a clear plastic cup full of tea; held the cup of tea over the ice cooler and filled the cup of tea with ice; and took the tea cup back to the resident's room. Continued observation revealed, without performing hand hygiene, the hydration aide went to the next resident room, brought a large cup out of the room, held it over the cooler of ice, filled it with ice, and returned to the resident's room. Continued observation revealed the hydration aide entered a total of 13 rooms on two halls, filling containers of ice by holding the individual residents' cups over the cooler of ice, and returning the cups to the residents' rooms. Continued observation revealed the hydration aide was touching items in residents' rooms, wiping off over bed tables, and touching residents, and did not wear gloves or perform hand hygiene between residents or resident rooms. Interview with the hydration aide on September 8, 2010, at 2:53 p.m., on the 500 hall, confirmed the hydration aide performed hand hygiene prior to starting the ice pass, but did not perform hand hygiene during the ice pass or between residents. Review of the facility's policy Handwashing revised October 1, 2008, revealed, ""Wash hands before and after contact with each patient..."" Interview with LPN (licensed practical nurse) #1 on September 8, 2010, at 2:45 p.m., on the 600 hall, and with the Director of Nursing (DON) on September 8, 2010, at 3:15 p.m., in the DON's office, confirmed the individual resident containers were not to be held over the cooler of ice for filling and hand hygiene was to be performed after touching resident items and residents. Observation of Licensed Practical Nurse #2, and Certified Nursing Assistant #1 on September 9, 2010, at 10:00 a.m., after completing a dressing change and wound care for resident #1, for stage II and stage IV pressure ulcers, with moderate serosanguineous drainage, staff failed to clean and disinfect the over bed table used during the dressing change. Continued observation (at the same time) revealed CNA #1 prepared to provide incontinence care for resident #1. CNA #1 placed the incontinence pad, brief, wash basin, and container of periwash on the over bed table, without cleaning and disinfecting the over bed table. After completing the incontinence care, observation revealed CNA #1 completed the incontinence care, and failed to clean and disinfect the over bed table. Interview with CNA #1, on September 9, 2010, at 10:15 a.m., outside the resident's room confirmed the over bed table was used for the resident's meals and food; the over bed table was not cleaned and disinfected prior to or after providing incontinence care. Interview with the Director of Nursing on September 9, 2010, at 1:55 p.m., at the west wing nursing station, confirmed the CNA failed to follow the nursing standard for infection control by failing to clean and disinfect the over bed table.",2014-04-01
14151,HOLSTON HEALTH & REHABILITATION CENTER,445344,3916 BOYDS BRIDGE PIKE,KNOXVILLE,TN,37914,2010-09-09,226,D,,,YDLM11,"Based on review of personnel files, policy review, and interview, the facility failed to provide documentation of an abuse registry check for one (#1) of five employees reviewed. The findings included: Review of the personnel files on September 9, 2010, revealed Staff #1 had a hire date of August 25, 2010. Continued review of the file revealed the Abuse Registry was not checked until September 7, 2010, a two week delay after the hire date. Review of the facility policy for Abuse Protection & Response Policy...revealed: ""...The center will not employ individuals who: Are currently listed on the State Nurse Aide Registry or any other State employee screening or disqualification list for Abuse, Neglect or Misappropriation of Patient Property."" Interview with the Director of Nursing on September 9, 2010, at 1:55 p.m., at the west wing nursing station, confirmed no documentation the Abuse Registry was checked prior to employment for Staff #1.",2014-04-01
14152,ROGERSVILLE CARE & REHABILITATION CENTER,445359,109 HWY 70 NORTH,ROGERSVILLE,TN,37857,2010-05-13,441,D,,,7ZXY11,"**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 follow the infection control policy and failed to maintain a clean technique, for one resident (#19), of twenty seven residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had difficulty with long and short term memory and severe difficulty with decision making skills. Observation of a dressing change on May 12, 2010, at 10:25 a.m., revealed Licensed Practical Nurse (LPN #1) gathered the supplies, placed the supplies on the over-bed table, positioned the resident on the right side, exposing the buttocks and a dressing covering the pressure sore. Continued observation revealed LPN #1 washed the hands, donned gloves, removed the soiled dressing, and placed it in the biohazard bag. Continued observation revealed LPN #1 cleaned the pressure sore with a 3 x 3 gauze, and wound cleanser, then patted dry with a 3 x 3 gauze. Continued observation revealed LPN #1 removed the gloves, washed the hands and donned gloves; applied Silver Sorb and dry dressing; removed the gloves, washed the hands and donned gloves. Continued observation revealed LPN #1 failed to remove the gloves after removing the soiled dressing and before cleaning the wound. Interview with LPN #1 on May 12, 2010, at 12:45 p.m., on the 200 hall, confirmed the gloves were not removed after removing the soiled dressing and before applying the clean dressing. Review of the Dressing Procedures (for) Clean Technique revealed, ""...Always change gloves after removing soiled dressing(s)."" Interview with the Director of Nursing on May 12, 2010, at 2:50 p.m., in the administrator's office confirmed the policy was not followed.",2014-04-01
14153,ROGERSVILLE CARE & REHABILITATION CENTER,445359,109 HWY 70 NORTH,ROGERSVILLE,TN,37857,2010-05-13,279,D,,,7ZXY11,"**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 include comfort measures for one resident (# 7) of twenty-seven residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Interview with the Director of Nursing (DON) and the Minimum Data Set (MDS) coordinator on May 12, 2010, at 10:05 a.m., in the MDS office confirmed the resident was on comfort measures and the facility had failed to revise the care plan to reflect the comfort measures.",2014-04-01
14154,ROGERSVILLE CARE & REHABILITATION CENTER,445359,109 HWY 70 NORTH,ROGERSVILLE,TN,37857,2010-05-13,328,D,,,7ZXY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to assure oxygen was administered as ordered for one resident (#7) of twenty-seven residents reviewed. The findings included: Resident # 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED]. Observation on May 11, 2010, at 9:53 a.m., and 11:15 a.m., in the resident's room, revealed the resident in bed with nasal cannula (extension of oxygen delivery system) not in place for resident to receive oxygen. Observation with unit manager # 1 on May 12, 2010, at 9:28 a.m., in the resident's room, revealed the resident sitting up in a Geri chair (type of wheelchair) with the oxygen concentrator (oxygen delivery device) in the off position and the nasal cannula placed on the resident bed not in reach of resident. Interview with unit manager # 1 on May 12, 2010, at 9:30 a.m., at the North hall nurse's desk confirmed the resident was to have oxygen administered continuously at two liters by nasal cannula.",2014-04-01
14155,LIFE CARE CENTER OF HIXSON,445380,5798 HIXSON HOME PLACE,HIXSON,TN,37343,2010-01-21,281,D,,,P3CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the [MEDICAL TREATMENT] contract, and interview, the facility failed to communicate to the [MEDICAL TREATMENT] center the assessment of a resident, and medication the resident received prior to the resident's visit to the [MEDICAL TREATMENT] center for one (#8) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, with modified independence in cognitive skills for daily decision making. Medical record review of the nursing note dated August 26, 2009, revealed, ""...Res. (resident) refused to go for [MEDICAL TREATMENT], called to NP (nurse practitioner). [MEDICATION NAME] (medication for anxiety) 1 mg (milligram) IM (injection)...PT (prior to) [MEDICAL TREATMENT]...Res. Left (at) 06:20 (a.m.)..."" Review of the Long Term Care Facility [MEDICAL TREATMENT] Services Agreement dated February 20, 2002, revealed, ""...Responsibilities of Facility...The appropriate healthcare staff at Facility will make an assessment of the patient's physical condition and determine whether the patient is stable enough to be dialyzed on an outpatient basis...This assessment and communication will occur prior to each and every transfer of a patient to...for [MEDICAL TREATMENT] on an outpatient basis..."" Interview on January 20, 2010, at 3:30 p.m., with the Social Service Director, at the nursing station, confirmed the resident was anxious about going to [MEDICAL TREATMENT] on August 26, 2009, but after the anti-anxiety medication was given, the resident agreed to go to [MEDICAL TREATMENT]. Interview on January 21, 2010, at 10:15 a.m., with the Director of Nursing, in the nursing office, confirmed no documentation of the assessment of the resident or the administration of the [MEDICATION NAME] was communicated prior to the transfer of the resident to the [MEDICAL TREATMENT] clinic on August 26, 2009.",2014-04-01
14156,LIFE CARE CENTER OF HIXSON,445380,5798 HIXSON HOME PLACE,HIXSON,TN,37343,2010-01-21,315,D,,,P3CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to provide a bladder training program for one (#5) resident of fifteen residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long term memory problems; had independent cognitive skills for daily decision making; and was usually continent of bladder. Medical record review of the assessment form for bowel and bladder training dated December 21, 2009, revealed the resident scored a ten, indicating the resident was a candidate for toileting, timed or scheduled voiding. Medical record review of the interim care plan dated December 21, 2009, revealed ""...initiate bladder observation for patterning..."" Medical record review of a urinary incontinence assessment dated [DATE], revealed ""...scheduled toileting...at regular intervals on a planned basis to match the resident's voiding habits...scheduled toileting includes timed voiding with the interval based on the resident's usual voiding pattern or usually every three to four hours while awake..."" Medical record review revealed no documentation the resident's usual voiding pattern was assessed or timed voiding was completed. Observation and interview on January 20, 2010, at 2:35 p.m. revealed the resident in a wheelchair. Interview with the resident revealed when asked if the resident was aware of the need to go to the bathroom, the resident stated ""...I know when I have to go when I'm awake but not when I'm asleep..."" Interview with the restorative nurse and the director of nursing on January 20, 2010, at 3:30 p.m., in the Director of Nursing's office confirmed the facility had failed to complete the voiding pattern assessment or the timed voiding.",2014-04-01
14157,LIFE CARE CENTER OF HIXSON,445380,5798 HIXSON HOME PLACE,HIXSON,TN,37343,2010-01-21,502,D,,,P3CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to obtain laboratory services for one resident (#5) of fifteen residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission physician orders [REDACTED]. Medical record review of a clarification physician order [REDACTED]. Observation on January 20, 2010, at 8:35 a.m., revealed the resident in a wheelchair for breakfast. Observation revealed the resident with no bruising or bleeding noted. Interview with licensed practical nurse (LPN #1) on January 20, 2010, at 10:00 a.m., in the conference room, confirmed the facility had failed to obtain the PTT as ordered by the physician.",2014-04-01
14158,MAURY REGIONAL HOSPITAL SNU,445398,1224 TROTWOOD AVE,COLUMBIA,TN,38401,2011-02-08,241,D,,,2EK511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the ""Medication Guide for the Long-Term Care Nurse"" and observations, it was determined 2 of 2 (Nurse #1 and 2) nurses failed to maintain residents' dignity and respect by entering residents' rooms without knocking or gaining permission to enter. The findings included: 1. Review of the ""Medication Guide for the Long-Term Care Nurse,"" Sixth Edition, page 68, documented, ""Medication Administration in Nursing Facilities ...11. The nurse should knock on the resident's door before entering..."" 2. Observations outside room [ROOM NUMBER] on 2/7/11 at 11:35 AM, Nurse #1 entered Resident #5's room without knocking or gaining permission to enter. Observations outside room [ROOM NUMBER] on 2/7/11 at 6:20 PM, Nurse #1 entered Resident #1's room without knocking or gaining permission to enter. 3. Observations outside room [ROOM NUMBER] on 2/8/11 at 12:05 PM, Nurse #2 entered Resident #2's room without knocking or gaining permission to enter.",2014-04-01
14159,MAURY REGIONAL HOSPITAL SNU,445398,1224 TROTWOOD AVE,COLUMBIA,TN,38401,2011-02-08,431,D,,,2EK511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined the facility failed to ensure medications were not left unattended in 1 of 10 (room [ROOM NUMBER]) resident rooms. The findings included: Review of the facility's medication storage policy documented ""...assure the proper safe handling, security, and storage of medications... Procedure: 1. Keep medications in the automated dispensing machine or designated medication room of the patient care area."" Observations in room [ROOM NUMBER] on 2/7/11 at 10:45 AM, revealed a medication cup with an orange liquid substance on the bedside table in room [ROOM NUMBER]. During an interview outside of resident room [ROOM NUMBER] on 2/7/11 at 10:45 AM, Nurse #1 stated the orange liquid substance was ""resident's (Resident #3's) Lactulose. Tried to give it to her earlier. I did not mean to leave that (Lactulose medication) there.""",2014-04-01
14160,MAURY REGIONAL HOSPITAL SNU,445398,1224 TROTWOOD AVE,COLUMBIA,TN,38401,2011-02-08,371,D,,,2EK511,"Based on policy review, observations and interviews, it was determined the facility failed to ensure dietary staff members prepared and served food under sanitary conditions as evidenced by not ensuring their hair or beards were covered on 2 of 2 (2/7/11 and 2/8/11) days of the survey. The findings included: 1. Review of the facility's ""FOOD & (and) NUTRITION"" policy documented, ""...Wear the approved hair restraint when on duty... Long facial hair must be covered with a surgical mask and/or hood..."" 2. Observations in the kitchen on 2/7/11 at 10:46 AM, Dietary Staff Member (DSM) #1 and #2 were working at the steam table wearing a cap, that did not completely cover their hair. DSM #3 and the Dietary Manager (DM) were walking throughout the kitchen wearing a cap, that did not completely cover their hair. DSM #4 was walking throughout the kitchen wearing a cap, that did not completed his hair nor was his beard covered. 3. Observations in the kitchen on 2/7/11 at 2:25 PM, DSM #3 and #5 were walking throughout the kitchen wearing a cap, that did not completely cover their hair. DSM #4 was walking throughout the kitchen with his hair and beard not covered. 4. Observations in the kitchen on 2/8/11 at 11:25 AM, DSM #6 was obtaining food temperatures wearing a chef hat. DSM #6's hair and beard were not covered. The DM was walking throughout the kitchen with a cap on that did not completely cover his hair. 5. During an interview in the kitchen on 2/7/11 at 2:35 PM, DSM #5 stated, ""We routinely wear baseball caps and not hair covers. Will fix this immediately."" During an interview in the kitchen on 2/8/11 at 11:45 AM, the DM stated, ""...we have always worn ball caps. Will be a big change (completely covering hair and beards) for us...""",2014-04-01
14161,MAURY REGIONAL HOSPITAL SNU,445398,1224 TROTWOOD AVE,COLUMBIA,TN,38401,2011-02-08,441,D,,,2EK511,"Based on review of the ""Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach"" and observations, it was determined 1 of 2 (Nurse #1) nurses failed to prevent the potential development or transmission of an infection by failing to wash her hands and turned the water off with her bare hands. The findings included: Review of the ""Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach"", Third Edition, page 518 through (-) 519, documented ""Handwashing... 7. Thoroughly dry hands with paper towel. 8. Unless foot or knee control are being used, use paper towel to turn off water faucet."" Observations in Random Resident #1's room on 2/7/11 at 10:35 AM, Nurse #1 did not wash her hands or use hand sanitizer before administering medications. Observations in Resident #5's room on 2/7/11 at 11:35 AM, Nurse #1 cleaned the accucheck machine, washed her hands and turned the faucet off with her bare hands. After obtaining the residents blood, Nurse #1 removed her gloves, washed her hands and turned the faucet off with her bare hands.",2014-04-01
14162,COMMUNITY CARE OF RUTHERFORD,445406,901 COUNTY FARM RD,MURFREESBORO,TN,37127,2010-05-12,323,G,,,5DZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility document review, and staff interview, the facility failed to ensure, on two occasions, to provide the required assistance and use the appropriate equipment for one resident (#21) of twenty-five records reviewed. The failure of the staff not providing the necessary assistance and using the appropriate equipment resulted in a fractured right hip to resident #21. The findings included: Medical record review revealed resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's care plan initiated September, 2009, revealed the resident was at high risk for falls. Continued review revealed the care plan was updated December 17, 2009, with the intervention ""...assist (resident) 1-2 (one to two persons) using gait belt..."" Continued review of the care plan revealed the intervention was updated March 17, 2010, to ""...2 people with gait belt..."" Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was totally dependent with two plus person physical assistance for transfers; extensive assistance with two plus persons physical assistance for bed mobility; and extensive assistance with one person physical assistance for toilet use, personal hygiene and bathing. Medical record review of the nursing note dated February 6, 2010, revealed ""...was called in resident's room...was informed resident slid down w/c (wheelchair) while transferring from toilet to w/c...Tech helped...slide to floor and went for help."" Two staff members ""helped...to get to...electric w/c with gait belt...informed resident had skin tear on right lower leg...denies pain."" Review of a facility investigation revealed on February 6, 2010, at 3:25 p.m., the resident had fallen. Further review revealed ""1-2 person assist needed to transfer and/or ambulate...resident slid off w/c (wheelchair) while transferring from the toilet to w/c (electric)...Found a skin tear on right lower leg near ankle...Resident helped up by 2 staff and gait belt."" Further review revealed ""careplan transfers with 1-2 assist and gait belt...not follow plan of care and using gait belt"". Review of the hand written statement of the Certified Nurse Aide (Technician) involved in the February 6, 2010, incident, revealed the resident ""was in the bathroom with light on for help. I went in and helped...sit on the toilet. When finished, I helped...get up. When...was going to sit on...chair...sat at the edge started sliding on the floor. I could not pull...back up on the chair by myself so I told...to let go of the bar...was holding because it was a struggle. So...sled (sic) down in a sitting position in front of...chair. I called for help..."" Medical record review of the nursing note dated April 1, 2010, at 7:10 p.m., revealed ""CNT (Certified Nurse Technician) trying to assist res (resident) to commode when...legs gave out. CNT stated that 'res right leg was curled under...body'...4 (four) CNT worked together to help res off floor to bed using lift...c/o (complaining of) unbearable pain to right hip and right leg...sent to ER (emergency room )."" Review of a facility investigation revealed the resident fell on [DATE], at 7:10 p.m., complaining of pain in right hip and right leg. Further review revealed ""1 - 2 person assistance needed to transfer and/or ambulate...equipment used appropriately?...No, no gait belt."" Further review reveled the ""CNT trying to assist res (resident) to commode when...legs gave out. CNT stated that 'right leg was curled under...body.'...4 (four) CNT worked together to help res off floor to bed using lift. C/o (complaining of) unbearable pain to right hip and right leg...sent to ER."" Further review revealed ""CNT did not transfer per plan of care. Walked off job after incident. Resident should have been transferred with 2 (two) people."" Medical record review of the nursing note dated April 2, 2010, at 12 a.m., revealed ""ER phoned to find out...status. Received report that...has been admitted ...for right hip fracture."" Interview with the Director of Nursing, on May 12, 2010, at 1:16 p.m., in the conference room, revealed the CNT involved in the February 6, 2010, incident, and the CNT involved on April 1, 2010, incident, were interviewed and both were aware the resident required two person assist with a gait belt for transfers. Further interview revealed the CNT involved in the April 1, 2010, incident, had been suspended for one day on March 26, 2010, for ""not following plan of care for transfer. Care issues discussed..."" The facility's failure to ensure the staff was providing two person assistance with a gait belt for transfers resulted in a fractured right hip for resident #21. C/O #",2014-04-01
14163,IVY HALL NURSING HOME,445469,301 WATAUGA AVE,ELIZABETHTON,TN,37643,2010-05-12,323,D,,,1WJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interviews, the facility failed to ensure a safety device was in place for one resident (#3) of twenty-six residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Medical record review of a Plan of Care, dated February 10, 2010, revealed, the resident had a history of [REDACTED]. Medical record review of facility documentation dated, May 3, 2010, revealed, ""...Notified by CNA (Certified Nursing Assistant) to res. (resident) room. Res. up in W/C (wheelchair) @ (at) this time...Skin tear observed 3 in. (inch) long on top (R) forearm..."" Continued review of facility documentation revealed, ""...Plan: Educate staff to ensure geri-sleeve is worn to (R) arm."" Interview with CNA #1 (on duty at the time of the skin tear) and the Director of Nursing, on May 11, 2010, at 10:05 a.m., in the 400 hall nurse's station, confirmed the geri-sleeve was not in place on May 3, 2010, when the resident sustained [REDACTED].",2014-04-01
14164,LAKESHORE HEARTLAND,44A114,3025 FERNBROOK LANE,NASHVILLE,TN,37214,2010-06-23,327,D,,,9JGX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain proper hydration for one resident (#9) of sixteen residents reviewed. The findings included: Resident #9 was originally admitted to the facility November 14, 2007, with [DIAGNOSES REDACTED]. Medical record review of the facility's Admission Evaluation and Interim Care Plan revealed the resident had readmitted to the facility from a hospital stay on May 22, 2010, with [DIAGNOSES REDACTED]. Further medical record review of the Admission Evaluation revealed the resident was dependent on staff for bed mobility and transfer. Medical record review of the Medical Nutrition Therapy Assessment revealed ""potential for dehydration due to leaving 25% (of meals) having UTI (Urinary Tract Infection) and poor cognition."" Continued medical record review of the nurse's notes revealed the resident had poor meal and fluid intake. Medical record review of the comprehensive care plan dated November 16, 2009, under the problem of alteration in nutrition revealed there were no specific approaches to keep the resident hydrated. Observation of the resident in bed on June 21, 2010, at 6:45 p.m., 7:40 p.m., June 22, 2010, at 9:44 a.m., and June 23, 201 0, at 7:26 a.m., and 10:45 a.m., revealed the water pitcher out of the reach of the resident. During the above observations, the water pitcher was positioned on a table at the foot of the resident's bed. Observation on June 23, 2010, at 7:26 a.m., revealed the resident in bed feeding self breakfast. Interview with the administrator on June 23, 2010, at 11:00 a.m., in the administrator's office confirmed the facility had failed to provide hydration for the resident.",2014-04-01
14165,LAKESHORE HEARTLAND,44A114,3025 FERNBROOK LANE,NASHVILLE,TN,37214,2010-06-23,176,D,,,9JGX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for self administration of medications for two residents (#2, #16) of sixteen residents reviewed. The findings included: Resident #2 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 intact short and long term memory, and required assistance with activities of daily living. Observation on June 23, 2010, at 7:45 a.m., with Licensed Practical Nurse (LPN) #1 in the resident's room revealed 12 Gas-X capsules and one 0.41 fluid ounce, 7/8 full bottle of Walgreen's Oral [MEDICATION NAME] with [MEDICATION NAME] (local anesthetic) on the resident's over the bed table. Interview with the resident on June 23, 2010, at 7:47 a.m., revealed the resident used both medications as needed, did not record or report to the nurses when used, and had not been assessed for self administration of medications. Interview on June 23, 2010, at 7:48 a.m., with LPN #1 confirmed the LPN was unaware if the resident had been assessed for self administration of medications and there had been no physician order to allow the resident to self administer medications. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had intact short and long term memory, required assistance with activities of daily living, and limited range of motion (ability to move) with one arm. Observation and interview on June 21, 2010, at 6:50 p.m., in the resident's room revealed one 96 count bottle, ? full of Tums on the resident's over the bed table. Interview with the resident revealed the resident took the Tums as needed, did not record when used or reported to the nurses when used, and was unsure if had been assessed for self administration of medications. Interview on June 21, 2010, at 6:55 p.m., with LPN #2 in the resident's room revealed the resident had had the Tums on the over the bed table for over a month. Interview on June 22, 2010, at 4:50 p.m., in the MDS office with the LPN, MDS coordinator, and the Director of Nursing confirmed the resident was not assessed for self administration of medications, and no physician order had been obtained for the resident to self administer medications.",2014-04-01
14166,LAKESHORE HEARTLAND,44A114,3025 FERNBROOK LANE,NASHVILLE,TN,37214,2010-06-23,431,D,,,9JGX11,"Based on observation, review of facility policy, and interview, the facility failed to ensure only licensed personnel had access to the medication room. The findings included: Observation on June 23, 2010, at 9:35 a.m., of the third floor medication room revealed Licensed Practical Nurse (LPN) #1 opened the medication room door and allowed the central supply clerk to enter the medication room unsupervised. Continued observation revealed LPN #1 walked down the hallway and out of visual supervision of the medication room. Continued observation revealed the central supply clerk was in the medication room unsupervised for ten minutes. Interview on June 23, 2010, at 9:45 a.m., with the central supply clerk revealed ""they let me in when I stock the medication room and no one stays with me."" Review of the facility's Storage of Medications policy revealed ""...Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys..."" Interview on June 23, 2010, at 10:15 a.m., in the conference room with the Director of Nursing confirmed unlicensed personnel must be supervised when in the medication room.",2014-04-01
14167,LAKESHORE HEARTLAND,44A114,3025 FERNBROOK LANE,NASHVILLE,TN,37214,2010-06-23,441,D,,,9JGX11,"Based on observation and interview the facility failed to handle clean linens so as to prevent the spread of infection. The findings included: Observation on June 23, 2010, at 10:00 a.m., in the facility laundry revealed one employee handling soiled linen then folding clean linen while wearing the same uniform. Further observation revealed no physical separation between the soiled linen side of the laundry area and the clean. Interview with the Environment Manager and the Administrator on June 23, at 11:00 a.m., confirmed the soiled linen must be processed separate from the clean linen to minimize aerosolization of waste products and staff handling soiled linen should remove outer uniform covering before handling clean linen.",2014-04-01
14168,BLEDSOE COUNTY NURSING HOME,4.4e+233,107 WHEELERTOWN AVENUE,PIKEVILLE,TN,37367,2010-09-07,281,D,,,C2K711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interview, the facility failed to follow physician's orders for frequency of wound care for two (#2, #3) of five residents reviewed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the resident was moderately cognitively impaired with short and long-term memory deficits; was totally dependent for ADLs; was incontinent of bowel and bladder; ate <75% of diet of pureed with nectar-thick liquids. Review of the Weekly Pressure Ulcer Progress Report dated September 2, 2010, reveled the resident had a stage II decubitus ulcer to the coccyx, which measured 3 cm by 1 cm with partial depth. Continued review of the Progress Report revealed the ulcer bed was red and had no odor or drainage. Further review of the Progress Report revealed the resident also had a 6 cm by 3 cm circular black area on the left heel. Observation of wound care on September 7, 2010, at 3:00 p.m., revealed no dressing on the coccyx ulcer when the resident's diaper was removed. Continued observation revealed the wound measurements to be correct with the wound bed red as well as wound edges, and no odor or drainage. Observation of the resident's left heel revealed almost the whole heel covered with black eschar. Observation of the resident revealed heel protectors were in place on both feet and the feet were elevated on pillows. Review of physician's orders dated August 5, 2010, revealed the ulcer was to be cleansed with normal saline; open area to be filled with Fibercal; surrounding areas painted with Hendrickson's cream; covered with [MEDICATION NAME] and [MEDICATION NAME]. Continued review of the orders revealed the dressing was to be changed every three days and as needed. Review of the Treatment Record revealed the dressing was to be changed on the 7:00 a.m. to 3:00 p.m. shift as well as on an as needed basis. Continued review of the Treatment Record revealed the dressing was documented as being changed on August 11, 2010 on the night shift and again on August 12, 2010, on the night shift. Continued review of the Treatment Record revealed the next treatment was not done until August 14, 2010, on the day shift. Further review of the Treatment Record revealed wound care was done on August 17, 2010, on the day shift as ordered as well as on August 18 and 19, 2010, on the night shift as needed. Continued review of the Treatment Record revealed wound care was done on August 21, 2010, on the day shift instead of on August 20, 2010 when the three day schedule required it to be done. Continued review of the Treatment Record revealed wound care was documented as being done on August 26, 2010, instead of August 24, 2010, on the three day schedule. Further review of the Treatment Record revealed wound care was documented as being done on August 29, 2010, instead of August 27, 2010, on the three day schedule. Interview with the Administrator and Director of Nursing (DON) on September 7, 2010, at 4:10 p.m., in the Chapel, confirmed the facility failed to follow physician's orders to complete wound care every three days as ordered and wound care was documented as being completed on August 21, 26, and 29, 2010, instead of on August 20, 24, and 27, 2010. Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Weekly Pressure Ulcer Progress Report revealed the resident had a Stage IV ulcer to the coccyx which measured 8 cm by 7 cm by 0.75 cm, with red wound bed, bloody drainage, and odor present. Continued review of the Progress Report reveled the resident had a Stage IV ulcer to the right heel which measured 4 cm by 7 cm by 1 cm, with dark red wound bed and small amount of bloody drainage. Further review of the Progress Report revealed the resident had a Stage IV ulcer to the left heel which measured 2.8 cm by 2.8 cm by 1 cm, with dark red wound bed and no exudate. On the day of survey the resident was at the Wound Clinic for the weekly appointment so the wounds were not observed. Review of physician's orders dated August 24, 2010, reveled the left lateral foot/heel ulcer was to be cleansed with [MEDICATION NAME]; silver alginate was to be applied; wound was to be covered with 4x4 dressing and wrapped with gauze on a daily basis. Continued review of physician's orders revealed the right heel/Achilles tendon ulcer was to be cleansed with [MEDICATION NAME]; Santyl applied to the wound; zinc oxide to the periwound area; covered with 4x4; and wrapped with gauze daily. Continued review of physician's orders dated August 24, 2010, revealed the resident also had a Wound-Vac to the coccyx and wound care was to be done on Tuesday, Thursday, and Saturday. Review of the Treatment Record revealed the previous wound care orders were documented as being discontinued on August 23, 2010. Continued review of the Treatment Record also revealed the resident was at Wound Clinic on August 24, 2010. Further review of the Treatment Record revealed the new wound care treatments received on August 24, 2010 were not begun until August 26, 2010. Interview with the Administrator and DON on September 7, 2010, at 4:15 p.m., in the Chapel, confirmed the facility failed to follow physician's orders to begin the new wound care orders on August 25, 2010.",2014-04-01
14169,BAPTIST HEALTH CARE CENTER,inf,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2010-09-09,281,D,,,TB7211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to monitor pain for three (#8, #9, and #25) residents receiving routine pain medication of twenty-five residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE] revealed the resident experienced less than daily moderate pain in the back, joint, and soft tissue. Medical record review of a nursing note dated July 8, 2010, revealed ""Resident c/o (complained of) pain in...back moderate to severe..."" Medical record review of a physician's telephone order dated July 8, 2010, revealed ""[MEDICATION NAME]/APAP 5/500 mg po q hs (by mouth every bedtime)...DX (diagnosis): Chronic Pain."" Further medical record review of the physician orders revealed the [MEDICATION NAME] order remained current through September 8, 2010. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the Pain Assessment Notes, dated July 6, 2010 revealed ""New order per Dr...to start [MEDICATION NAME] 5/500 mg one tab po q h.s."" Medical record review of a Pain Assessment Form, signed by Licensed Practical Nurse (LPN) #1 on July 6, 2010, revealed ""...mild back pain every day at bedtime."" Review of the facility policy for pain assessment dated [DATE] and revised on July 2007 revealed the pain assessment ""will be performed by a licensed nurse upon admission, when there is a significant change in the residents condition and with each MDS assessment identifying pain."" Further policy review revealed ""5. Ongoing Monitoring...Residents on a pain management program will be monitored for pain by the charge nurse. The findings, will be documented on a pain management flow sheet that will remain a part of the resident's record..."" Interview with LPN #1 on September 8, 2010, at 8:55 a.m., in the administrative nurse office, confirmed the facility did not monitor or document the pain level for routine pain medications. Interview with the Director of Nursing (DON), on September 8, 2010, in the DON's office, at 9:22 a.m., confirmed the charge nurse's were not monitoring the resident for pain or documenting the pain level per facility policy. Resident #9 was admitted on [DATE], with [DIAGNOSES REDACTED]., and Depression with Anxiety. Medical record review of the Minimum Data Sets dated July 6, 2010, April 12, 2010 and January 18, 2010 revealed the resident had not experienced any pain during the assessment periods. Medical record review of a physician telephone order dated February 10, 2010, revealed ""Increase [MEDICATION NAME]/APAP (pain mediation) 5/325 milligrams (mg) po TID (by mouth three times daily)."" Further medical record review revealed ""[MEDICATION NAME] 50 micrograms (mcg)/hr (per hour) TD ([MEDICATION NAME]) q 72 (every 72) (hours)...DX: Chronic Pain"" had been initiated on April 2009. Further medical record review revealed the [MEDICATION NAME] and [MEDICATION NAME] medications continued through September 8, 2010. Medical record review of a Pain Assessment Note dated November 12, 2008, revealed ""...Spoke with Dr...re (regarding): pain control on resident new order to start [MEDICATION NAME] 5/325 mg po BID (by mouth two times daily)...cont (continue) with [MEDICATION NAME] 50 mcg. Will continue to check on Resident pain and adjust med (medication) as needed."" Further medical record review revealed a note dated February 10, 2010, ""NO (new order) for [MEDICATION NAME] 5/325 po TID."" Further medical record review revealed the next note was dated July 4, 2010, currently takes [MEDICATION NAME] 5/325 po TID [MEDICATION NAME] Patch 50 mcg q 72 hrs. (hours)."" Review of a facility policy for pain assessment dated [DATE] and revised on July 2007 revealed the pain assessment ""will be performed by a licensed nurse upon admission, when there is a significant change in the residents condition and with each MDS assessment identifying pain."" Further policy review revealed ""5. Ongoing Monitoring...Residents on a pain management program will be monitored for pain by the charge nurse. The findings, will be documented on a pain management flow sheet that will remain a part of the resident's record..."" Interview, with Licensed Practical Nurse (LPN) #2 and LPN #3, on September 8, 2010, at 11:05 a.m., at nursing station 2, confirmed LPN #2 and LPN #3 administered medications to resident #9. Further interview confirmed LPN #2 and LPN #3 did not monitor or document pain level for routine pain medication. Interview, with the Medical Director on September 8, 2010, at 11:45 a.m., in the conference room, revealed ""would help if nursing documented effectiveness of pain medication."" Interview, with LPN #1, on September 8, 2010, at 11:10 a.m., in the administrative nurse office, confirmed the facility did not monitor or document the resident's pain level for routine pain medication. Resident #25 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 experienced less than daily moderate pain in the joint and soft tissue. Medical record review of the MDS's dated January 4, 2010, and March 29, 2010, revealed the resident had experienced moderate pain less than daily during the assessment period. Medical record review of a physician telephone order dated February 24, 2010, revealed ""D/C (discontinue) [MEDICATION NAME] 5/325 mg (milligrams) one po BID prn (by mouth two times daily as needed)[MEDICATION NAME] 5/500 one by mouth q HS (every bedtime)."" Further medical record review of the physician orders revealed [MEDICATION NAME] was ordered routinely through September 9, 2010. Medical record review of the Medication Administration Records from December 2009 through September 9, 2010, revealed the [MEDICATION NAME] was administered as ordered. Medcial record review of Pain Assessment Notes, dated December 17, 2009, revealed ""0900 Resident is experiencing pain when...legs are repositioned..."" Further medical record review of the next documented note dated February 24, 2010, revealed ""new order received to D/C previous [MEDICATION NAME] PRN and start [MEDICATION NAME] 5/500 at h.s."" Further medical record review of teh next documented note dated April 28, 2010, revealed ""new order for [MEDICATION NAME] BID for pain in hip."" Interview, with Licensed Practical Nurse #1, on September 9, 2010, at 9:45 a.m., in the administrative nurse office, confirmed the facility did not monitor or document pain level for routine pain medication.",2014-04-01
14170,BAPTIST HEALTH CARE CENTER,inf,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2010-09-09,323,D,,,TB7211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one resident (#7) of twenty-five residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had moderately impaired cognitive skills, was totally dependent for transfers, did not walk, and had fallen in the past thirty days. Medical record review of the Assessment for Risk of Falls dated June 8, 2010, revealed the resident was at high risk for falls. Medical record review of the Care Plan dated June 30, 2010, revealed ""...Resident has hx (history) of fall...apply mobility monitor at all times...may get up daily in a...roll about reclining chair..."" Medical record review of a nursing note dated September 7, 2010, revealed ""late entry for 9/3/10. Res (resident) observed in upright sitting position @ (at) foot of rollabout chair...(no) injuries noted..."" Observation on September 7, 2010, at 9:24 a.m., revealed the resident seated in the roll about chair with a mobility monitor in place. Interview on September 8, 2010, at 11:59 a.m., with Licensed Practical Nurse (LPN) #1, in the conference room, revealed LPN #1 had observed the resident at the time of the fall on September 3, 2010, and confirmed the mobility monitor was not in place at the time of the fall.",2014-04-01
14171,BAPTIST HEALTH CARE CENTER,inf,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2010-09-09,441,D,,,TB7211,"Based on observation and interview the facility staff failed to change the gloves prior to applying a clean dressing for one resident (#3) of twenty-five residents reviewed. The findings included: Observation on September 8, 2010, at 10:10 a.m., revealed Licensed Practical Nurse (LPN #4) gathering supplies to perform for a dressing change for resident #3. Continued observation revealed LPN #4 placed a towel on top of the over bed table and placed the supplies on the table and pulled the table toward the bed. Continued observation revealed the LPN addressed the resident briefly explained the procedure; and with gloved hands, removed the dressing from the resident's coccyx area; disposed of the dressing in a red bag; removed the gloves; and cleansed the hands. Continued observation revealed LPN #4 applied gloves from the dressing tray; removed gauze dressings from the tray and dipped the gauze into sterile water; patted the wound with the saturated gauze and disposed of the gauze in the red bag; then patted the wound with dry gauze and disposed of the gauze in the red bag. Continued observation revealed LPN #4, without changing the gloves, applied a petroleum dressing to the wound; applied a triple-antibiotic ointment around the perimeter of the dressing with a gloved finger; and applied a cover dressing secured with taped edges. Interview with LPN #4 on September 8, 2010, at 10:25 a.m., in the resident's room, confirmed the dirty gloves were not removed prior to applying the clean dressing to the wound. Interview with the Director of Nursing (DON) on September 8, 2010, at 10:50 a.m., in the DON's office, confirmed the facility failed to change dirty gloves prior to applying a clean dressing to the wound.",2014-04-01
14172,BAPTIST HEALTH CARE CENTER,inf,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2010-09-09,159,F,,,TB7211,"Based on review of patient trust accounts and interview the facility failed to ensure the resident trust accounts were maintained in an interest bearing account and failed to provide quarterly statements of the accounts to the resident or the resident's representative for six residents (#4, #14, #15, #16, #17, and #18) of six residents reviewed with resident trust accounts. The findings included: Review of the balance of six patient trust accounts revealed the following balances, on August 30, 2010: Resident #4's balance was $1465.86; Resident #14's balance was $1287.03; Resident #15's balance was $252.00; Resident #16's balance was $490.51; Resident #17's balance was $438.29: and Resident #18's balance was $1548.75. Review of a patient trust account statement from the bank dated August 31, 2010 revealed there had been no interest credited to the patient trust account. Review of the patient trust ledgers revealed no interest had been credited to the six patient trust accounts and no evidence quarterly statements had been provided to the resident or the residents' representatives. Interview on September 8, 2010, at 10:35 a.m., with the Business Office Manager (BOM), in the BOM's office revealed there were six residents who had patient trust accounts and the personal funds were in a pooled account. Continued interview confirmed interest was not applied to the residents trust accounts and confirmed quarterly statements were not provided to the resident or the residents representatives quarterly.",2014-04-01
14173,BAPTIST HEALTH CARE CENTER,inf,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2010-09-09,280,D,,,TB7211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, care plan review, and interview, the facility failed to revise the care plan approaches addressing pain medication for one resident (#25) of twenty-five residents reviewed. The findings included: Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident experienced less than daily moderate pain in the joint and soft tissue. Medical record review of the MDS's dated January 4, 2010, and March 29, 2010, revealed the resident experienced moderate pain less than daily. Medical record review of a physician telephone order dated December 17, 2009, revealed ""Tylenol Arthritis one tablet po (by mouth) BID (two times daily)."" Further medical record review of a telephone order dated January 19, 2010, revealed ""DC (discontinue) Tylenol [MEDICATION NAME] 5/325 mg (milligrams) po BID PRN (as needed) indef (indefinitely) Chronic Pain."" Further medical record review of a physician order [REDACTED]."" Further medical record review of the physician orders [REDACTED]. Medical record review of the Medication Administration Records from December 2009 through September 9, 2010, revealed the [MEDICATION NAME] was administered as ordered. Medical record review of the care plan initiated January 5, 2010, and updated on March 29, 2010, and June 21, 2010, revealed the problem ""shows evidence of pain less than daily."" Further medical record review revealed an approach of ""...Medicate as ordered with Tylenol Arthritis..."" Interview with Licensed Practical Nurse #1, on September 9, 2010, at 9:45 a.m., in the administrative nurse office, confirmed the facility had failed to update the care plan to reflect the medication change from Tylenol Arthritis to [MEDICATION NAME] from January 19, 2010, through September 9, 2010.",2014-04-01
14174,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2014-01-23,246,D,,,S0XG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain the bathroom call light cords within reach for two residents (#78, #93) of thirty residents reviewed. The findings included: Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident was independent in ambulation and required extensive assistance with one person physical assistance for toileting. Observation on January 21, 2014, at 2:17 p.m., revealed the resident's shared bathroom had a call light located behind the toilet, mounted high on the wall, and the pull cord was wrapped around the rail attached to the wall near the toilet tank. Interview with Licensed Practical Nurse (LPN) #2 on January 22, 2014, at 10:24 a.m., at the 300/400 hall nursing station, confirmed resident #78 was capable of ambulating and toileting independently. Resident #93, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set, dated dated dated [DATE], revealed the resident was independent with ambulation and required extensive assistance with one person for toileting. Observation in the resident's room on January 22, 2014, at 9:11 a.m., revealed resident #93 entered the room using a rolling walker. Continued observation revealed resident #93 entered and exited the shared bathroom independently. Interview with LPN #2 on January 22, 2014, at 3:00 p.m., at the 300/400 nursing station, confirmed resident #93 was capable of independently ambulating and toileting. Interview with Certified Nurse Aide #1 on January 21, 2014, at 2:30 p.m., in the shared bathroom, confirmed the call light pull cord was not within reach of the residents.",2014-03-01
14175,GOLDEN LIVINGCENTER - MOUNTAIN VIEW,445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2010-11-03,157,D,,,V25G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation and interview, the facility failed to notify the physician of a Pressure Ulcer and failed to obtain orders for treatment of [REDACTED]. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the ""Clinical Health Status"" (initial nursing assessment) dated September 9, 2010, revealed the resident had one Stage 3 Pressure Ulcer on the right buttock which measured ""1 ? "" inches and was covered with a foam dressing and had an ""unstageable"" wound to the left heel. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long-term memory problems and was independent in decision-making skills; required extensive assistance with bed mobility, transfers, and activities of daily living; was incontinent of bowel and had an indwelling urinary catheter; had moderate pain daily; and had three stage 3 Pressure Ulcers. Medical record review of the physician's admission orders [REDACTED]. Continued review of the admission physician's orders revealed, "" ...May use low loss air mattress d/t (due to) Pressure Ulcer to coccyx ..."" Medical record review of physicians' orders dated September 9-22, 2010, revealed orders for wound care were not obtained by the facility until September 22, 2010. Medical record review of a physician's order dated September 22, 2010, revealed, ""clean open areas to rt (right) buttock with wound cleanser(.) apply [MEDICATION NAME] cover with combiderm(.) change qd (every day) and prn (as needed) until healed."" Medical record review of a physician's order dated September 22, 2010, revealed, ""cleanse red areas to lt (left) buttock with wound cleanser and apply Duoderm(.) change q (every) 3 days and prn until healed."" Review of the facility's policy for ""Skin Care Management"" revealed, "" ...Pressure Ulcer Flow Diagram ...Pressure Ulcer identified from admission skin assessment/weekly skin assessment observation ...Notify physician and document notification ...Input MD (Medical Doctor) order/treatment ...Print new treatment order and place on Treatment Administration Record (TAR) ..."" Medical record review of nurse's notes revealed a Duoderm dressing was applied to the buttock on September 21, 2010, and with no physician's order for the Duoderm. Observation on September 27, 2010, at 4:30 p.m., with the Director of Nursing (DON) and Licensed Practical Nurse #1 revealed the resident had three wounds on the right buttocks which were measured by the DON as follows: one stage 3 measured 3.0 cm (centimeters) x (times) 2.0 cm; one stage 2 measured 1.0 cm x 1.5 cm, both described with ""yellow slough;"" and one stage 2, measured 0.3 cm x 0.3 cm. Continued observation with the DON and LPN #1 revealed an unstageable wound to the left heel which was measured by the DON as 2.5 cm x 3.0 cm and a ""new"" unstageable wound at the base of the right ""little toe"" which measured 0.3 cm x 0.3 cm. Medical record review and interview on October 5, 2010, at 1:00 p.m., in the conference room, with the Treatment Nurse (RN #2), who was providing wound care in the facility in the month of September 2010, revealed the Treatment Nurse ""never knew about ...wounds"" and confirmed the Treatment Nurse did not notify the physician to obtain treatment orders for the Pressure Ulcers which were present on admission or which developed after admission to the facility. Medical record review and interview on October 6, 2010, at 8:40 a.m., in the conference room, with the DON confirmed the only dressing change which was documented from the date of admission until September 21, 2010, was Duoderm which was applied on September 21, 2010. Continued medical record review and interview with the DON on October 6, 2010, at 8:40 a.m., confirmed the resident had one stage 3 pressure ulcer on admission on September 9, 2010, and on September 21, 2010, the resident had a stage 3 and two stage 2 Pressure Ulcers to the right buttock. Continued interview with the DON confirmed the facility failed to notify the physician of the wounds which were present on admission and failed to secure orders for treatment to the wounds from September 9, 2010, until September 22, 2010. C/O #",2014-03-01
14176,GOLDEN LIVINGCENTER - MOUNTAIN VIEW,445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2010-11-03,281,D,,,V25G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to assess the surgical wounds and injuries for one (#2) and failed to implement the care plan for one (#3) of sixteen residents reviewed. The findings included: Resident #2 who was involved in a high-speed motorcycle crash, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long-term memory problems and was independent in decision-making; had no behavioral symptoms or indicators of Depression, Anxiety or sad mood; required limited assistance with bed mobility, transfers, dressing, toileting and hygiene and was continent of bladder and bowel. Medical record review of a physician's orders [REDACTED]. Medical record review of the ""Clinical Health Status"" (initial nursing assessment) dated June 11, 2010, revealed no assessment of the resident's skin condition. Medical record review and interview on October 5, 2010, at 1:00 p.m., in the conference room, with Registered Nurse (RN #2)/Treatment Nurse confirmed the resident had surgical and trauma wounds on admission and confirmed the initial nursing assessment dated [DATE], did not include any skin assessment or assessment of the resident's wounds. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills and was totally dependent of staff for all activities of daily living. Medical record review of the current care plan revealed, "" ...Resident to use a heel boot to right heel."" Review of the facility's policy for ""Skin Care Management"" revealed, "" ...Determine care plans consistently implemented ...based on the needs of the resident ..."" Observation and interview on September 27, 2010, at 3:45 p.m., with the Director of Nursing (DON) revealed the resident's right leg was lying on a pillow with the right heel lying on the bed. Continued observation revealed a heel protector was not in place to the right heel. Observation revealed black necrosis to the right heel measured by the DON as 4.0 cm (centimeters) x (by) 5.0 cm and described by the DON as unstageable. Continued observation with the DON revealed a wound to the right great toe which was measured by the DON as 4.0 cm x 4.0 cm. Interview with the DON at the time of the observation confirmed a heel boot was not in place on the right heel. C/O #",2014-03-01
14177,GOLDEN LIVINGCENTER - MOUNTAIN VIEW,445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2010-11-03,314,D,,,V25G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policies, observation and interview, the facility failed to accurately assess and provide dressing change as ordered by the physician for one (#7); failed to obtain physician's orders [REDACTED].#8); and failed to pad oxygen tubing to prevent a Pressure Ulcer for one (#14) of fifteen residents with Pressure Ulcers reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], for a five-day hospice respite stay, with [DIAGNOSES REDACTED]. Medical record review of the physician's recapitulation orders dated July 8-31, 2010, revealed, "" ...Change [MEDICATION NAME] dsg (dressing) every 3 days or if soiled cleanse with saline, pat dry with gauze sponges then apply dressing ..."" Medical record review of a nurse's note dated July 8, 2010, at 7:07 p.m., revealed, "" ...Resident came with orders for wound care: Change [MEDICATION NAME] dressing to right lower sacral areas every 3 days and prn ..."" Medical record review of the Treatment Record dated July 8-31, 2010, revealed no documentation wound care was provided July 8-13, 2010, (date of discharge). Review of the facility's ""Skin Care Management"" policy and ""Pressure Ulcer Flow Diagram"" revealed, "" ...Implement resident specific interventions immediately: ...Treatment as ordered ..."" Interview on September 29, 2010, at 9:05 a.m., in the conference room, with Registered Nurse (RN) #1, (assigned to the unit where the resident resided) revealed the RN was ""unaware"" the resident had a dressing and stated, ""No one told me (resident) had a place that needed attention."" Continued interview with the RN confirmed the Duoderm dressing was not changed during the resident's stay in the facility from July 8-13, 2010, as ordered by the physician. Interview on September 29, 2010, at 12:20 p.m., in the conference room, with the Director of Nursing (DON) confirmed the dressing to the Pressure Ulcer was not changed during the resident's five-day stay in the facility from July 8-13, 2010. Medical record review of the ""Clinical Health Status"" dated July 8, 2010, revealed no documentation the Pressure Ulcer on the sacrum was assessed for location, size, stage, drainage, surrounding tissue nature of the wound. Medical record review revealed no documentation the Pressure Ulcer was assessed during the resident's five-day stay in the facility from July 8-13, 2010. Review of the facility's ""Skin Care Management"" and ""Risk Identification/Prevention"" policy revealed, "" ...All residents will be assessed/observed for risk of skin breakdown within 24 hours of admission...Pressure Ulcer identified from admission skin assessment ...document initial assessment of pressure area including: Location and staging(,) Size(,) Exudate (drainage)/ if present: type, color, odor, and approximate amounts(,) Pain/if present: nature and frequency(,) Wound bed: color & (and) type of tissue/character including evidence of healing (granulation) or necrosis (slough and exchar)(,) Description of (wound) edges and surrounding tissue ..."" Medical record review and interview on October 5, 2010, at 10:25 a.m., in the conference room, with the DON confirmed the facility's policy was not followed, and the Pressure Ulcer was not assessed on admission or at any time during the resident's five day stay in the facility from July 8-13, 2010. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had no short or long-term memory problems and was independent in decision-making skills; required extensive assistance with bed mobility, transfers, and activities of daily living; was incontinent of bowel and had an indwelling urinary catheter; and had three stage 3 Pressure Ulcers. Medical record review of the ""Clinical Health Status"" (initial nursing assessment) dated September 9, 2010, revealed the resident was at moderate risk for Pressure Ulcers; had a Stage 3 Pressure Ulcer on the left buttock which measured ""1 ? "" inches (one inch equals 2.5 centimeters) and was covered with a foam dressing; and had an ""unstageable"" wound to the left heel (no measurements documented). Continued review revealed no documentation of the size or nature of the unstageable wound on the left heel. Review of the weekly skin report for Pressure Ulcers revealed the wounds were not assessed again until September 21, 2010 (twelve days later). Medical record review of the weekly Pressure Ulcer report dated September 21, 2010, revealed the resident had a Stage 2 Pressure Ulcer on the right buttock measuring 1.0 cm (centimeters) x (by) 1.5 cm, a Stage 2 Pressure Ulcer on the right buttock measuring 0.5 cm x 1.3 cm, a Stage 3 pressure on the right buttock measuring 3.0 cm x 2.0 cm and a Stage 1 Pressure Ulcer to the left buttock (no measurement documented). Medical record review of a ""Wound Evaluation Flow Sheet"" dated September 22, 2010, revealed the resident had an unstageable Pressure Ulcer to the left heel measuring 3.0 cm x 3.0 cm. Review of the facility's ""Skin Care Management"" policy revealed, "" ...Purpose: to provide a systemic approach and monitoring process for skin ...All residents will be assessed/observed for risk of skin breakdown within 24 hours of admission ...(facility) develops a routine to review residents with wounds or at risk on a weekly basis ...Wound status is monitored on a weekly basis ...Documentation of Weekly Skin Assessments/Observations: Licensed nurse will be responsible for performing this skin assessment/observation ...Licensed nurse to document weekly on all wounds using the ""Wound Evaluation Flow Sheet ...document...Location and staging...Size (length x width/depth) presence and location of undermining and tunneling...Exudate/if present: nature and frequency...Wound bed: color & (and) type of tissue/character including evidence of healing (granulation) or necrosis (slough and eschar)...Description of (wound) edges and surrounding tissue..."" Medical record review, review of the weekly skin reports for Pressure Ulcers and interview on October 6, 2010, at 8:40 a.m., in the conference room, with the DON confirmed the Pressure Ulcers had not been assessed between September 9, 2010, and September 21, 2010. Continued interview confirmed on September 9, 2010, the resident had one stage 3 Pressure Ulcer on the left buttock, and on September 21, 2010, the resident had two stage 2 and one stage 3 on the right buttock and a stage 1 Pressure Ulcer on the left buttock. Continued interview confirmed the pressure ulcers were not assessed the week of September 13, 2010, and confirmed the facility's policy to perform weekly Pressure Ulcer assessments had not been followed. Medical record review of the physician's admission orders [REDACTED]. Continued review of the admission physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED].) apply [MEDICATION NAME] cover with combiderm(.) change qd (every day) and prn (as needed) until healed."" Medical record review of another physician's orders [REDACTED].) change q (every) 3 days and prn until healed."" Medical record review of the Treatment Record dated September 2010, and nursing notes dated September 9-22, 2010, revealed wound care was not provided from September 9-21, 2010. Medical record review of nurses' notes dated September 9-22, 2010, revealed no documentation wound care had been provided from September 9-20, 2010, and revealed a Duoderm dressing was applied to the buttock on September 21, 2010 (twelve days after admission). Observation and interview on September 27, 2010, at 4:30 p.m., with the DON and the Licensed Practical Nurse (LPN) #1 revealed the resident lying in bed on a low air-loss mattress. Continued observation with the DON and LPN #1 revealed the resident had Pressure Ulcers on the right buttocks, described by the DON as: one stage 3, 3.0 cm x 2.0 cm and one stage 2, 1.0 cm x 1.5 cm, both with ""yellow slough"" and one stage 2, 0.3 cm x 0.3 cm. The DON described an unstageable wound to the left heel, 2.5 cm x 3.0 cm with the margins intact and a ""new"" unstageable wound to the base of the right ""little toe"" which measured 0.3 cm x 0.3 cm. Medical record review and interview on October 5, 2010, at 1:00 p.m., in the conference room, with RN #2/Treatment Nurse, who was providing wound care in the facility, in the month of September 2010, confirmed the Treatment Nurse had no knowledge of the resident's wounds; did not provide wound care for the resident; and did not notify the physician to obtain treatment orders for the Pressure Ulcers. Medical record review and interview on October 6, 2010, at 8:40 a.m., in the conference room, with the DON confirmed wound care was not provided from September 9-20, 2010, and confirmed the facility failed to obtain physician's orders [REDACTED]. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and severely impaired decision-making skills; was totally dependent on staff for all activities of daily living; and had no pressure ulcers. Medical record review of the ""Clinical Health Status"" dated October 5, 2010, revealed the resident had no Pressure Ulcers. Medical record review of the physician's orders [REDACTED]. Medical record review of a nurse's note dated October 25, 2010, at 2:57 p.m., revealed, ""Open area noted to crease of right ear with bloody drainage noted; resident grimaces when area is touched. Tx (treatment) nurse aware & (and) area cleaned with NS (normal saline), bactracin ([MEDICATION NAME]) ointment applied, gauze in place to keep tubing off area..."" Medical record review of a nurse's note dated October 25, 2010, at 3:45 p.m., revealed, "" ...CNA noted an open area behind residents ear while shaving ...Area appears to be caused from O2 tubing ..."" Review of the facility's weekly Pressure Ulcer report dated October 26, 2010, revealed the resident had a Stage 2 Pressure Ulcer to the right posterior ear which measured 1.6 cm x 0.2 cm. Medical record review of a nurse's note by RN #4/Treatment Nurse dated October 26, 2010, revealed, ""raw area to rt (right) ear 1.6 (cm) x 0.2 (cm), cleaned with normal saline and applied Oxy Ears (foam padding around O2 tubing) to O2 tubing for preventive measures."" Medical record review of the ""Wound Evaluation Flow Sheet"" dated October 26, 2010, revealed the Stage 2 Pressure Ulcer to the right posterior ear measured 1.6 cm x 0.2 cm. Medical record review of the ""Wound Evaluation Flow Sheet"" dated October 29, 2010, revealed the Stage 2 Pressure Ulcer to the right posterior ear had healed. Interview on November 2, 2010, at 11:30 a.m., in the conference room, with the RN/Treatment Nurse #4 confirmed the resident had a painful Stage 2 Pressure Ulcer ""caused by oxygen tubing."" Continued interview with RN#4/Treatment Nurse revealed Oxy Ears (foam padding around oxygen tubing) were placed on the oxygen tubing over both ears to promote healing. Continued interview with RN #4/Treatment Nurse revealed the Pressure Ulcer to the right posterior ear was healed as of October 29, 2010. Observation and interview on November 2, 2010, at 11:40 a.m., with RN #4/Treatment Nurse revealed the resident was lying in bed with oxygen tubing in place around both ears, and Oxy Ears were not in place. Continued observation and interview with RN #4/Treatment Nurse confirmed the Oxy Ears were not in place and confirmed the resident had a new Stage 2 Pressure Ulcer to the right posterior ear which was red and moist but with no drainage and measured by the Treatment Nurse as 0.5 cm x 0.5 cm. Continued interview with the Treatment Nurse confirmed the Treatment Nurse would reapply Oxy Ears to the O2 tubing. C/O # , #",2014-03-01
14178,GOLDEN LIVINGCENTER - MOUNTAIN VIEW,445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2010-11-03,279,E,,,V25G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation and interview, the facility failed to update the care plan to include wounds and interventions to promote healing of the wounds for four (#3, #9, #13, #14) of sixteen residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills and was totally dependent of staff for all activities of daily living. Medical record review of a physician's orders [REDACTED]."" Medical record review of a physician's orders [REDACTED]."" Medical record review of the current care plan revealed the care plan included the resident's "" ...risk for Pressure Ulcers and altered skin integrity ..."" with the goal of "" ...will have no loss of skin integrity ..."" Continued review of the current care plan revealed the care plan had not been updated to reflect the unstageable wound to the right heel and the intervention to ""float"" the heel from the bed to relieve pressure on the heel. Observation and interview on September 27, 2010, at 3:45 p.m., with the Director of Nursing (DON) revealed the resident's right leg was lying on a pillow with the right heel lying on the bed. Observation revealed black necrosis to the right heel measured by the DON as 4.0 cm (centimeters) x (by) 5.0 cm and described by the DON as unstageable. Continued observation with the DON revealed a wound to the right great toe which was measured by the DON as 4.0 cm x 4.0 cm. Interview with the DON at the time of the observation confirmed the right heel was resting on the bed and was not ""floated"" to relieve pressure on the heel. Medical record review and interview on October 5, 2010, at 7:25 a.m., with the MDS Coordinator confirmed the current care plan addressed prevention of loss of skin integrity and had not been updated to include the unstageable wound to the right heel and the intervention to ""float"" the heel from the bed to relieve pressure on the heel. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS] Disk Disease and Decubitus Ulcer. Review of the ""Clinical Health Status"" (initial nursing assessment) dated June 29, 2010, revealed the resident had a Pressure Ulcer on the coccyx which measured 11.0 cm x 9.0 cm x 4.0 cm with tunneling of 8.0 cm. Medical record review of the care plan dated June 30, 2010, revealed the care plan did not address the stage 4 Pressure Ulcer to the coccyx and did not include interventions related to treatment of [REDACTED]. Telephone interview and review of the care plan on October 21, 2010, with the MDS Coordinator confirmed the care plan did not address the stage 4 Pressure Ulcer to the coccyx and did not include interventions related to treatment of [REDACTED]. Resident #13 was readmitted 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 and moderately impaired decision-making skills; was totally dependent on staff for activities of daily living; and had one stage 2 Pressure Ulcer. Medical record review of the current care plan revealed the care plan included the resident's ""potential for altered skin integrity"" with the goal of "" ...will have no loss of skin integrity ..."" Continued review of the current care plan revealed no interventions were included related to the stage 2 Pressure Ulcer. Medical record review of the facility's skin care management policy revealed, "" ...The interdisciplinary plan of care will address problems, goals and interventions directed toward prevention of Pressure Ulcers and/or skin integrity concerns identified ...Determine care plans consistently ...revised based on the needs of the resident ..."" Medical record review and interview on October 5, 2010, at 7:20 a.m., with the MDS Coordinator confirmed the current care plan addressed prevention of loss of skin integrity and had not been updated to include the stage 2 Pressure Ulcer and interventions to promote healing. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and severely impaired decision-making skills; was totally dependent on staff for all activities of daily living; and had no pressure ulcers. Medical record review of the ""Clinical Health Status"" dated October 5, 2010, revealed the resident had no wounds except to the left ankle. Medical record review of a nurse's note dated October 25, 2010, revealed, ""Open area note to crease of right ear with bloody drainage noted; resident grimaces when area is touched. Tx (treatment) nurse aware & (and) area cleaned with NS (normal saline), bactracin ([MEDICATION NAME]) ointment applied, gauze in place to keep tubing off area..."" Review of the facility's weekly Pressure Ulcer report dated October 26, 2010, revealed the resident had a Stage 2 Pressure Ulcer to the right posterior ear which measured 1.6 cm x 0.2 cm. Medical record review of a nurse's note by RN #4/Treatment Nurse revealed, ""raw area to rt (right) ear 1.6 (cm) x 0.2 (cm), cleaned with normal saline and applied oxy ears (foam padding around oxygen tubing) to O2 (oxygen) for preventive measures."" Medical record review of the ""Wound Evaluation Flow Sheet"" dated October 26, 2010, revealed the Stage 2 Pressure Ulcer to the right posterior ear measured 1.6 cm x 0.2 cm. Medical record review and interview, in the conference room, on November 2, 2010, at 12:00 p.m., with the RN/Treatment Nurse #4 confirmed the care plan had not been updated to include the Stage 2 Pressure Ulcer and interventions to reduce the risk of the development of a Pressure Ulcer from the pressure of oxygen tubing on the ears. C/O #",2014-03-01
14179,BETHANY HEALTH CARE CENTER,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2010-01-06,371,F,,,K66O11,"Based on observation, facility document review and staff interview, the facility failed to maintain dietary equipment in a sanitary manner and failed to operate the low temperature dish machine at the manufacturer's recommended temperature. The findings included: Observation of the facility dietary department on January 4, 2010, beginning at 10:10 a.m., with the Dietary Manager present during the observations revealed the following: The can opener blade, base, and base slot had a heavy, sticky, black colored build-up of debris with metal shavings on the build-up. The grill trough and trough slot had a heavy build-up of blackened debris. The interior of the dish machine doors had a heavy, sticky, white colored build-up. Interview with the Dietary Manger, present during the observation on January 4, 2010, beginning at 10:10 a.m., confirmed the can opener blade, base, and base slot had a heavy, sticky, black colored build-up of debris with metal shavings on the build-up. Further interview confirmed the grill trough and trough slot had a heavy build-up of blackened debris and the interior of the dish machine doors had a heavy, sticky, white colored build-up. Observation of two dish machine operations on January 4, 2010, beginning at 10:25 a.m., revealed wash temperatures of 84 and 92 degrees Fahrenheit and rinse temperatures of 92 and 94 degrees Fahrenheit. The manufacturer's recommended temperatures were 125 degrees minimum for wash and rinse cycles. Review of the facility document entitled Dishmachine Temperature Chart, dated January 2010, revealed wash temperature, rinse or ppm (parts per million) and staff initials for ""AM Staff"" (breakfast), ""Noon Staff"" (lunch) and ""PM Staff"" (supper) for each day of the month. Further review of this document revealed a total of ten recording of 150 degree wash temperature and 50 rinse or ppm from January 1, 2010, AM Staff, through January 4, 2010, AM Staff. Interview with the Dietary Manger, present during the observation of the dish machine observation on January 4, 2010, at 10:25 a.m., confirmed the wash temperature was 92 degrees Fahrenheit and the rinse temperature was 94 degrees Fahrenheit. Continued interview revealed the dietary staff recorded the wash temperature and the ppm level three times daily. Further interview confirmed the January 2010, Dishmachine Temperature Chart had 150 degree wash temperature and 50 rinse or ppm, for a total of ten recordings, from January 1, 2010, AM Staff, through January 4, 2010, AM Staff. Interview with maintenance staff on January 4, 2010, at 12:55 p.m., by the dish machine, revealed the dietary department had a designated boiler set at 140 degrees Fahrenheit and the dish machine did not have a booster heater since it was a low temperature machine. Further interview revealed the mixing valve on the dish machine had been moved, admitting more cold water into the system, thereby lowering the wash and rinse temperature during the observation on January 4, 2010, at 10:25 a.m.",2014-03-01
14180,BETHANY HEALTH CARE CENTER,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2010-01-06,456,D,,,K66O11,"Based on observation and staff interview, the facility failed to maintain the integrity of the dietary walk-in refrigerator unit. The findings included: Observation on January 4, 2010, at 10:10 a.m., of the right hand side of the interior of the walk-in refrigerator unit door jam, revealed rust had penetrated through the wall of the unit exposing the interior of the wall. Interview with the Dietary Manager, present at the observation on January 4, 2010, at 10:10 a.m., confirmed the right hand side of the walk-in refrigerator interior door jam was rusted through and the interior of the wall was exposed.",2014-03-01
14181,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2010-02-17,226,E,,,FOGM11,"Based on policy review, review of personnel files and interview, it was determined the facility failed to implement policies for the prevention of abuse, neglect, mistreatment and misappropriation of property by providing incomplete screening of 45 of 54 (Employees #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 44, 46, 47, 49, 50, 52, 53 and 54) sampled employees. The findings included: Review of the facility's ""Prevention of Resident Abuse"" policy documented, ""...Before hiring, all applicants are screened by reviewing their applications, calling past employers for references... verify certification, background checks... Screening Components... references ...certification/license verification... criminal background checks..."" Review of facility personnel files of employees hired since 6/1/2009 revealed the following information was not completed: a. License or certification verification - Employee #1, 2, 12, 14, 42 and 52. b. Documentation of reference checks - Employee #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 18, 19, 21, 22, 23, 24, 25, 26, 27, 29, 31, 33, 34, 35, 36, 44, 46, 47, 49, 50, 52, 53, and 54. c. Abuse registry checks - Employee #1, 2, 7, 12, 42, and 52. d. Criminal background checks - Employee #1, 2, 4, 5, 7, 9, 27, 28, 30, 31, 37, 38, 39, 40, 41, 42, 50, and 52. During an interview in the consultation room, on 2/17/10 at 8:30 AM, the Administrator confirmed the screening information was not documented as required.",2014-03-01
14182,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2010-02-17,323,E,,,FOGM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to identify risk, and develop and implement interventions to prevent recurrent falls for 2 of 4 (Residents #5 and 10) sampled residents with falls. The findings included: 1. Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]."" Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #5's cognitive skills were assessed as ""SEVERELY IMPAIRED"" and ""SOMETIMES UNDERSTANDS"" simple direct communication. Resident #5 required ""EXTENSIVE ASSISTANCE"" with transfers, did not ambulate and was assessed as ""TOTAL DEPENDENCE"" with wheelchair locomotion. Resident #5 fell in the past 31 to (-) 180 days and required a trunk restraint. Review of the Care Plan updated 10/19/09 identified Resident #5 as a ""FALL RISK... POTENTIAL FOR INJURY Related to ...Unsteady Gait...Cognitive Deficit... Weakness... Impaired Vision (Blind)... As evidenced by... History of falls... APPROACHES... Labs (laboratory tests)/diagnostic work as ordered... for abnormal results... Move to room closer to nurse's station... Shoes well-fitting with non-slip soles... PT/OT (physical therapy/occupational therapy) eval (evaluation) or Restorative nursing for strength training, gait, or transfer... Side rails up x (times) 2... Maintain room and hall ways free of clutter..."" and requiring ""RESTRAINT... Related to use of...Non-accessible seatbelt... APPROACHES...Make sure restraint is applied properly... Provide verbal reminders to resident to call when needing assistance... Keep call light and most frequently used personal items within reach..."" Review of the nurses' notes dated 11/23/09 documented, ""Resident (#5) was found on the floor on his side with the w/c (wheelchair) almost on his side with his NASB (non-accessible seat belt) attached... All staff inservice (inserviced) about fall and safety precautions + (plus) prevention. Will continue to monitor..."" Review of the Care Plan updated 11/23/09 documented, ""FALL RISK POTENTIAL FOR INJURY... APPROACHES... Will continue to monitor for fall and safety precautions..."" Review of the nurses' notes dated 12/21/09 documented, ""Resident (#5) was found on the floor with NASB strapped to him with the w/c over him... Inservice given to staff not to leave resident in room unattended unless in bed. Fall and safety prevention continues to be monitored..."" Review of the Care Plan updated 12/21/09 documented, ""RESIDENT (#5) FOUND ON FLOOR... Risk for repeat fall / injurious fall... APPROACH... Resident not to be left alone in his room unattended unless in bed..."" 2. Medical record review for Resident #10 documented an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS five day assessment dated [DATE] documented Resident #10's cognitive skills were assessed as ""SEVERELY IMPAIRED"" and ""SOMETIMES UNDERSTANDS"" simple direct communication. Resident #10 required ""EXTENSIVE ASSISTANCE"" with transfers and ambulation. Resident #10 fell in the past 30 days and required a trunk restraint. Review of the Care Plan dated 12/9/09 for Resident #10 documented, ""...FALL RISK POTENTIAL FOR INJURY... Related to... Unsteady Gait... Cognitive deficit... Weakness... Use of psyche (psychotropic) meds (medications)... As evidenced by... History of falls and fracture... APPROACH...Monitor for possible side effects of medications... Keep call light and personal items within easy reach... Low bed or bed in lowest position... Side rails up x 2... Maintain room and hall ways free of clutter... Train/demonstrate to resident on how to use the call light... fall precautions..."" Review of daily licensed notes dated 12/11/09 documented, ""...Resident (#10) noted on floor in dayroom lying on side still inside w/c. No noted injury..."" During an interview in the consultation room on 2/17/10 at 2:10 PM, the Director of Nursing (DON) was asked to explain the note regarding the fall on 12/11/09. The DON confirmed that Resident #10 was found with the w/c turned over. Review of Resident #10's Care Plan updated 12/11/09 documented, ""...Resident to be in w/c (with) NASB D/T (due to) poor safety awareness..."" Review of nurses' notes dated 12/25/09 documented, ""...1030 AM yelling... attempting to tilt w/c backwards... Ativan 1 mg (milligram) IM (intramuscular) given...715 PM Resident released from NASB and placed in bed. Noted continuous agitation and confusion. Resident attempting to get OOB (out of bed) (without) assist. Unable to re-direct resident... 740 PM Resident up in w/c (with) NASB attached... continues to display agitation and confusion. Unable to re-direct... attempts to disrobe and pull on NASB & (and) rocking his w/c while rolling. Will keep resident near nurses station for monitoring... 752 PM Placed resident @ (at) nurses station and played soft music. Resident remains agitated. Repeatedly attempts to stand while in w/c (with) NASB attached... 835 PM Resident noted lying on floor in w/c (with) NASB attached. W/C lying on left side around nurses station. Removed NASB, assessed resident..."" 3. During an interview in the consultation room on 2/17/10 at 2:10 PM, the DON confirmed Resident #5 and Resident #10 had turned over their wheelchairs twice.",2014-03-01
14183,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2010-11-10,309,D,,,45DK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure an ointment (which had not been ordered by the physician) was not applied to the face of one resident (#4) of five residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long-term memory problems and was independent in decision-making skills. Medical record review of a hospital History and Physical dated July 31, 2010, revealed, ""...followed by (physician) for basal [MEDICAL CONDITION] of the nose and multiple facial areas, been undergoing treatment for [REDACTED]. No [DIAGNOSES REDACTED] noted..."" Medical record review of the admission nursing evaluation dated August 3, 2010, revealed, ""...black area completely covering nose area..."" Medical record review of a physician's progress note dated August 5, 2010, revealed, ""...Nasal skin graft, thick-black in color. Multiple facial/head scars-skin CA (Cancer)...nasal reconstruction-skin grafting..."" Medical record review of a physician's orders [REDACTED]."" Medical record review of a physician's orders [REDACTED]. Medical record review of a nurse's note dated August 13, 2010, revealed, ""Res (Resident) observed (with) [MEDICATION NAME] (Zinc Oxide) on nose...When asked...stated staff had put on...Wound care tx (treatment) done as [MEDICATION NAME] removed. Res tolerated well...spoke (with physician's office)...would cause (no) damage et (and) apt (appointment) set up for 8/16...Black area in tact (with) no s/s(signs or symptoms) of infection or pain. (No) red areas noted around...wound..."" Review of documentation by the Director of Nursing (DON) dated August 13, 2010, at 8:15 a.m., revealed, ""...observed some type of pinkish ointment on...nose...wound nurse will begin working to get cream/ointment off of nose gently..."" Review of documentation by the DON dated August 13, 2010, at 3:30 p.m., revealed, ""...(complains) eyes dry/burning. Natural tears used (with) relief..."" Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of a physician's progress note dated August 16, 2010, revealed, ""...Concerned about [MEDICATION NAME] placed on face...eschar still present...no damage apparently done..."" Interview on November 9, 2010, at 11:30 a.m., in the conference room, with the Licensed Practical Nurse/Treatment Nurse confirmed the resident had a ""hard darkened area all across the nose"" and confirmed, on August 13, 2010, the Treatment Nurse observed ""pink ointment on the nose,"" and the resident had complained of ""irritation"" under the left eye. Continued interview with the Treatment Nurse confirmed cleaning the resident's face of the [MEDICATION NAME] ointment ""took close to an hour."" Interview on November 8, 2010, at 11:50 a.m., in the conference room, with the Director of Nursing confirmed a night shift Certified Nursing Assistant (CNA #1) had applied [MEDICATION NAME] ointment to the resident's face. Telephone interview on November 8, 2010, at 12:55 p.m., with CNA #1 revealed ""another CNA (CNA #1 did not identify.) told me...had cream to apply to...nose. Cream was in...room on...(overbed table)."" Continued interview with CNA #1 confirmed CNA #1 applied the [MEDICATION NAME] ointment to the resident's face after the resident told CNA #1 the cream made the face ""feel better."" Interview on November 9, 2010, at 9:40 a.m., in the conference room, with the DON confirmed the resident reported ""burning"" of the eyes after the [MEDICATION NAME] had been applied to the face and confirmed the artificial tears were ordered on August 13, 2010, to provide relief from the burning sensation. C/O #",2014-03-01
14184,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,281,E,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of manufacturer's instruction sheet and interview, the facility failed to follow physician's orders for five (#7, #1, #6, #10, #16) residents, failed to develop an interim care plan for five (#1, #5, #3, #13, #15) residents of twenty-six residents reviewed and failed to follow manufacturers recommendations for medication administration for one (#12) of twenty-six residents reviewed. The findings included: Resident #7 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated December 19, 2011, revealed, ""...Make [MEDICATION NAME] (pain medication) 7.5 mg (milligrams) po (by mouth) Bid (twice a day) prn (as needed)...D/C (discontinue) Aspirin 81 mg..."" Review of the Medication Record dated January 1, 2012, through January 8, 2012, revealed [MEDICATION NAME] 7.5 mg initialed as administered at 9:00 a.m. and 9:00 p.m. on January 1, 2012, through January 8, 2012. Review of the Medication Record dated January 1, 2012, through January 9, 2012, revealed Aspirin 81 mg initialed as administered at 9:00 a.m. on January 1, 2012 through January 9, 2012. Interview on January 9, 2012, at 2:20 p.m., with the Assistant Director of Nursing, at the nursing station, confirmed the Aspirin had been discontinued and was administered January 1-9, 2012 without a physician's order. Interview on January 10, 2012, at 9:10 a.m., with the Assistant Director of Nursing, in the Director of Nursing office, confirmed the [MEDICATION NAME] was administered January 1-8, 2012 without a physician's order. Resident #1 was admitted to the facility on [DATE], and readmitted on November16, 2011 after a five day hospital stay, with [DIAGNOSES REDACTED]. Medical record review of a Pharmacist Consultation Report dated December 7, 2011, revealed ""...consider initiating Calcium 600 mg (milligrams) with Vitamin D 400 Units twice daily..."" Continued medical record review revealed the recommendation was reviewed by the physician December 16, 2011, and the physician signed the order. Medical record review of the Medication Record dated January 1, 2012, through January 31, 2012, revealed the facility failed to implement the physician's order until January 5, 2012, resulting in nineteen missed doses of the Calcium 600 mg with Vitamin D 400 units. Interview on January 10, 2012, at 8:30 a.m., with the Assistant Director of Nursing (ADON) at the B-Wing Nurse's Station, confirmed the facility failed to implement the physician's order resulting in nineteen missed doses of the Calcium 600 mg with Vitamin D 400 units. Further Medical record review revealed an Interim Care Plan had not been completed with goals and interventions after admission and prior to the development of a comprehensive care plan. Interview on January 10, 2012, at 8:45 a.m., at B-Wing Nurses Station with the Assistant Director of Nursing (ADON), confirmed an Interim Care Plan had not been completed with goals and interventions prior to the devopment of a comprehensive care plan. Resident #6 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Pharmacist Consultation Report dated November 1, 2011, revealed ""...consider [MEDICATION NAME] (overactive bladder) 4 mg to 2 mg daily..."" Continued medical record review revealed the recommendation was reviewed by the physician November 10, 2011, and the physician signed the order. Medical record review of the Medication Record dated November 1, 2011, through November 30, 2011, revealed the facility failed to implement the physician's order until November 17, 2011, resulting in six doses of [MEDICATION NAME] 4 mg instead of two mg. Interview on January 11, 2012, at 9:00 a.m., with the Director of Nursing (DON), at the B-Wing Nurse's Station, confirmed the facility failed to implement the reduction in dosage until November 17, 2011. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Pharmacist Consultation Report dated June 13, 2011, revealed ""...consider increasing [MEDICATION NAME] (Anti-Alzheimer) to 10 mg each am and 5 mg each pm for one week, then twice daily..."" Continued medical record review revealed the recommendation was reviewed by the physician June 27, 2011, and the physician signed the order. Medical record review of the Medication Record dated June 1, 2011, through June 30, 2011, revealed the facility failed to implement the physician's order for increasing the Mamenda dosage until June 30, 2011, resulting in the administration of three doses of the wrong milligrams of the [MEDICATION NAME]. Interview on January 9, 2012, at 2:00 p.m., with the DON, in the DON office, confirmed the facility failed to implement the physician's order on June 27, 2011 until June 30, 2011 resulting in the administration of three doses of the wrong milligrams of the [MEDICATION NAME]. Resident #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Recapitulation Orders dated December 2011, revealed an order for [REDACTED]. Medical record review of the Intake form, dated December 2011, revealed the fluid intake had not been documented for the resident. Interview on January 12, 2012, at 8:50 a.m., with the DON at the B-Wing Nurse's Station, confirmed the fluid restriction had not been implemented for the resident and the facility failed to follow the Physician's orders. Reseident #1 was admitted to the facility November 11, 2011, and readmitted to the facility November 16, 2011, after a five day hospital stay. Medical record review revealed an interim care plan had not been developed prior to the development of a comprehensive care plan. Interview on January 10, 2012, at 8:45 a.m., at the B-Wing Nurse's Station with the ADON confirmed an interim care plan had not been completed . Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed no interim care plan had been completed with goals and interventions prior to the development of a comprehensive care plan. Interview on January 11, 2012, at 3:00 p.m., at the nursing station, with the Director of Nursing, confirmed a interim care plan had not been completed with goals and interventions after admission to the facility. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed no interim care plan completed with goals and interventions. Interview on January 12, 2012, at 9:55 a.m., at the B-Wing Nurses Station with the Director of Nursing, confirmed an interim care plan had not been completed prior to the comprehensive care plan being developed. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the facility failed to complete an interim care plan with measurable objectives on upon admit October 14, 2011, and a comprehensive care plan was not developed until November 1, 2011. Interview with the Minimum Data Set (MDS) Coordinator on January 11, 2012, at 7:20 a.m., in the MDS office confirmed the facility failed to complete an interim care plan for resident #3. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the facility failed to complete an interim care plan with measurable objectives after admit December 28, 2011, and prior to the development of a comprehensive care plan. Interview with the Minimum Data Set (MDS) Coordinator on January 11, 2012, at 7:20 a.m., in the MDS office confirmed the facility failed to complete an interim care plan for resident #15 prior to the development of a comprehensive care plan. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long term memory impairment and was independent with decision making. Continued medical record review of the Physician's Recapitulation Orders dated November 18, 2011, revealed, ""[MEDICATION NAME] Diskus (type of inhaler)...use 1(one) puff twice daily..."" Observation of Charge Nurse # 2 in the resident's room on January 10, 2012, at 4:50 p.m., revealed Charge Nurse #2 administered the [MEDICATION NAME] Diskus and failed to provide the resident with instructions to rinse the mouth after the inhaler dose was administered. Review of the manufactures instructions for [MEDICATION NAME] administration provided by the facility revealed, ""...After each dose, rinse your mouth with water and spit the water out. Do not swallow..."" Interview with the Director of Nursing (DON) on January 10, 2012, at 4:58 p.m., in the DON's office confirmed the facility failed to follow the manufactures recommendations for [MEDICATION NAME] administration.",2014-03-01
14185,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,157,D,,,VAMW11,"**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 change in the resident's condition for one (#1) of twenty-six residents reviewed. The findings included: Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assistance for all activities of daily living, and was moderately impaired for decision making. Medical record review of Nurse's Notes dated December 25, 2011, at 6:45 p.m., revealed ""...3 cm (centimeter) x 3 cm darkened area on R (right) heel...MD notified..."" Further medical record review revealed no documentation of family notification. Interview on January 10, 2012, at 3:15 p.m., with the Director of Nursing (DON), in the DON office confirmed the facility failed to notify the family of a change in condition.",2014-03-01
14186,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,441,E,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure infection control practices were maintained for five ( #7, #8, #3, #10, #16) residents of twenty-six residents reviewed. The finding included: Resident #7 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation with Charge Nurse #4 on January 9, 2012, at 9:20 a.m., revealed the resident lying on the bed. Continued observation revealed a nebulizer mask (aerosol treatment) lying on the bedside table uncovered. Interview with Charge Nurse #4 on January 9, 2012, at 9:20 a.m., in the resident's room, confirmed the nebulizer mask was to be placed in a bag when not in use. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation with Charge Nurse #5 on January 9, 2012, at 9:45 a.m., in the resident's room revealed the resident seated in a wheelchair. Continued observation revealed a nebulizer mask lying on the bedside table uncovered. Interview with Charge Nurse #5 on January 9, 2012, at 9:45 a.m., in the resident's room, confirmed the nebulizer mask was to be placed in a bag when not in use. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation in the resident's room on January 10, 2012, at 11:31 a.m., revealed Charge Nurse #1 obtained a lancet and stuck the finger of resident #3. Further observation revealed the Charge Nurse placed the finger with visible blood against a blood glucose strip, then placed the strip with visible blood on top of the roommate's overbed table. Interview with Charge Nurse #1 and the Assistant Director of Nursing on January 10, 2012, at 11:32 a.m., outside the resident's room confirmed the contaminated strip was placed on the roommate's overbed table and the table was not cleaned/disinfected until concern was expressed to the Charge Nurse. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on January 9, 2012, at 3:15 a.m., in the resident's room revealed staff preparing to place the resident in the bed. Continued observation revealed the staff picked up a falls mat which was lying on the floor next to the resident's bed. Continued observation revealed Certified Nurse Technician (CNT) #2 placed the falls mat onto the resident's bed, removed the mat and without changing the bed linens placed the resident on the bed. Interview on January 9, 2012, at 3:15 a.m., with CNT #2 outside the resident's room confirmed the unclean fall mat had been placed on the residents bed linens and the linens were not changed prior to assisting the resident into bed. Interview on January 9, 2012, at 4:00 p.m., with the Assistant Director of Nursing (ADON) at B-Wing Nurse's Station confirmed the facility failed to maintain infection control prevention measures. Resident #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on January 11, 2012, at 3:20 p.m., in the resident's room revealed the staff preparing to place the resident in bed. Continued observation revealed two clear plastic bags of soiled linen lying on the floor and Certified Nurse Technician (CNT) #1 picked up the clear plastic bags from the floor and layed the bags on the bed. Interview on January 11, 2012, at 3:20 p.m., with CNT #1 in the resident's room confirmed the plastic bags contained soiled linen and bags that had been placed on the floor and confirmed the bags were placed on the bed linens. Interview on January 12, 2012, at 8:50 a.m., with the Director of Nursing (DON) at the B-Wing Nurse's Station, confirmed the facility failed to maintain infection control prevention measures.",2014-03-01
14187,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,502,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain labs timely for three residents (#8, #3, #17) of twenty-six residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapitulation orders dated December 1, 2011, through December 31, 2011, revealed, ""...Hgb AIC (test to monitor blood sugar) every 3 months..."" Medical record review revealed the Hgb AIC was obtained on July 6, 2011, and December 30, 2011. Interview on January 10, 2012, at 9:10 a.m., in the Director of Nursing office, with the Assistant Director of Nursing, confirmed the Hgb AIC due in October was not completed until December. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]...2 (secondary) wound..."" Continued medical record review revealed the [MEDICATION NAME] was not ordered until December 29, 2011, (two day delay). Interview with the Assistant Director of Nursing and Charge Nurse #4 (the nurse responsible for taking the lab order) at the B wing nurse's desk on January 10, 2012, at 9:10 a.m., confirmed the lab was not obtained timely. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a pharmacy consultation report dated March 2, 2011, revealed, ""...please consider monitoring a [MEDICATION NAME] acid serum concentration..."" Continued review of the consultation report revealed the physician was not notified until March 17, 2011 (a fifteen day delay). Interview with the Assistant Director of Nursing on January 12, 2012, at 8:50 a.m., in the Director's office confirmed that the facility failed to ensure the lab was done timely.",2014-03-01
14188,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,278,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurate for three residents (#1, #6, and #10) of twenty-six residents reviewed. The findings included: Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had been coded ""...Formal assessment instrument...(Braden)...no Weight Loss... no ulcer care...Bowel Incontinence...Always incontinent..."" Medical record review revealed no Braden skin assessment had been completed with the readmission on November 16, 2011. Medical record review of the Treatment Record dated November 2011, revealed ""...Apply skin prep to R (right) heel daily until healed..."", with the treatment initialed and signed by the nurse for November 25, 2011. Medical record review of the Resident Weight Record revealed ""...11-17-11...(weight)126.8...11-23...(weight)120.2..."" and the weight loss had not been coded on the MDS. Medical record review of the Nursing Home Resident Care Record dated November 2011, revealed no incontinent episodes of bowel had been documented. Interview on January 10, 2012, with Assistant Director of Nursing (ADON), in the B-Wing Nurse's Station, at 2:00 p.m., confirmed the was incontinent of bowel, had weight loss and developed a pressure sore, and confirmed the MDS assessment was inaccurate. Resident #6 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had been coded ""... Urinary Continence...Always continent...Bowel Continence...Always Continent..."" Medical record review of the Nursing Home Resident Care Record dated November 1, 2011 through November 30, 2011 revealed the resident was incontinent of urine daily, and had four incontinent episodes of BM (bowel movement) on November 5, 6, 9, and 10th. Interview on January 11, 2012, with Director of Nursing (DON), in the B-Wing Nurse's Station, at 9:00 a.m., confirmed the resident was incontinent of urine and bowels and the facility failed to ensure the MDS assessment was inaccurate. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had not experienced any falls, since the prior MDS assessment dated [DATE]. Medical record review of a Progress Notes Listing dated June 11, 2011, revealed the resident fell on [DATE], at 8:55 a.m. Interview on January 10, 2012, with the Minimum Data Set (MDS) Coordinator, in the MDS office, at 2:15 p.m., confirmed the resident had a fall with no injury on June 11, 2011, and confirmed the MDS assessment was inaccurate.",2014-03-01
14189,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,164,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure privacy for three residents (#23, #3, #4) of twenty-six residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on January 12, 2012, at 10:40 a.m., revealed a volunteer entered the resident's room without knocking to provide ice to the resident. Interview on January 12, 2012, at 10:45 a.m., with the Director of Nursing (DON), in the DON's office, confirmed the volunteers are to knock prior to entering the resident's room. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation in the resident's room on January 10, 2012, at 11:12 a.m., revealed resident #3 sitting in the room in view of other residents and visitors. Continued observation at this time revealed Charge Nurse #1 completed a treatment to the resident and failed to close the door or pull privacy curtain. Interview with Charge Nurse #1 on January 10, 2012, at 11:15 a.m., confirmed privacy was not provided during the treatment. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation in the resident's room on January 10, 2012, at 8:03 a.m., revealed resident #4 sitting in the room in view of other residents and visitors. Continued observation at this time revealed Charge Nurse #1 retrieved a suction tube from behind the resident's bed and began suctioning the resident's mouth. Continued observation in the resident's room on January 10, 2012, at 8:26 a.m., revealed the Charge Nurse pulled the resident's feeding tube (tube used to administer medications and feedings) through the top of the resident's shirt, administered medications through the tube and failed to close the door or pull the privacy curtain. Interview with the Director of Nursing (DON) on January 10, 2012, at 9:48 a.m., confirmed that the facility failed to ensure privacy during the resident's care.",2014-03-01
14190,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,329,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to prevent the administration of an unneccessary drug for one resident (#6) of twenty-six residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a pharmacy consultation report dated November 1, 2011, and signed by the physician on November 10, 2011, revealed ""takes Tolterodine ([MEDICATION NAME])...4 mg (milligrams) daily...Recommendation: Please consider reducing Tolterodine to 2 mg daily...Physician's Response: I accept the recommendation(s) above, please implement as written..."" Medical record review of the Medication Record dated November 1, 2011, through November 30, 2011, revealed [MEDICATION NAME] LA 4 mg initialed as administered on November 10, 2011, through November 16, 2011. Interview on January 11, 2012, at 9:00 a.m., with the Director of Nursing (DON), in the DON's office confirmed the resident received 4 mg dosage instead of 2 mg dosage November 11-16, 2011, and confirmed an unnecessary higher dosage of the medication was administered.",2014-03-01
14191,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,314,G,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility Policy and Procedure review, observation and interview, the facility failed to prevent pressure sore development for two residents (#1, #3) resulting in harm to the residents, and failed to accurately assess and provide pressure sore treatment in a timely manner for one resident (#16) of twenty-six residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on November 16, 2011, after a five day hospital stay with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assistance for bed mobility and limited assistance for transfers. Medical record review of a Braden Risk scale (Predicts Pressure Sore Risk) dated November 11, 2011, revealed the resident was high risk for pressure sore development. Further medical record review revealed no documention a Braden Scale assessment had been completed for the readmission to the facility on [DATE]. Medical record review of the Nurse's Note dated November 16, 2011, revealed ""...skin intact..."" Medical record review of a Specialized Services dated November 16, 2011, revealed the resident was non-weight bearing for the left lower extremity. Medical record review of a Nurse's Note dated November 25, 2011, revealed ""...3 cm (centimeter) x (by) 3 cm darkened area on residents R (right) heel..."" Medical record review of a Physician's Order Sheet dated November 25, 2011, revealed ""...Apply skin prep to R heel daily until healed..."" Medical record review of a Nurse's Note dated December 2, 2011, revealed ""...order obtained for heel protectors and off loading (floating) of heels while in bed..."" Medical record review of the Physician's Order Sheet dated December 2, 2011, revealed ""...Heel protectors to be worn at all times (right heel)...off loading of heels while in bed, heel protector to be worn on left heel except for transfers and ambulating..."" Medical record review of the Care Plan dated December 4, 2011, revealed ""...at risk for skin breakdown...on admission evaluate skin risk with Braden Scale...perform full body skin assessment...inspect skin daily...consult Registered Dietician as needed..."" Medical record review of the Nutrition Note dated December 6, 2011, revealed ""...res (resident) wt (weight) down to 120# (pounds) from 127...pt (patient) with wound (unstageable) will initiate...(nutritional supplement) and stress tab (tablet) wt weekly..."" Medical record review of a Physician's Order Sheet dated December 6, 2011, revealed ""...Stress Tab daily...Ensure 80 ml (milliliters) four times a day...second to wound... weight loss...needs with wound healing..."" Medical record review of the Medication Record dated December 2011, revealed the first dose of the Stress Tab and Ensure was initialed as administered on December 7, 2011. Medical record review revealed the following Skin Assessment Forms: December 4, 2011, ""...R heel 3 X 3..."" December 23, 2011, ""...R heel hard black tx (treatment) continue..."" December 30, 2011, ""...R heel 7.5 X 3 cm..."" January 7, 2012, ""...R heel 2.25 X 2.75..."" January 12, 2012, ""...R heel 2.15 X 2.5..."" Review of a facility (untitled) policy and procedure , effective date August 2, 2001, revealed ""...patient who enters the facility without pressure sores does not develop pressure sores...skin assessment made according to wound protocol...Braden Risk scale will be performed on admission..."" Review of the facility's policy (undated) Skin and Wound Protocol revealed ""...notify physician of wound status changes...obtain physician order for [REDACTED]. Observation on January 9, 2012, at 2:15 p.m., on the B-Wing revealed the resident sitting in a wheel chair with no heel protectors in place. Observation on January 9, 2012, at 3:00 p.m., in the resident's room, revealed the resident lying on the bed and heel protectors were not in place and the heels were not floated. Observation on January 10, 2012, at 8:00 a.m., on B-Wing hallway, revealed the resident sitting in the wheel chair and no heel protectors in place. Observation on January 10, 2012, at 3:30 p.m., in the resident's room, revealed the resident lying on the bed without heel protectors in place and the heels not floated. Interview on January 11, 2012, at 8:30 a.m., with the Director of Nursing (DON), in the B-Wing Nurse's Station confirmed the resident was moderately impaired for decision making, and confirmed the Braden Scale was not completed upon readmission (November 16, 2011); the right heel pressure sore was not identified until November 25, 2011, and a physician's order was not obtained until December 2, 2011, for heel protectors on at all times to the right heel. The DON confirmed the facility policy did not specify the frequency for skin assessments and confirmed weekly skin assessments had not been consistently completed. Further interview with the DON confirmed the pressure sore was identified on November 25, 2011, and the Registered Dietician did not assess the resident's nutritional status for pressure sore healing until December 6, 2011, when an order was obtained for nutritional interventions to promote wound healing. The DON confirmed the pressure sore was avoidable and the physician's orders for heel protectors and floating of the heels had not been consistently implemented. Resident #3 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 severe cognitive impairment. Medical record review of a Braden Scale completed October 14, 2011, revealed the resident was high risk of developing a pressure sore. Review of the facility provided documentation (progress note) dated November 16, 2011, revealed ""...abrasion right heel/blue/purple...1.5 X (by) 1 cm (centimeter)...reddened area around the abrasion, area closed, had tennis shoes on with no socks...could have potentially caused abrasion..."" Medical record review of a Physician's Order Sheet dated December 5, 2011, revealed ""...skin prep (preparation) daily until healed...2.5 cm X 2.3 cm darkened area on R (right) heel..."" Review of the facility policy (undated) Skin and Wound Protocol revealed ""...notify physician of wound status...obtain order for treatment..."" Observation on January 9, 2012, at 9:40 a.m., revealed the resident was seated in a wheel chair and propelled self by sliding the feet in a back/forward motion on the floor to move self up and down the hallway outside of the resident's room. Interview and documentation review of a Nutritional Note dated December 27, 2011, with the ADON and the Registered Dietician (RD) on January 10, 2012, at 9:00 a.m. in the facility billing office confirmed there was no documentationthe RD was notified of the pressure sore (discovered on November 16, 2011) until December 27, 2011, at which time a Stress Tablet and a [MEDICATION NAME] level was recommended. Continued interview and review of the [MEDICATION NAME] level (ordered by the physician on December 29, 2011) results obtained on December 30, 2011, revealed the [MEDICATION NAME] results were 14.6 (low) ( range Low =18.0, High = 38). Observation with Charge Nurse #1 and the Assistant Director of Nursing (ADON) on January 10, 2012, at 11:12 a.m. in the resident's room revealed the resident had two dark areas on the right heel measuring 1 cm X .8 cm and .2 cm X .3 cm. Interview with the ADON on January 12, 2012, at 8:50 a.m., in thr Director's office confirmed the resident developed an avoidable pressure sore on the right heel; confirmed the facility failed to ensure socks were worn with shoes, and the resident used the feet to propel self in a wheel chair by sliding the feet on the floor. Continued interview confirmed the RD was not notified of the pressure sore until December 27, 2011. Resident #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was at risk for developing pressure ulcers; always incontinent of bladder and bowel, and required total dependence cleansing self after elimination. Observation with the Assistant Director of Nursing (ADON), on January 11, 2012, at 3:20 p.m., in the resident's room revealed the resident had a sore to the left Great toe with a black area to the inner aspect of the sore and the second toe had a red area, draining clear fluid, to the inner aspect of the toe. Interview with the ADON on January 11, 2012, at 3:30 p.m., in the resident's room confirmed the resident had developed sores and the ADON stated the Licensed Practical Nurse would complete a wound assessment and notify the physician for orders. Medical record review of a Nurse's Note dated January 11, 2012, at 4:00 p.m., revealed ""...checked all of residents wounds...left lower buttocks 1cm x .5 cm... "" and no documentation of an assessment of the toes. Medical record review of the Skin Assessment Form dated January 11, 2012, revealed ""Lt. (left) buttocks 1 cm X .5 cm area..."" and no documentation of an assessment of the sores on the left foot. Medical record review completed on January 12, 2012, at 8:20 a.m., of the January 2012, Treatment Record revealed no new orders/treatments for the sores on the resident's buttocks/toes identified on January 11, 2012. Observation with the Director of Nursing (DON) and the ADON, on January 12, 2012, at 8:45 a.m., in the shower room, revealed the resident had a stage two pressure sore to left buttocks measuring 1cm x .5 cm. Medical record review of a Physician's Order Sheet dated January 12, 2012, at 1:00 p.m., revealed ""...pt (patient) with new sores reported...great toe and buttocks...will continue to have breakdown periodically second to chronic medical problems..."" Review of an undated facility policy titled Skin and Wound Protocol revealed ""...notify physician of wound status changes...obtain physician order for [REDACTED]. Interview with the DON on January 12, 2012, at 8:50 a.m., at the B-Wing Nurse's Station, confirmed the resident had new areas of skin breakdown observed on January 11, 2012 and the skin assessment form completed January 11, 2012, did not include an assessment of the sores on the left toes. Further interview with the DON confirmed the physician was notified of the sores on January 11, 2012 and a treatment order was not obtained until January 12, 2012.",2014-03-01
14192,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,280,E,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to reviseupdate the Care Plans for five residents (#1, #3, #6, #10, and #16) of twenty-six residents reviewed. The findings included: Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurse's Note dated November 25, 2011, revealed ""...3 cm (centimeter) x (by) 3 cm darkened area on residents R (right) heel..."" Medical record review of the physician's orders [REDACTED]. Medical record review of a facility investigation report dated November 25, 2011, revealed ""...injury related...deep tissue related..."" Medical record review of the current Interdisciplinary Care Plan dated December 4, 2011, revealed the care plan had not been revised to reflect the resident's pressure ulcer. Interview with Assistant Director of Nursing (ADON) on January 10, 2012, at 8:45 a.m., at B-Wing Nurse's Station, confirmed the care plan had not been updated or revised to reflect the resident's pressure ulcer. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the resident's current care plan revealed no documentation to reflect the skin breakdown. Interview with the Minimum Data Set (MDS) Coordinator on January 11, 2012, at 7:20 a.m., in the MDS office confirmed the facility failed to update the care plan to reflect the skin breakdown. Resident #6 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Medication Record dated December 25, 2011, revealed ""...Glucerna at 45 ml/hr (milliliters/hour)...flush with 25 ml/hr...flush with free water...dc'd (discontuned).."" The Glucerna was administered per nasogastric tube. Medical record review of the physician's orders [REDACTED]. Medical record review of the current Interdisciplinary Care Plan last reviewed on November 14, 2011, revealed the care plan had not been revised to reflect the discontinuation of the nasogastric tube or the Hohn catheter. Interview with Director of Nursing (DON) on January 11, 2012, at 9:00 a.m., at B-Wing Nurse's Station, confirmed the nasogastric tube/tube feeding and the Hohn catheter had been discontinued and the care plan had not been updated/revised. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician Recapitulation orders dated January 2012, revealed ""...clean left hand with wound cleanser...allevyn dressing [MEDICATION NAME] (antibiotic) ointment...to palm..."" Further medical record review revealed the resident had been scheduled for hand surgery January 10, 2012. Medical record review of the current Interdisciplinary Care Plan last reviewed on October 24, 2011, revealed the care plan had not been revised to reflect the resident's treatment to left hand and the scheduled hand surgery. Interview with Director of Nursing (DON) on January 11, 2012, at 9:00 a.m., at B-Wing Nurse's Station, confirmed the care plan had not been updated or revised to reflect the resident's treatment to the left hand and the scheduled hand surgery. Resident #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Skin Assessment form dated January 11, 2012, revealed ""...left heel 1 cm (centimeter) x .5cm...right heel .2cm round black area...left buttocks .5 cm area..."" Medical record review of a facility investigation report dated January 10, 2012, revealed the resident had a fall on January 10, 2012. Medical record review of a Physician's Recapitulation Orders dated December 2011, revealed an order for [REDACTED]. Medical record review of the current Interdisciplinary Care Plan last reviewed on October 31, 2011, revealed the care plan had not been updated or revised to reflect the resident's pressure sore development, fall status, and fluid restrictions. Interview with MDS Coordinator on January 11, 2012, at 4:00 p.m., in the Care Plan Office, confirmed the care plan had not been updated or revised to reflect the resident's skin breakdown, fall status, and fluid restriction.",2014-03-01
14193,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,428,E,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to notify the physician timely of pharmacy consultant reports for four residents (#17, #1, #6, #10) of twenty-six residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a pharmacy consultation report dated March 2, 2011, revealed, "" ...please consider monitoring a valproic acid serum concentration..."" Continued review of the consultation report revealed the physician was not notified of the consultant pharmacist recommendation until March 17, 2011 (a fifteen day delay). Interview with the Assistant Director of Nursing (ADON) on January 12, 2012, at 8:50 a.m., in the Director's office confirmed that the facility failed to notify the physician of the pharmacy consultant recommendations in a timely manner. Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Pharmacist Consultation Report dated December 7, 2011, revealed ""...consider initiating Calcium 600 mg (milligram) with vitamin D 400 Units twice daily..."" Continued medical record review revealed the recommendation was accepted by the physician December 16, 2011, (nine days later). Interview on January 10, 2012, at 8:30 a.m., with the ADON, at the B-Wing Nurse's Station, confirmed the facility failed to notify the physician of the pharmacist recommendations for the Calcium 600 mg with Vitamin D 400 units in a timely manner. Resident #6 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Pharmacist Consultation Report dated November 1, 2011, revealed ""...consider reducing...Detrol (overactive bladder) 4 mg to 2 mg daily..."" Continued medical record review revealed the recommendation was accepted by the physician November 10, 2011 (nine days later). Interview on January 11, 2012, at 9:00 a.m., with the Director of Nursing (DON) at the B-Wing Nurse's Station, confirmed the facility failed to notify the physician of the pharmacist recommendations for dose reduction for the Detrol in a timely manner. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Pharmacist Consultation Report dated June 13, 2011, revealed ""...consider increasing Namenda (Anti-Alzheimer) to 10 mg each am and 5 mg each pm for one week, then twice daily..."" Continued medical record review revealed the recommendation was accepted by the physician June 27, 2011 (two weeks later). Interview on January 9, 2012, at 2:00 p.m., with the DON, in the DON office, confirmed the facility failed to notify the physician of the pharmacist recommendations for increasing the dose of the Namenda in a timely manner.",2014-03-01
14194,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,315,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement an individualized bladder training program for one resident (#6) of twenty-six residents reviewed. The findings included: Resident #6 was readmitted to the facility after a hospital stay on October 25, 2011, with [DIAGNOSES REDACTED]. Medical record review of the Nursing Home Resident Care Record dated October 1, 2011, through October 14, 2011, revealed prior to hospital stay the resident was continent of urine daily. Medical record review of the Nursing Home Resident Care Record dated October 25, 2011, through October 31, 2011, (after return from hospital) revealed the resident was incontinent of urine daily. Interview on January 11, 2012, at 9:00 a.m., with the Director of Nursing, at B-Wing Nurse's Station, confirmed a bladder assessment had been completed after the resident had returned from the hospital stay and confirmed a bladder training program had not been implemented to restore/improve bladder continence.",2014-03-01
14195,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,323,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one resident (#10) and failed to implement a intervention for one resident (#16) after a non-injury fall. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assistance for transfers, and had not experienced a fall since the last assessment. Medical record review of a Screen for Fall Risk dated May 18, 2011, revealed resident was high risk for falls. Medical record review of a Nurse's Note dated June 11, 2011, revealed ""...in floor in front of W/C (wheelchair)... "" Medical record review of a facility investigation report dated June 11, 2011, at 8:55 p.m., revealed ""...lying in floor...clip alarm pulled off shirt...not activated... "" Medical record review of a Progress Note Listing dated June 11, 2011, at 8:55 p.m., revealed ""...clip alarm had detached...not activating the alarm...intervention...pressure pad alarm placed on W/C... "" Medical record review of the Interdisciplinary Care Plan dated May 31, 2011, and last reviewed October 24, 2011, revealed ""...at risk for falls...clip alarm in wheel chair... "" Observation on January 9, 2012, revealed the resident in the wheel chair with a clip alarm in place and no pressure pad alarm on the wheel chair. Interview on January 10, 2012, at 9:10 a.m., with the Director of Nursing (DON) at the A-Wing Nurse's Station confirmed the pressure pad alarm was not on the wheel chair. Resident #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent for transfers, did not ambulate, and had not experienced a fall since the last assessment. Medical record review of a Nurse's Note dated January 10, 2012, revealed ""...resident to ER (emergency room ) fell out of chair... "" Medical record review of a facility investigation report dated January 10, 2012, at 10:20 a.m., revealed ""...witnessed fall... "" Medical record review of the Interdisciplinary Care Plan revealed no updates since resident fell on [DATE]. Interview on January 11, 2012, at 4:25 p.m., with the DON at the B-Wing Nurse's Station confirmed no new intervention to prevent further falls from the wheel chair had been implemented since the fall from the wheel chair on January 10, 2012.",2014-03-01
14196,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,309,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide the necessay care/services for two residents (#16 and #23) receiving [MEDICAL TREATMENT] Services. The findings included: Resident #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review of the resident's medical record on January 11, 2012, at 3:30 p.m., revealed no monitoring of the resident'd [MEDICAL TREATMENT]/vital signs after the resident's return from [MEDICAL TREATMENT]. Observation on January 11, 2012, at 3:20 p.m., in the resident's room revealed the resident lying on the bed and the resident had returned from outpatient [MEDICAL TREATMENT]. Interview on January 11, 2012, at 3:30 p.m., with Charge Nurse #6 at the B-Wing Nurse's Station, confirmed the resident returned from outpatient [MEDICAL TREATMENT] at 9:00 a.m., and the resident's [MEDICAL TREATMENT] catheter had not been assessed for bleeding, infection or the resident's vital signs had not been monitored. Resident #23 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Interview on January 12, 2012, at 8:50 a.m., with the Director of Nursing (DON) at the B-Wing Nurse's Station confirmed the resident received [MEDICAL TREATMENT] services on a out patient basis on Monday, Tuesday, and Wednesday and the facility did not have an order for [REDACTED]. Interview on January 12, 2012, at 10:30 a.m., with the Nursing Home Administrator in the Conference Room confirmed the facility failed to have a contract with the outside entity providing [MEDICAL TREATMENT] Services.",2014-03-01
14197,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,176,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assure one resident (#4) was assessed for self administration of drugs prior to the resident self administering medications of twenty-six residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Physician's recapitulation orders signed December 15, 2011, revealed, "" [MEDICATION NAME] 4 (four) [MEDICATION NAME] 4 [MEDICATION NAME] times [MEDICATION NAME]...6 (six) times daily..."" Observation of resident #4 in the resident's room on January 10, 2012, at 8:05 a.m., revealed Charge Nurse #1 placed medications in a nebulizer mask, placed the nebulizer mask around the resident's mouth and turned the nebulizer machine on. Continued observation at 8:24 a.m., revealed the Charge Nurse left the resident's room while the medications were being administered. Interview with the Director of Nursing (DON) in the Director's office, on January 10, 2012, at 9:48 a.m., confirmed the resident was not a candidate for self administration and had not been assessed for self administration of medications via (by way of) nebulizer.",2014-03-01
14198,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,221,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for the use of a restraint for one resident (#11) of twenty-six residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation and interview with Charge Nurse #2 on January 10, 2012, at 4:28 p.m., in the B wing hallway, revealed resident #11 sitting in a wheelchair with a soft release belt (restraint) in place. Continued interview at this time revealed the resident could not self release the belt upon request. Interview with the Director of Nursing (DON) in the Director's office on January 11, 2012, at 9:02 a.m., confirmed the resident was unable to remove the self release belt and had not been assessed for the use of the restraint.",2014-03-01
14199,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,241,D,,,VAMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to promote care that maintained or enhanced dignity during a medication administration pass for one resident (#4) of twenty-six residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation in the resident's room on January 10, 2012, at 7:49 a.m., revealed Charge Nurse #1 preparing to administer medications to resident #4. Continued observation revealed Charge Nurse #1 entered and exited the resident's room at 8:03 a.m., 8:21 a.m., 8:24 a.m., 8:26 a.m., 8:37 a.m., and 8:44 a.m. without knocking on the resident's door prior to entering. Interview with the Director of Nursing (DON) in the Director's office, on January 10, 2012, at 9:48 a.m., confirmed the facility failed to maintain or enhance dignity during medication administration for resident #4.",2014-03-01
14200,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,431,E,,,VAMW11,"Based on observation and interview, the facility failed to ensure safe and secure storage of controlled substances in one of two medication storage areas. The findings included: Observation and interview with Charge Nurse #3 in the A wing medication room on January 11, 2012, at 8:45 a.m., revealed no refrigerator in the medication room. Continued interview at this time revealed the drug refrigerator is kept just outside the medication room not behind a locked door. Observation revealed a small refrigerator with a lock located just outside the medication room containing ten morphine 2 mg (milligram) per one ml (milliliter) carpuject syringes, ten Lorazepam 2 mg per one ml carpujects and one 2 mg per one milliliter vial of Lorazepam. Interview with the Director of Nursing in the Director's office on January 11, 2012, at 9:06 a.m., confirmed the facility failed to provide safe and secure storage of controlled medications on the A wing.",2014-03-01
14201,MCMINN MEMORIAL NURSING HOME & REHAB CENTER,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2012-01-12,371,F,,,VAMW11,"Based on observation and interview, the facility failed to maintain proper sanitation for food preparation equipment, safe food temperatures, and safe storage of refrigerated and dry foods in the dietary department. The findings included: Observation and interview on January 9, 2012, at 9:20 a.m., with the Dietary Manager in the dietary department, revealed Dietary Aide #1 wore no hair net; a five gallon clear plastic container labeled gravy bowls was placed on the unclean floor surface. Observation of the walk-in cooler entrance revealed water was present on the floor and a black substance covered three-fourths of the kick plate. Observation in the cooler revealed a quarter pan (per Dietary Manager) contained a five pound bag of carrots one-fourth full with no date when opened, six ounce bag of radishes in a plastic bag not sealed with no date when opened, five pound bag of coleslaw one-fourth full with expiration date 1-1-12, on a shelf three pieces of French toast with no date when opened, five pound container of pimento spread with an the expiration date 1-3-12. Observation on a storage self revealed a five pound container of tuna salad with an expiration date 12-18-11, one gallon of ranch dressing one-fourth full with an expiration date 7-29-11, and two brown cardboard boxes containing six cartons of frozen eggs stored in a full pan which contained a yellow and brown liquid in bottom of pan. Interview with the Dietary Manager at the time of the observations confirmed all employees are required to wear hair nets; items are not to be stored on the floor, the cooler floor was dirty, and undated/outdated food items were available for resident use. Observation on January 9, 2012, at 9:40 a.m., with the Dietary Manager in the dietary department, revealed twelve hoagie buns with visible mold on the buns stored on a bread rack shelf; a quarter pan on a shelf next to bread rack contained the following items: one 3 ounce package (1/2 full) of ranch dry mix; one fourteen ounce plastic bag (1/2 full) of organic quinoa (rice) 5 ounce package (1/4 full) with no expiration date or date opened. Interview at this time with the Dietary Manager confirmed the items were available for resident use and were not stored properly. Observation on January 9, 2012, at 9:50 a.m., with the Dietary Manager in the walk in freezer, revealed the temperature was nine degrees below zero and the door to the walk-in freezer did not close properly; ice build-up was on the floor of the freezer; six chicken patties stored in an opened/undated plastic bag; five pound bag of green peas stored in an opened/undated plastic bag; two pounds of diced potatoes in an opened/undated brown bag and a two pound bag of frozen french fries stored in an opened/undated brown bag. Interview at this time confirmed the items were available for resident use and were not stored properly. Observation on January 9, 2012, at 10:15 a.m., with the Dietary manager in the dry storage pantry, revealed twenty-nine .85 ounce packets of Juven (dietary supplement) with the expiration date 1-1-12. Interview at this time confirmed the items were outdated and were available for resident use. Observation on January 9, 2012, at 10:20 a.m., with the Dietary Manager in the dietary department, revealed two dry storage bins labeled flour and sugar with two full pans of uncovered cookies stored on top of the storage bins which was located two inches from a twenty-five gallon gray trash can with the lid three-fourths opened. Interview at this time confirmed the items were not stored in a sanitary manner. Observation on January 10, 2012, at 11:20 a.m., with the Dietary Manager in the dietary department, revealed black debris on the rack and sides of the toaster and Dietary Aide #2 turned the toaster on for use. Interview at this time confirmed the toaster was unclean. Observation of food temperatures on January 10, 2012, at 11:30 a.m., with the Dietary Manager, in the dietary department, revealed the temperature of the coleslaw was forty seven degrees. Interview at this time confirmed the safe temperature required is forty-one degrees, and confirmed six trays containing one serving each of coleslaw had been served for resident consumption prior to the observation of the unsafe food temperature of forty-seven degrees. Observation with the Dietary Manager on January 10, 2012, at 12:00 p.m., in a hallway outside the dietary department, revealed Dietary Aide #2 exited the dietary department wearing gloves then re-entered the dietry department immediately wearing the gloves and did not remove the gloves or wash the hands and prior to preparing food. Interview at this time with the Dietary Manager confirmed the Dietary Aid failed to remove the gloves and wash the hands upon re-entry into the dietary department and prepared food wearing the gloves.",2014-03-01
14202,ERWIN HEALTH CARE CENTER,445291,100 STALLING LANE,ERWIN,TN,37650,2010-06-03,323,D,,,3MB811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were in place for two residents (#10, #17) of twenty-five residents reviewed. The findings included: Resident #10 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems with moderately impaired cognitive skills and required extensive assistance with all activities of daily living. Medical record review revealed the resident had a history of [REDACTED]. Medical record review revealed the resident was assessed at being at risk of falls and on February 1, 2010, a physician's orders [REDACTED]."" Observation in the resident's room on June 1, 2010, at 2:45 p.m., revealed the resident sitting in a chair. Observation revealed the pull alarm was in place on the chair but was not attached to the resident. Observation and interview with Certified Nursing Assistant (CNA) #1, at the time of the observation, confirmed the resident did not have the pull alarm attached to the resident. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory deficits, moderately impaired cognitive skills, and had not experienced any falls in the past 180 days. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the Care Plan dated December 23, 2009, revealed the resident had a history of [REDACTED]. Medical record review of the nursing notes dated December 28, 2009, at 7:00 p.m., revealed ""Resident noted in floor on buttocks in front of w/c (wheelchair), an approx. (approximately) 1 inch laceration noted to (R) (right) outer elbow..."" Review of facility documentation revealed the safety alarm was not in place at the time of the resident's fall on December 28, 2009. Observation on June 2, 2010, at 2:00 p.m., revealed the resident lying on a bed, in the lowest position, with a safety alarm in place. Interview on June 3, 2010, at 10:30 a.m., with the Director of Nursing (DON), in the DON's office, confirmed the safety alarm was not in place at the time of the fall on December 28, 2009.",2014-03-01
14203,ERWIN HEALTH CARE CENTER,445291,100 STALLING LANE,ERWIN,TN,37650,2010-06-03,278,D,,,3MB811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two residents (#1, #17) of twenty-five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had not experienced any falls in the past 180 days. Medical record review of the nursing notes revealed the resident experienced a fall from a chair on March 6, 2010. Interview on June 3, 2010, at 11:10 a.m., with the Director of Nursing (DON), at the nursing station, confirmed the MDS dated [DATE], was not accurate, and did not reflect the resident's fall on March 6, 2010. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Sets dated March 10, 2010, and April 7, 2010, revealed the resident had not experienced any falls in the past 180 days. Medical record review of the nursing notes revealed the resident experienced falls on the following dates: December 28, 2009, January 11, 2010, and March 29, 2010. Interview on June 3, 2010, at 10:30 a.m., with the DON, in the DON's office, confirmed the Minimum Data Sets dated March 10, 2010, and April 7, 2010, were not accurate, and did not reflect the resident's falls on December 28, 2009, January 11, 2010, and March 29, 2010.",2014-03-01
14204,ERWIN HEALTH CARE CENTER,445291,100 STALLING LANE,ERWIN,TN,37650,2010-06-03,279,D,,,3MB811,"**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 fall risk for one resident (#14) of twenty-five residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Fall Risk Assessment completed February 19, 2010, and February 26, 2010, revealed, ""...February 19, 2010, fall risk score of 10...February 26, 2010, fall risk score of 12..."" Continued review of the Fall Risk Assessment revealed, ""...total score of 10 or above represents HIGH RISK..."" Interview with the Director of Nursing (DON) on June 3, 2010, at 9:25 a.m., confirmed the resident was a fall risk and the care plan did not address the fall risk.",2014-03-01
14205,ERWIN HEALTH CARE CENTER,445291,100 STALLING LANE,ERWIN,TN,37650,2010-06-03,514,D,,,3MB811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure the medical record was accurate for one resident (#21) of twenty-five residents reviewed. The findings included: Medical record review of the monthly recapitulation physician orders' dated January 2010 through June 2010, revealed the resident was to receive [MEDICATION NAME] (antidepressant). Medical record review of a Auto Substitution Notice Medication Change Order dated January 12, 2010 revealed, discontinue [MEDICATION NAME] and replace with [MEDICATION NAME]. Medical record review of medication records [REDACTED]. Interview with the Director of Nursing (DON) in the Director's office on June 2, 2010, at 10:20 a.m., confirmed the resident had received [MEDICATION NAME] in place of the [MEDICATION NAME] per the Auto Substitution Policy since February 6, 2010, and the monthly recapitulation physician orders [REDACTED].",2014-03-01
14206,ERWIN HEALTH CARE CENTER,445291,100 STALLING LANE,ERWIN,TN,37650,2010-06-03,166,E,,,3MB811,"Based on review of the Resident Council Minutes and interviews, the facility failed to resolve grievances in a timely manner for five months of nine months reviewed. The findings included: Review of the Resident Council Minutes dated September 30, 2009, November 30, 2009, December 29, 2009, January 29, 2010, and May 26, 2010, revealed the residents would like more fruits offered for bedtime snacks. Interview with the Resident Council on June 2, 2010, at 10:00 a.m., in the dining room, revealed three of seven residents voiced grievances of fruits not being offered with bedtime snacks after multiple requests. Interview on June 3, 2010, at 9:00 a.m., with the Director of Dietary Services in the conference room, revealed the Director was unaware of the residents' requests for more fruit as requested in the past Resident Council Meetings. Continued interview with the Director of Dietary Services confirmed the facility had failed to resolve resident grievances in a timely manner.",2014-03-01
14207,NORRIS HEALTH AND REHABILITATION CENTER,445303,3382 ANDERSONVILLE HIGHWAY,ANDERSONVILLE,TN,37705,2010-06-03,281,D,,,0W9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to administer medications and obtain weights as ordered by the physician for one (#16) of twenty-one residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. (sodium) ([MEDICATION NAME]) (a respiratory medication) 10mg po (by mouth) (at) bedtime [MEDICATION NAME] (an [MEDICATION NAME] medication) 75 mcg (micrograms)...Q (every) 3 days...QD (daily) wt (weight)..."" Medical record review of the Medication Record dated May 13, 2010, through May 31, 2010, revealed no documentation the [MEDICATION NAME] and the Montelukast Sodium was administered. Medical record review of the Medication Record dated May 13, 2010, through May 31, 2010, revealed the Montelukast Sodium circled as not being administered on May 17, 2010. Medical record review of the Nurse's Medication Notes (back of the Medication Record) revealed, "" ...5-17-10...Montelukast awaiting delivery..."" Review of the pharmacy invoices revealed the Montelukast Sodium was delivered to the facility on [DATE] and was available to be administered on May 17, 2010. Medical record review of the Vital sign and Weight Flow Record revealed no documentation weights were obtained on May 14, 15, 16 and 17, 2010. Interview on June 2, 2010, at 1:15 p.m., with the Director of Nursing, in the Administrator's office, confirmed no documentation the [MEDICATION NAME] and Montelukast Sodium were administered as ordered. Interview on June 3, 2010, at 1:50 p.m., in the nursing office, with the Director of Nursing, confirmed the weights had not been obtained as ordered by the physician. c/o #",2014-03-01
14208,NORRIS HEALTH AND REHABILITATION CENTER,445303,3382 ANDERSONVILLE HIGHWAY,ANDERSONVILLE,TN,37705,2010-06-03,425,D,,,0W9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy records, and interview, the facility failed to ensure medications were available to meet the needs for one (#16) of twenty-one residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review of the Medication Record dated May 13, 2010, through May 31, 2010, revealed no documentation the Fentanyl Citrate patch was administered. Review of the pharmacy shipment record revealed the Fentanyl patch was filled on May 18, 2010. Review of the pharmacy delivery record revealed the Fentanyl patch was delivered on May 19, 2010, the day after the resident was discharged . Interview on June 3, 2010, at 9:00 a.m., with the Director of Nursing, in the Administrator's office, confirmed the facility failed to ensure medications were available to meet the needs of the resident. c/o #",2014-03-01
14209,NORRIS HEALTH AND REHABILITATION CENTER,445303,3382 ANDERSONVILLE HIGHWAY,ANDERSONVILLE,TN,37705,2010-06-03,254,D,,,0W9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a continuous supply of washcloths for one resident (# 19) of twenty-one residents reviewed. The findings included: Resident # 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview with the resident during the survey group meeting, on June 2, 2010, at 9:30 a.m., in the dining room, revealed the resident complained of not having a continuous supply of wash cloths available for bathing. Observation of four of four available linen carts, on June 2, 2010, at 1:10 p.m., revealed signs posted on the linen carts ""...For Staffing Only..."" and one cart containing three washcloths. Interview on June 2, 2010, at 1:15 p.m., with the Supervisor of Environmental Services, at the Nurse's Station, revealed twelve clean washcloths were available for residents to use and the remainder of washcloths were in the dryer. On June 1, 2010 when the survey began, the facility census was 86 residents. Interview on June 2, 2010, at 1:28 p.m., with the Administrator, in the Director of Nursing office, confirmed the facility has a dwindling supply of washcloths and has a shortage of washcloths available for the residents.",2014-03-01
14210,NORRIS HEALTH AND REHABILITATION CENTER,445303,3382 ANDERSONVILLE HIGHWAY,ANDERSONVILLE,TN,37705,2010-06-03,323,D,,,0W9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one resident (#14) of twenty-one residents reviewed. The findings include: Resident #14 was admitted to the facility April 5, 2010 with [DIAGNOSES REDACTED]. Medical Record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory impairment, moderately impaired cognitive skills for daily decision making, an unsteady gait, and required limited assistance for transfers and ambulation. Review if the Fall Risk Assessment, dated April 5, 2010, revealed the resident was at moderate risk for falls. Medical record review of the Care Plan, revealed planned interventions to a provide chair alarm and a wander guard to the resident. Observation during initial tour, at 9:00 a.m., June 1, 2010, revealed the resident was sitting in the room, in the wheelchair, the chair alarm device on the back of the chair without the clip attached to the resident. Interview with the Regional Nurse at 10:25 a.m., June 3, 2010, confirmed the clip was not attached to the resident.",2014-03-01
14211,NORRIS HEALTH AND REHABILITATION CENTER,445303,3382 ANDERSONVILLE HIGHWAY,ANDERSONVILLE,TN,37705,2010-06-03,221,D,,,0W9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a wrist restraint was applied for a medical reason for one (# 13) of twenty-one residents reviewed. The findings included: Resident # 13 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 impairment; severely impaired cognitive skills for daily decision making; and required total assistance with transfers. Medical record review of the care plan dated June 25, 2009, revealed ""...Care Plan...Restraints...Cerebral Palsey with spastic quadraparesis-movements that are spontaneous with no safety awareness. Frequent non-controlled pelvic thrusting that could lead to falls and OOB (out of bed) injuries and [DEVICE] (gastric tube) complications..."" Further review revealed the care plan was updated on February 23, 2010, ""...Restraints remain appropriate-Cont. (continue) POC (plan of care)..."" Medical record review of a physician's orders [REDACTED]. Check Q (every) 30 min (minutes), Release Q 2 hrs (hours)..."" Observations on June 1, 2010, at 8:35 a.m. and June 2, 2010, at 3:36 p.m., in the resident's room, revealed the resident lying in bed with a soft wrist restraint applied to the right wrist and tied to the right side of the bed frame; full-length, padded, bilateral siderails in up position; and a scoop mattress on the resident's bed. Continued observation revealed the resident had flexion at the elbow of the right arm. Interview on June 3, 2010, at 1:10 p.m., with Nurse Practitioner, in the Administrator's office, revealed ""...still want (resident) to have mobility of the shoulder..."", ""...I wish (resident) wasn't restrained...the family wants it...we go over this every year..."", ""...has not pulled the peg tube in five years that I've known (resident)..."". Interview on June 3, 2010, at 2:00 p.m., with the Administrator, in the Administrator's office, confirmed the resident has not attempted to pull out the peg tube; and the restraint was not indicated to prevent the resident from pulling out the peg tube but rather to accommodate the family's wishes.",2014-03-01
14212,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,332,E,,,IMX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of manufacturer's specifications, facility policy review, and interview, the facility failed to prevent medication errors less than five percent resulting in five errors within forty-one opportunities to equal an error rate of twelve percent. The findings included: Observation on May 19, 2010, at 7:40 a.m., at the East Wing medication Cart, revealed Licensed Practical Nurse (LPN) #1 administered one dose of Calcium 500 milligram (mg) with Vitamin D 200 International Units (IU) tablet by mouth to Resident #31. Medical record review of the April, 2010, Recap (Recapitulation orders-monthly cumulative list of current medication and treatment orders) orders, signed and dated by the physician on March 31, 2010, revealed ""Calcium + D TABS, 600MG TWICE A DAY"". Interview with LPN #1 on May 19, 2010, at 9:30 a.m., at the East Wing Cart confirmed the resident received 500 mg of Calcium instead of the ordered 600 mg. Observation on May 19, 2010, at 7:49 a.m., at the East Wing medication cart, revealed LPN #1 administered one dose of Calcium 500 mg with Vitamin D 200 IU tablet by mouth to Resident #1. Medical record review of the April, 2010, Physician Recap orders, signed and dated by the physician on March 31, 2010, revealed ""Calcium + D 600 MG TABLET TWICE A DAY"". Interview with LPN #1 on May 19, 2010, at 9:35 a.m., at the East Wing medication cart confirmed the resident received the wrong dosage of calcium. Observation on May 19, 2010, at 9:45 a.m., at the Secure Wing medication cart, revealed LPN #2 crushed one Aspirin (ASA) [MEDICATION NAME] Coated (EC) 81 mg tablet and placed the crushed tablet in one heaping teaspoonful of applesauce. Continued observation revealed LPN #2 entered the room of resident #32 and was stopped by the surveyor who requested LPN #2 to return to the medication cart to clarify crushing the [MEDICATION NAME] coating of the Aspirin and the physician's order. Medical record review of the April, 2010, Physician Recap orders, signed and dated by the physician on March 31, 2010, revealed, ""ASPIRIN 81 MG TAB (TABLET) EC DAILY"". Review of the manufacturer's specifications on the label of the ASA EC 81 mg bottle revealed ""...swallow whole, do not chew or crush."" Interview with LPN #2 on May 19, 2010, at 9:52 a.m., at the Secure Wing medication cart confirmed the LPN had crushed the medication and intended to administer the medication to the resident if the surveyor had not intervened. Observation on May 19, 2010, at 1:35 p.m., at the West Wing medication Cart #2, revealed LPN #3 administered one dose of [MEDICATION NAME] Sodium ([MEDICATION NAME]) Delayed Release 125 mg tablet by mouth to resident #33. Further observation revealed resident #33 could not swallow the tablet and expelled the tablet into LPN #3's hand. Medical record review of the May, 2010, Physician Recap orders, signed and dated by the physician on May 16, 2010, revealed ""[MEDICATION NAME] 125 MG SPRINKLE CAP (CAPSULE) THREE TIMES A DAY."" Interview with LPN #3 on May 19, 2010, at 3:00 p.m., at the West Wing Nursing station, confirmed a medication error occurred when the tablet form of [MEDICATION NAME] was administered instead of the sprinkle capsule which ""could have been opened and administered (to resident #33) in applesauce and been easier to swallow."" Observation on May 19, 2010, at 4:00 p.m., at the New Wing medication cart #1, revealed LPN #4 administered one 20 milliliter (ml) dose of [MEDICATION NAME] 10 mg with [MEDICATION NAME] 666 mg via (by way of) Percutaneous Endoscopic Gastrostomy) (PEG) tube to resident #4. Medical record review of the May, 2010, Physician Recap orders, signed and dated by the physician on May 12, 2010, revealed ""[MEDICATION NAME] 10MG EVERY 4 HOURS VIA PEG TUBE."" Interview with the Assistant Director of Nursing (ADON) and the Consultant Pharmacist on May 19, 2010, at 4:10 p.m., at the New Wing Nursing station, confirmed the facility failed to administer the medication as ordered. Review of the facility policy titled, Policies for Medication Administration revealed, ""...3. Check Medication Administration Record (MAR). 4. Read each order entirely 5. Remove medication from drawer. Read label three times: a. When removing from drawer. b. Before pouring. c. After pouring. 6. If there is any discrepancy between the MAR and the label, check physician orders before administering medication...8...c. Crush medication only after checking with the pharmacy and/or supervisor since the medication may be time-release capsules or [MEDICATION NAME]-coated drugs.""",2014-03-01
14213,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,431,D,,,IMX711,"Based on observation, review of facility policy, and interview, the facility failed to dispose of out of date medications on two (East Wing Treatment Cart and West Wing Treatment Cart) of 10 medication carts observed. The findings included: Observation on May 19, 2010, at 8:25 a.m., at the East Wing Treatment Cart, revealed an opened bottle of Povidone Iodine Solution (antiseptic) 16 ounces, with approximately 15 ounces remaining, with the expiration date of March 2009, and an opened bottle of Povidone Iodine Solution 16 ounces, with approximately 1 ounce remaining, with the expiration date of October 2008. Observation on May 19, 2010, at 8:50 a.m., at the West Wing Treatment Cart, revealed an opened one-half full ointment jar of Dr. Zirkle's Compound Ointment (topical mixture containing antibiotics and steroids) with an expiration date of August 23, 2009, and an opened, full ointment jar of Dr. Zirkle's Compound Ointment with an expiration date of March 25, 2010. Review of the facility policy, 5.4 Disposal of Medications, revealed, ""...PROCEDURES...4...c. A non-controlled medication disposition log or form shall be used for documentation and shall be retained as per federal privacy and state regulations...7. Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy."" Interview with the Assistant Director of Nursing (ADON) on May 19, 2010, at 8:30 a.m., at the East Wing Treatment Cart, confirmed the two bottles of Povidone Iodine Solution were outdated and ""Expired medications had not been removed from the medication cart."" Interview with the ADON on May 19, 2010, at 8:55 a.m., at the West Wing Treatment Cart, confirmed the two opened ointment jars containing Dr. Zirkle's Compound were outdated and ""Expired medications had not been removed from the medication cart.""",2014-03-01
14214,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,157,D,,,IMX711,"**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 dietary recommendation for one (#2) of thirty-three sampled residents. The findings included: Resident # 2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had moderately impaired cognitive skills with long and short term memory problems and required assistance with all activities of daily living. Medical record review of the Nutritional Progress Notes dated April 5, 2010, revealed the resident had experienced a nine percent weight loss in the past three months. Further review revealed the resident's current weight was 119.2 lbs. (pounds) with ideal body weight range 117-143. The resident was currently on fortified foods and Med Pass (dietary supplement) 2.0, 60 cc (cubic centimeter) four times daily. A dietary recommendation was made for ""[MEDICATION NAME] (appetite stimulate) 15 cc's TID (three times daily)."" Medical record review revealed no documentation the physician was notified of the dietary intervention. Review of the MARs (Medication Administration Record) for April 2010, and May 2010, revealed no documentation the resident received the medication. Interview with the Director of Nursing (DON) on May 20, 2010, at 10:00 a.m., in the DON's office confirmed the resident's weight for May 2010, was 118 (loss of one pound) and the physician had not been notified of the dietary recommendation dated April 5, 2010, for [MEDICATION NAME].",2014-03-01
14215,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,322,D,,,IMX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to take appropriate action in the treatment of [REDACTED]. The findings included: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was dependant on staff for activities of daily living. Medical record review of the Physician Recapitulation Orders dated May 2010, revealed an order for [REDACTED]."" Observation on May 19, 2010, at 8:01 a.m., revealed two Restorative Certified Nursing Assistants (RCNA #1 AND RCNA #2) in the resident's room with the lift scales. Continued observation revealed the resident lying flat supine without a pillow under the head. Continued observation revealed the feeding pump was running continuously at 60cc per hour. Continued observation revealed RCNA#1 rolled the resident to the left and tucked the sling under the resident. Continued observation revealed RCNA #2 rolled the resident onto the right side and unrolled the lift under the resident. RCNA #1 obtained the mechanical lift and positioned it under the bed, secured the sling to the hooks, and manually lifted the resident to obtain the weight. Continued observation revealed RCNA #1 lowered the resident to the bed; rolled the resident to the left; tucked the sling under the resident; RCNA #2 rolled the resident to the right; removed the sling from under the resident, and rolled the resident onto the back. Continued observation revealed RCNA #1 removed the mechanical lift scales from under the bed, pulled the linens onto the resident and raised the head of the bed to 45 degrees. Review of the facility policy revealed the policy did not address the issue of weights being obtained while residents were receiving feeding per Gastrostomy tube with the restriction of lying flat. Interview with the RCNA #1 and #2 in the room at 8:10 a.m., revealed, ""We weigh (the resident) every week...is on weekly weights...have to lay (the resident) flat...do it this way every time...no we do not turn off the feeding pump..."" Interview with the New Wing Unit Manager on May 19, 2010, at 8:25 a.m., at the nurses' station, confirmed the facility failed to take the appropriate treatment during the procedure of weighing the resident with the tube feeding running continuously and the resident lying flat.",2014-03-01
14216,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,281,D,,,IMX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow the physician's order for obtaining weights for one (#16); for the administration of [MEDICATION NAME] for one (#17); and for the placement of foot rests / calf support for one (#18) of thirty-three residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's order dated March 23, 2010, revealed ""...weight twice a week and report > (greater than) 3 (pound) gain..."" Medical record review of the resident's weight record revealed the only weight documented for the month of March was dated March 30, 2010, with the weight documented as 241.6 lbs (pounds). Continued review revealed the resident was not weighed 2x (times) a week as ordered and the following weights were recorded: April 7, 2010, 232.6 lbs; April 21, 2010, 246.2 lbs. Interview with Unit Charge Nurse #1 on May 20, 2010 at the 300 hall Nurse's station at 11:00 a.m., confirmed the resident readmitted to the facility on [DATE], and no weight was obtained until March 30, 2010 (7 days later). Further interview confirmed the resident was not weighed twice a week as ordered from March 23, 2010, through April 23, 2010. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had moderately impaired cognitive skills with long and short term memory problems, and required assistance with all activities of daily living. Medical record review revealed a psych (psychiatric) consult was obtained on April 16, 2010, due to the resident's constant yelling and [MEDICAL CONDITION]. Medical record review of the psych consult revealed a recommendation was made for [MEDICATION NAME] (antipsychotic) ER (extended release) 25 mg. (milligrams) at bedtime. Medical record review revealed a physician's order dated April 18, 2010, for [MEDICATION NAME] ER 25 mg. at bedtime. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the May 2010, MARs revealed the resident began receiving the medication on May 1, 2010. Observation on May 20, 2010, revealed the resident sitting quietly in a wheelchair in the hallway. Interview with the Assistant Director of Nursing at the 200 Hall nursing station on May 20, 2010, at 10:30 a.m., confirmed the resident did not receive the medication as ordered in April 2010. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nurse's Notes dated March 14, 2010, revealed the bilateral lower extremities had 3+ [MEDICAL CONDITION] and redness noted. Medical record review of the Physician's Telephone Orders dated March 29, 2010, revealed an order including ""Foot rest with calf support."" Observation on May 19, 2010, at 3:00 p.m., revealed the resident sitting in a high-back wheelchair in the hallway interacting with another resident. Observation revealed the resident was using the feet to continuously rock back and forth. Observation in the dining room on May 20, 2010, at 7:43 a.m., revealed the resident wearing white compression hose, the feet on the floor, rocking back and forth. Interview with certified nursing assistant (CNA #7) in the dining room on May 20, 2010, at 8:30 a.m., confirmed the resident did not have foot rest / calf support on the wheelchair. Interview with Licensed Practical Nurse (LPN #8) on the secure unit on May 20, 2010, at 8:35 a.m., confirmed the facility failed to follow the physician's order.",2014-03-01
14217,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,327,E,,,IMX711,"**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 monitor fluid restrictions for five residents (#19, #1, #15, #21, #16) of thirty-three residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory impairment and modified cognitive skills for daily decision making. Medical record review of the Care Plan dated July 23, 2009, revealed the resident receives [MEDICAL TREATMENT] and has a fluid restriction of 50 oz (ounces) (1500 milliliters) a day. Medical record review of a physician's orders [REDACTED]. Medical record review of the facility's Projected Allocation of Fluids revealed, ""...7-3 Shift...Breakfast 240 cc...Lunch 240 cc...Medication(s) 120 cc...Free Fluids 120 cc...3-11 Shift...Dinner 240 cc...Medication(s) 90 cc...Free Fluids 120 cc...11-7 Shift...90 cc...Free Fluids 240 cc..."" (a total daily fluid intake of 1500 cc). Review of the resident's tray card revealed the resident is to receive Nepro 8 ounces (240 cc) with each meal and no other fluids to be served with meals to the resident. Observation on May 20, 2010, at 12:55 p.m., in the dining room, revealed the resident eating lunch and drinking a Nepro (240 cc), a Diet Mountain Dew (355 cc), and a carton of Milk (240 cc) (a total of 595 cc over the lunch fluid restriction). Interview on May 20, 2010, at 12:55 p.m., in the dining room, with the 300 Hall Unit Manager #1, confirmed the resident was served over the lunch fluid restriction amount and the facility had failed to maintain documentation of monitoring the resident's intake and fluid restriction. Resident #1was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]...1 (0ne) Liter / 24 (every 24 hours)..."" Interview and documentation review of intake / output records with Unit Manager # 2 on May 18, 2010, at 3:20 p.m., revealed, incomplete documentation of the intake / output records from March 1, 2010, through May 18, 2010, (a total of seventy-nine days). Resident # 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Interview and documentation review on May 19, 2010, at 4:20 p.m.,at the 200 Hall nurses's desk revealed, the facility did not have any documentation to reflect monitoring of the fluid restriction. Interview with the Administrator and Director of Nursing, in the conference room on May 20, 2010, at 9:45 a.m., confirmed the facility failed to monitor fluid restrictions and the facility policy did not reflect complete monitoring of fluid restrictions. Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission orders ...Fluid restriction 1-2 liters a day. Avoid water, ice..."" Medical record review of the Initial Nutritional assessment dated [DATE], revealed, ""...Fluids likely impact wt (weight) [MEDICATION NAME] 40mg (milligrams) (diuretic) prn (as needed)...is on 1-2 liter fluid restriction/(per) day..."" Medical record review of the Physician Recapitulation Orders dated May 2010, revealed, ""...Clarification: Fluid restriction of 1.2 Liters/day..."" Medical record review of the facility's Fluid Restriction Alert (no date) with Projected Allocation of Fluids revealed, ""...Amount of Fluid Restriction 1500cc (cubic centimeters)...7-3 Shift...Breakfast 600cc...Lunch 240cc...Medication(s) 120cc...(Projected Shift Total 960cc)...3-11 Shift...Dinner 240cc...Medication(s) 120cc...(Projected Shift Total 360cc)...11-7 Shift...Medication(s) 120cc...Free Fluids 60cc...(Projected Shift Total 180cc)..."" Interview with the Administrator and Director of Nursing, in the conference room on May 20, 2010, at 9:45 a.m., confirmed the facility failed to monitor fluid restrictions and the facility policy did not reflect complete monitoring of fluid restrictions. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was re- admitted to the facility from the hospital on March 23, 2010. Medical record review of the physician's orders [REDACTED]. Medical record review revealed no documented monitoring of the fluid restriction. Interview with the Administrator and Director of Nursing, in the conference room on May 20, 2010, at 9:45 a.m., confirmed the facility failed to monitor fluid restrictions.",2014-03-01
14218,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,312,D,,,IMX711,"**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 for one resident (#6) of thirty-three residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short-term memory problems, moderately impaired cognitive skills for daily decision making, and required extensive assistance for personal hygiene and bathing. Medical record review of the care plan dated February 24, 2010, revealed, ""...Resident requires assistance with...bathing, grooming...1-2 assist with...grooming, hygiene needs..."" Observation on May 18, 2010, at 10:20 a.m., in the resident's room, revealed the resident lying on the bed with both hands exposed. Further observation revealed the resident's fingernails on both hands extended approximately ? inch beyond the finger tips and had a build-up of a dark brown substance under the fingernails and around the cuticles. Observation on May 19, 2010, at 8:45 a.m., in the resident's room, revealed the resident lying on the bed. Continued observation revealed the resident's fingernails on both hands extended approximately ? inch beyond the finger tips and had a build-up of a dark brown substance under the fingernails and around the cuticles. Interview on May 18, 2010, at 10:25 a.m., in the resident's room, with LPN #3, confirmed the resident's fingernails needed to be cleaned and trimmed.",2014-03-01
14219,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,280,D,,,IMX711,"**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 fluid restrictions for one resident (#1) of thirty-three residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]...1 (0ne) Liter / 24 (every 24 hours)..."" Interview with Unit Manager #2 and Minimum Data Set (MDS) coordinators #1, #2 in the MDS office, on May 18, 2010, at 3:15 a.m., confirmed the resident was on a one liter fluid restriction and the care plan did not address the one liter fluid restriction.",2014-03-01
14220,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,325,D,,,IMX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to indentify a significant weight loss in a timely manner for one resident (#24) of thirty-three residents reviewed. The findings included: Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's weight record revealed on November 14, 2009, the resident weighed 130.8 lbs (pounds). Medical record review of a nurse's note dated November 28, 2009, revealed the resident was admitted to the local hospital with Pneumonia, and was readmitted to the facility on [DATE]. Medical record review of a Hospital Discharge Summary dated December 16, 2009, revealed ""...failed to thrive ..."" Medical record review revealed the next recorded weight dated December 23, 2009, (7 days after readmission to the facility with 18 day hospital stay) was 105 lbs. Medical record review of the Dietary Manager note dated December 17, 2009, revealed ""...continue diet ...monitor weight weekly x4. Medical record review of the Registered Dietician note dated December 29, 2009, (after 18 day hospital stay) revealed ""RTN (return) weight 105lbs (decrease) 25 lbs from last month...intake (approximately) 38%...rec (recommend) MVI/Min(multi-vitamin with minerals), 2.0 Med Pass (dietary supplement)..."" Medical record review of the residnet's weight record dated December 30, 2009, revealed a weight of 99.8 lbs (5.2 lbs loss). Interview with the Dietary Manager on May 19, 2010, at 3:10 p.m. in the conference room, confirmed on return from the hospital on December 16, 2009, the resident's diet was continued with puree fortified foods, large portions of protein at lunch and dinner 8oz (ounces) of glucerna (nutritional supplement) at meals. In addition the resident was also on [MEDICATION NAME] to increase appetite. Interview with the Director of Nursing on May 20, 2010, at 9:00 a.m., in the Director of Nursing office, confirmed on re-admission to the facility on [DATE], (after a 18 day hospital stay) the hospital discharge summary reported the resident failed to thrive, and there was no documented weight until December 23, 2009 (7 day delay). Continued interview confirmed on December 23, 2009, the recorded weight of 105 lbs was noted representing a 25.8 lb weight loss, (7 days after retrun from 18 day hospital stay) and the Registered Dietician did not review the resident until December 29, 2009, (13 days after return from hospital and 6 days after 25.8 lb weight loss was noted. C/O #",2014-03-01
14221,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,514,D,,,IMX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to maintain an accurate medical record for one resident (#24) of thirty-three residents reviewed. The findings included: Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nurse's note dated November 28, 2009, revealed the resident was admitted to the local hospital with Pneumonia and was readmitted to the facility on [DATE]. Medical record review of the weekly skin assessment signed and dated December 2, 2009, revealed skin intact and dry. Medical record review of the skin assessment signed and dated December 14, 2009, revealed skin intact. Interview with the Director of Nursing on May 20, 2010, at 9:00 a.m., in the Director of Nursing office confirmed the resident was not in the facility on the above signed and dated skin assessments and the clinical record was not accurate.",2014-03-01
14222,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2010-05-20,371,F,,,IMX711,"Based on observation, review of manufacturer's specifications, and interview, the facility failed to ensure the kitchen dishwasher maintained the required water temperatures for sanitization. The findings included: Observation on May 18, 2010, at 10:05 a.m., in the facility kitchen, revealed wash cycle water temperatures of 119 and 110 degrees F (Farenheit), and a rinse cycle water temperature of 116 degrees F. Continued observation on May 18, 2010, at 1:30 p.m., revealed a rinse cycle temperature of 118 degrees F. Continued observation on May 19, 2010, at 2:45 p.m., revealed wash cycle water temperatures of 110, 118, and 114 degrees F. Review of the manufacturer's specification for minimum water temperatures for the dishwasher revealed the wash and rinse minimum temperature as 120 degrees F and the recommended water temperature for wash and rinse as 140 degrees F. Interview with Certified Dietary Manager #1 on May 18, 2010, at 10:10 a.m., 1:30 p.m., and on May 19, 2010, at 3:00 p.m., in the kitchen, confirmed the dishwasher water temperature failed to meet the manufacturer's minimum recommended temperature. Interview with the Administrator on May 20, 2010, at 10:35 a.m., in the conference room confirmed awareness with maintaining the minimum recommended dishwasher water temperature.",2014-03-01
14223,FAYETTEVILLE HEALTH AND REHABILITATION CENTER,445320,4081 THORNTON TAYLOR PARKWAY,FAYETTEVILLE,TN,37334,2009-07-08,312,E,,,MV1911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint Investigation for TN 291 Based on policy review, medical record review, observations and interview, it was determined the facility failed to ensure staff provided assistance with Activities of Daily Living (ADLs) for toileting, incontinence care or repositioning for 5 of 18 (Residents #2, 6, 9, 10 and 19) sampled residents observed. The findings included: 1. Review of the facility's ""Skin Care & (and) Pressure Ulcer Management Program"" policy documented, ""Residents face many challenges because both urine and feces contain substances that may irritate the epidermis and may make the skin more susceptible to break down. Prolonged exposure to urine and feces may cause irritation or maceration (softening of the skin), which can then hasten skin breakdown. In fact, some studies have found that fecal incontinence may pose the greater threat to skin integrity, most likely due to bile acids and enzymes in the feces. Moisture, on the other hand, may make skin more susceptible to damage from friction and sheer during repositioning ...A pressure ulcer often presents as a localized area of [DIAGNOSES REDACTED] (skin discoloration) where the urine or stool has come in contact with the skin ...If incontinence is a concern, then look for specific products and other key tactics you can use when moisture is a risk factor, such as: Checking to see if the resident is incontinent every two hours ...Nursing assistants play a key role in preventing pressure ulcers. Because they work so closely with residents, nursing assistants are most often in a position to identify the development of a pressure ulcer at an early stage. A quick acting nursing assistant can make a difference in a resident's condition by documenting and communicating new skin issues to the charge nurse immediately, so that treatment can begin as soon as possible..."" 2. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most current Minimum Data Set ((MDS) dated [DATE] documented the resident needed extensive to total assistance with personal hygiene. During an interview in Resident #2's room on 7/6/09 at 11:50 AM, Resident #2's roommate (Random Resident (RR) #20) stated, ""They (facility staff) mistreat him (Resident #2). They get him up in a chair that goes back (reclines) and expect him to stay that way all day..."" Observations in Resident #2's room on 7/7/09 at 8:00 PM, revealed Certified Nursing Assistants (CNA #8 and 9) assisted Resident #2 to his bed. On Resident #2's left and right buttocks area were half dollar size blanchable areas. 3. Medical record review for Resident #6 documented an admitted 11/27/03 with [DIAGNOSES REDACTED]. Review of the most current Minimum Data Set ((MDS) dated [DATE] documented Resident #6 needed total assistance with personal hygiene. Observations in Resident #6's room on 7/7/09 at 8:00 AM, revealed Resident #6 lying in bed. CNA #2 turned Resident #6 on her left side and held her over, exposing the resident's buttocks and back. Resident #6's buttocks were dark burgundy red in color with an open area approximately half the size of a dime on her right buttock. The dark burgundy redness covered Resident #6's buttocks and approximately 3 inches up her back. During an interview in Resident #6's room on 7/7/09 at 8:00 AM, CNA #2 stated, ""Her bottom is red now and then. She scratches it (buttocks) until it bleeds..."" During an interview in Resident #6's room on 7/8/09 at 8:25 AM, the Hospice CNA stated, ""I come in three times a week to pretty her up..."" The surveyor asked in what condition did she usually find Resident #6 and was the resident ever found lying in urine or feces. The Hospice CNA stated, ""I find her soaking wet all the time. I've reported it...She's (Resident #6) has been broke down for a long time. I've reported that too, but it does no good so I come in and just do what I can for her...The Chaplain asked me one time did I notice her mouth it looked like bees had made a nest in her mouth...It's awful..."" During an interview in the solarium, on 7/8/09 at 11:20 AM, the Hospice nurse stated, ""...I talked to ...(Resident #6's regular Case Manager) and she said she finds her in a mess every time... with dried brown circle on her pad... I did look at her today they had cream on it (Resident #6's bottom). It (Resident #6's bottom) was worse than I've ever seen ..."" 4. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Progress Notes (IPN) dated 8/27/08 documented ""...New onset Stage II (pressure sore) to coccyx..."" Review of the Care Plan initiated 12/26/08 documented ""...Potential for complications R/T (related to) Incontinence of Bowels and Bladder...Incontinent Care as needed... "" The IPN dated 1/9/09 documented ""...wound continues, foley catheter for wound healing..."" Review of the Care Plan dated 1/16/09 documented ""Potential for complications R/T Stage II wound to sacrum... Provide/assist c (with) proper peri (perineal) care... Monitor for pain and tx (treat) as ordered... "" Review of a Pain Evaluation dated 1/21/09 documented ""...REASON FOR EVALUATION...New onset of pain...Pressure ulcer (date and stage) 1/21/09 Stage III...3. CAREGIVER OBSERVATIONS OF COGNITIVELY IMPAIRED... Body Pattern...Immobile... Facial Expression... Tense... Vocalization...Sighing... 4. PAIN...TYPE...E (E = External)...A (A = Acute)... FREQUENCY...F (F = Frequent)... 5. ONSET AND DURATION...Daily...while lying on bottom or being turned or cleaned...9. PAIN EVALUATION...Acute Pain..."" Review of the Care Plan dated 2/6/09 documented ""...Incontinence related to: Bowel incontinence... Monitor Skin for redness...Provide skin care after incontinence episodes..."" Review of the quarterly MDS dated [DATE] documented the resident is totally dependent for all ADLs, is incontinent of bowel, and has an indwelling Foley catheter. Observations during the initial tour in Resident #9's room on 7/6/09 at 12:08 PM, revealed Resident #9 lying on her back on an air mattress with a Foley catheter draining to a bedside bag. There was a strong foul fecal odor present. Observations in Resident #9's room on 7/6/09 at 3:45 PM, 5:32 PM, and 8:05 PM, on 7/7/09 at 7:15 AM, and 10:30 AM, and on 7/8/09 at 7:48 AM, revealed Resident #9 lying in bed on her back with a Foley catheter draining to a bedside bag. Observations of Resident #9's room on 7/8/09 at 7:48 AM, revealed the resident was in bed on her back with the Foley catheter draining to a bedside drain bag. Continuous observations on 7/8/09 from 7:48 AM until 10:00 AM, revealed Resident #9 remained on her back and was not repositioned or checked for incontinence care needs. Observations in Resident #9's room on 7/8/09 beginning at 2:05 PM, revealed Nurse #5 performed a dressing change to the Stage 3 wound on Resident #9's coccyx. Resident #9 was oozing stool during the entire treatment, and was not provided with incontinent care until after the dressing change was completed. 5. Medical record review for Resident #10 documented an admitted 9/8/04 with [DIAGNOSES REDACTED]. During the resident group interview on 7/6/09 beginning at 4:00 PM, Resident #10 stated, ""I am sitting on hot coals..."" Resident #10 explained the staff would get him up and leave him up and he felt as if he was sitting on hot coals. During an interview requested by Resident #10 in Resident #10's room on 7/7/09 at 3:45 PM until 4:00 PM, Resident #10 asked and stated, ""Have you seen those pictures?"" The surveyor asked him which pictures. He stated, ""My wife sent in pictures of my bottom...It's raw meat ...They leave me up from six (6 AM) until six (6 PM)... No, they don't put me to bed...I had a nurse tell me, once you are up you are up...I wanted to go to bed and felt like I was sitting on hot coals. They wouldn't (put him to bed) so I tried to get out (of the facility)... after that (the resident's attempted elopement), they tried to get rid of me..."" The surveyor asked if she could observe his skin on his bottom. Resident #10 stated, ""I wished you would...I wish all of the surveyors would come look."" Observations in the Resident #10's room on 7/7/09 at 4:05 PM until 4:35 PM, revealed CNA #5 and #6 transferred Resident #10 from his motorized wheelchair (w/c) to his bed. They removed his diaper and sweat pants. When they rolled him to his right side, Resident #10's left and right buttocks were burgundy red with several open areas. The burgundy redness measured approximately eight inches by twelve inches on each buttock extending up to the sacral area, down into his groin area and the backs of his thighs. He had indentations on the back of his thighs where there were wrinkles in the cushions on the w/c air. While observing Resident #10's buttocks, he began having loose stool. CNA #5 began wiping him to clean his rectal area and buttocks. The resident grimaced and moaned when CNA #5 cleaned him. During an interview in Resident #10's room on 7/7/09 at 4:35 PM, the surveyor asked if the resident is changed during the day or goes to bed during the day. CNA #6 stated, ""We usually check him when we get him to bed after supper unless he tells us he needs changing..."" 6. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 6/3/09 documented ""...TURN AND REPOSITON (reposition) AT LEAST Q2HRS (every 2 hours) AND PRN (as needed)..."" A telephone order dated 6/24/09 documented ""...Cleanse (L) (left) heel c (with) wound cleanser & (and) pat dry. Apply skin prep q (every) shift & prn FOR PRESSURE RELIEF AND COMFORT..."" A nurse's note dated 6/24/09 documented ""...6A-6P (6:00 AM to 6:00 PM shift)....Tech's (CNAs) instructed to feed res. (resident) q meal...6P N.O. (new order) to cleanse (L) heel c wound cleanser & pat dry. Apply skin prep q shift & prn..."" Review of an IDT note dated 6/26/09 documented ""...Potential for skin breakdown..."" Review of a physician's telephone order dated 6/29/09 documented ""...May have air mattress..."" Review of the Care Plan dated 7/7/09 documented ""...POTENTIAL CONCERN WITH INCONTINENCE TO BOWEL AND BLADDER RELATED TO MULTIPLE DISEASE PROCESSES...CHECK AND CHANGE PADS/BRIEFS EVERY 2 HOURS AND AS NEEDED...PROVIDE GOOD PERICARE...MONITOR FOR...SKIN BREAKDOWN...POTENTIAL CONCERN Rt heel noted c small area of breakdown..."" Review of the significant change MDS dated [DATE] documented the resident is totally dependent for all ADLs, and is incontinent of bowel and bladder. A nurse's noted dated 7/9/09 documented ""...Rt (right) heel noted to have a small area of breakdown..."" and was signed by the Regional Director of Clinical Services. Observations during tour in Resident #19's room on 7/6/09 at 12:00 Noon, revealed Resident #19 lying on a bolstered air mattress. Observations in Resident #19's room on 7/7/09 at 5:18 PM, revealed the resident lying on an air mattress. There was a strong urine odor present. Continuous observations of Resident #19's room beginning on 7/8/09 at 7:35 AM revealed the following: a. 7:35 AM, the resident lying on an air mattress with a very strong urine odor present. Resident #19 was feeding herself a biscuit from her breakfast tray on the overbed table with no assistance from staff. CNA #10 entered the room and emptied the bedside commode of the B-bed resident (Random Resident (RR) #15). The urine odor remained after the bedside commode had been emptied. b. 8:00 AM, Nurse #2 entered the room and administered medications to RR #15. c. 9:15 AM, Nurse #8 (Regional Nurse Consultant) stopped at the door and spoke to RR #15. d. 9:20 AM, CNA #5 entered and removed Resident #19's breakfast tray, then lowered the head of the bed, and turned out the lights. e. 9:30 AM, CNA #10 entered and made the bed of RR #15. f. 9:40 AM, Resident #19 remained in bed with her eyes closed and the strong urine odor present. g. 9:55 AM, CNA #11 entered and filled the water pitchers of both residents with ice and water. Observations and interview in Resident #19's room on 7/8/09 at 9:57 AM, the Hospice CNA entered Resident #19's room to give the resident a bath. The Hospice CNA was asked how often she comes to care for Resident #19. The Hospice CNA stated, ""...three time a week...Monday, Wednesday, and Friday..."" When the Hospice CNA was gathering supplies to bathe the resident she could not find any soap in the resident's room. The Hospice CNA stated, ""...I don't know why she (Resident #19) don't have any (soap)...she never does..."" The Hospice CNA then left to get bath soap for the resident and came back into the room and stated, ""...No soap, (for Resident #19)...They told me to use this stuff (indicated the antibacterial soap dispenser over the sink)...can't use this (antibacterial soap) on her..."" The Hospice CNA then asked RR #15 if she could use some of her personal soap. RR #15 stated that the Hospice CNA could use her personal soap and shampoo. When the Hospice CNA loosed the incontinent briefs to wash the perineal area, the brief was very wet and smelled strongly of urine. The Hospice CNA was asked if the brief was wet. The Hospice CNA stated, ""...Wet as a pickle...see the ring (indicated a yellow ring on the incontinent pad under the resident)..."" There was a large yellowed circle on the incontinent pad underneath the resident's bottom. The Hospice CNA was asked if the circle on the pad was dry. The Hospice CNA stated, ""Yeah."" The Hospice CNA was asked if she finds the resident like that often. The Hospice CNA stated, ""...Am I supposed to tell you... Yeah, for here it is (normal)... I just do what I can..."" Resident #19 also had a small amount of feces smeared on the brief she had been wearing. When the Hospice CNA washed Resident #19's feet, she showed the resident's feet to the surveyor. Resident #19 had a reddened area approximately 4 centimeters on the inside of the right heel. The Hospice CNA stated, ""...that one's (right heel) real bad...I can feel the heat on it..."" The area was mushy and non-blanchable. During an interview in Resident #19's room with RR #15 (Resident #19's roommate and identified by the facility as alert and oriented and interviewable) on 7/8/09 at 10:05 AM, RR #15 was asked if anyone had been into the room to turn or change Resident #19. RR #15 stated, ""...No...came in about 11:00 (prior evening), then I didn't see anybody since then..."" RR #15 was then asked if Resident #19 could use the call light, and RR #15 stated, ""...Not here lately, I have to do it for her..."" 7. During an interview in the Administrator's office on 7/8/09 at 9:00 PM, Nurse #7 (Regional Director of Clinical Operations) was informed of the concerns with resident's skin conditions. Nurse #7 stated, ""...Oh, we definitely know it's a problem...that's why we no longer have a DON (Director of Nurses)... ADON (Assistant Director of Nurses) was over it (skin program)... (ADON) no longer here...We know it's (skin problem) an issue..."" The facility failed to ensure staff provided assistance with ADLs for toileting, incontinence care or repositioning for Residents #2, 6, 9, 10 and 19 as noted above.",2014-03-01
14224,"BRIDGE AT SOUTH PITTSBURG, THE",445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2010-01-13,332,D,,,ZTTU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to administer four of forty medications without error for two (#26, #27) of six residents observed, resulting in a ten percent medication error rate. The findings included: Medical record review of resident #26's physician's orders [REDACTED]. Observation on January 14, 2010, 7:10 a.m., in the resident's room, revealed Licensed Practical Nurse (LPN) #1 administered two [MEDICATION NAME] coated (coating to dissolve in the small intestine and is non-chewable) Aspirin 81 mg; one Calcium 500 mg (no vitamin D); and one Multivitamin with minerals. Review of the physician's orders [REDACTED]. [REDACTED]. Medical record review of resident #27's physician's orders [REDACTED]. Observation on January 14, 2010, 7:50 a.m., in the resident's room, revealed LPN #1 administered one [MEDICATION NAME] coated Aspirin 81 mg. Medical record review of the physician's orders [REDACTED]. [REDACTED].",2014-03-01
14225,"BRIDGE AT SOUTH PITTSBURG, THE",445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2010-01-13,312,D,,,ZTTU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nail care for one resident (#2) of twenty seven reviewed residents. The findings included: Resident # 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Minimum Data Set, dated dated dated [DATE], revealed the resident was totally dependent on staff for hygiene including nail care. Medical record review of the Nursing Assistant Care Plan currently in use revealed nail care checked as being provided by the nursing assistant. Observation of the resident's finger nails on January 11, 2010, at 10:00 a.m.; January 12, 2010, at 1:00 p.m.; and January 13, 2010, at 9:00 a.m., revealed the fingernails long, and soiled with brown debris. Interview with the Director of Nursing at the resident's bedside and at the 200 Hall nursing station, on January 13, 2010, at 9:10 a.m., confirmed the resident's finger nails were long, soiled with brown debris and required trimming and cleaning.",2014-03-01
14226,"BRIDGE AT SOUTH PITTSBURG, THE",445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2010-01-13,252,D,,,ZTTU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide a homelike environment for one resident (#16) of twenty-seven residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, had difficulty making self understood, and required assistance with all activities of daily living. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) dated December 4, 2009, revealed the resident has adequate vision and hearing; makes noises and communicates some needs non-verbally; and requires sensory stimulation. Observation on January 11, 2010, at 9:30 a.m., and January 12, 2010, at 3:00 p.m., of the resident's room revealed no personal items, ie: pictures, television, radio, magazines etc. Interview on January 12, 2010, at 4:00 p.m., in the conference room, with the Director of Nurses confirmed the resident did not have any personal items in the room, and the room was not homelike.",2014-03-01
14227,"BRIDGE AT SOUTH PITTSBURG, THE",445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2010-01-13,248,D,,,ZTTU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide activities of interest for one resident (#16) of twenty-seven residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident's activity interests were music and watching television. Medical record review of the MDS dated [DATE], revealed the resident had impaired short and long term memory, had difficulty making self understood, and required assistance with all activities of daily living. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) dated December 4, 2009, revealed the resident has ""...adequate vision and hearing...makes noises and communicates some needs non-verbally...requires sensory stimulation..."" Observation on January 11, 2010, at 9:30 a.m., and January 12, 2010, at 3:00 p.m., of the resident's room revealed no personal items, ie: pictures, television, radio, magazines etc. Interview on January 12, 2010, at 4:30 p.m., with the activity assistant in the busy bee activity room revealed the resident did not like crowds, did not come to the activity room very often, and had not been assessed for like or dislikes for sensory toys, stuffed animals, simple puzzles, or other sensory items.",2014-03-01
14228,"BRIDGE AT SOUTH PITTSBURG, THE",445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2010-01-13,241,D,,,ZTTU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide dignity for one resident (#16) of twenty-seven residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, had difficulty making self understood, and required assistance with all activities of daily living. Observation on January 12, 2010, at 3:00 p.m., of the resident ambulating in the hallway revealed the resident's pants fell down exposing the buttocks. Observation continued to the therapy room where the pants fell to the resident's feet, exposing the perianal area, and several residents of the opposite sex laughed. Interview on January 12, 2010, at 3:15 p.m., with the Registered Nurse for Staff Development (present when the pants fell down) in the therapy room, confirmed dignity was not provided for the resident.",2014-03-01
14229,"BRIDGE AT SOUTH PITTSBURG, THE",445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2010-01-13,250,D,,,ZTTU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide social services to maintain the psychosocial well-being for one resident (#16) of twenty-seven residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, had difficulty making self understood, and required assistance with all activities of daily living. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) dated December 4, 2009, revealed the resident has adequate vision and hearing; makes noises and communicates some needs non-verbally; and requires sensory stimulation. Observation on January 11, 2010, at 9:30 a.m., of the resident's room revealed no personal items, such as pictures, books, magazines, toys, television, or radio. Observation and interview on January 12, 2010, at 3:15 p.m., in the resident's room with Certified Nurse Assistant (CNA) #1 revealed several old pairs of pants and shirts in the closet. Interview with the CNA revealed the clothing had been obtained from discharged residents that had donated clothing and did not fit this resident. Review of the resident's Ledger Card revealed the resident had over $500.00 in the resident's trust fund account. Interview with the Social Worker (SW) on January 12, 2010, at 4:10 p.m., in the conference room, confirmed the resident on admission to the facility had arrived with no personal items, and had no family to bring or purchase personal items including clothing. Interview revealed the SW was aware the resident did not have personal items in the room or clothing that fit adequately, and the resident had over $500.00 in the trust account. Continued interview with the SW revealed the resident was on a waiting list for two facilities that specialize in care for Mental Retardation, but would be three to five years before the resident would be accepted. Interview revealed the SW was not spending the resident's money now so the resident could take the money to the new facility.",2014-03-01
14230,"BRIDGE AT SOUTH PITTSBURG, THE",445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2010-01-13,323,D,,,ZTTU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, observation, and interview, the facility failed to ensure a safety device was functional for one resident (#4) of twenty-seven residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory problems, did not walk, and required extensive assistance with transfers. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the Care Plan, reviewed on September 8, 2009, revealed "" ...At risk for fall related injury...Bed/chair alarm..."" Medical record review of the Interdisciplinary Progress Notes dated September 24, 2009, at 12:15 a.m., revealed ""Resident found sitting on bottom in floor...@ (at) end of...bed going thru...chest drawers. Tells nurse...fell ...denies pain, discomfort. Assessed for injuries. None apparent..."" Review of the investigatio, provided by the facility revealed the bed alarm did not sound at the time of the resident's fall on September 24, 2009. Telephone interview on January 12, 2010, at 1:55 p.m., with Licensed Practical Nurse (LPN) #2, (LPN responsible for the resident's care on September 24, 2009) revealed the bed alarm did not sound at the time of the resident's fall, and the alarm was replaced. Interview on January 12, 2010, at 2:20 p.m., with the Director of Nursing, in the hallway, revealed at the time of the resident's fall on September 24, 2009, there was no system in place to check the functioning of the safety alarm, and it was unknown when the safety alarm had been checked prior to the resident's fall on September 24, 2009.",2014-03-01
14231,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2010-11-23,250,D,,,2WZS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policies, observation and interview, the facility failed to ensure social services was provided in a timely manner to replace dentures for one (#4) of five residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living and had no oral problems or weight loss. Medical record review of a Social Worker note dated November 4, 2010, revealed the Social Worker was notified on October 26, 2010, the resident's lower dentures were missing. Review of documentation provided by the Assistant Director of Nursing revealed on October 26, 2010, the facility faxed a request to the dental service for evaluation for lower dentures for the resident. Review of the facility's ""Lost Articles"" policy revealed, ""Every attempt will be made to ensure that lost articles are found. All personal articles will be handled in a manner to ensure that those personal items will be given back to the appropriate resident if possible. The following procedure will outline a facility search...1. Resident/family member or staff will notify or write a notice to the grievance coordinator or designated department responsible for the grievance policy. 2. Using the description for the lost article, the grievance coordinator or designated department will search the facility and look for the missing article or articles...4. Facility will replace articles at their discretion."" Medical record review of Registered Dietician (RD) notes revealed the resident's weight in September 2010, was 96 lbs. (pounds); in October 2010, was 89.8 lbs.; and in November 2010, the weight was 90.4 lbs. Medical record review of the ""Clinicallly Unavoidable Weight Loss/Abnormal Labs/Pressure Ulcer(s)"" which had been signed by the physician and dated June 7, 2010, confirmed the resident had unavoidable weight loss due to an advanced disease state of Failure to Thrive. Medical record review revealed interventions had been put in place to address potential weight loss, including multivitamins, Med Plus 2.0, regular diet with chopped meats, thin liquids, fortified foods and a sandwich snack at bedtime. Medical record review revealed the dentist saw the resident on November 4, 2010, and made an ""impression to make new lower denture..."" Observation and interview on November 17, 2010, at 12:30 p.m., revealed the resident in a geri-chair in the hallway and without lower dentures in place. The resident stated, ""I could eat better if I had them (lower dentures). It's hard to chew."" Continued interview with the resident revealed the lower dentures had been missing ""over a month."" Interview on November 18, 2010, at 8:00 a.m., with the Administrator, in the lobby, confirmed the Administrator had no knowledge of the missing dentures until October 26, 2010, when the Administrator was informed by the Social Worker. Interview with Certified Nursing Assistant (CNA) #1 on November 18, 2010, at 9:40 a.m., in the office revealed CNA #1 had been assigned to the resident since the ""first of August."" Continued interview with CNA #1 revealed CNA #1 recalled cleaning the resident's upper but not the lower dentures, and CNA #1 stated, ""I don't believe she ever had lower dentures."" Interview on November 18, 2010, a 9:50 a.m., in the office, with CNA #2 (who reported ""taking care"" of the resident since admission), confirmed the resident's lower dentures had been ""missing"" since August. Continued interview with CNA #2 confirmed CNA #2 had ""searched everywhere"" the first day the dentures were found missing and could not locate them. Continued interview with CNA #2 confirmed the family had previously inquired about the missing dentures, and CNA #2 stated, ""We told the nurses."" Interview on November 18, 2010, at 11:10 a.m., with the Social Worker, in the office, confirmed the Social Worker had no knowledge of the missing dentures until an outside Case Manager for the resident reported the missing dentures to the Social Worker on October 26, 2010. C/O",2014-03-01
14232,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2010-11-23,333,D,,,2WZS11,"**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 a significant medication error did not occur for one (#4) of five residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills and was totally dependent on staff for all activities of daily living. Medical record review of a physician's orders [REDACTED]. Watch B/P (blood pressure) closely & (and) call MD (physician) for new orders if systolic drops below 75...2. Push po (by mouth) fluids...3. IV NS (intravenous normal saline) @ (at) 100 cc (cubic centimeter) X (times) 1 liter..."" Review of the facility's investigation of a medication error revealed on June 21, 2010, at 7:30 a.m., Registered Nurse (RN) #1 administered the medications of resident #2 to resident #4. Continued review of the investigation revealed resident #2's medications which RN #1 administered to resident #4 included [MEDICATION NAME] (Hypertension) 5 mg (milligrams), [MEDICATION NAME] (Hypertension/[MEDICAL CONDITION]) 25 mg, [MEDICATION NAME] ([MEDICAL CONDITION] replacement) 0.112 mcg (microgram), [MEDICATION NAME] (Depression) 10 mg, [MEDICATION NAME] ([MEDICAL CONDITION]) 100 mg, [MEDICATION NAME] (Hypertension) 0.2 mg, [MEDICATION NAME] (Hypertension) 20 mg and [MEDICATION NAME] (Hypertension) 25 mg. Continued review revealed resident #4's blood pressure after the medications were administered was 87/54. Medical record review of the physicians' orders dated June 1-30, 2010, for resident #4 revealed none of the medications administered to resident #4 had been ordered by the physician. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of nurses' notes dated June 21, 2010, revealed the resident's blood pressure was checked every fifteen to thirty minutes, after the medications were administered, from June 21, 2010, at 7:35 a.m., until June 21, 2010, at 2:30 p.m., and ranged from 81/54 to 110/48. Continued medical record review of nurses' notes dated June 21, 2010, revealed the IV NS was administered from 11:00 a.m., to 8:10 p.m. Medical record review and interview on November 17, 2010, at 11:15 a.m., in the office, with the Assistant Director of Nursing (ADON) confirmed RN #1 administered the medications listed above and ordered for resident #2, to resident #4 on June 21, 2010. Continued interview with the ADON confirmed resident #4 had no orders for blood pressure medications, and ""We were concerned because (resident #4's) B/P was already a little low."" Telephone interview on November 19, 2010, at 1:15 p.m., with RN #1 confirmed RN #1 administered resident #2's medications to resident #4 on June 21, 2010. Continued interview with RN #1 confirmed the medications had been crushed and mixed with applesauce, and resident #4 had taken approximately one third of the medications before RN #1 was made aware by a Certified Nursing Assistant that the medications were being administered to the wrong resident. C/O #",2014-03-01
14233,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2010-11-23,411,D,,,2WZS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policies, observation and interview, the facility failed to promptly refer one resident (#4) to the dental service for denture replacement of five residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living and had no oral problems or weight loss. Medical record review of a Social Worker note dated November 4, 2010, revealed the Social Worker was notified on October 26, 2010, the resident's lower dentures were missing. Review of documentation provided by the Assistant Director of Nursing revealed on October 26, 2010, the facility faxed a request to the dental service for evaluation for lower dentures for the resident. Medical record review of Registered Dietician (RD) notes revealed the resident's weight in September 2010, was 96 lbs. (pounds); in October 2010, was 89.8 lbs.; and in November 2010, the weight was 90.4 lbs. Medical record review revealed the physician had confirmed the resident had unavoidable weight loss due to an advanced disease state of Failure to Thrive. Medical record review revealed interventions had been put in place to address potential weight loss, including multivitamins, Med Plus 2.0, regular diet with chopped meats, thin liquids, fortified foods and a sandwich snack at bedtime. Observation and interview on November 17, 2010, at 12:30 p.m., revealed the resident in a geri-chair in the hallway and without lower dentures in place. The resident stated, ""I could eat better if I had my lower dentures."" Continued interview with the resident revealed the lower dentures had been missing ""over a month."" Interview on November 18, 2010, at 8:00 a.m., with the Administrator, in the lobby, confirmed the Administrator had no knowledge of the missing dentures until October 26, 2010, when the Administrator was informed by the Social Worker. Interview with Certified Nursing Assistant (CNA) #1 on November 18, 2010, at 9:40 a.m., in the office revealed CNA #1 had been assigned to the resident since the ""first of August."" Continued interview with CNA #1 revealed CNA #1 recalled cleaning the resident's upper but not the lower dentures, and CNA #1 stated, ""I don't believe she ever had lower dentures."" Interview on November 18, 2010, a 9:50 a.m., in the office, with CNA #2 (who reported ""taking care"" of the resident since admission), confirmed the resident's lower dentures had been ""missing"" since August. Continued interview with CNA #2 confirmed the family had previously inquired about the missing dentures, and CNA #2 stated, ""We told the nurses."" Interview on November 18, 2010, at 11:10 a.m., with the Social Worker, in the office, confirmed the resident had not been referred to the dental service until October 26, 2010. C/O",2014-03-01
14234,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2010-04-07,323,D,,,CHDZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to safely transfer two (#1, #2) of twenty-two residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had impaired short term memory, impaired decision making skills, required assistance with transfers, was non-ambulatory, and had fallen in the past 31-180 days. Observation on April 6, 2010, at 7:05 a.m. revealed Certified Nurse Assistant (CNA) #1 assisted resident #1 to sit on the side of the bed without first placing a gait belt on the resident to assist with the transfer. CNA #1 told the resident to put the arms around CNA #1's waist but the resident was not able to comply. Observation revealed the CNA #1 pulled the resident off the side of the bed and the resident was unable to stand well and started to slide down. The CNA was able to get the resident to the front of the wheel chair preventing the resident from falling to the floor. Interview with CNA #1 on April 6, 2010 at 7:08 a.m. in the resident's room confirmed the CNA should have used a transfer belt. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had impaired short and long term memory, impaired decision making skills, and required assistance with all activities of daily living including transfers. Observation on April 7, 2010, at 7:30 a.m., in resident #2's room revealed CNA #2 assisted resident #2 to the side of the bed and applied the sling around the resident's back without fastening the safety belt. The CNA instructed resident #2 to hold onto the grips on the lift. The resident required instruction several times due to confusion. CNA #2 used the lift to raise the resident off the bed and while the resident was dangling approximately three feet from the floor, the CNA retrieved the resident's wheel chair from the bathroom and lowered the resident into the wheel chair. Interview with CNA #2 on April 7, 2010, at 7:40 a.m., in the resident's room revealed part of the buckle for the safety belt was missing and the CNA was unable to fasten it for the resident's safety. Observation on April 7, 2010, at 7:55 a.m., in resident #22's room, with the Registered Nurse Staff Education Coordinator revealed CNA #2 preparing resident #22 to be transferred in the lift with the safety belt buckle missing. Continued observation revealed the Registered Nurse Staff Education Coordinator checked the safety belt and part of the safety belt buckle was missing. Interview on April 7, 2010, at 7:56 a.m., with the Registered Nurse Staff Education Coordinator confirmed the buckle was missing and the lift was not safe to use for transferring residents. The RN Staff Education Coordinator secured another lift to facilitate the transfer.",2014-03-01
14235,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2010-04-07,254,C,,,CHDZ11,"Based on observation and interview the facility failed to provide clean wash cloths for all residents. The findings included: Interview during the resident council meeting in the activity room on April 5, 2010, at 1:45 p.m., revealed a shortage of wash cloths. Interview on April 6, 2010, at 2:35 p.m., on 100 hall, with certified nurse assistant #2 and #5 revealed a frequent shortage of wash cloths. Observation on April 6, 2010, at 2:30 p.m. and 3:50 p.m.; April 7, 2010, at 7:45 a.m. and 9:15 a.m., revealed the following: No wash cloths in the ""clean linen room"", and fewer than 6 wash cloths on the 500 and the 100 hall linen carts. Interview with the administrator on April 7, 2010, at 11:30 a.m., in the conference room confirmed the frequent shortage of wash cloths.",2014-03-01
14236,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2010-04-07,281,D,,,CHDZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow the physician's orders for one (#14) of twenty-two residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, and required assistance with all activities of daily living. Medical record review of the April 2010, physician's orders revealed "" ...Apply geri sleeves (skin protectors) to both arms at all times AM PM Noc (night)..."" Observation on April 7, 2010, at 7:10 a.m., and 7:40 a.m., in the resident's room, revealed the resident in the bed without the geri sleeves on, and multiple small bruises on the arms. Observation on April 7, 2010, at 8:15 a.m., in the resident's room revealed Certified Nurse Assistant #2 and #3 dressed the resident and transferred the resident to the geri chair, failed to apply the geri sleeves, and left the resident's room. Observation on April 7, 2010, at 9:45 a.m., in the resident's room revealed the resident in the geri chair without the geri sleeves applied. Observation on April 7, 2010, at 10:40 a.m., in the activity room with the Registered Nurse Staff Education Coordinator revealed the resident sitting in the geri chair without the geri sleeves applied. Review of the April 2010, physician's orders on April 7, 2010, at 10:42 a.m., at the nurse's desk with the Registered Nurse Staff Education Coordinator and the Registered Nurse Quality Assurance Coordinator confirmed the physician's orders "" ... Apply geri sleeves (skin protectors) to both arms at all times AM PM Noc (night) ..."" Interview with the Registered Nurse Staff Education Coordinator at that time confirmed the resident did not have the geri sleeves applied as ordered by the physician.",2014-03-01
14237,SODDY-DAISY HEALTH CARE CENTER,445408,701 SEQUOYAH ROAD,SODDY-DAISY,TN,37379,2010-06-23,315,D,,,Z79T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, observation, and interview, the facility failed to complete a bladder assessment for one (#16) resident of twenty-five residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, moderately impaired cognitive skills for daily decision making, and occasionally incontinent of bladder. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was frequently incontinent of bladder. Medical record review of an Assessment for Bowel and Bladder Training dated February 2, 2010, revealed, ""...07-14 Candidate for toileting ...(score) 10..."" Medical record review of an Assessment for Bowel and Bladder training dated April 26, 2010, revealed, ""...7-14 candidate for scheduled toileting program...Grand Total 12..."" Medical record review of a 3-Day Voiding Form dated October 15, 2009, revealed, ""...Every hour, the nurse aide will check if the resident if wet or dry...circle the information as applicable..."" Medical record review of a 3-Day Voiding Form dated October 15, 2009, revealed the 6:00 a.m. to 12:00 p.m., condition not checked as completed (did not indicate if the resident was wet or dry). Review of facility policy Toileting Program revealed, ""...A toileting program is used for residents who do not demonstrate the cognition or physical ability required to be internally aware of the need to void or who has an unpredictable voiding pattern...The goal of a toileting program is to determine the resident's normal voiding pattern and to establish a voiding schedule that matches the resident's needs and past patterns..."" Interview on June 23, 2010, at 7:40 a.m., on the 200 nursing station, with CNA (certified nursing assistant) #1 confirmed the resident is toileted every two hours at no specific time. Interview on June 23, 2010, at 8:15 a.m., in the Administrator's office, with the Assistant Director of Nursing, confirmed the bladder assessment had not been completed to establish the resident's voiding pattern.",2014-03-01
14238,SODDY-DAISY HEALTH CARE CENTER,445408,701 SEQUOYAH ROAD,SODDY-DAISY,TN,37379,2010-06-23,323,D,,,Z79T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one resident (#13), and failed to implement interventions after a fall for two residents (#21,#22) of twenty-five residents reviewed. The findings included: Resident #13 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 deficits, and moderately impaired cognitive skills. Medical record review of a Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the nursing notes revealed the resident experienced a fall on June 10, 2010, without injury. Medical record review of a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Care Plan dated April 16, 2010, revealed the resident was at risk for falls, had an unsteady gait, and had been revised on June 15, 2010, to include a bed/chair alarm. Continued review of the Care Plan revealed the application and placement of the alarm was to be checked every shift. Observation on June 21, 2010, at 1:05 p.m., revealed the resident seated in the merry walker without the chair alarm attached to the resident. Observation and interview, on June 21, 2010, at 1:07 p.m., with the Director of Nursing, revealed the resident seated in the merry walker, and confirmed the chair alarm was not attached to the resident. Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, moderately impaired cognition, required extensive assistance with transfers, did not ambulate, and had experienced falls within the last thirty days. Medical record review of the resident's care plan revised June 5 and 28, 2009, revealed the resident had experienced three falls, without injury, between June 5, 2009, and June 28, 2009, with interventions placed to prevent further falls. Medical record review of the nursing notes and revised care plan dated August 27, 2009, revealed the resident was found in the floor of the bathroom at 9:00 p.m., with no injuries noted. Review of the nursing notes, care plan, and facility documentation dated August 27, 2009, revealed the only intervention placed following the fall had been to re-educate the resident on using the call light to call for assistance. Medical record review of the nursing notes and care plan from October 15 to November 4, 2009, revealed the resident experienced three additional falls, without injury between October 15, 2009, and November 4, 2009, with additional interventions placed to prevent further falls. Interview with the Administrator and the Director of Nursing on June 23, 2010, at 10:10 a.m., in the conference room, confirmed the resident was not capable of understanding or remembering to use a call light, and the intervention to prevent further falls after the August 27, 2009, fall had not been appropriate for the resident. Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired long and short term memory, moderately impaired cognition, required extensive assistance with transfers and ambulation, and had experienced falls. Medical record review of the nursing notes and care plan from April 18, 2009, until November 12, 2009, revealed the resident had experienced 19 falls, without injury, between April 18, 2009, and November 12, 2009, with interventions placed after each fall. Medical record review of the care plan, updated after each fall, revealed the resident was to have a pressure pad alarm at all times in the chair and bed, and the resident was on a 1:1 supervision reduction plan (plan to reduce the amount of time the resident required constant supervision). Medical record review of the nursing notes, care plan, and facility documentation dated November 14, 2009, at 8:00 p.m., revealed, a CNA (Certified Nursing Assistant) took the resident to the bathroom, left the resident on the commode to obtain a brief in the bedroom closet, and the resident stood up from the commode and fell , without injury. Medical record review of the care plan updated November 14, 2009, revealed, an intervention of, ""CNA to take all items needed into restroom before (resident) is took."" Interview with the Administrator and Director of Nursing on June 23, 2010, at 9:20 a.m., in the conference room, confirmed the resident was to have alarms on at all times, required supervision at all times, and had not been safe to leave on a commode unsupervised. C/O # , #",2014-03-01
14239,SODDY-DAISY HEALTH CARE CENTER,445408,701 SEQUOYAH ROAD,SODDY-DAISY,TN,37379,2010-06-23,312,D,,,Z79T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide the necessary services to maintain good nail care for one resident (#15) of twenty-five residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, had moderately impaired cognitive skills for daily decision making, and required extensive assistance for personal hygiene and bathing. Medical record review of the May 2010 Monthly Nursing Summary revealed, ""...18. Grooming...Total Care..."" Medical record review of the care plan dated May 11, 2010, revealed, ""...Patient has had a decline in self performance with ADLs (activities of daily living)...requires assist of one and / or two with all daily needs...will receive assistance at level required to meet daily needs AEB (as evidenced by) clean, neat ongoing appearance...assist with...grooming PRN..."" Medical record review of the CNA (Certified Nurse Assistant) Kardex (no date) revealed, ""...Resident requires assistance with and / or provision for ADLs...Resident will experience cleanliness and comfort each day...Resident will receive assistance as needed for ADLs each day...Nail Care every Friday on day shift..."" Observation on June 21, 2010, at 10:20 a.m., in the resident's room, revealed the resident in a wheelchair with very long and dirty fingernails on both hands. Observation on June 22, 2010, at 1:00 p.m., in the resident's room, revealed the resident in a wheelchair; the fingernails on both hands extended approximately ? inch beyond the finger tips and had a thick build-up of a yellowish-brown substance under the fingernails. Observation and interview on June 22, 2010, at 1:05 p.m., in the resident's room, with LPN (Licensed Practical Nurse) #1, confirmed the resident's fingernails needed to be cleaned and trimmed. Interview with the DON (Director of Nursing) on June 22, 2010, at 2:45 p.m., at the Nurse's Station, confirmed the facility failed to provide the necessary services to maintain good nail care.",2014-03-01
14240,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2010-03-31,371,F,,,V5X911,"Based on observation, review of manufacturer's recommendation, and interview, the facility failed to maintain adequate sanitizing solution in the dishwasher to prevent the spread of infection. The findings included: Observation of the kitchen on March 29, 2010, at 9:30 a.m., revealed the Certified Dietary Manager (CDM) tested the chlorine bleach dishwasher sanitizer solution resulting in a level below 50 parts per million (ppm). Observation in the kitchen on March 29, 2010 at 3:10 p.m., revealed the maintenance staff had repaired the dishwasher sanitizing equipment, and the CDM tested the chlorine bleach dishwasher sanitizer solution resulting in a level below 50 ppp. Review of the Manufacturer's recommendation for the Stationary Rack Dishwashing Machines for available chlorine, revealed the minimum was 50 ppm for appropriate sanitation. Interview with the Certified Dietary Manager (CDM) on March 31, 2010, at 8:30 a.m., in the hall near the dining room, confirmed the sanitizer, for the dishwasher, was not working properly to prevent spread of infection.",2014-03-01
14241,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2010-03-31,323,D,,,V5X911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were placed according to manufacturer's instructions for one resident (#21) and failed to provide supervision to prevent a fall for one resident (#1) of twenty-one residents reviewed. The findings included: Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had difficulty with long and short term memory, and severe difficulty with decision making skills. Continued review of the MDS revealed the resident was dependent on the staff for all activities of daily living, and required a trunk restraint for safety (in the wheel chair), and had a history of [REDACTED]. Observation on March 30, 2010, at 1:57 p.m., on the 400 hall, revealed the resident seated in a wheel chair, secured with a self release seat belt. Continued observation revealed the self release belt was draped across the resident's lap with the left strap brought over the resident's left thigh, crossed under the wheel chair, and secured to the kick spur on the opposite side. Continued observation revealed the right strap was placed around the outside of the back post, crossed behind the wheel chair and secured to the kick spur on the opposite side. Review of the manufacturer's recommendations revealed, ""...Bring the straps directly behind the patient. Thread the straps through the space between the space between the wheel chair seat and backrest ...Behind the wheel chair, criss-cross the straps and loop the strap from the patient's right side over the left kickspur and the strap from the patient's left side over the right kickspur..."" Interview with LPN #2 on March 31, 2010, at 9:10 a.m., in the dining room, confirmed the restraint was not secured according to the manufacturer's recommendations. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, with moderately impaired cognitive skills for daily decision making, and required extensive assistance with one person physical assistance for ambulation. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the nurse's note dated October 27, 2009, revealed, "" ...was found by staff member on floor (and) they reported it to this nurse that they had put ...or assisted ...to the bathroom reminded ...to use call-light when finished (and) resident forgot to pull light, pt. (patient) was found in fetal position on floor ...(no injuries)"" Review of documentation provided by the facility dated October 27, 2009, revealed, ""...found in fetal position on floor of pts (patient) BR (bathroom)...Alert, oriented to self ...Summary of findings...Educate staff not to leave resident unattended..."" Interview on March 31, 2010, at 12:45 p.m., in the Activity Room, with the Director of Nursing, confirmed the resident was left unattended in the bathroom resulting in a fall.",2014-03-01
14242,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2010-03-31,226,D,,,V5X911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility policy, and interview, the facility failed to report an allegation of abuse timely for one (#1) resident of twenty-one residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, with moderately impaired cognitive skills for daily decision making. Review of the documentation provided by the facility dated January 25, 2010, revealed, "" ...Date of Incident: 1/20/2010 ...Date Reported...: Morning of 1/21/2010 ...Time of Incident: Approx. 11:00:00 PM ...CNA's (#1 and #2) were assisting (resident #1) ...having hallucinations ...Apparently (resident #1) had hit the button on the call light and was yelling for help. (CNA #3) came in the room and told (resident #1) ...was in a nursing home ...the other 2 CNAs reported that (CNA #3) began popping the resident's leg and telling (resident #1) to shut up ...(Administrator) was notified on the morning of 1/21/2010 of the concerns from the 2 CNAs ...immediately placed (CNA #3) on administrative leave pending investigation ...Injury: none. Resident was interviewed by (Administrator) but wasn't able to tell ...anything about the incident ...Interview with (CNA #1) ...Stated ...and (CNA #2) responded to the resident ' s room and (resident #1) thought ...was chasing mules. (CNA #1)...observed (CNA #3) tell the resident to shut up and hit (resident #1) on the leg. Interview with (CNA #2)states ...and (CNA #1) responded to the resident's room and (resident #1) thought ...was in the field with the mules ...said (CNA #3) entered the room and stated smacking (resident #1) legs telling (resident #1) to shut up in a hateful way. Interview with (CNA #3) stated ...went to the resident's room and ...(resident #1) was yelling ...states (CNA #3) told (resident #1) ...was in a nursing home. States (CNA #3) was trying to calm (resident #1) down, but did not pop (resident #1) leg at all and did not tell (resident #1) to shut up. Findings and Follow-up: The Facility feels that the allegation of verbal abuse is substantiated. Unable to substantiate physical abuse...(CNA #3) was terminated...Initiated a staff inservice on 1/22/2010 to re-educate employees on how to identify, report, and prohibit abuse and mistreatment of [REDACTED]. Interview on March 29, 2010, at 3:10 p.m., in the dining room with CNA #2, revealed CNA #3 came into resident #1 room and smacked resident #1 on leg and told resident #1 to shut up. Further interview revealed the incident was not reported to the nurse; it was reported to the administrator the following day. Interview on March 30, 2010, at 9:00 a.m., with resident #1, in the resident's room, revealed resident #1 denied mistreatment or being hit by staff. Interview on March 30, 2010, at 10:05 a.m., by phone, with CNA #1, revealed, went into resident #1 room, CNA #3 was in the resident's room, CNA #3 hit resident #1 on the leg and told resident #1 to shut up. Further interview revealed the incident was not reported immediately to the nurse. Interview on March 30, 2010, at 10:15 a.m., by phone, with CNA #3 revealed, CNA #1 and #2 were in resident #1 room, resident #1 calling out field with mules, went into resident #1 room to calm down, standing at bathroom door, told resident #1 was not in a field, was in a nursing home, denied hitting the resident or telling the resident to shut up. Review of the Abuse policy revealed, ""...Anyone who witnesses an incident of suspected abuse...is to...report it to the nursing supervisor immediately...All reports of suspected abuse must be reported to the Administrator and Director of Nurses immediately..."" Interview on March 30, 2010, at 8:15 a.m., with the Director of Nursing, in the Activity Room, confirmed the allegation of abuse was not reported immediately. c/o #",2014-03-01
14243,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2010-03-31,309,G,,,V5X911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to provide interventions to prevent fecal impactions for one resident (#2) of twenty-one residents reviewed. The findings included: Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, required assistance with all activities of daily living, and was incontinent of bowel and bladder. Medical record review of the nurse's notes dated January 11, 2010, 3:00 a.m., revealed ""...checked for impaction manually (using the fingers) removed Med. (medium) Amount of hard stool (from the rectum..."" Medical record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued review revealed no medications to aid the resident to have soft formed bowel movements, and to prevent fecal impactions. Medical record review of the resident's January 2010, Personal Care Record revealed: January 5, 2010, no bowel movement January 6, 2010, a small bowel movement January 7, 2010, no bowel movement January 8, 2010, a small bowel movement January 9, 2010, no bowel movement January 10, 2010, no bowel movement January 11, 2010 (represented on the Personal Care Record as January 10, on the 10:00 p.m., to 6:00 a.m, shift) the resident only had the medium hard stool the nurse digitally removed from the resident's rectum at 3:00 a.m. Medical record review of the nurse's notes dated February 24, 2010, revealed "" ...Had 1 medium to large stool @ 2200 (10:00 p.m.) last pm-had to be removed digitally (using the fingers) d/t (due to) resident unable to push to defecate (move the bowels) ..."" Medical record review of the resident's February 2010, MAR indicated [REDACTED]. Medical record review of the resident's February 2010, Personal Care Record revealed the resident on February 20, 2010, had no bowel movement, on February 21, 2010, a small bowel movement, and on February 23, 2010, the resident only had the medium to large bowel movement the nurse removed digitally from the rectum. Medical record review of the March 2010, MAR indicated [REDACTED]. Interview on March 31, 2010, at 1:50 p.m., in the Activity Room, with the Director of Nursing confirmed the resident had a fecal impaction on January 11, 2010, and no interventions were put in place to aid the resident to have soft formed stools, resulting in the second impaction on February 24, 2010.",2014-03-01
14244,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2010-03-31,157,G,,,V5X911,"**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 fecal impactions for one (#2) of twenty-one residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, required assistance with all activities of daily living, and was incontinent of bowel and bladder. Medical record review of the nurse's notes dated January 11, 2010, 3:00 a.m., revealed ""...checked for impaction manually (using the fingers) removed Med. (medium) Amount of hard stool (from the rectum..."" Medical record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""common"" side effect of constipation. Continued review revealed no medications to aid the resident to have soft formed bowel movements, and to prevent fecal impactions. Medical record review of the physician's orders [REDACTED]. was notified of the fecal impaction on January 11, 2010. Medical record review of the nurse's notes dated February 24, 2010, "" ...Had 1 medium to large stool @ 2200 (10:00 p.m.) last pm-had to be removed digitally (using the fingers) (from the rectum)..."" Medical record review of the resident's February 2010, MAR indicated [REDACTED]. Continued review revealed no medications to aid the resident to have soft formed bowel movements, and to prevent fecal impactions. Medical record review of the resident's February 2010, physician's orders [REDACTED]. was notified of the resident requiring the nurse to disimpact stool from the resident's rectum. Medical record review of the March 2010, MAR indicated [REDACTED]. Interview on March 31, 2010, at 1:50 p.m., in the Activity Room, with the Director of Nursing confirmed the resident had a fecal impaction on January 10, 2010, and the resident's physician was not notified to obtain new orders to aid the resident to have soft formed stools. Continued interview confirmed the resident had a second fecal impaction on February 23, 2010, and the physician was not notified.",2014-03-01
14245,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2010-03-31,312,D,,,V5X911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nail care for one (#7) of twenty-one residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, impaired decision making skills, and required assistance with hygiene and all activities of daily living. Observation on March 30, 2010, at 12:50 p.m., revealed the resident in the dining room feeding self lunch and had dark debris under the finger nails. Observation on March 31, 2010, at 8:50 a.m., revealed the resident sitting in the dining room feeding self breakfast and had dark debris under the finger nails. Observation on March 31, 2010, at 9:40 a.m., in the 400 hallway revealed a Certified Nurse Assistant (CNA) took the resident into the shower room. Observation and interview, on March 31, 2010, at 10:10 a.m., at the 300/400 hallway nurse's desk with the 300/400 hallway Registered Nurse (RN) Unit Manager, revealed dark debris under the resident's finger nails. Continued observation in the resident's room revealed the 300/400 hallway RN unit manager used an orange stick and removed debris from under the resident's finger nails. Interview with the RN unit manager confirmed the resident's finger nails were soiled and required cleaning.",2014-03-01
14246,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2010-03-31,492,D,,,V5X911,"Based on a review of facility documents, and interview, the facility failed to ensure compliance with Federal regulations relating to Title VI, and with State regulations relating to maintaining and updating an Single Admission Waiting List. The findings included: Review of facility documents regarding Title VI (handicap accessibility) requirements at 1200-8-16-.02(10), revealed the SSD (Social Services Director) was designated as the Title VI coordinator. Interview with the SSD on March 31, 2010, at 11:00 a.m., in the SSD's office, revealed the SSD was unaware of the meaning of Title VI, and was unaware of being designated the Title VI Coordinator. Review of the Single Admission Waiting List revealed the waiting list had not been updated quarterly, as required at 1200-8-13-1-.08(2), for ten of ten potential residents added to the waiting list from July 1, 2009, to November 23, 2009. Continued review of the waiting list revealed no letters confirming placement on the waiting list, as required at 1200-8-13-1-.08(3), had been sent to ten of ten potential residents added to the waiting list from July 1, 2009, to March 31, 2010. Interview with the SSD on March 31, 2010, at 11:20 a.m., in the SSD's office, confirmed the state requirements to update the Single Admission Waiting List quarterly and to send letters to the potential residents, confirming their placement on the waiting list, were out of compliance.",2014-03-01
14247,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2010-03-31,406,D,,,V5X911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure one (#14) of twenty-one sampled residents received mental health rehabilitative services. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission physician's orders [REDACTED]. Medical record review of the December 28, 2009, Minimum Data Set (MDS) revealed the resident had no short or long term memory impairment; with moderately impaired cognitive skills for daily decisionmaking; no mood indicators observed in the last thirty days; and no indicators for inappropriate behavior observed in the last seven days. Medical record review of nurse's notes revealed October 3, 2009...""(the resident) requested 5 mg (milligrams) [MEDICATION NAME] (antipsychotic) IM (intramuscular) to R (right) deltoid (upper arm) muscle for increased anxiety""...October 5, 2009...""(The resident) requesting prn (as needed) meds for pain, then anxiety, stated was still anxious but requested [MEDICATION NAME] IM with effective results""...October 6, 2009 at 2200 (10 p.m.)...""PRN pain med given. Pt. (patient) very nervous requested [MEDICATION NAME] IM. Given [MEDICATION NAME] 5 mg IM L (left) gluteal (buttocks)""...October 8, 2009 at 2330 (11:30 p.m.)...""Medicated for pain @ (at) 6 p.m. and 11:30 p.m. with [MEDICATION NAME] 10 mg and [MEDICATION NAME], resident also had 30 mg [MEDICATION NAME] (for sleep) and requested IM inj (injection) of [MEDICATION NAME] to help (the resident) sleep. Explained to resident (the resident) has had pain meds and sleeping pills and (the resident's) doctor had discussed (the resident's) meds with (the resident) and [MEDICATION NAME] was not for helping (the resident) sleep, and to try and relax and let (the resident's) sleeping pills work..."" Medical record review of nurse's notes revealed November 15, 2009, at 2300 (11:00 p.m.)...Resident cont. (continued) to want more pain and anxiety meds than are ordered. Explained to resident that this nurse had to follow (the physician's) order and could not just give (the resident's) pain and anxiety meds when (the resident) wanted them, only just what (the physician) ordered. Resident became angry. After this nurse left resident's room resident started talking to people who were not there. Upon entering resident's room within minutes resident smiled and said, 'I'm talking to these people outside.' Resident given [MEDICATION NAME] inj 5 mg right after inj of [MEDICATION NAME] resident was smiling and talking normal...November 19, 2009 at 5:50 p.m....M.D. (medical doctor) here, did not want to speak with resident about increasing meds..."" Medical record review of nurse's notes revealed December 3, 2009...""(The physician) here-note order to DC (discontinue) [MEDICATION NAME]"" Continued review revealed December 9, 2009, at 3:00 p.m""...(the resident) continues to ask for pain meds often and nerve meds and continue to tell (the resident) they are ordered q (every) 6 hours..."" Medical record review of the February, 2010, MAR (Medication Administration Record) revealed the resident's medication orders included: ""[MEDICATION NAME] 20 mg (milligrams) 1 tablet by mouth every day for depression/[MEDICATION NAME] Patch 4.6 mg/24 hr (hours) for [MEDICATION NAME] (antipsychotic) 5 mg 1 tablet by mouth twice [MEDICATION NAME] 30 mg 1 capsule by mouth at bedtime...Klonopin 1 mg by mouth three times daily as needed...back spasms...anxiety...and [MEDICATION NAME] 10-500 mg 1 tablet as needed for pain four times daily"". Medical record review of the nurse's notes revealed March 21, 2010, at 6:30 a.m., ""Res. (resident) up @ desk informed this nurse (the resident) would be going out with (the resident's) friend to get (the resident's) hair done, states '(the friend's) in my room'... staff never seen any visitors in (the residents) room...9 a.m...This nurse outside of room in hall talking to resident when resident began speaking to someone else, when asked who (the resident) was talking to pointed toward window and said 'them', no one else noted in room. Resident became defensive when asked where they were, upset asking 'them' to speak louder. Hx (history) of [MEDICAL CONDITIONS], hallucinations, and schizoaffect ([MEDICAL CONDITION] disorder) noted...10:00 a.m...(The physician) called back and informed of behaviors noted, n/o (new order) to restart [MEDICATION NAME] 5 mg IM PRN q 12 hours for [MEDICAL CONDITION] and/or hallucinations"". Medical record review of the nurse's notes dated March 23, 2010, at 2:30 a.m., revealed ""Resident came to me several times, seeking meds and wanted (the resident's) prn meds earlier than time allowed. I stated how often they were ordered and I could not give (the resident) anything else....Resident got upset and stated (the resident) needed more meds because (the resident) could not sleep and was very nervous. Resident wanted to know if (the resident) could have a [MEDICATION NAME] injection. I stated they were ordered for extreme [MEDICAL CONDITION] and hallucinations, that is what the M.D. ordered, (the resident) then decided (the resident) would wait until next dose of Klonopin."" Medical record review revealed no documentation the psychiatric evaluation had been completed. Observation on March 29, 2010, at 2:30 p.m., revealed the resident participating in a Resident Council meeting for alert/oriented residents. Interview with the Social Services Director (SSD) and Director of Nursing (DON) on March 31, 2010, at 10:15 a.m., in the activity office, confirmed the resident was admitted to the facility with a [DIAGNOSES REDACTED].",2014-03-01
14248,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2010-06-17,441,D,,,10J811,"Based on observation, facility policy review, and interview, the staff failed to wash the hands and provide appropriate wound care during a dressing change for one (#1) of twenty-two residents reviewed. The findings included: Observation on June 15, 2010, at 1:10 p.m., revealed Licensed Practical Nurse (LPN) #1 providing wound care to resident #1. Observation revealed LPN #1 washed the hands, applied gloves, removed a soiled dressing from the right lateral ankle area, and described the wound as a Stage III wound with a moderate amount of yellow drainage. Continued observation revealed LPN #1 removed the soiled gloves and without washing the hands, obtained a paper measuring device from the treatment cart, located in the hallway. Continued observation revealed LPN #1 reentered the resident's room, washed the hands and applied clean gloves. Continued observation revealed LPN #1 applied saline to a gauze pad and patted/touched the wound seven times with the same area of the gauze pad. Continued observation revealed LPN #1, without changing the gloves or washing the hands, applied ointment with a gloved finger to the perimeter of the wound, and applied a dressing with medication, applied a foam dressing, and wrapped the right lateral ankle area with a gauze wrap. Continued observation revealed LPN #1 spilled a small bottle of saline, removed the gloves and wiped the saline from the floor with a wash cloth, and without washing the hands, obtained another small bottle of saline from the treatment cart, reentered the resident's room, placed the saline on a clean drape, and washed the hands. Continued observation revealed the following: LPN #1 applied gloves and removed a dressing from the left lateral foot; removed the gloves, washed the hands, and applied clean gloves; measured and described the wound as unstageable 5.0 cm. (centimeters) X 2.8 cm. with a small amount of brownish colored drainage; applied saline to a gauze pad and patted/touched the wound twelve times with the same area of the gauze pad. Observation revealed resident #1 complained of pain, and LPN #1 removed the soiled gloves, and without washing the hands exited the resident's room, walked down the hallway to the Medication Prep room, unlocked and touched the door handle to the Medication Prep room, and told LPN #2 the resident needed pain medication. Observation revealed LPN #2 crushed pain medication for the resident and placed the medication in applesauce. Continued observation revealed LPN #1, without washing the hands, poured water into a cup from a pitcher located on the medication cart, took the medication prepared by LPN #2, and returned to resident #1's room and administered the pain medication. Continued observation revealed LPN #1 held a straw for the resident to drink water after administering the pain medication, without washing the hands. Continued observation revealed LPN #1 washed the hands after administering the pain medication and applied gloves. Continued observation revealed LPN #1 applied saline to a gauze pad, patted/touched the wound, on the left lateral foot, four times with the same area of the gauze pad, and without changing the gloves or washing the hands, applied ointment to a soiled gloved finger, and applied ointment to the perimeter of the wound. Continued observation revealed without changing the gloves or washing the hands LPN #1 applied a medicated dressing to the wound, applied a foam dressing, and wrapped the wound with gauze. Continued observation revealed LPN #1 replaced the lid on the ointment with soiled gloves, and then removed the gloves and washed the hands. Continued observation revealed after washing the hands LPN #1 spilled a cola from the resident's table, splashing onto resident #1's dressing on the right foot. Continued observation revealed LPN #1 applied gloves, removed the gauze wrapping, wet with cola, noted the foam dressing under the gauze wrapping was wet with cola, exited the resident's room, without removing the soiled gloves or washing the hands, and opened the treatment cart to obtain clean supplies. Observation revealed LPN #1 removed the soiled gloves, and without washing the hands, proceeded to Central Supply to obtain an additional foam dressing. Observation revealed LPN #1 unlocked the Central Supply room and obtained five foam dressings, without washing the hands, returned to the treatment cart and placed four of the dressings into the treatment cart. Continued observation revealed LPN #1 returned to the resident's room, washed the hands, applied gloves, and removed the soiled foam dressing from the resident's right foot, washed the hands, applied gloves, and applied the clean foam dressing and gauze. Review of the facility's policy Dressing Changes revealed ""...Remove soiled dressing in trash bag. Discard gloves in trash bag and wash hands. Don new pair of gloves. Clean wound per order. Cleanse away from debris and drainage from wound, moving from center outward; use a new pad for each area cleaned, discarding the old pads...Discard gloves in trash bag and wash hands. Don new pair of gloves. Place ordered treatment into wound or onto dressing, as appropriate for type of wound. Dress the wound as ordered...Dispose of gloves and materials and store supplies as appropriate. Wash hands..."" Interview on June 15, 2010, at 2:05 p.m., with LPN #1, with the Director of Nursing (DON) present, in the DON's office, revealed the hands were to be washed each time the gloves were removed, and confirmed the hands were not washed each time the gloves were removed and after cleaning the wound on the right foot prior to applying medication or a clean dressing to the wound. Continued interview confirmed the wounds were not cleansed appropriately from the center outward and the facility's Dressing Changes policy was not followed.",2014-03-01
14249,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2010-06-17,318,D,,,10J811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide services to maintain Range of Motion for one resident (#3) of twenty-two residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Sets dated August 27, 2009, November 17, 2009, and February 11, 2010, revealed the resident had limitations of the leg (including hip and knee and the foot) (including ankle or toes) on one side with full loss of voluntary movement. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had limitations of the leg (including hip and knee) and the foot (including ankle or toes) on both sides with full loss of voluntary movement. Medical record review of the care plan updated May 1, 2010, revealed no interventions to address Range of Motion. Medical record review revealed the resident was not currently receiving any therapy services. Observation on June 15, 2010, at 3:10 p.m., with the Minimum Data Set Nurse confirmed the resident had limitations to the leg and foot on both sides more on the left side than the right side. Interview with the Minimum Data Set Nurse at 3:15 p.m., at the 300 hall Nurse's station, confirmed the resident's Range of Motion was as reflected on the Minimum Data Set, dated dated dated [DATE], and indicated a decline in Range of Motion. Continued interview confirmed therapy is to be notified when a change is noted and therapy had not been notified of the decline in Range of Motion. Further interview confirmed the resident's care plan did not have any interventions to address the decline of Range of Motion. Interview with Certified Nursing Assistant #1 on June 16, 2010, at 8:45 a.m., at the 300 hall Nurses Station, revealed the only Range of Motion provided was during showering, transferring, and dressing the resident. Interview with the Nurse Practitioner on June 16, 2010, at 9:00 a.m., at the 300 Nurse's station, confirmed the decline in Range of Motion would be a natural progression with a history of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Interview with the Director of Nursing on June 16, 2010, at 2:00 p.m., in the Director of Nursing office, confirmed the resident had a decline in Range of Motion as per the Minimum Data Set, dated dated dated [DATE]. Continued interview confirmed when a decline is noted in Range of Motion therapy is to be notified to screen and / or evaluate the resident. Continued interview confirmed the resident was not evaluated by therapy until June 16, 2010. Further interview confirmed the resident's care plan updated May 1, 2010, did not include any interventions to address the resident's decline in Range of Motion. Interview with the Physical Therapist on June 17, 2010, at 8:30 a.m., in the conference room, confirmed a restorative program would be required for the resident to maintain and or delay the progression of a loss in Range of Motion, and the resident did not have a restorative program in place prior to evaluating the resident on June 16, 2010.",2014-03-01
14250,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2010-06-17,323,D,,,10J811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one (#10) of twenty-two residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory problems, required extensive assistance with transfers, and had fallen in the past thirty days. Medical record review of the Fall Risk Assessments dated February 8, 2010, and April 1, 2010, revealed the resident was at high risk for falls. Medical record review of a Nurse's Event Note dated January 9, 2010, at 12:30 a.m., revealed the resident experienced a fall from the bed without injury. Medical record review of a Care Plan / Comprehensive Assessment Review note dated January 9, 2010, revealed a bed alarm was to be placed on the resident's bed when available. Medical record review of the Plan of Care dated November 23, 2009, February 11, 2010, and May 4, 2010, revealed the resident was at increased risk for injury from falls, and on January 9, 2010, the intervention was added to the Plan of Care to place a bed alarm when available. Medical record review of a Nurse's Event Note dated April 1, 2010, at 12:30 a.m., revealed ""Called to room per CNA's (Certified Nursing Assistants) making rounds found sitting on floor @ (at) foot of bed. Awake no c/o's (complaints). ROM (range of motion) to extremities good. No bruises or abrasions...had taken body alarm off...Immediate Steps Implemented to Prevent Recurrence: Bed alarm placed..."" Medical record review of a Nurse's Event Note dated June 15, 2010, at 12:20 a.m., revealed ""Pt (patient) was attempting to get out of bed and slid down to floor, 'stated my legs got weak and gave out '...no apparent injury..."" Observation on June 16, 2010, at 7:55 a.m., revealed the resident lying on the bed without a bed alarm in place. Observation on June 16, 2010, at 2:47 p.m., with the Director of Nursing (DON), of the resident's bed, revealed the DON removed the sheets from the bed and confirmed there was no bed alarm present. Telephone interview on June 16, 2010, at 1:55 p.m., with CNA #2 revealed CNA #2 had found the resident on the floor on April 1, 2010, at 12:30 a.m. Continued interview revealed CNA #2 had provided care for the resident from January through April 2010, and could not remember seeing a bed alarm on the resident's bed. Continued interview confirmed there was no alarm sounding at the time of the resident's fall on April 1, 2010. Telephone interview on June 17, 2010, at 10:05 a.m., with Licensed Practical Nurse (LPN) #3, nurse in charge of the resident's care at the time of the fall on June 16, 2010, confirmed there was no alarm in place at the time of the fall. Interview on June 16, 2010, at 2:45 p.m., with the Director of Nursing (DON) in the DON's office revealed there was no documentation the resident had a bed alarm in place from January 9, 2010, until June 16, 2010.",2014-03-01
14251,ISLAND HOME PARK HEALTH AND REHAB,445476,1758 HILLWOOD DRIVE,KNOXVILLE,TN,37920,2010-03-24,312,D,,,TBFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy and procedure review, and interview, the facility failed to provide nail care for two (#6, #16) of nineteen residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, had impaired vision, and required assistance with all activities of daily living including hygiene. Observation in the resident's room on March 22, 2010, at 9:20 a.m., 1:50 p.m., and 3:40 p.m., and on March 23, 2010, at 8:10 a.m., 10:10 a.m., 12:20 p.m., and 2:35 p.m., revealed the resident's finger nails (all ten) were approximately ? inch past the fingertips, the left ring finger nail was ragged, and the base of the finger tips were soiled with dark debris. Review of the Care of Fingernails/Toenails policy/proceedure revealed ""...Nailcare includes daily cleaning and regular trimming..."" Observation and interview in the resident's room on March 23, 2010, at 2:35 p.m., with Licensed Practical Nurse (LPN) #4, confirmed the resident's finger nails were approximately ? inch past the fingertips, the left ring finger nail was ragged, the base of the finger tips were soiled with dark debris, and required trimming and cleaning. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, moderately impaired cognitive skills for daily decision making, and required extensive assistance for personal hygiene. Observation on March 24, 2010, at 7:40 a.m., with LPN (Licensed Practical Nurse) #3, revealed the resident sitting in a wheelchair in the resident's room, with the fingernails extending approximately a 1/4 inch beyond the tip of the fingers on both hands. Interview on March 24, 2010, at 7:45 a.m., with LPN #3, in the resident's room, confirmed the fingernails were long and needed to be trimmed.",2014-03-01
14252,ISLAND HOME PARK HEALTH AND REHAB,445476,1758 HILLWOOD DRIVE,KNOXVILLE,TN,37920,2010-03-24,441,D,,,TBFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, policy review, and interview, the facility failed to ensure staff washed hands after providing perineal care for one resident (#10) nineteen residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory deficit, moderately impaired decision making skills, was non-ambulatory, total dependent for hygiene, and incontinent for bladder and bowel. Observation on March 23, 2010, at 9:15 a.m., in the resident's room, revealed the resident had been incontinent of urine and bowel. CNA #2 (Certified Nursing Assistant) was providing incontinence care wearing gloves. Continued observation revealed the CNA performed care to the front perineal area, positioned the resident on the left side, wiped the buttocks with wet wash cloths removing fecal material. The CNA went to the bathroom opened the door without removing gloves, turned on the faucet, wet additional wash cloths, returned to the resident and completed the incontinence care. Continued observation revealed CNA #2 placed the dirty cloths in the plastic bag, did not remove the gloves and continued to place a clean brief on the resident, adjusted the resident's gown, adjusted the bedrail, placed a sling behind the resident to use for a lift, retrieved the lift and brought the lift to the bed, adjusted the lift's controls, using the lift brought the resident from the bed and placed the resident in a chair, placed a blanket on the resident, and placed the resident's bible in the resident's lap. Review of the facility's policy ""Perineal Care...12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly."" Interview with CNA #2 on March 23, 2010, at 9:35 a.m., in the hallway, confirmed the gloves had not been changed or hands disinfected after providing incontinence care and prior to touching the resident's personal items. Interview with the Director of Nursing on March 23, 2010, at 4:15 p.m., in the conference room, confirmed the gloves are to be removed and hands washed after providing perineal care and prior to touching the resident's personal items.",2014-03-01
14253,ISLAND HOME PARK HEALTH AND REHAB,445476,1758 HILLWOOD DRIVE,KNOXVILLE,TN,37920,2010-03-24,226,D,,,TBFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility investigation, review of the abuse policy, and interview, the facility failed to report an allegation of abuse timely for one (#9) resident of nineteen residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory problems, no long term memory problems, and moderately impaired cognitive skills for daily decision making. Review of a Resident Interview completed by the Activity Director, dated December 9, 2009, at 4:00 p.m., revealed ""...(resident #9) asked me to come into...room...while we were talking...(resident #9 stated) another staff member ""threw a warm wash cloth"" at (resident #9)...I told (resident #9)...this would have to be reported and that I would tell (Assistant Director of Nursing)(ADON) about this..."" Review of a facility investigation interview form completed by the (ADON) dated December 9, 2009, at 5:08 p.m., revealed ""...upon telephoning CNA #1...was advised of a complaint with regards to ""throwing a wet wash cloth at a resident...(CNA #1) immediately knew the event I was referring to. (CNA #1) told me that (CNA #1)...did not throw a wet wash cloth at the resident (CNA #1) stated ""I put the wash cloth on (resident #9) bed and (resident #9) couldn't reach it so I picked it up and handed it to (resident #9)"" I advised (CNA #1) that...was suspended pending investigation..."" Review of a Resident Interview completed by the Social Service Director dated December 10, 2009, revealed ""...(resident #9) stated...asked for the aide, (CNA #1) to wet a wash cloth (resident #9) said (CNA #1) did, but then threw the wash cloth on (resident #9) leg...(resident #9) stated...asked the aide not to throw things at (resident #9) and (CNA #1) explained that (CNA #1) didn't..."" Review of a written statement completed by the accused (CNA #1) dated December 9, 2009, revealed ""...(resident #9) said ""Hand me my rag"" I took the rag from off the siderail and handed it to (resident #9) (resident #9) said ""don't hit me"" and I said...I didn't hit you...I did not hit (resident #9) with a rag and I have answered (resident #9) call light as soon as I can..."" Review of a written statement completed by LPN #1, dated December 10, 2009, revealed ""...on one of the nights we worked, I think it was last week, (CNA #1) came up to the nurses' station and said...just came out of (resident #9) room and (resident #9) had accused (CNA #1) of throwing a wash cloth at (resident #9) of which (CNA #1) said...did not do (CNA #1) said it looked like someone would need to go with (CNA #1) when (CNA #1) needs to go into (resident #9) room to care for (resident #9)..."" Review of the facility Abuse Policy revealed ""...All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint of, allegation of, observation of, 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...immediately initiate the Investigation protocol..."" Interview on March 22, 2010, at 12:50 p.m., with resident #9, in the resident's room, revealed CNA #1 took the wash cloth and threw it at (resident #9) hitting the resident on the thigh. Interview on March 22, 2010, at 1:30 p.m., with the ADON, in the ADON office, revealed resident #9 said CNA #1 ""threw the wash cloth at (resident #9)""...CNA #1 said ""...put the wash cloth on the bed and did not throw the wash cloth."" Interview on March 22, 2010, at 4:00 p.m., with CNA #1, by telephone, revealed "" anded the resident a rag, the resident said don't hit me, and I told (resident #9)...I didn't hit (resident #9)...handed ...the rag ...I did not abuse..."" Interview on March 23, 2010, at 12:30 p.m., with the Administrator, in the conference room, confirmed the allegation of abuse was not reported immediately when the nursing staff was informed of the allegation by CNA #1. c/o #",2014-03-01
14254,ISLAND HOME PARK HEALTH AND REHAB,445476,1758 HILLWOOD DRIVE,KNOXVILLE,TN,37920,2010-03-24,327,D,,,TBFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to monitor the fluid intake for one (#8) of nineteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's Minimum Data Set, dated dated dated [DATE], revealed the resident required assistance with all activities of daily living. Review of the March 2010, physician's orders [REDACTED]...1600cc/day fluid restriction..."" Medical record review of the dietician's worksheet revealed ""...Fluid Restriction 1600cc Breakfast...600 ml (same as cc) Lunch 240 ml Supper 360 ml...NO WATER PITCHER...60 cc with med pass..."" Medical record review revealed no fluid intake measurements recorded. Observation in the resident's room on March 22, 2010, at 9:00 a.m., 12:30 p.m., 1:30 p.m., and 3:30 p.m., and March 23, 2010, at 8:05 a.m., at 10:15 a.m., revealed two water pitchers on the resident's over the bed table and both pitchers were approximately 1/3 full of fluid. Interview with the resident in the resident's room on March 22, 2010, at 1:30 p.m., revealed one of the water pitchers is from the facility and the other one is from the family to put ice and diet coke into, ""...one bottle (12 ounces) lasts about two to three days..."" Observation and interview in the resident's room with the Director of Nursing (DON) on March 23, 2010, at 10:40 a.m., confirmed two water pitchers on the resident's over the bed table and both pitchers were approximately 1/3 full of fluid. Medical record review of the physician's March 2010, orders with the DON at the nurse's desk confirmed the physician ordered a 1600 cc daily fluid restriction. Further review of the resident's medical record revealed [REDACTED]. Interview with Licensed Practical Nurse #5 on March 23, 2010, at 10:50 a.m., at the nurse's desk with the DON present revealed LPN #5 was unsure of the amount of fluids allotted to administer the resident's medications, and the amount of fluids the resident consumed daily was not recorded, therefore the staff was unsure of the amount of fluids the resident had consumed. C/O #",2014-03-01
14255,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2010-04-28,323,D,,,FSYY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide supervision to prevent a fall for one (#21) of twenty-eight residents reviewed. The findings included: Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short/long term memory problems, moderately impaired cognitive skills for daily decision making, required extensive assistance for transfers, and was not able to attempt balance test for standing or sitting without physical help. Medical record review of the High Risk Patient Selection Form dated March 30, 2010, revealed the resident was at risk for falls. Medical record review of the post falls nursing assessment dated [DATE], revealed, ""...CNA entered bathroom to find (resident) sitting on the bathroom floor...leaning against the shower chair that was over the toilet...4/12/10 staff reports pt. (patient) was...reaching for the sink ...placed on CNA sheet ""do not leave alone in bathroom...was assessed for injury (with) no apparent injury noted...new intervention Do not leave unattended in BR-shower chair has seat belt and wheels that lock ..."" Medical record review of the post falls nursing assessment dated [DATE], revealed, "" ...CNA reported ...needed to get a washcloth for patient and no linen cart in hallway had to go to front hall to get washcloth off linen cart and upon returning to patient in bathroom ...found patient sitting on floor leaning to left side patient had stood up to get paper towel forgot that CNA had gone to get washcloth...patient not to be left alone in bathroom...assessed for injury (with) no apparent injury noted..."" Observation on April 27, 2010, at 3:15 p.m., in the resident's room, revealed the resident lying on the low bed with mats on the floor beside the bed, and a tab alarm attached to the resident's shirt. Interview on April 27, 2010, at 3:55 p.m., with LPN #2, in the Director of Nursing office, confirmed the resident was not to be left alone in the bathroom.",2014-02-01
14256,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2010-04-28,226,D,,,FSYY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to implement the Abuse Protection and Response Policy for one (#28) of twenty-eight residents reviewed. The findings included: Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged from the facility to the hospital on February 15, 2010. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory problems, moderately impaired cognitive skills, had repetitive health and anxious complaints, was verbally abusive, and was resistive to care. Medical record review of a nursing note dated December 28, 2009, at 1:00 a.m., revealed ""Writer went into pt's (patient's) room to give meds. Pt was upset and started crying. When asked what was wrong pt stated, 'I've got to tell you something and I want it reported. The CNA (Certified Nursing Assistant) threw my call light where I could not reach it and all I wanted was her to turn my fan."" The pt continued to repeat this over and over. The CNA had been in to pts room to answer the call light once since the shift started, and pt wanted (her/him) to ask writer if...could have...meds. After CNA had came out of pts room, the pt rang the call light again, and this is when the writer answered it and gave pt...meds. After several minutes of care per writer, the pt stated, 'and (she/he) told me that I was going to hell, and that I was the worst pt in the whole facility.' I want this reported because nobody is going to talk to me like this. I do not want the CNA to come back into this room and take care of me. Writer asked pt if...knew where...tissues were so writer could wipe pts face off. Pt stated, 'I don't have any, I've been asking everybody for some for two days and nobody will bring me any. Pt's tissues were by...cooler. Writer explained to pt that if...wanted someone reported, that...would also need to talk to whomever...wanted to report the CNA to. All needs were met for pt by writer before leaving the room, however pt has on the light again within 15 minutes. Pt's call light is in reach."" Review of documentation provided by the facility revealed Licensed Practical Nurse (LPN) #1 had been in charge of the resident's care on December 28, 2009, and had received the complaint from the resident regarding allegations related to Certified Nursing Assistant (CNA) #1. Continued review of the documentation revealed LPN #1 had talked to CNA #1 after receiving the allegations from the resident and CNA #1 had denied the allegations. Telephone interview on April 27, 2010, at 9:30 p.m., with LPN #1, (LPN in charge of the resident on December 28, 2009, at the time of the incident) revealed resident #28 had reported CNA #1 had placed the call light out of the resident's reach, had told the resident (he/she) was the worst patient in the facility, and told the resident to go to hell. Continued interview revealed the resident had a touch pad call light, and when LPN #1 had entered the resident's room on December 28, 2009, at approximately 1:00 a.m., it appeared the call light had slid from the resident's chest. Continued interview with LPN #1 revealed the resident had requested CNA #1 to not return to the resident's room to provide care to the resident. Continued interview revealed LPN #1 and another LPN provided care to the resident for the remainder of the shift, with the exception of two times when LPN #1 needed help providing care to the resident, and CNA #1 assisted LPN #1 with the resident's care. Review of the facility's Abuse Protection and Response Policy revealed ""...Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of abuse if it meets any of the following criteria...Any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others...Partner(s) suspected of abuse will be immediately placed on administrative leave pending result of investigation..."" Interview on April 27, 2010, at 8:25 a.m., with the Administrator, in the Administrator's office, revealed CNA #1 was not immediately placed on administrative leave after the allegation of verbal abuse, and confirmed the facility's policy was not followed. C/O #",2014-02-01
14257,BORDEAUX LONG TERM CARE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2010-03-30,157,D,,,DJ8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #TN 194 Based on policy review, medical record review and interview, it was determined the facility failed to ensure the physician was notified of a low blood sugar (BS) for 1 of 30 (Resident #30) sampled residents. The findings included: Review of the facility's ""Protocol: [DIAGNOSES REDACTED]"" documented, ""...Risk for Injury related to insufficient glucose to meet metabolic needs. Blood glucose less than or = (equal) 60 mg/dl (milligrams per deciliter) and are symptomatic. Notify MD (Medical Doctor)... 2. treatment of [REDACTED].=60 mg/dl (complete a - (through) f below ASAP (as soon as possible) a. Check glucostick b. If less than or equal to 60 mg/dl then treat resident based on level of consciousness and notify medical staff for further instructions. c. If after hours contact house supervisor who will in turn notify medical staff. 1. If responsive, give juice, milk, ensure or Insta Glucose and recheck blood glucose within 15 min. (minutes). If blood glucose continues to be = or < (less than) 60 mg/dl then give the [MEDICATION NAME] IM (intramuscular) and recheck blood glucose in 15 min. If blood glucose continues to be = or <60 mg/dl repeat IM [MEDICATION NAME], recheck blood glucose in 15 minutes. If resident continues not to respond to treatment then start process to send resident out for evaluation and treatment..."" Medical record review for Resident #30 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #30's diabetic monitoring flow sheet documented ""BS for 1/22/09 - 1600 (4:00 PM) BS= (result) 40 food/juice given."" Review of a progress note dated ""1/22/10-1600- Res (resident) c/o (complained of) not feeling well, asked for feet to be put on bed, BS (checked) earlier was 40. Food and drink given, family present. 1700 (5:00 PM) Res c/o (not) feeling well still... 1740 (5:40 PM) Res called for assistance. Wanted her legs off bed. Still appears tired... Will continue to monitor. 1815 (6:15 PM) Found Res in w/c (wheelchair) in room, unresponsive, attempted to revive c (with) out success. Called for assistance to put in bed. 1822 (6:22 PM) Code Blue called D/T (due to) unresponsiveness..."" There was no documentation Resident #30's BS was being checked every 15 minutes after the initial blood sugar of 40. The next documented BS on the diabetic monitoring flow sheet was at 6:30 PM with a BS of 161. There was no documentation the MD was notified of the low BS. During an interview in the conference room on 3/30/10 at 8:20 AM, the Director of Nursing (DON) stated, ""Less than 60 MD or medical staff should be notified. Give juice, milk, food or Instant glucose. Recheck BS in 15 minutes, still not up give IM [MEDICATION NAME] recheck in 15 minutes, still not up repeat IM [MEDICATION NAME]. If not responding need to go out."" The DON was asked what should have been done for this resident. The DON stated, ""Should have been checked (referring to BS) again in 15 minutes and the doctor should have been notified.""",2014-02-01
14258,BORDEAUX LONG TERM CARE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2010-03-30,309,D,,,DJ8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Amended 2567 on 4/27/10 Based on policy review, medical record review, observation and interview, it was determined the facility failed to follow physician's orders [REDACTED].#1, 15 and 30) sampled residents. The findings included: 1. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]."" Observations in the recreation room on 3/29/10 at 11:21 AM, revealed Resident #1 sitting in a wheelchair (w/c) with her feet dangling. Observations in Resident #1's room on 3/29/10 at 11:45 AM, revealed Resident #1 sitting in the w/c eating lunch with her feet dangling. During an interview in the Patient Care Manager's office, on 3/29/10 at 11:34 AM, the Patient Care Manager stated, ""(Resident #1's) feet should be elevated."" 2. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]."" Observations in Resident #15's room on 3/29/10 at 12:05 PM and on 3/30/10 at 9:00 AM, revealed Resident #15 lying in bed with no heel protectors in use as ordered. During an interview in Resident #15's room on 3/30/10 at 9:00 AM, Nurse #5 stated, ""Oh you (Resident #15) don't have your heel protectors on."" 3. Review of the facility's ""Protocol: [DIAGNOSES REDACTED]"" documented, ""...Risk for Injury related to insufficient glucose to meet metabolic needs. Blood glucose less than or = (equal) 60 mg/dl (milligrams per deciliter) and are symptomatic. Notify MD... 2. treatment of [REDACTED].=60 mg/dl (complete a - (through) f below ASAP (as soon as possible) a. Check glucostick b. If less than or equal to 60 mg/dl then treat resident based on level of consciousness and notify medical staff for further instructions. c. If after hours contact house supervisor who will in turn notify medical staff. 1. If responsive, give juice, milk, ensure or Insta Glucose and recheck blood glucose within 15 min. (minutes). If blood glucose continues to be = or < (less than) 60 mg/dl then give the [MEDICATION NAME] IM (intramuscular) and recheck blood glucose in 15 min. If blood glucose continues to be = or <60 mg/dl repeat IM [MEDICATION NAME], recheck blood glucose in 15 minutes. If resident continues not to respond to treatment then start process to send resident out for evaluation and treatment..."" Medical record review for Resident #30 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #30's diabetic monitoring flow sheet documented ""BS for 1/22/09 - 1600 (4:00 PM) BS= (result) 40 food/juice given."" Review of a progress note dated ""1/22/10-1600- Res (resident) c/o (complained of) not feeling well, asked for feet to be put on bed, BS (checked) earlier was 40. Food and drink given, family present. 1700 (5:00 PM) Res c/o (not) feeling well still... 1740 (5:40 PM) Res called for assistance. Wanted her legs off bed. Still appears tired... Will continue to monitor. 1815 (6:15 PM) Found Res in w/c (wheelchair) in room, unresponsive, attempted to revive c (with) out success. Called for assistance to put in bed. 1822 (6:22 PM) Code Blue called D/T (due to) unresponsiveness..."" There was no documentation Resident #30's BS was being checked every 15 minutes after the initial BS of 40. The next documented BS on the diabetic monitoring flow sheet was at 6:30 PM with a BS of 161. There was no documentation the MD was notified of the low BS. During an interview in the conference room on 3/30/10 at 8:20 AM, the Director of Nursing (DON) stated, ""Less than 60 MD or medical staff should be notified. Give juice, milk, food or Instant glucose. Recheck BS in 15 minutes, still not up give IM [MEDICATION NAME] recheck in 15 minutes, still not up repeat IM [MEDICATION NAME]. If not responding need to go out."" The DON was asked what should have been done for this resident. The DON stated, ""Should have been checked (referring to BS) again in 15 minutes and the doctor should have been notified.""",2014-02-01
14259,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2010-01-28,315,D,,,VI5B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interview, the facility failed to provide incontinence care for one incontinent resident (#17) of seven incontinent residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had short term memory deficits with moderately impaired cognitive skills for daily decision making. Continued review revealed the resident required extensive assistance for transfers, was dependent on staff for personal hygiene and bathing and was incontinent of bowel and bladder. Observation on January 27, 2010, at 8:50 a.m., in the resident's room revealed Certified Nurse's Aide (CNA) #1 provided incontinence care to the resident after the resident had voided. Observation revealed CNA #1 positioned the resident on the left side, sprayed peri-wash on the resident's buttocks, and wiped the area with a dry towel. Observation revealed CNA #1 changed the incontinence pad, repositioned the resident in a supine position, and covered the resident with the sheet and blanket. Review of the facility policy, Perineal Care, revealed,""Purpose: Perineal cleansing will be done after incontinent episodes ..."" Interview with CNA #1 on January 27, 2010, at 9:00 a.m., in the resident's bathroom, confirmed the resident had not been cleansed from the front and the incontinence care was incomplete. Interview with the Corporate Nurse in the Director of Nurses office on January 28, 2010, at 8:30 a.m., confirmed the facility policy for providing incontinence care had not been followed.",2014-02-01
14260,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2010-01-28,252,D,,,VI5B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide an odor-free environment for two residents (#8, #17) of twenty-five residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had bowel and bladder incontinence daily, and required extensive assistance with personal hygiene and bathing. Review of the nurse's note dated January 5, 2010, revealed,"" ...Remains totally incontinent and urinates on each turn also - Has a constant dribble and foul smell to urine. Often with loose stools ..."" Review of the nurse's note dated January 13, 2010, revealed,"" ...Foul odor to urine ..."" Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance for transfers, and was dependent on staff for personal hygiene and bathing. Continued review of the same MDS revealed the resident was incontinent of bowel and bladder daily. Observation during the initial facility tour on January 26, 2010, at 10:20 a.m., revealed resident #8 and #17 were roommates. Observation at this time revealed a strong, stale, pungent, urine odor present in the residents' room. Observation on January 26, 2010, at 1:30 p.m., and January 27, 2010, at 8:50 a.m., revealed the strong, stale, urine odor remained. Observation on January 27, 2010, at 8:50 a.m., revealed resident #17 and resident #8 had breakfast trays on their over-bed tables. Observation revealed resident #17 complained twice about the odor stating, ""It is not very appetizing trying to eat when it smells so bad."" Interview with Licensed Practical Nurse #1 on January 27, 2010 at 9:30 a.m., at the 200 hall nurses station, confirmed the room of resident #8 and #17 had a chronic foul odor; sometimes worse than others. Interview on January 27, 2010, at 4:45 p.m., in the hall, with a family member, confirmed,"" ...the room has had a foul odor for sometime ..."" Continued interview confirmed the family member visited resident #17 on a weekly basis.",2014-02-01
14261,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2010-01-28,312,D,,,VI5B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nail care for one (#6) of twenty-five residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory and required assistance with all activities of daily living including nail care. Observation on January 26, 2010, at 10:30 a.m., in the resident's room revealed the resident in bed receiving a bed bath from a Certified Nurse Assistant. Observation on January 27, 2010, at 9:15 a.m., and 1:00 p.m., in the resident's room revealed the resident in bed, eyes closed, and scratching the nose with the right index fingernail. Observation revealed the fingernail was jagged and soiled with dark debris under the fingernail tip. Observation revealed the remaining fingernails on the right hand also had dark debris under the finger nails; the left hand was under the covers. Observation on January 28, 2010, at 12:15 p.m., in the resident's room revealed the resident in bed feeding self with the right hand using the fingers and a fork; the five right hand finger nails were soiled with dark debris; and the index finger nail was jagged; the left hand middle and thumb nails were soiled with dark debris. Interview on January 28, 2010, at 12:20 p.m., with Licensed Practical Nurse #2 in the resident's room confirmed the resident's finger nails were soiled with dark debris and required cleaning and trimming.",2014-02-01
14262,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,431,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure medications were dated when opened and failed to ensure expired biologicals were not available for resident use for one of four medication carts and one of two medication rooms. The findings included: Observation of the medication cart on the 300 hall on [DATE], at 8:00 a.m., with LPN #1 (Licensed Practical Nurse) revealed a drawer containing the following multiple stock medications, not dated when opened: Aspirin 325 mg 125 tablets, ,[DATE] full; Colace Stool Softener 100 tablets, ,[DATE] full; Tussin DM Sugar Free Cough medicine 4 ounces, ,[DATE] full; Aspirin 325 mg 100 tablets, ? full; Enulose one pint, ,[DATE] full; Pepto 8 ounces, ? full; Liquid Acetaminophen 16 ounces more than ? full; Docusate 16 ounces, more than ? full. Observation of a drawer on the cart revealed a glucometer kit (to check blood sugar) containing glucometer strips with an expiration date of March, 2010, and dated as opened [DATE]. Interview with LPN #1 on [DATE], at 8:00 a.m., on the 300 hall confirmed the stock medications had not been dated when opened and the glucometer strips were expired and had been used for a resident's blood sugar checks. Observation of the medication room on the 300 and 400 hall on [DATE], at 8:15 a.m., revealed the following expired biologicals and undated medications: Glucometer strips with an expiration date of March, 2010; Stomahesive (for ostomy bag changes) one ounce expired September, 2009; Hemoccult (to check for blood in stool) 15 mL expired March, 2009; and, in the refrigerator, one Humulin-R insulin ? full, not dated when opened. Interview with the wound care nurse on [DATE], at 8:15 a.m., in the 300 and 400 hall medication room, confirmed the biologicals had expired and were available for resident use. Interview with the Director of Nursing (DON) on [DATE], at 8:20 a.m., in the 300 and 400 hall medication room, confirmed the insulin had not been dated when opened. Interview with the DON on [DATE], at 8:40 a.m., confirmed stock medications and insulin are to be dated when opened.",2014-02-01
14263,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,246,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to place the call light within reach for three residents (#16, #17, #18) of twenty-one residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated May 22, 2010, revealed ""Risk for Falls"" and ""keep call light within my reach."" Observation on May 24, 2010, at 6:10 p.m., revealed the resident in bed with the call light draped over a reclining chair near the bed and out of reach of the resident. Interview with the Director of Nursing on May 26, 2010, at 9:15 a.m., in the Administrator's office confirmed the call light is to be within reach of the resident. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated March 1, 2010, revealed ""ADL's"" (activities of daily living) and ""Please keep my call light within my reach."" Observation on May 24, 2010, at 6:15 p.m., revealed the resident in bed with the call light cord draped across the foot board of the bed and out of the resident's reach. Continued interview with the resident revealed the resident was unable to reach the cord and ask the surveyor to please move the cord near the resident's left side. Interview with the Director of Nursing on May 26, 2010, at 9:15 a.m., in the Administrator's office confirmed the call light is to be positioned within reach of the resident. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated February 24, 2010, revealed ""ADL's"" and ""please keep call light within my reach."" Observation on May 24, 2010, at 6:20 p.m., revealed the resident in bed with the call light cord draped across the foot board of the bed and out of the resident's reach. Interview with the Director of Nursing on May 26, 2010, at 9:15 a.m., in the Administrator's office confirmed the call light is to be positioned within reach of the resident.",2014-02-01
14264,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,157,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and interview, the facility failed to notify the physician of low finger stick blood sugar (FSBS) levels and/or high FSBS for three residents (#2, #13, #10) of twenty-one sampled residents. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders For April and May of 2010, revealed, ""...FSBS AC (before meals) and HS (at bedtime) ...Sliding scale insulin with [MEDICATION NAME] SQ (subcutaneous injection) as follows: 400=12 units and call MD..."" Medical record review of the Diabetic Monitoring Log revealed the resident had a FSBS of 44 on April 10, 2010, at 5:30 p.m., a FSBS of 56 on April 11, 2010, at 7:00 a.m., a FSBS of 55 on April 11, 2010, at 5:30 p.m., a FSBS of 54 on April 12, 2010, at 5:30 p.m., and a FSBS of 54 on May 1, 2010 at 11:00 a.m. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders for April and May of 2010, revealed ""...FSBS AC (before meals) and HS (at bedtime) ...Sliding scale insulin with [MEDICATION NAME] SQ (subcutaneous injection) as follows: 400=12 units and call MD..."". Medical record review of the Diabetic Monitoring Log revealed the resident had a FSBS of 42 on April 2, 2010, at 4:20 a.m., a FSBS of 44 on April 8, 2010, at 1:20 a.m., and a FSBS of 56 on April 22, 2010, at 7:00 a.m. Review of facility policy Insulin Administration revealed ""...5. Physician to be notified of blood sugars below 60 or above 200 unless there is a specific order addressing blood sugars outside these ranges or directing otherwise..."" Interview with the DON (Director Of Nursing) in the DON office on May 25, 2010, at 3:00 p.m., confirmed the facility had failed to notify the physician of the low blood sugars. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's March, April and May 2010, Physician Recapitulation Orders revealed, ""FSBS AC & HS (finger stick blood sugars before meals and at bedtime)"" and ""Sliding scale insulin with [MEDICATION NAME] SQ as follows: (greater than) 400 = 10 units."" Medical record review of the resident's Diabetic Log dated April 2010, revealed a low FSBS of 56 on April 18, 2010, at 11:00 a.m. Medical record review of the resident's Diabetic Logs dated March 2010, and April 2010, revealed the following high FSBS: March 26, 2010, at 7:00 a.m., 423 and 11:00 a.m., 477; March 27, 2010, at 11:00 a.m., 471; March 28, 2010, at 8:00 p.m., 415; March 30, 2010, at 11:00 a.m., 484 and 5:00 p.m., 457; April 3, 2010, at 8:00 p.m., 431; April 7, 2010, at 5:00 p.m., 422; and April 22, 2010, at 5:00 p.m., 413. Review of facility policy Insulin Aadministration revealed ""...5. Physician to be notified of blood sugars below 60 or above 200 unless there is a specific order addressing blood sugars outside these ranges or directing otherwise..."" Interview with the DON in the Conference Room on May 25, 2010, at 10:30 a.m., confirmed the facility had failed to notify the physician of the low and high blood sugars.",2014-02-01
14265,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,176,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure assessment for self-administration of medications was completed for one resident (#10) of twenty-one residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation of a medication pass on May 24, 2010, at 8:20 p.m., with RN #1 (Registered Nurse), revealed the RN entered the resident's room and administered oral medications to the resident, applied an ointment to the resident's cheeks, and left a plastic medicine cup with [MEDICATION NAME] cream 0.01% setting on the resident's over bed table. Interview with RN #1 on May 24, 2010, at 8:40 p.m., on the 200 hall confirmed the [MEDICATION NAME] cream was left on the resident's over bed table for the resident to self-administer when ready. Interview with the Director of Nursing on May 24, 2010, at 9:05 p.m., at the 200 hall nursing station, confirmed the resident had not been assessed for self-administration of medications and medications were not to be left in the resident's room.",2014-02-01
14266,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,323,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety alarm was in place for one resident (#3) of twenty-one residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory problems, moderately impaired cognitive skills for daily decision making, and required assistance with most activities of daily living. Medical record review of a Falls Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the Care Plan dated March 25, 2010, revealed ""...alarms after supper to remind me to call for help..."" Medical record review of a Post Falls Nursing assessment dated [DATE], 8:00 p.m., revealed ""...Patient was found sitting on floor with call light in hand by bedside...was reaching for lotion on the bedside table when...slipped from bed to floor..."" Review of a facility fall investigation form dated May 17, 2010, revealed ""...no alarms on when the incident occurred..."" Observation on May 24, 2010, at 8:15 p.m. revealed the resident in bed, the bed in the lowest position, pressure pad alarm on the bed and activated. Interview with LPN (Licensed Practical Nurse) #1, on May 26, 2010, at 10:25 a.m., confirmed the resident did not have the pressure pad alarm in place at the time of the fall on May 17, 2010.",2014-02-01
14267,KINDRED NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2010-10-19,323,G,,,HD6911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, observation, and interview, the facility failed to provide supervision and/or ensure safety devices were in place for two residents (#1 and #5) of eleven residents reviewed. The facility's failure resulted in harm to resident #1. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was severely impaired cognitively; required two people for transfer; required extensive assistance with Activities of Daily Living (ADLs); was fed; and was incontinent of bowel and bladder. Medical record review of a nurse's note dated August 24, 2010, revealed ""Called to room by CNA (Certified Nursing Assistant). Resident on floor on left side, facing away from window. Laceration to center of forehead. Blood pressure 220/119. Pressure alarm sounding."" Continued medical record review revealed the resident was transferred to the hospital for evaluation and treatment. Medical record review of a hospital discharge summary dated August 26, 2010, revealed the resident suffered a ""C1 (first cervical vertebra) impaction fracture with mild displacement of left lateral mass."" Continued medical record review of the hospital discharge summary revealed ""...did not feel (resident) was a candidate for any further treatment in terms of...fracture...did feel it would be best to keep (resident) in a collar as best (resident) can tolerate...however, if the collar did become uncomfortable or started to cause pressure sores, it could be discontinued with the understanding that (resident) could wind up with a catastrophic spinal cord injury..."" Medical record review revealed the resident was readmitted to the facility on [DATE]. Review of the facility investigation dated August 24, 2010, revealed an untimed interview with CNA #1 on August 24, 2010, ""went into the room to get tray, resident's chair was reclined all the way back when I left room."" Continued review revealed an untimed interview with the Activities Director dated August 26, 2010, which stated ""Passed room I noted ... was facing window with chair reclined."" Further review revealed an untimed interview with CNA #2 dated August 24, 2010, which stated, ""Brought resident out of dining room and took to room. Picked up tray and chair was reclined all the way back."" Continued review revealed an untimed interview with the Registered Nurse dated August 24, 2010, who stated ""Resident was lying on floor beside air conditioner on left side. Head turned on left side. Area 6""-9"" blood pooled around head, face. Right hand laying flat in it. Turned resident on back. Left upper sleeve was soaked with blood. Cut blouse off and had large area that skin was all gone. All bleeding areas cleaned and wrapped."" Further review revealed an untimed interview with the Maintenance Director dated August 24, 2010, who stated ""Chair was in proper working order."" Observation of the resident on October 4, 2010, at 1:10 p.m., revealed the resident lying in bed on a pressure-relieving mattress on the back with a soft cervical collar in place. Continued observation revealed the resident did not respond to verbal comments. Observation of the resident on October 5, 2010, at 11:30 a.m., revealed the resident in bed with the head of the bed raised and the sitter beginning to feed lunch. Further observation revealed the resident was eating a puree diet and was able to utter some comments about lunch. Interview with the Director of Nursing (DON) on October 5, 2010, at 3:50 p.m., in the Wound Care Nurse's office, revealed prior to the accident, the resident would ""whip (resident) legs over the side of the geri chair. The resident was kept out at the nursing station so (resident) could look around and staff could keep an eye on the resident. The (resident's) daughter had said if (resident) got too noisy in the dining room, just to take (resident) to room and let (resident) look out window...that usually calms for a while..."" Further interview with the DON revealed on August 24, 2010, ""the resident was particularly rambunctious (noisy, yelling out) in the dining room so the CNA took the resident to the resident's room to look out the window (not the nurse's station where the resident could be observed). Further interview with the DON revealed the Maintenance Director walked past the resident's room and noted the resident to be on the floor. Interview with the DON and Administrator on October 6, 2010, at 5:00 p.m., in the Administrator's office, revealed the resident was able to throw legs over the side of the geri chair but was unable to stand. Continued interview confirmed the resident was left alone in the room and the resident was not supervised or observed by staff resulting in a fall from the gerichair requiring hospitialization for a cervical fracture. Resident #5 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. edical record review of the MDS dated [DATE], revealed the resident had short and long term memory deficits; required assistance with ADLs; was occasionally incontinent of bowel and frequently incontinent of bladder; was independent with eating. Medical record review of a nursing note dated September 5, 2010, revealed ""...sitting on floor six feet from w/c (wheelchair). Shut alarm off. Got out of w/c. Feet tangled when turned around."" Continued medical record review of a nursing note dated September 9, 2010, revealed ""Sitting on floor in front of w/c leaning into seat. Was trying to scoot back in w/c and chair rolled. Alarm in place on w/c."" Medical record review of a nursing note dated September 10, 2010, revealed ""Sit on floor of bathroom. Was trying to get to bathroom but lost balance and fell . No shoes or socks. Pressure alarm to be placed in bed and chair."" Medical record review of a nursing note dated September 19, 2010, revealed ""Sit on bathroom floor near toilet. 'I got up to go to bathroom and missed toilet.' BM (bowel movement) on floor. Pressure alarm in place. Unplugged and turned off alarm."" edcial record review of a nursing note dated September 22, 2010, revealed ""Lying on floor in hallway. Was trying to walk and fell . Alarm box on w/c, not bed."" Interview with the DON on October 5, 2010, at 2:30 p.m., in the Wound Care Nurse's office, revealed the resident ""goes through spells without falls then starts again. The resident gets belligerent and says 'I can do this.'"" Continued interview with the DON revealed the DON was unaware how long it had been since Physical Therapy worked with the resident. Further interview with the DON confirmed the resident turned off or removed alarms so the alarms could not alert staff of unassisted transfers by the resident resulting in frequent falls. COMPLAINT #",2014-02-01
14268,KINDRED NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2010-10-19,280,D,,,HD6911,"**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 to include essential information to provide care for one resident (#1) of eleven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was severely impaired cognitively; required two people for transfer; required extensive assistance with Activities of Daily Living (ADLs); was fed; and was incontinent of bowel and bladder. Medical record review of a nurse's note dated July 14, 2010, July 15, 2010, July 20, 2010, August 1, 2010, and August 3, 2010, revealed ""...up in geri chair..."" and ""..at nurse's station..."" Medical record review of a nursing note dated August 24, 2010, revealed ""Called to room by CNA (Certified Nursing Assistant). Resident on floor on left side, facing away from window. Laceration to center of forehead. Blood pressure 220/119. Pressure alarm sounding."" Continued medical record review revealed the resident was transferred to the hospital for evaluation and treatment. Medical record review of a hospital discharge summary dated August 26, 2010, revealed the resident suffered a ""C1 (first cervical vertebra) impaction fracture with mild displacement of left lateral mass."" Continued medical record review of the hospital discharge summary revealed ""...did not feel (resident) was a candidate for any further treatment in terms of...fracture...did feel it would be best to keep (resident) in a collar as best (resident) can tolerate...however, if the collar did become uncomfortable or started to cause pressure sores, it could be discontinued with the understanding that (resident) could wind up with a catastrophic spinal cord injury..."" Medical record review revealed the resident was readmitted to the facility on [DATE]. Medical record review of the current care plan updated September 9, 2010, revealed a problem of ""Risk for falls/injury as evidenced by h/o (history of) falls, nonambulatory, dependent for transfers, incontinent of B&B (bowel and bladder), receives [MEDICAL CONDITION] and pain medications...2/17/2009 Keep bed in lowest position for safe transfers...06/18/2009 Falling stars program...09/22/2009 use hoyer lift & 2 staff for all transfers...08/13/2009 fall intervention: pressure alarm at all times...bolsters on bed..."" Interview with the Director of Nursing (DON) on October 5, 2010, at 3:50 p.m., in the Wound Care Nurse's office, revealed prior to the accident, the resident would ""whip (resident) legs over the side of the geri chair. The resident was kept out at the nursing station so (resident) could look around and staff could keep an eye on the resident. The (resident's) daughter had said if (resident) got too noisy in the dining room, just to take (resident) to room and let (resident) look out window...that usually calms for a while..."" Further interview with the DON revealed on August 24, 2010, ""the resident was particularly rambunctious (noisy and yelling out) in the dining room so the CNA took the resident to the resident's room to look out the window. Medical record review of the care plan revealed no mention the resident would sit up in a geri chair or the chair needed to be reclined to prevent falls. Further review of the care plan revealed the statement ""Pressure alarm at all times"" but does not state whether that is to be in bed or in the chair or both. Continued review of the care plan revealed no approach of placing the resident in the room to look out the window when the resident became too noisy in the dining room. Further review of the care plan revealed no documentation of the fact the resident has a cervical collar in place or the need for specific care to prevent skin breakdown under the collar. Continued review of the care plan revealed no documentation the resident would whip legs over the side of the geri-chair, increasing the fall risk. Continued interview with the Director of Nursing (DON) on October 5, 2010, at 3:50 p.m., in the Wound Care Nurse's office, revealed the DON was unaware of the omissions on the care plan but confirmed the issues should have been addressed. COMPLAINT # .",2014-02-01
14269,KINDRED NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2010-10-19,279,D,,,HD6911,"**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 based on data from the Minimum Data Set for one resident (#6) of eleven residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had moderately impaired cognition but could answer simple yes/no questions; was independent with Activities of Daily Living (ADLs); was independent with eating, transfers, and ambulation. Medical record review of the current care plan, dated July 7, 2010 revealed the resident required extensive assistance with bathing and limited assistance with dressing. Interview with two random Certified Nursing Assistants on October 4, 2010, at 3:30 p.m., revealed the resident was independent with all ADLs and able to walk all about the facility. Interview with the DON on October 5, 2010, at 3:30 p.m., revealed the DON was unaware the care plan stated the resident needed extensive assistance and confirmed the resident was independent in all ADLs. COMPLAINT #",2014-02-01
14270,KINDRED NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2010-10-19,226,D,,,HD6911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, facility policy review, and interview, the facility failed to complete a timely and thorough investigation of an injury of unknow source for one resident (#6) of eleven residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had moderately impaired cognition but could answer simple yes/no questions; was independent with Activities of Daily Living (ADLs); was independent with eating, transfers, and ambulation. Medical record review of a nursing note dated February 15, 2010, revealed ""Heard loud noise outside res. (resident's) door. Res. slamming both fists on side table."" Continued medical record review of a nursing note dated February 23, 2010, revealed ""Hitting at bed and stomping feet."" Medical record review of a Behavior Monitoring Log dated July 25, 2010, revealed ""Hitting self and furniture in room with hands. Laying down on bed; picking up legs with hands on thighs and slamming legs on bed. When standing up, pounding on sides and buttocks. Was told to stop - that behavior was not acceptable and could cause harm. Then resident sat down on bed; grabbed both inner thighs; and slammed legs down on bed."" Medical record review of a nursing note dated July 31, 2010, revealed ""Multiple bruises to bilateral thigh area. Bruises appear to be healing. Attempted to notify brother. Message left."" Review of a facility event report dated July 31, 2010, revealed ""...Injury of unknow source...Injury to self...hits self...circumstances unknown..bruise...bilateral thigh..."" Continued review revealed the DON was unaware of the bruising since the DON had been out of town from July 31, to August 3, 2010, and scheduled a meeting with the resident's brother for August 3, 2010, to review concerns expressed by the brother. Continued review revealed during the meeting the resident was brought to the DON's office and on examination the DON noted a large pale green bruised area on the left anterior thigh with several smaller pale green in color on the inside and top of the right thigh. Further review of the investigation revealed ""...when i asked resident how bruises got there, (resident) said 'boy'...when I asked what the boy looked like...big or little...(resident) showed me with...hand, low to the floor...approximately 1-2 feet in height...when I asked color of hair (resident) pointed to my desk top which is light green...earlier in AM...I received documentation from night supervisor regarding (night supervisor's statement dated July 31, 2010) about resident's brothers conversation with (name nurse on night shift)...that resident told...brother that boy did it...brother asked (nurse) if there was a boy working that shift and (nurse) said 'oh you mean (name)(referring to CNA #1)?'"" Review of the facility's ""Abuse"" policy under ""Compliance Guidelines"" #2 revealed ""Injuries of an unknown source are reported and investigated in accordance with this policy and its supporting procedures."" Interview with the DON on October 5, 2010, at 3:30 p.m., in the Wound Care Nurse's office, revealed the resident liked to sit on the bed; legs folded under, yoga style; and slap thighs. Continued interview with the DON revealed CNA#1 was not interviewed because the CNA was not working the night of July 30, 2010, but did work 10:00 p.m. to 6:00 a.m., on July 25, 26, 27, and 29; 6:00 p.m. to 6:00 a.m. on July 28. Interview with the DON revealed the bruises were fresh so the incident had to have occurred on July 31, 2010. Further interview with the DON revealed CNA#1 was not assigned to the resident so the CNA was not considered as abusing the resident. Further interview with the DON revealed the resident frequently hit both thighs and that this was felt to be the cause of the bruising. Review of nurses notes verified this was an on-going behavior of the resident. Continued interview with the DON revealed the facility failed to follow their abuse policy to fully investigate timely an injury of unknown origin by interviewing all staff that had worked on the same unit the resident resided on. Interview with two random CNAs on October 18, 2010, at 9:15 a.m., in the nursing station, revealed no voiced concerns related to CNA #1's treatment of [REDACTED].#1 had cared for the residents on nights. Telephone interview with LPN #1 on October 19, 2010, at 8:45 a.m., revealed the LPN had no voiced concerns with the care CNA #1 provided and revealed the LPN felt ""100% that...was not capable of abusing residents."" COMPLAINT #",2014-02-01
14271,KINDRED NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2010-01-27,508,D,,,S2CF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure an x-ray was completed for one (#6) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted the facility on August 3, 2009, with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated December 30, 2009, revealed ""Resident noted to have very congested cough with thick yellow sputum...order obtained for chest x-ray..."" Medical record review of a chest x-ray dated December 30, 2009, revealed ""Impression:...probable left pleural effusion and left retrocardiac opacity that may represent atelectasis versus infiltrate."" Medical record review of a physician's orders [REDACTED]."" Medical record review revealed no documentation a repeat chest x-ray had been completed after December 30, 2009. Interview on January 25, 2010, at 2:25 p.m., with the Director of Nursing, in the conference room, confirmed the repeat chest x-ray ordered on December 30, 2009, was not completed.",2014-02-01
14272,KINDRED NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2010-01-27,281,D,,,S2CF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to discontinue a medication as ordered by the physician for one (#6), and failed to ensure a fluid restriction was followed for one (#24) of twenty-nine residents reviewed. The Findings included: Resident #6 was admitted the facility on August 3, 2009, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems and moderately impaired cognitive skills. Medical record review of a physician's orders [REDACTED]. Observation on January 26, 2010, at 2:20 p.m., revealed the resident lying on the bed, receiving oxygen at two liters per minute via a nasal cannula. Interview with the resident, at the time of the observation, revealed the resident was not experiencing any pain. Interview on January 25, 2010, at 1:10 p.m., with the Director of Nursing, in the conference room, confirmed the [MEDICATION NAME] was not discontinued as ordered by the physician. Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]...1000 ML (milliliter) Fluid Restriction: Dietary to send 120 ML w/Ea (with each) meal...100 ML to be given at HS (bedtime) w/snack...Nursing to use 540 ML: 90 ML w/ea med pass (medication administration)."" Medical record review of the Intake and Output Records dated September 1, 2009, through January 27, 2010, revealed ""...12/9/09 24 HR. (hour) Total PO (by mouth) intake 1160...12/11/09 Total PO intake 1220...12/15/09 Total PO intake 1280...12/22/09 Total PO intake 1210...1/4/10 Total PO intake 1130...1/7/10 PO intake 220 plus 600 plus 240 Total 860 (Corrected total amount 1060)...1/19/10 Total PO intake 450 plus 870 Total 1020 (Corrected total amount 1320)...1/20/10 Total PO intake 1280...1/21/10 Total PO intake 1310...1/25/10 Total PO intake 1240..."" Interview on January 27, 2010, at 12:45 p.m., with LPN #6 (Licensed Practical Nurse), at the nursing station, confirmed the facility failed to assure and monitor the resident only received 1000 milliliters of fluids by mouth a day.",2014-02-01
14273,KINDRED NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2010-01-27,502,D,,,S2CF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain laboratory studies for three ( #1, #2, #10) of twenty-nine residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the January 2010 Physician's Recapitulation Orders revealed an order initiated June 30, 2009, for a lab study of CBC (Complete Blood Count) to be done every 6 months (June and December). Medical record review of the laboratory results revealed no documentation of the CBC analysis for December 2009. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the January 2010 Physician's Recapitulation Orders revealed an order initiated February 22, 2008, for a lab study of Hemoglobin A1C (to monitor diabetic therapy) to be done every 3 months (February/May/August/November). Medical record review of the laboratory results revealed no documentation of the Hemoglobin A1C analysis for November 2009. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the January 2010 Physician's Recapitulation Orders revealed an order for [REDACTED]. Interview with the Unit Manager at the 200 Hall Nurses station on January 25, 2010, at 1:25 p.m., confirmed the facility failed to obtain the laboratory studies for residents #1, #2, and #10 as ordered by the physician.",2014-02-01
14274,KINDRED NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2010-01-27,323,D,,,S2CF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were functional or in the lowest position for three (#6, #13, #14) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted 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, moderately impaired cognitive skills, required extensive assistance with transfers/ambulation, and had fallen in the past ,[DATE] days. Medical record review of the current Care Plan reviewed on [DATE], revealed ""...Resident is at risk for falls...alarms to bed/chair..."" Observation on [DATE], at 9:00 a.m., revealed the resident lying on the bed with a pressure pad alarm in place, however, the alarm box was not activated. Observation and interview, on [DATE], at 9:15 a.m., with Licensed Practical Nurse (LPN) #1 revealed the resident lying on the bed, with a pressure pad alarm in place, and confirmed the alarm was not turned on/activated. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, and moderately impaired cognitive skills for daily decision making. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the physician's recapitulation orders dated [DATE], revealed, "" ...Pressure Alarm On When Resident in Bed... "" Medical record review of the Care Plan dated [DATE], revealed, ""...pp (pressure pad) alarm in bed..."" Observation on [DATE], at 1:50 p.m., revealed the resident entered the bathroom and closed the door. Continued observation with RN #2 revealed a pressure pad alarm on the bed, but not sounding. Further observation of the pressure pad alarm revealed, "" Six month thin bed sensor pad"", dated [DATE], in black marker. Interview on [DATE], at 1:50 p.m., with RN #2, in the resident's room, confirmed the pressure pad alarm was not sounding, and the sensor pad had expired. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems with severely impaired cognitive skills for daily decision making. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the physician's recapitulation orders dated [DATE], through February 10, 2010, revealed, ""...Low Bed with mat ..."" Medical record review of the care plan dated [DATE], revealed, ""...Low Bed..."" Observation on [DATE], at 10:45 a.m., with LPN #4, revealed the resident lying in the bed. Observation revealed the bed was not in the low position. Interview at this time with LPN #4, in the resident's room, confirmed the bed was not in the low position.",2014-02-01
14275,KINDRED NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2010-01-27,176,D,,,S2CF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for self-administration of medications for one (#6) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems and moderately impaired cognitive skills. Medical record review of the January 2010, physician's recapitulation orders revealed the resident was to receive [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) and Atrovent ([MEDICATION NAME][MEDICATION NAME]) by a nebulizer treatment. Medical record review revealed no documentation the resident had been assessed for self-administration of medications. Observation on January 25, 2010, at 9:00 a.m., revealed the resident lying on the bed, unattended, with a mask over the nose and mouth, receiving a nebulizer treatment. Continued observation revealed the resident used the left hand to try to remove the mask. Observation and interview on January 25, 2010, at 9:15 a.m., with Licensed Practical Nurse (LPN) #1 revealed the resident lying on the bed receiving the nebulizer treatment, and confirmed LPN #1 had initiated the nebulizer treatment then left the resident unattended. Interview on January 25, 2010, at 1:10 p.m., with the Director of Nursing, in the conference room, confirmed the resident had not been assessed for self-administration of medications.",2014-02-01
14276,KINDRED NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2010-01-27,514,E,,,S2CF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, observation and interview, the facility failed to maintain complete documentation of fluid intake for five (#15, #23, #24, #27, #28,) of 29 sampled residents. The finding included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed physician's orders [REDACTED]. Observation in the resident's room, on January 25, 2010, at 10:30 a.m., revealed a posted sign indicating fluid restriction. Review of the facility's policy for fluid intake and output revealed that intake and output measurements are to be recorded for residents if there is a physician's orders [REDACTED]. Interview with the Director of Nursing on January 25, 2009, on the D Hall, confirmed the fluid intake records were incomplete. Resident #23 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Medical record review revealed physician's orders [REDACTED]. Review of the ""Comprehensive Intake and Output Record"" revealed incomplete documentation of fluid intake for sixty days from October 19, 2009, through December 28, 2009. Interview with the Director of Nursing on January 27, 2010, on the D Hall, confirmed the fluid intake records were incomplete. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Telephone Orders dated November 13, 2009, revealed an order to increase fluid restriction to 1500 ml per day. Medical record review of the Comprehensive Intake-Output Records revealed no documentation of the fluid intake from November 16, 2009, until December 1, 2009. Interview at the nurses' station on January 26, 2010, at 4:10 p.m., with the 200 Hall Unit Manager, revealed the ""intake should be recorded each day,"" and verified there was no documentation of the the resident's intake for the 15 day period from November 16 - December 1, 2009. Continued interview confirmed the facility failed to complete the intake record. Resident #28 was readmitted to the facility January 7, 2010, with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]."" Medical record review of the current care plan and dated January 25, 2010, revealed ""...1500 ml fluid restriction...480 ml from dietary...1020 ml free fluid @ (at) bedside ...res. (resident) prefers sprite to drink...use bedside allowed fluids with med passes..."" Medical record review of daily Intake and Output sheets dated January 8, 2010, through January 26, 2010, revealed no entries for day shift on January 12 through January 14, 2010, January 16, 2010, and no 24 hour Intake/output totals entered for January 8, 2010 through January 16, 2010. Interview with LPN # 6 (Licensed Practical Nurse) confirmed the facility failed to maintain accurate and complete documentation of the resident's intake and output. Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Intake and Output Records dated September 1, 2009, through January 27, 2010, revealed no intake recorded on first shift for 61 of 149 days. Interview with LPN #6 on January 27, 2009, at 9:55 a.m., at the nursing station, confirmed the facility failed to maintain accurate and complete documentation of the resident's intake.",2014-02-01
14277,LIFE CARE CENTER OF JEFFERSON CITY,445275,336 WEST OLD ANDREW JOHNSON HWY,JEFFERSON CITY,TN,37760,2010-01-13,315,D,,,NRDI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility policy, observation, and interview, the facility failed to complete a bladder training assessment for one (#20) of thirty-three residents reviewed. The findings included: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory problems, no long term memory problems, and moderately impaired cognitive skills for daily decision making. Medical record review of a physician's order dated October 20, 2009, revealed, ""...D/C (discontinue) foley (catheter to drain bladder)...timed toileting program ... "" Medical record review of the urinary incontinence questionnaire (undated) revealed, ""...Bladder: Are you incontinent Occasionally..."" Medical record review of the Assessment for Bowel and Bladder Training dated December 31, 2009, revealed, ""...Mentally aware of toileting needs ...sometimes ...(total score of 14) ...7-14 Candidate for toileting, timed or scheduled voiding ... "" Medical record review of a urinary incontinence assessment (undated) revealed, "" ...Perform a 3 day Bladder Flow Record to assist with choice of Program ...scheduled toileting ...scheduled toileting at regular intervals on a planned basis to match the resident's voiding habits ..."" Review of the facility policy, Guidelines to Assessment, revealed, ""...complete the Assessment for Bowel and Bladder training if the resident is incontinent to determine if the resident is a candidate for individual training or timed/scheduled toileting...the resident will be placed in a bladder program appropriate for the resident ..."" Observation on January 13, 2010, at 7:55 a.m., revealed the resident lying in the bed. Interview on January 13, 2010, at 12:30 p.m., with the Director of Nursing, at the nursing station, confirmed no documentation a three day voiding pattern had been completed.",2014-02-01
14278,LIFE CARE CENTER OF JEFFERSON CITY,445275,336 WEST OLD ANDREW JOHNSON HWY,JEFFERSON CITY,TN,37760,2010-01-13,323,D,,,NRDI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility investigation, observation, and interview, the facility failed to ensure a safety device was in place for one (#4) of thirty-three residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, with severely impaired cognitive skills for daily decision making. Medical record review of the fall risk evaluation dated November 2, 2009, revealed the resident was at risk for falls. Medical record review of the nurse's note dated November 14, 2009, revealed, "" ...Resident's self-release chair alarm is not working correctly ..."" Medical record review of a physician's orders [REDACTED]. Review of the facility investigation dated November 15, 2009, revealed, ""...found resident sitting in floor of BR (bathroom) (with) SR (self-release) belt off (no) injury ..."" Medical record review of a physician's orders [REDACTED]. Observation on January 12, 2010, at 8:25 a.m., revealed the resident sitting in the wheelchair, in front of the nursing station, with a self release chair alarm in place. Interview on January 13, 2010, at 12:30 p.m., with the Director of Nursing, at the nursing station, confirmed the safety device was not in place at the time of the fall on November 15, 2009.",2014-02-01
14279,LIFE CARE CENTER OF JEFFERSON CITY,445275,336 WEST OLD ANDREW JOHNSON HWY,JEFFERSON CITY,TN,37760,2010-01-13,431,D,,,NRDI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of current Individual Patient's Controlled Substances Record, review of facility policy, and interview, the facility and licensed pharmacist failed to establish a system of records of disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for seven (Resident #29,#30,#31,#32,#17,#11,#33) of thirty-three sampled residents. The findings included: Review of Facility Policy ""Clinical Services Policies & Procedures, Nursing Volume l Policies for Medication Administration, Chapter 12"" Controlled Drugs...Standard...A "" controlled drugs proof of use sheet"" is accurately maintained on all residents requiring controlled medications. Strict control of narcotics is always maintained...Policy ...Appropriate storage, recording, and use of controlled drugs are always maintained on all units. Narcotic proof of use sheet is accurately maintained on all residents requiring such medication...Procedure...4. The nurse signs off each dose of the controlled drug given by documenting: a. Date. b. Hour. c. Resident name d. Physician. e. Amount dispensed. f. Signature of nurse. g. Balance after subtracting amount dispensed...5. The nurse handling the controlled drug must follow the procedure in the event a dose is broken, partially used, discarded, or lost. a. The nurse records broken, partially used, or lost dose on the ""proof of use sheet. b. The nurse and another nurse co-sign the "" proof of use sheet."" c. Two licensed nurses must witness the destruction of a controlled substance ...7. Narcotics are counted at the change of each shift by the off-going and the on-coming nurse and both sign the Change of Shift Count Record...c. If the count is incorrect, notify the supervisor and pharmacist...NOTE: The nurse remains on duty until the count is reconciled or the supervisor has given permisison to leave. d. The supervisor notifies the DON and security if necessary. Review on January 11, 2010, between 12:13 p.m., and 2:40 p.m., of Individual Patient's Controlled Substances Records revealed the following: Review of Resident #29 Individual Patient's Controlled Substances Record and prescription label with dispensing date of December 24, 2009, revealed: Alprazolam 1 milligram (mg) tablet (Control Substance IV medication for anxiety) with the directions to take one tablet by mouth every six hours as needed for anxiety. The review was conducted with LPN #1 at the Unit One Cart One. Further review of the record revealed one dose of Alprazolam 1 mg tablet was signed out as administered on January 9, 2010, at 3:00 a.m., by RN #1 with the notation that one tablet was pulled and wasted because the resident ""did not want."" Further review revealed the destruction of the wasted dose was not witnessed by another nurse. Interview at the time of the review at the Unit One Cart One with LPN #1, confirmed RN #1 failed to follow facility policy by not documenting another nurse witnessed the destruction of the Alprazolam 1mg tablet. Review of Resident #30 Individual Patient's Controlled Substances Record and prescription label with dispensing date of July 2, 2008, revealed: Lorazepam 2 mg per one milliliter (ml) Injection (Control Substance IV medication for agitation) with the directions to inject 0.5 mg intramuscularly every four hours. The review was conducted with LPN #1 at the Unit One Cart One. Further review of the record revealed one dose of Lorazepam 0.5 mg Injection was signed out as administered on June 18, 2009, at 2:45 p.m. by LPN #2 with the notation ""wasted"". Further review revealed the waste of the remaining 1.5 mg of Lorazepam in the injection was not witnessed by a nurse. Interview at the time of the review at Unit One Cart One with LPN #1, confirmed LPN #2 failed to follow facility policy by not documenting the destruction of the Lorazepam 1.5 mg Injection with another nurse. Review of Resident #31 Individual Patient's Controlled Substances Record and prescription label with dispensing date of January 8, 2010, revealed: Lorazepam 2 mg per one milliliter (ml) vials (Control Substance IV medication for agitation) with the directions to inject 0.5 mg intramuscularly every four hours as needed. The review was conducted with LPN #1 at the Unit One Cart One. Further review of the record revealed one dose of Lorazepam 0.5 mg injection was signed out as administered on December 30, 2009, with the number four (4.) under the column for ""Time""; with a notation 0.5 mg was wasted by LPN # 4 and the waste was witnessed by RN # 1. The remaining 1 mg of the 2 mg/ml injection was not documented as wasted. Further review of the Controlled Substances Record revealed four remaining vials of Lorazepam documented on the record with five vials available for usage. Interview on January 11, 2010, at 1:00 p.m., in the Unit One Nursing Station Medication Room with LPN #1, the Assistant Director of Nursing (ADON), and the DON and during an interview on January 13, 2010, in the Unit One Day Room at 1:30 p.m., with the DON and ADON, confirmed LPN # 4 and RN # 1 failed to witness the destruction of the remaining 1 mg of Lorazepam injection; LPN # 4 failed to follow facility policy by not properly completing the Individual Patient's Controlled Substances Record with the hour of administration and with the entry error; and shift to shift nurses failed to follow facility policy by not notifying the supervisor and pharmacist when the count was incorrect during shift change. The DON and ADON were unaware of the discrepancies since the supervisor and pharmacist were not notified. Review of Resident #32's Individual Patient's Controlled Substances Record and prescription label with dispensing date of January 5, 2010, revealed: Hydrocodone 5 mg with Acetaminophen 500 mg tablet (Control Substance III medication for pain) with directions to take one tablet by mouth every six hours as needed. The review was conducted with LPN #9 at the Unit One Cart Two. Further review of the record revealed one dose was administered on January 5, 2010, at 10:15 p.m., with no documentation of a nurse's signature. Interview at the time of the review at Unit One Cart Two with LPN #9, confirmed the nurse failed to follow facility policy by not signing the administration of the medication. Interview on January 13, 2010, at 8:30 a.m, in the Unit One Day Room with the ADON, identified the nurse as LPN #5 and confirmed LPN #5 failed to follow facility policy by not signing the administration of the dose on the Individual Patient's Controlled Substances Record of Resident #32. Review of Resident #17 Individual Patient's Controlled Substances Record and prescription label with dispensing date of August 26, 2009, revealed: Hydrocodone 5 mg with Acetaminophen 500 mg tablet (Control Substance III medication for pain) with directions to take one or two tablets by mouth every four hours as needed for severe pain. The review was conducted with LPN #9 at the Unit One Cart Two. LPN #9 confirmed the record revealed the following administrations: one tablet each was administered on December 22, 2009, at 1:30 p.m., and on December 26, 2009 at 8 p.m., by LPN #6; one tablet was administered on December 28, 2009, at 12:50 a.m., by LPN #4; and two doses (one each on January 2, 2010, at 10 a.m., and January 3, 2010, at 10 a.m., by LPN #7. Interview on January 13, 2010, at 8:30 a.m, in the Unit One Day Room with the ADON, confirmed a signed and dated physician order [REDACTED]. The ADON confirmed LPNs #6, #4, and #7 documented the administration of five whole tablet doses of Hydrocodone 5 mg with Acetaminophen 500 mg on the Individual Patient's Controlled Substances Record and documented the administration of five half-tablet doses on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s Controlled Substances Record with another . Review of Resident #11 Individual Patient's Controlled Substances Record and prescription label with dispensing date of October 27, 2009, revealed: Lorazepam 1 mg tablet (Control Substance IV medication for anxiety) with the directions to take one tablet by mouth every four hours as needed. The review was conducted with LPN #10 at the Unit Two Cart Three. Further review of the record revealed one dose of Lorazepam 1 mg tablet was signed out as administered with the number ""12."" (twelve) in the ""Date"" column by LPN #6. Interview at the time of the review at Unit Two Cart Three with LPN #10, confirmed LPN #6 failed to follow facility policy by not completing the date column on the Patient's Controlled Substances Record of Resident #11. Review of Resident #33 Individual Patient's Controlled Substances Record and prescription label with dispensing date of December 24, 2009, revealed: Alprazolam 0.25 mg tablet (Control Substance IV medication for anxiety) with the directions to take one tablet by mouth daily at 5 p.m., and take one tablet by mouth every twelve hours as needed for anxiety. The review was conducted with LPN #11 at Unit Two Cart Four. Further review of the record revealed one dose of Alprazolam 0.25 mg tablet was signed out as administered on January 10, 2010, at 6 p.m., by LPN #8 with the following notation, ""dropped on floor stepped on it,"" Further review revealed the destruction was not witnessed. Interview at the time of the review at Unit Two Cart Four with LPN #11, confirmed LPN #8 failed to follow facility policy by not documenting the destruction of the Alprazolam 0.25mg tablet dose with another nurse. Interview on January 13, 2010, at 1:30 p.m., in the Unit One Day Room with the DON and ADON and on January 13, 2010, at 3:30 p.m., by telephone with the Consultant Pharmacist and Consultant Pharmacist Supervisor confirmed the discrepancies.",2014-02-01
14280,LIFE CARE CENTER OF JEFFERSON CITY,445275,336 WEST OLD ANDREW JOHNSON HWY,JEFFERSON CITY,TN,37760,2010-01-13,441,D,,,NRDI11,"Based on observation, policy review, and interview, the facility failed to ensure staff washed the hands after direct resident contact for one (#22) of thirty-three residents reviewed. The findings included: Observation on January 12, 2010, at 9:00 a.m., in the one hundred hallway, revealed CNA #1 (certified nursing assistant) adjusted resident #14's wheelchair footrest. CNA #1 after adjusting the footrest proceeded to pick up a breakfast tray from the meal cart. Further observation revealed CNA#1 took the breakfast tray into resident #22's room; placed the tray on the table; donned gloves; adjusted the resident to the upright position; proceeded to cut resident #22's food; and fed the resident. Review of the Handwashing Information-Handout #2, revealed ...the single most important factor in preventing and controlling infections is that of handwashing. ...Washing Your Hands ...6.Before serving food ....9. After handling the resident's belongings. Interview with the CNA #1 on January 12, 2010, at 9:10 a.m., in the hallway, confirmed the hands were not washed after adjusting the footrest on resident's wheelchair. Interview with the R.N. (registered nurse) supervisor unit #1, on January 12, 2010, at 10:15 a.m., in the hallway, confirmed staff hands are to be washed or disinfected between each resident.",2014-02-01
14281,LIFE CARE CENTER OF JEFFERSON CITY,445275,336 WEST OLD ANDREW JOHNSON HWY,JEFFERSON CITY,TN,37760,2010-01-13,281,D,,,NRDI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the care plan for two residents (#16) of thirty-three residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with Diabetes, End Stage [MEDICAL CONDITION], Hypertension, and [MEDICAL CONDITION]. Medical record review of the physician notes dated January 2010, revealed the resident had a [MEDICAL TREATMENT] access (fistula) (access to use for [MEDICAL TREATMENT]) on the left arm and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan updated October 2009, revealed the care plan did not address the resident's [MEDICAL TREATMENT] access located on the resident's left arm or the practice which requires no needle sticks or blood pressures checks in the arm of the access. Interview with the ADON on January 13, 2010, at 8:05 a.m., at the second unit nurses' station, confirmed the care plan did not address the care of the access for [MEDICAL TREATMENT].",2014-02-01
14282,LIFE CARE CENTER OF EAST RIDGE,445296,1500 FINCHER AVENUE,EAST RIDGE,TN,37412,2010-02-10,309,D,,,1RJR11,"**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 one (#23) of twenty-five residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short/long term memory problems, and was independent in cognitive skills for daily decision making. Medical record review of the hospital transfer physician's orders dated September 5, 2009, revealed, ""[MEDICATION NAME] (blood pressure) 1 mg...po (by mouth) BT (bedtime)[MEDICATION NAME] XL (blood pressure)...90 mg po BT..."" Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of a physician's order dated September 6, 2009, revealed, ""...Clarification of med (medication) administration times per pt (patient) [MEDICATION NAME] XL 90 mg po daily (at) 9 p.m., [MEDICATION NAME] 1 mg po daily (at) 9 p.m..."" Medical record review of the Vital Sign Flow Sheet dated September 5, 2009, revealed, ""...2 p 165/71 (blood pressure)...(September 6, 2009) 3:15 a.m. 157/78..."" Medical record review of a OT (Occupational Therapy) Progress Note dated September 6, 2009, revealed, ""...Eval (Evaluation) complete and treatment initiated...OT took BP (blood pressure) which was high and notified nursing immediately. Nurse came and provided blood pressure medications before continuing with assessment ... "" Medical record review of a nurse's note dated September 6, 2009, revealed, ""...7:30 A Notified by therapy pt B/P was elevated to (space left blank in nursing notes to document the blood pressure). APN (Advanced Practice Nurse) gave...order [MEDICATION NAME] 160mg to be given now instead of 12n..."" Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Interview on February 9, 2010, at 10:45 a.m., with the DON (Director of Nursing), in the DON's office, confirmed the resident was admitted to the facility at 1:30 p.m. and the medications were not administered as ordered by the physician. c/o #",2014-02-01
14283,LIFE CARE CENTER OF EAST RIDGE,445296,1500 FINCHER AVENUE,EAST RIDGE,TN,37412,2010-02-10,514,D,,,1RJR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure the medical record was complete and accurate for two (#23, #22) of twenty-five residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Hospital transfer orders dated September 5, 2009, revealed, ""[MEDICATION NAME] 160 mg tablet...320mg po (by mouth) 1200 (noon)..."" Medical record review of the Physician's Recapitulation Orders dated September, 2009, revealed, ""[MEDICATION NAME] 160 mg 1 po daily..."" Review of a (named drug store pharmacy receipt) dated September 5, 2009, at 9:04 p.m. revealed the facility received [MEDICATION NAME] 320 mg tablets, quanity 4. Medical record review of an OT (Occupational Therapy) Progress Note dated September 6, 2009, revealed, ""...Eval (Evaluation) complete and treatment initiated. Upon entering room to assess patient, patient's daughter expressed concern regarding blood pressure. OT took BP (blood pressure) which was high and notified nursing immediately. Nurse came and provided blood pressure medications before continuing with assessment..."" Medical record review of a nurse's note dated September 6, 2009, revealed, ""...7:30 A Notified by therapy pt B/P was elevated to (space left blank in the nursing notes to document the blood pressure). APN (Advanced Practice Nurse) gave...order [MEDICATION NAME] 160 mg to be given now instead of 12n..."" Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Interview on February 10, 2010, at 8:20 a.m., with the DON (Director of Nursing), in the DON's office confirmed the blood pressure was not documented by the Occupational Therapist or the Nurse, and the physician's orders [REDACTED]. c/o #",2014-02-01
14284,LIFE CARE CENTER OF EAST RIDGE,445296,1500 FINCHER AVENUE,EAST RIDGE,TN,37412,2010-02-10,281,D,,,1RJR11,"**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 a medication for one (#24) of twenty-five residents reviewed. The findings included: Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Nurse's Notes revealed on July 5, 2009, the resident's daughter requested a [MEDICATION NAME] (pain medication) for the resident. Medical record review revealed the Nurse Practitioner (NP) was notified on July 5, 2009, at 5:30 p.m., and ordered the medication. Medical record review of Nurse's Notes revealed [MEDICATION NAME] (pain medication) 75 mg. and [MEDICATION NAME] (for nausea) 50 mg. was ordered and to be given until the [MEDICATION NAME] could be obtained. Medical record review of Nurse's Notes revealed the facility received the medication on July 5, 2009, at 11:30 p.m., but was not applied. Review of the Controlled Medication Utilization Record revealed the pain patch was not applied until July 6, 2009, at 11:00 a.m. Interview with the NP in the Assistant Director of Nursing's office on February 10, 2010, at 1:00 p.m., confirmed the medication was to have been applied when obtained. C/O #",2014-02-01
14285,LIFE CARE CENTER OF COPPER BASIN,445310,166 COPPER BASIN INDUSTRIAL PARK PO BOX 518,DUCKTOWN,TN,37326,2010-02-03,502,D,,,NCHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete laboratory studies for one #15, of twenty-four residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a laboratory report for a Complete Blood Count dated January 7, 2010, revealed the hemoglobin was 9.9 (reference range 12.1-15.5) and the hematocrit was 29.7 (reference range 36.1-46.0). Medical record review of the same laboratory report dated January 7, 2010, revealed an undated physician's orders [REDACTED]."" Medical record review revealed no documentation the hemoccults had been completed. Interview on February 2, 2010, at 4:20 p.m., with the Director of Nursing (DON), in the DON's office, confirmed the hemoccults had not been completed.",2014-02-01
14286,LIFE CARE CENTER OF COPPER BASIN,445310,166 COPPER BASIN INDUSTRIAL PARK PO BOX 518,DUCKTOWN,TN,37326,2010-02-03,333,D,,,NCHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to prevent a significant medication error one (#17) resident of twenty-four residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Diabetic Treatment Administration Record dated January, 2010, revealed the accucheck (finger stick) blood sugars ranged from 106 to 95 (normal blood sugar is 80-100). Medical record review of the Diabetic Treatment Administration Record dated February 2, 2010, revealed an accucheck blood sugar result of 202. Observation on February 2, 2010, at 8:45 a.m., revealed RN #1 administered [MEDICATION NAME] (insulin) 10 units subcutaneous (injection) in the right arm to resident #17. Interview on February 2, 2010, at 9:25 a.m., with RN #1, at the 200 nursing station, confirmed the resident did not receive 15 units of [MEDICATION NAME] as ordered by the physician.",2014-02-01
14287,LIFE CARE CENTER OF COPPER BASIN,445310,166 COPPER BASIN INDUSTRIAL PARK PO BOX 518,DUCKTOWN,TN,37326,2010-02-03,281,E,,,NCHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to address dietary recommendations in a timely manner for two residents (#13, #18), failed to address Mental Health Provider recommendations in a timely manner for one resident (#8), and failed to initiate treatment for [REDACTED].#14) of twenty-four residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Registered Dietician note dated November 4, 2009, revealed ""...1) D/C (discontinue) (name supplement...3) Continue (name protein supplement) but (decrease) to 1 pkt (packet) qd...(every day) x (times) 30 d (days)...5) weekly wt (weight)"" Medical record review of the faxed order request/notification dated November 25, 2009, revealed the Physician noted the above recommendations on December 2, 2009, and the Physician response was not noted by the facility prior to December 9, 2009. Medical review of the Physician order [REDACTED]. Interview with the Director of Nursing and the Regional Director of Clinical Services on February 2, 2010, at 3:30 p.m. in the Director of Nursing office confirmed the Registered Dietician's recommendations made on November 24, 2009; the Physician signed the fax notification with a response to the recommendations on December 2, 2009, and the facility did not recieve the Physician's response to address the recommendations until December 9, 2009, resulting in a 12 day delay. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Registered Dietician note dated December 28, 2009, revealed ""...3) 30 ml (milliliters) of (named supplement) x 30 d (days) for meeting protein needs..."" Medical record review of the faxed order Request/Notification form dated December 30, 2009, revealed the Physician's response was dated January 5, 2010, and noted by the Facility on January 12, 2010. Medical record review of the Physician order [REDACTED]. Interview with the Director of Nursing on February 2, 2010, at 4:30 p.m., in the Director of Nursing office confirmed the Registered Dietician made the recommendation on December 28, 2009; the Physician signed the faxed notification form the with a response to the recommendations on January 5, 2010, and the facility did not recieve the Phyiscian's response to address the recommendations prior to January 12, 2010, resulting in a 15 day delay in implementation of the recommendations. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Behavorial Medicine recommendation by the Nurse Practitioner dated October 28, 2009, revealed ""(increase) [MEDICATION NAME] to 2 mg (milligrams) BID (two times a day) for treatment of [REDACTED]. Medical record review of a Behavorial Medicine recommendation dated November 17, 2009, revealed ...""Proceed (with) previous recommendation to (increase) [MEDICATION NAME] to 2 mg BID."" Review of the physician's orders [REDACTED]. Interview with the Nurse Consultant on February 2, 2010, at 10:00 a.m., in the Director of Nursing Office, confirmed the facility failed to implement the Behavioral Medicine recommendations from October 28, 2009, until November 17, 2009, a delay of 21 days. Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a Laboratory report for a Culture and Sensitivity of the right eye, obtained on December 10, 2009, and results reported to the facility on [DATE]. Continued review revealed, ""Very light growth of Coagulase Negative Staphylococcus."" Review of the nursing notes dated December 14, 2009, revealed the report was faxed to the physician (on December 14, 2009). Review of the physician's orders [REDACTED]. (Ophthalmic antibiotic/steroid preparation) (one) drop each eye qid (four times a day) x 10 days..."" Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the Assistant Director of Nursing (ADON) and the Nurse Consultant on February 3, 2009, at 8:20 a.m., in the ADON's office, confirmed there was an eight day delay in services and treatment of [REDACTED]. Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated January 4, 2010, revealed ""UA (urinalysis) obtained by sterile technique C&S (culture and sensitivity) if indicated. Resident was having strong smell to urine with dark discoloration and scant amount of urine output throughout the am..."" Medical record review of a laboratory report for the urine culture, revealed the urine culture was obtained on January 4, 2010, with positive results (indicating infection)reported to the facility on [DATE]. Continued review of the laboratory report revealed the causative organism was Escherichia coli, and the laboratory report was faxed to the physician on January 8, 2010. Medical record review of a physician's orders [REDACTED]. Interview on February 2, 2010, at 9:30 a.m., with the Director of Nursing (DON), in the Social Services office, revealed after laboratory reports are faxed to the physician, the nurse was to follow-up with a phone call to the physician to ensure the physician was aware of laboratory results. Continued interview and review of the resident's medical record, revealed no documentation a nurse followed up to ensure treatment was initiated immediately after the physician was notified (by fax) of the positive urine culture, resulting in a five day delay in treatment for [REDACTED].",2014-02-01
14288,LIFE CARE CENTER OF COPPER BASIN,445310,166 COPPER BASIN INDUSTRIAL PARK PO BOX 518,DUCKTOWN,TN,37326,2010-02-03,323,D,,,NCHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were in place or functional for two (#14, #3) of twenty-four residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, severely impaired cognitive skills, was totally dependent for transfers and did not walk. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of the Care Plan, reviewed by the facility on January 26, 2010, revealed ""...Potential for injury related to falls...unmindful of safety...Pressure sensitive alarm to bed to alert staff of unassisted transfers..."" Observation on February 1, 2010, at 4:12 p.m., revealed the resident lying on a low bed, and the pressure sensitive alarm was in place, however, the cord from the pressure sensitive alarm was not attached to the alarm box. Observation and interview on February 1, 2010, at 4:15 p.m., with Licensed Practical Nurse (LPN) #1, revealed the resident lying on the bed, with the cord from the pressure sensitive alarm lying on the floor, disconnected from the alarm box and confirmed the alarm was not functional. Resident #3 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, severely impaired cognitive skills, required extensive assistance with transfers, and did not walk. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of the Care Plan, reviewed by the facility on February 1, 2010, revealed "" ...Potential for falls ...unmindful of safety ...Place bed alarm in an unassessible area ..."" Observation on February 1, 2010, at 1:42 p.m., revealed the resident lying on a low bed, with a bed alarm in place, with the alarm box attached to the bed frame. Continued observation revealed the cord from the bed alarm was not attached to the alarm box. Observation and interview, on February 1, 2010, at 1:50 p.m., with LPN #2, revealed the resident lying on the bed, and confirmed the cord from the bed alarm was not attached to the alarm box.",2014-02-01
14289,LIFE CARE CENTER OF COPPER BASIN,445310,166 COPPER BASIN INDUSTRIAL PARK PO BOX 518,DUCKTOWN,TN,37326,2010-02-03,314,D,,,NCHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a pressure relieving device was in place to promote healing of a pressure sore for one resident (#2) of twenty-four residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was admitted to the hospital September 13, 2009, and returned to the facility on [DATE], with a pressure sore to the left heel described on the Pressure Ulcer Status Record as, ""Soft and Mushy"", 3.0 (width) x 4.0 (lenght) cm (centimeters). Continued review of the Pressure Ulcer Status Record revealed the pressure area progressed to a brown/black area 5.0 x 3.5 cm, Stage IV on October 9, 2009. Medical record review of the plan of care updated January 11, 2010, revealed, ""Apply synthetic wool heel protectors' bilateral (feet), and heels elevated off bed at all times."" Observation on February 2, 2010, at 11:00 a.m., revealed the resident in the bed with an abduction pillow supporting the resident's knees; however, heel protectors were not on the resident's feet, and the feet were pressing directly onto the mattress. Continued observation on February 3, 2010, at 9:30 a.m., revealed the resident's left heel pressing directly onto the mattress, without heel protectors on the feet. Continued observation with LPN #5, on February 3, 2010, at 10:05 a.m., revealed the (clean) fleece/wool heel protectors were located in the resident's closet. Observation on February 3, 2010, at 1:25 p.m., with (wound care nurse) LPN #5, revealed the wound to the left heel was a healing Stage IV, presenting as a healing Stage II, approximately 2.5 x 1.5 cm., with a small to moderate amount of serous drainage. Interview with the Licensed Practical Nurse #4, on February 3, 2010, at 10:15 a.m., at the north nursing station, confirmed the facility failed to ensure heel protectors were in place.",2014-02-01
14290,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2010-10-27,224,D,,,K55Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, facility investigation report review, and interview, the facility failed to prevent the misappropriation of narcotic medications for one resident (#1) of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident was alert and oriented in all areas; had no problems with decision making skills; and experienced moderate pain less than daily. Medical record review of the Physician's Order, dated December 3, 2009, revealed ""[MEDICATION NAME] ([MEDICATION NAME]-APAP, a [MEDICATION NAME] based controlled narcotic [MEDICATION NAME]) 5/500 mg (5 milligrams [MEDICATION NAME] and 500 milligrams [MEDICATION NAME]) 2 tabs (tablets) po (by mouth) q (every) 4 hrs (hours) prn (as needed) for pain..."" Medical record review of the Care Plan, dated December 15, 2009, revealed the resident had been identified as being at risk for pain with interventions to include ""...prn pain medication..."" Medical record review of resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued review of the MAR indicated [REDACTED]. Review of the controlled substance count sheet (record of number of controlled medications administered and number of controlled medications remaining) for resident #1's [MEDICATION NAME] 5/500 mg tablets, dated December 3 - 31, 2009, revealed the resident had 30 doses administered with LPN #1 signing out for 28 of the 30 doses. Review of a facility investigation report, dated December 30, 2009, at 2:15 p.m., revealed the Director of Nursing (DON) was informed by Licensed Practical Nurse (LPN) #2 that a shift count controlled substance ([MEDICATION NAME] 5/500 mg) record sheet for resident #1 was missing and the 28 doses of [MEDICATION NAME] 5/500 mg was not present. Continued review revealed an investigation began at that time. Continued review of the facility report revealed the Pharmacy had been contacted on December 27, 2009 by LPN #1 who had requested the additional medication, [MEDICATION NAME] 5/500 mg, for resident #1. Continued review revealed on December 27, 2009 the pharmacy delivered the controlled substance count sheet and twelve [MEDICATION NAME] 5/500 mg for the resident. Continued review revealed LPN #2 worked December 28, 2009 from 2:00 p.m. through 10:00 p.m., and the [MEDICATION NAME] 5/500 mg and the controlled substance count sheet for the [MEDICATION NAME] 5/500 mg were present. Continued review revealed interviews were conducted and it was determined the [MEDICATION NAME] 5/500 mg and the count sheet were present in the medication cart and was last accounted for on December 28 - 29, 2009 at the end of the 10:00 p.m. through 6:00 a.m. shift by LPN #4, who was handing over the keys to the medication cart to LPN #1. Continued review revealed LPN #1 handed over the keys to the medication cart to LPN #5 on December 30, 2009 at the beginning of the 2:00 p.m. through 10:00 p.m. shift. Continued review revealed LPN #5 was interviewed and did not recall the count sheet or [MEDICATION NAME] 5/500 mg being present at the beginning of the 2:00 p.m. to 10:00 p.m. shift on December 30, 2009. Continued review revealed LPN #1 worked the 6:00 a.m. through 2:00 p.m. shift on December 30, 2009. Continued review revealed LPN #2, returned to work on December 30, 2009 for the 2:00 p.m. through 10:00 p.m. shift and the 12 [MEDICATION NAME] and the count sheet delivered on December 27, 2010 for resident #1 were missing. Review of the facility investigation revealed on December 31, 2009 LPN #1, #2, #4, and #5 were drug tested . LPN #2, #4 and #5 tested negative for drugs. LPN #1 tested positive for marijuana, opiates/[MEDICATION NAME], and benzodiazepine. Continued review revealed LPN #1 reported having a prescription for the positive [MEDICATION NAME]/opiate and benzodiazepine; and admitted to the illegal use of marijuana. Continued review revealed LPN #1 denied ever taking any medication from the facility. Continued review revealed LPN #1 refused to be drug tested at the local hospital and resigned at that time. Review of the facility investigation revealed the facility and the pharmacy consultant did an investigation of patients under the care of LPN #1 to determine if LPN #1 signed out more narcotic medications than might be expected or were out of keeping with the patients' usual dosing of narcotic medications. Continued review revealed LPN #1 did sign out numerous narcotic medications to confused and disoriented residents who, generally, only occasionally required medication for controlling pain. Continued review of the medical records was completed to determine if the residents' experienced unaddressed pain. All residents reviewed did not have documentation to indicate they experience unaddressed pain. Interview by phone with LPN #1 on October 7, 2010 at 2:30 p.m., revealed LPN #1 denied ever taking any medication from the facility. Continued interview revealed LPN#1 had not worked since resigning from the facility. Continued interview with LPN #1 confirmed the positive drug screen results taken by the facility; admitted to smoking marijuana; and related being on prescription medications causing positive results for the [MEDICATION NAME]/opiate and benzodiazepine. Review of the facility policy, Prevention of Abuse, Neglect, and Misappropriation of Resident's Property, (no number documented) revised April 2009, revealed ""...This facility upholds resident rights and strictly prohibits...misappropriation of resident's property..."" Interview in the chaplain's office with the Director of Nursing on September 7, 2010 at 11:00 a.m., confirmed 12 tablets of the controlled narcotic medication [MEDICATION NAME] 5/500 mg for resident #1 were missing on December 30, 2009 on the 6:00 a.m. through 2:00 p.m. shift. C/O #",2014-02-01
14291,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2010-10-27,322,D,,,K55Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, review of the facility policy ""Gastrostomy Feedings #G-3"" and review of manufacturer's directions, the facility failed to ensure staff provided appropriate care for a feeding tube for one resident (#4) of seven residents reviewed. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident was alert and oriented only to recent events; had problems with decision making skills; was total assist with all activities of daily living; and was receiving nourishment via jejunostomy (tube used for feeding, surgically inserted into the lower stomach) tube feeding. Medical record review of the Physician's Order's, dated July 21, 2010, no time noted, revealed ""...(named tube feeding solution) at 80 ml (milliliters) per hr (hour) ...on 4 (hours), off 2 (hours)...Flush a/ (before) and p/ (after feeding with 30 ml H2O (water)..."" Observation with Licensed Practical Nurse (LPN) #4 of the resident in the resident's room on September 7, 2010, at 1:05 p.m., revealed the resident in a semi-seated position in the bed with a tube feeding running via pump at 80 ml/hr. Continued observation revealed, hanging from the tube feeding pump was an 18 inch guide wire in an open plastic sleeve. Continued observation revealed the tip of the guide wire was covered in a crusted yellow substance. Interview with LPN #4 in the resident's room on September 7, 2010, at 1:05 p.m., revealed the guide wire is utilized to ""unclog"" a feeding tube; the guide wire is reusable; and the tip of the guide wire was covered in a crusted yellow substance. Interview revealed the LPN had not been inserviced on the use of the guide wire to unclog the feeding tube. Interview at the Nurses' Station with the Nurse Practitioner on September 8, 2010, at 4:00 p.m., revealed there had been no symptoms related to the reuse of the guide wire to unclog the feeding tubes in residents receiving tube feedings. Review of facility policy Gastrostomy Feedings, # G-3, revised June 2008, revealed ""...To use volumetric infusion pump: 1. Follow the manufacturer's directions for preparing the equipment. 2. After feeding is complete, flush the tube as ordered by physician...5. Clean and store other reusable equipment..."" Review of the manufacturer's directions for the (named) guide wire utilized to unclog feeding tubes revealed ""...Protocol for use of the (named guide wire)...to maintain patency of [MEDICAL CONDITION] and/or jejunostomy enteral tubes...Policy:...The (named guide wire) should be disposed of after a single use..."" Interview at the Nurses' Station with LPN #5 on September 7, 2010, at 1:25 p.m., revealed the guide wire used to unclog feeding tubes was reusable and the LPN had not been inserviced on the use of the guide wire. Interview in the Chaplain's office with the Director of Nursing on September 8, 2010, at 1:10 p.m., confirmed guide wires utilized to unclog feeding tubes were not to be re-used and the manufacturer's directions had not been followed. C/O #",2014-02-01
14292,HORIZON HEALTH AND REHAB CENTER,445383,811 KEYLON STREET,MANCHESTER,TN,37355,2010-06-09,224,D,,,M3K711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Controlled Substances records, facility policy review, and interview, the facility failed to prevent misappropriation of medications for two (#10, #11) of sixteen residents reviewed. The findings included: Review of the Controlled Substances record for resident #10 revealed thirty tablets of [MEDICATION NAME]-Apap (pain medication) 5-325 tablets were dispensed by the pharmacy to the facility on [DATE]. Continued review of the Controlled Substances record revealed one tablet of the [MEDICATION NAME]-Apap 5-325 was administered to another resident on May 26, 2010. Review of the Controlled Substances record for resident #11 revealed thirty [MEDICATION NAME] (antianxiety medication) 0.5 mg. (milligrams), with instructions to take 1/2 tablet by mouth once daily, were dispensed by the pharmacy to the facility on [DATE]. Continued review of the Controlled Substances record revealed the [MEDICATION NAME] was administered to another resident on the following days: May 31, 2010, June 2, 3, 4, and 7, 2010. Review of a second Controlled Substances record for resident #11 revealed thirty [MEDICATION NAME] 0.5 mg., with instructions to take one tablet by mouth daily, were dispensed by the pharmacy to the facility on [DATE]. Continued review of the Controlled Substances record revealed the [MEDICATION NAME] was administered to another resident on the following days: June 2, 3, 4, 6, and 7, 2010. Review of the facility's policy Borrowing Narcotic Medications revealed ""It is the policy of United Regional Medical Center to assure that residents receive their medications in a timely manner. Although borrowing narcotic medications from resident to resident is strongly discouraged...when all other possible options have been exhausted the following procedure is to be utilized: If all options have been exhausted, and the medication in question cannot be acquired for the resident in a timely manner...then and only then should the facility borrow a medication. The borrowed medication should be noted on the narcotic sheet of the resident of whom it was borrowed. The pharmacy should be notified of both whom the medication was borrowed from and whom it was borrowed for. The pharmacy will work with the facility as indicated to ensure that the resident from whom it was borrowed is properly credited..."" Review of the facility's policy Resident Protection Suspected Abuse Investigation & Reporting revealed ""...Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent..."" Interview on June 8, 2010, at 12:55 p.m., with Registered Nurse (RN) #1, in the Director of Nursing's office, confirmed RN #1 had borrowed the [MEDICATION NAME]-Apap 5-325 and [MEDICATION NAME] on the above listed dates for resident #10 and resident #11. Continued interview confirmed the pharmacy was not notified of the borrowed medications. Interview on June 8, 2010, at 1:00 p.m., with the facility's pharmacist, at the nursing station, confirmed resident #10 and #11 had not been credited for the borrowed medications. Interview on June 9, 2010, at 9:00 a.m., with the Administrator, at the nursing station, revealed the pharmacy had credited resident #10 and #11 for the borrowed medications on June 9, 2010. Complaint # .",2014-02-01
14293,HILLVIEW HEALTH CENTER,445464,1666 HILLVIEW DRIVE,ELIZABETHTON,TN,37643,2010-07-29,323,D,,,R51U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide supervision to prevent accidents and ensure safety devices were in place for one resident (#10) of fifteen sampled residents reviewed. The findings include: Resident #10 was admitted to the facility September 22, 2008, with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set ) dated March 7, 2010, revealed the resident had short and long term memory loss, moderately impaired cognitive skills for daily decision making and was independent with ambulation. Medical record review of the MDS dated [DATE], revealed the resident had short and long term memory loss, severely impaired cognitive skills for daily decision making, was totally dependent for transfer and locomotion on unit, required a wheelchair for mobility, and had a history of [REDACTED]. Medical record review of Falls Risk Assessments dated September 22, 2008, through June 19, 2010, revealed the resident to be at high risk for falls. Medical record review of the nurse's notes and facility documents dated March 27, 2010, through July 20, 2010, revealed the resident had a history of [REDACTED]. Medical record review of the care plan updated May 22, 2010, following a fall on that date, revealed a planned new approach ""...mats placed on left side of bed ..."" Medical record review of a facility document dated May 25, 2010, revealed ""...resident lying in floor beside of bed..."" ""Immediate intervention implemented: placed non-skid socks on resident."" Further review revealed no documentation the safety mat was in place at the time of the fall. Interview with the Director of Nursing, (DON) July 29, 2010, at 9:15 a.m., in the conference room, confirmed there was no documentation of the mat being in place at the resident's bedside at the time of the fall. Medical record review of the care plan dated June 10, 2010, revealed approaches listed: ""...Mats on floor at bedside and bed alarm used for safety...assistance of one or two for transfers and uses a wheelchair for locomotion with assistance of one...Certified Nursing Assistants to assist ...to bed directly after meals...non-skid socks applied."" Medical record review of documents provided by the facility dated June 13, 2010, revealed, ""resident noted to be laying on floor at doorway to room 30...u-shaped laceration in crown area of head with small abrasion on right side of head...Possible cause of event listed as ""...resident up in stocking feet, in hallway walking ..."" Immediate intervention implemented...""resident instructed not to ambulate without assistance, to use his wheelchair, and to wear shoes."" Further review revealed the facility implemented additional interventions: ""...6-13-10 bed alarm; 6-14-10 moved to Rm (room) ... for closer observation ..."" Interview with the DON, July 29, 2010, at 9:15 a.m., in the conference room, revealed the resident had got out of bed and ambulated to the doorway and confirmed there was no documentation the resident was wearing non-skid socks, no documentation the bed alarm or mat was in place at the time of the fall. Medical record of the facility document dated June 18, 2010, at 2:20 a.m., revealed ""...resident sitting on floor beside of bed next to window ...1 cm skin tear on left hand ...0.25 cm bruise on right arm, abrasion on lower right side of back..."" Interview with the DON, July 29, 2010, at 9:15 a.m., in the conference room, confirmed there was no documentation of the care planned non-skid socks on the resident, the mat on the floor at bedside, or of the bed alarm in place and functioning at the time of the fall. Observation on July 29, 2010, at 10:00 a.m., in the resident's room, revealed the resident to resting on the bed. The pad was on the floor at the left side of the bed, the pressure pad alarm was still in place, but the non-skid sock was not on the right foot.",2014-02-01
14294,ISLAND HOME PARK HEALTH AND REHAB,445476,1758 HILLWOOD DRIVE,KNOXVILLE,TN,37920,2010-10-28,514,D,,,4S8L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain accurate clinical records for two residents (#3, #5) of six residents reviewed. The findings included: Resident #5 was admitted to the facility September 5, 2007, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, was totally dependent for activities of daily living, had no indications of depression, anxiety, or sad mood, and had exhibited no behavior symptoms or psychosocial deficits. Medical record review of the social services notes dated August 28, 2008 through May 17, 2010, revealed "" ...no mood or behavior problems ..."" Medical record review of a psychiatric consultant Nurse Practitioner Progress notes dated January 10, 2010 through October 22, 2010, revealed ""recent exac (exacerbation) of sexually inappropriate behaviors ...seen for E&M (evaluation and management) of DAT (dementia) c (with) [MEDICAL CONDITION] and beh (behavior) sxs (symptoms) including sexual inappropriateness & physical aggressive ..."" Observation on October 27, 2010, at 9:30 a.m., in the dining room with the resident revealed the resident sitting in a wheelchair, smiling, alert, oriented to person and time, pleasant, and socially appropriate. Interview with the Administrator and Director of Nursing (DON) October 27, 2010, at 10:45 a.m., in the conference room, confirmed the resident had no current behavioral issues. Further interview with the Administrator and the DON confirmed the resident's medical record was inaccurately documented in describing the problem behaviors as ""current"" and/or ""recent"" rather than ""history of."" Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a notorized document dated June 27, 2010, revealed "" ...Appointment of Healthcare Agent ..."" with one daughter listed as the Agent and no alternate listed. Medical record review of a Social Service Note dated June 28, 2010, revealed "" ...New POA (Power of Attorney) papers on chart this date. HC (Healthcare) POA papers signed 6/27/10. Per POA, if (sibling) calls r/t (related to) (resident) ...we are not to provide info (information) & refer (sibling) to contact (health care agent) for information ..."" Continued medical record review of a Social Service Note dated June 30, 2010, revealed "" ...POA's (sister) in to see this worker ...apologized to this worker ...for giving the staff such a hard time because ...didn't realize ...wasn't on the recent POA papers ...showed this worker old POA papers and inquired if they were on chart. This worker informed ...that they were not and newer POA doct. (document) is on chart with ...(other sibling) named as POA ( this sibling) verbalized ...disagreement. This worker reported that it was not done at this facility and again advised (this sibling) to speak with (other sibling) ..."" Interview with the Administrator, Director of Nursing, and Medical Records Director on October 25, 2010, at 3:45 p.m., at the Nurses Station revealed no POA papers on resident's current chart. Continued interview confirmed there was no new POA form and that the Appointment of Healthcare Agent form was not an alternate POA form. Further interview with the Medical Records Director on October 25, 2010, at 4:05 p.m., in the conference room, confirmed that the new POA referenced in the Social Service notes was the Appointment of Healthcare Agent, not an actual new POA. Review of a notarized POA dated September 4, 2003, found in the thinned record, and provided by the Medical Records Director revealed both siblings listed as POA's. Interview with the Medical Records Director confirmed both sister's were listed as POA's and the document dated September 4, 2003, is the only POA for the resident at this time.",2014-02-01
14295,ISLAND HOME PARK HEALTH AND REHAB,445476,1758 HILLWOOD DRIVE,KNOXVILLE,TN,37920,2010-10-28,226,D,,,4S8L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility investigation, and interview, the facility failed to notify the State Agency of an allegation of abuse within the required time frame for one resident (#1) of six residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident with no loss in short or long term memory and required only supervision with cognitive skills for daily decision making. Review of a facility investigation dated May 6, 2010, revealed "" ...Notified by Regional nurse that pt. (patient) felt afraid of staff member...Pt notified another staff member of feeling afraid ..."" Continued review of the facility investigation revealed the facility completed interviews with the resident, staff, and the alleged perpetrator and had been unable to substantiate any abuse had occurred. Review of the facility investigation revealed the facility reported the allegation of abuse to the state agency on May 25, 2010. Interview with the Administrator and DON (Director of Nursing) on October 27, 2010, at 3:15p.m., in the conference room, confirmed the facility failed to report the allegation of abuse to the state agency in the required time frame as required.",2014-02-01
14296,SENATOR BEN ATCHLEY STATE VETERANS' HOME,445484,ONE VETERANS WAY,KNOXVILLE,TN,37931,2010-06-03,323,D,,,JRLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure a safety device was in place for one resident (#5) of twenty-six residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was ""...total dependence..."" and required ""...two + (plus) persons physical assist..."" for transfers. Medical record review of a Plan of Care, dated November 2, 2009, revealed the resident was at risk for falls and was to use a ""...Sit to Stand (used for transfers) lift for all transfers..."" Medical record review of facility documentation dated, December 26, 2009, revealed, "" ...CNA (Certified Nursing Assistant) who was assisting res (resident) with transfer was loosing safe grip. Res was safely lowered to floor to prevent fall..."" Continued review of facility documentation revealed, ""...Comments/Conclusion: Use lift for transfers, Two person transfers..."" Interview with CNA #1 (on duty at the time of the fall) and the Director of Nursing, on June 2, 2010, at 9:40 a.m., in the Director of Nursing's office, confirmed the Sit to Stand lift was not in use on December 26, 2009, when the resident sustained [REDACTED].",2014-02-01
14297,RIDGETOP HAVEN HEALTH CARE CENTER,445486,2002 GREER ROAD,RIDGETOP,TN,37152,2010-04-29,281,D,,,RTKP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to assess one resident's (#5) blood glucose level after the resident developed [MEDICAL CONDITION], of eighteen residents reviewed. The findings included: Medical record review revealed resident #5 was admitted to the facility in September 2005, with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Record review revealed on January 30, 2010, the resident had blood glucose checks with an accompanying sliding scale for insulin administration ordered before each meal and at bedtime. Medical record review of the Diabetic Record revealed on February 10, 2010, the resident received 12 units of [MEDICATION NAME](a fast acting insulin) at 4:00 p.m., for a blood glucose level of 351. Medical record review revealed an untimed entry in the Nurse's Notes on February 10, 2010, ""...CNA (certified nurse aide)...noted resident unresponsive...this nurse noted resident having [MEDICAL CONDITION]. Called 911...had other nurse stay with resident...resident having [MEDICAL CONDITION] activity about every 30 seconds. Around 6:45 EMS here to transport."" Medical record review of the history and physical examination ...The patient apparently was having [MEDICAL CONDITION] for over 15-20 minutes and EMS arrived and checked the blood sugar. The blood sugar was 26...given D50 (an IV solution with 50% [MEDICATION NAME]). After which...more awake and alert, but still very confused and sleepy. Blood sugar after initial improvement came back down to 66...CT of the head reported as negative...being admitted to the intensive care unit for close observation for the follow up of the blood sugars."" Further review of the H & P revealed, ""IMPRESSION: 1. [MEDICAL CONDITION] activity related to most likely [DIAGNOSES REDACTED] (low blood glucose level)."" Medical record review revealed the resident was readmitted to the nursing home the following day, February 12, 2010. Observation and interview of a group of residents from the Resident Council on April 28, 2010, at 9:30 a.m., revealed resident #5 was included in the group and offered appropriate responses to questions, readily entering into the conversation. Interview at 4:00 p.m., on April 28, 2010, in the nursing station with the Licensed Practical Nurse (LPN #1), responsible for administering the 12 units of [MEDICATION NAME] Insulin on the evening of February 10, 2010, verified neither LPN #1, or the second LPN (#2), who remained in the room with the resident as the [MEDICAL CONDITION] activity continued, checked the resident's blood glucose level. Interview with the DON (Director of Nurses) at 4:30 p.m., on April 27, 2010, in the private dining room, verified the DON was unaware the whether the nursing staff had assessed the resident's blood glucose level on the evening of February 10, 2010. Interview with the DON (Director of Nurses) at 4:45 p.m., on April 27, 2010, in the private dining room, verified the nursing staff had not assessed the resident's blood glucose level after the resident developed [MEDICAL CONDITION] activity (a symptom of low blood glucose levels) and the DON stated, ""Any blood sugar lower than the low normal range can become life threatening.""",2014-02-01
14298,RIDGETOP HAVEN HEALTH CARE CENTER,445486,2002 GREER ROAD,RIDGETOP,TN,37152,2010-04-29,323,D,,,RTKP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent resident to resident incidents for three residents (#7, #8, # 18) of eighteen residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory deficit, moderately impaired decision making skills, with wandering behavior that occurred daily and the behavior was not easily altered. Medical record review of the nurse's notes dated April 11, 2010, revealed ""resident wandering up and down hallways today and into other resident's rooms. As a result of this (resident #7) was hit (L)(left) jaw area by another resident (#8). No injuries on (resident #7) will monitor."" Continued review revealed April 14, 2010, ""(resident #7) had altercation with resident (#8) in the common front hallway and the two residents had an argument over a chair, resident (#8) punched resident (#7)."" ""No injuries found...will monitor "" was redirected. Nurse's notes dated April 20, 2010, revealed, ""resident continues to wandering into rooms of other residents, frequent reorientation and assistance given to move to commons area, communication verbalized is confused and intelligible."" Observation on April 27, 2010, at 2:30 p.m., revealed, resident #7 in the dining room attempting to interfere with the task of housekeeping; after several attempts to redirect staff was able to walk resident out of the dining room. Continued observation revealed resident #7 was escorted out of room #5 (room #5 occupied by female residents) by DON (Director of Nursing). Continued observation revealed resident #7 entered resident #14's room and stand in front of the resident. (Resident #14 was observed sitting in a rock-n-go chair.) Resident #7 entered adjoining room of resident #18. Resident #18 was agitated and yelling ""get out of my room."" There was no staff present at the time. Interview with the DON on April 28, 2010, at 8:05 a.m., in the private dining room, confirmed the only intervention in place for resident #7 was redirection and to have psychiatric services to evaluate. Interview with the Administrator on April 28, 2010, at 8:25 a.m., in the nurse's station, revealed, if resident #7 enters a resident's room unwanted the resident has been instructed to call for the staff. Interview with the Social Services on April 28, 2010, at 4:00 p.m., in the private dining room, confirmed the only intervention for resident #7 was for staff to redirect. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed resident had short and long term memory deficit, was modified independence for daily decision making skills. Medical record review of the History and Physical dated February 5, 2010, revealed,"" ...patient was combative, belligerent, actively hallucinating, urinating, and incontinent of bowels and defecating in the trash can...was very difficult to be redirected..."" Medical record review of the Social Services notes dated April 14, 2010, revealed resident #8 hit resident #7, no injuries; April 21, 2010, revealed resident #8 hit resident #7, no injuries. Interview with the Social Services on April 28, 2010, at 4:00 p.m., in the hallway, confirmed the only intervention was to redirect the resident and confirmed the resident does not like anyone to invade their space. Interview with the DON on April 28, 2010, at 4:30 p.m., in the private dining room, confirmed no new interventions were put in place, and the facility had failed to provide adequate supervision.",2014-02-01
14299,MCKENDREE VILLAGE INC,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2010-02-24,157,D,,,ECRM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to notify the physician for abnormal blood glucose levels for one resident (#24) of twenty-six residents reviewed. The findings included: Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a physician's note dated May 18, 2009, revealed ""Very demented, delusional often. DM (Diabetes Mellitus) ?new diagnosis. On [MEDICATION NAME] XL; glucose 145 on lab (laboratory), start accu-checks (blood glucose monitoring). Review of the physician's Recapitulation Orders dated May 24, 2009, revealed ""Sliding scale with [MEDICATION NAME] Insulin 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; greater than 400 = 10 units."" Review of the Diabetic Monitoring Log for May 2009, revealed an entry dated May 20, 2009, at 4:00 p.m., of blood glucose of 418 but no documentation the physician was notified of the elevated abnormal result. Continued review of the medical record revealed an entry dated May 24, 2009 at 4:00 p.m., of blood glucose of 474 and an entry at 9:00 p.m., of blood glucose of 498 but no documentation the physician was notified of the elevated abnormal results recorded for 4:00 p.m. and 9:00 p.m.. Medical record review revealed an entry dated May 28, 2009, at 4:00 p.m., of blood glucose of 451, an entry dated May 29, 2009, at 11:00 a.m., of blood glucose of 437, and an entry dated May 30, 2009, at 9:00 p.m., of blood glucose of 595 but no documentation the physician was notified of the elevated abnormal blood glucose results. Review of the facility policy entitled ""Insulin Administration"" revealed ""Physician to be notified of blood sugars below 60 or above 400 unless there is a specific order addressing blood sugars outside these ranges directing otherwise."" Interview with the Director of Nursing (DON) on February 24, 2010, at 10:15 a.m., in the DON's office, confirmed there were six instances of abnormal blood glucose results and there was no documentation in the medical record to indicate the nurse informed the physician of the elevated abnormal results. C/O #",2014-02-01
14300,MCKENDREE VILLAGE INC,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2010-02-24,281,D,,,ECRM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the care plan for two residents (#15, # 16 ) for the protection of a [MEDICAL TREATMENT] access for twenty-six residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a [MEDICAL TREATMENT] access (fistula) (access to use for [MEDICAL TREATMENT]) on the left arm, and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan updated February 16, 2010, revealed the care plan did not address the resident's [MEDICAL TREATMENT] access located on the resident's left arm or the practice which requires no needle sticks or blood pressures checks in the arm of the access. Interview with the Director of Nursing (DON) on February 23, 2010, at 3:30 p.m., in the north hallway, confirmed the care plan did not address the care of the access for [MEDICAL TREATMENT]. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a [MEDICAL TREATMENT] access (fistula) on the left arm and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan dated February 22, 2010, revealed the care plan did not address the resident's access located on the resident's left arm or the practice which requires no needle sticks or blood pressure checks in the arm of the access. Interview with the Director of Nursing on February 23, 2010, at 3:30 p.m., in the north hallway, confirmed the care plan did not address the care of the access for [MEDICAL TREATMENT].",2014-02-01
14301,MCKENDREE VILLAGE INC,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2010-02-24,431,D,,,ECRM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the disposal of an expired medication from one of two medications carts. The findings included: Observation on February 23, 2010, at 11:20 a.m., of the A Medication Cart located in the 200 East Medication Room, revealed a one pint (473 ml) bottle of Guituss Syrup, approximately half-full, with a manufacture's expiration date of ,[DATE] on the label of the bottle. Interview with Licensed Practical Nurse (LPN) #1 and LPN #2 in the 200 East Medication Room on February 23, 2010, at 11:30 a.m., confirmed the Guituss Syrup in the A Medication Cart was expired and should have been removed from the cart and disposed of.",2014-02-01
14302,MCKENDREE VILLAGE INC,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2010-02-24,441,D,,,ECRM11,"Based on observation, facility policy review, and interview, the facility failed to ensure a sanitary environment to help prevent the development and transmission of disease and infection for one of two ice machines and two of three shower rooms. The findings included: Observation on February 23, 2010, at 10:40 a.m., in the 200 East Nurse's Pantry, revealed employee #1 took a Styrofoam cup from the counter beside the sink, placed it in the sink basin, then removed it from the sink basin, walked over to the ice machine and scooped through the ice twice using the same Styrofoam cup. Observation on February 23, 2010, at 11:00 a.m., revealed a dried dark brown substance on four of four walls in the 200 East shower room; a dark brown substance on the floor of the 200 East shower room; and a dried dark brown substance on the floor of the 200 North shower room. Review on February 23, 2010, of the policy and procedure dated 4/2003 for Ice Safety revealed ""...Use a clean, sanitized container (ice bucket designed for this purpose is ideal) and ice scoop to transfer ice from an ice machine to other containers..."" Review on February 23, 2010, of the policy and procedure for Shower Rooms revealed ""...2. In the event of an accident occurring in the shower room requiring disinfecting and cleaning, the nurse aide will notify environmental services as soon as possible, with resident care, safety, and privacy taking precedence..."" Interview with the Director of Nursing (DON) at the Nurse's Station on February 23, 2010, at 3:05 p.m., confirmed an ice scoop is to be used to transfer ice from the ice machine and Environmental Services should have been notified to clean the dried, dark- brown substance from the shower rooms. Interview with the Director of Environmental Services in the Conference Room on February 24, 2010 at 10:20 a.m., confirmed ""... was not notified of the condition of the shower rooms "".",2014-02-01
14303,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-09-24,312,D,,,B9UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nail care for one (#3) of five sampled residents. The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE] revealed the resident was impaired with decision-making skills and dependent on staff for mobility and hygiene/grooming. Continued review revealed the resident had decreased range of motion of the right and left hands. Medical record review of the care plan effective through November 11, 2010 revealed, ""...nail care as needed..."" Observation on September 23, 2010 at 10:33 a.m. revealed the fingers of the resident's left hand clenched into the palm, and the resident used the right hand to open up the fingers of the left hand. Continued observation revealed the fingernails extended past the fingertips and left red indentions in the palm of the hand. Observation and interview with RN #1 on September 23, 2010 at 10:35 a.m. revealed the nurse obtained the resident's permission to trim the nails, and confirmed the facility had failed to provide nail care for Resident #3. C/O: #",2014-01-01
14304,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2010-09-24,406,D,,,B9UY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide occupational therapy services for one resident (#2) of five sampled residents. The findings included: Resident #2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had decreased range of motion and partial loss of movement on one hand. Medical record review of the MDS dated [DATE] revealed the resident was severely impaired with decision-making skills and totally dependent on staff for all activities of daily living. Continued review revealed the resident had decreased range of motion and partial loss of movement on one hand. Medical record review of the care plan dated September 16, 2010 revealed, ""PT/OT to eval & tx (physical therapy/occupational therapy to evaluate and treat)."" Medical record review of a physician's orders [REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED].(joint) contractures ...pulls away from this therapist on attempts at PROM (passive range of motion) but ultimately allowed gentle PROM ...and application of palmar rolls ..."" Observation on September 23, 2010 at 10:55 a.m. revealed the resident in bed and without any contracture preventive device in either hand. Observation on September 24, 2010 at 10:35 a.m. revealed the resident in a geri-chair in the room and hand rolls in the right and left hands. Interview with OT #1 on September 24, 2010 at 10:58 a.m. in a lower level conference room revealed a communication error had occurred regarding the physician's orders [REDACTED].#2. C/O: #",2014-01-01
14305,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2010-09-02,322,D,,,3DE411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure tube feeding was disconnected and reconnected by licensed staff, which had been trained in the procedure, for one (#6) of eighteen residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living; and was fed via a feeding tube. Medical record review of the physician's recapitulation orders dated August 1-31, 2010, revealed ? strength Glucerna was administered at eighty milliliters each hour for twenty-three hours each day. Review of a statement written by Certified Nursing Assistant (CNA) #1, related to an allegation CNA #1 had abused resident #6 on August 5, 2010, (unsubstantiated) revealed, ""...saw (CNA #2)...asked (CNA #2) to help me put (resident) to bed...took (resident) to...room and helped me undress (resident). Then I put...gown on and changed...brief...hooked (resident) back up to...feeding tube...raised...head. Interview on August 23, 2010, at 11:10 a.m., in the office with the Director of Nursing (DON) confirmed CNAs were not authorized to disconnect and reconnect tube feedings. Interview on August 24, 2010, at 8:05 a.m., in the office with CNA #1 confirmed on August 5, 2010, CNA #1 disconnected the tube feeding for resident #6; showered the resident; reconnected the tube feeding; and turned on the tube feeding pump ""to keep the same rate flowing."" Continued interview with CNA #1 confirmed CNA #1 had turned off the pump and disconnected the tube feeding on other occasions ""to get (resident) ready to go to the shower"" and had reconnected the tube feeding and turned on the pump after the resident's shower. C/O #",2014-01-01
14306,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2010-09-02,365,D,,,3DE411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to honor a dietary request for soft food and failed to follow through with a speech therapy evaluation for one (#1) of eighteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living; had no chewing or swallowing problems and had no weight loss. Medical record review of documentation by the Speech Therapist dated June 16, 2010, revealed, ""...Eval (Evaluation) not indicated...No report or C/O (complaint) pt (resident) having difficulty...swallowing. Deficits in self-feeding reported to OT (Occupational Therapy)..."" Medical record review of a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Review of documentation of a ""Post Admit Meeting"" with the resident's Power of Attorney (POA-family member), dated June 22, 2010, revealed, ""...Softer foods...POA says (resident) having trouble eating/speech to eval...Discussed current diet. Resident choking. Recommend ST (Speech Therapy) to evaluate..."" Medical record review revealed no documentation soft food was provided to the resident as requested by the resident's POA on June 22, 2010,and revealed no documentation speech therapy evaluated the resident after the POA reported the resident was having swallowing difficulty. Review of the Post-Admit Meeting documentation dated June 22, 2010, and interview on August 24, 2010, at 10:35 a.m., in the office, with the Dietary Manager, revealed the Speech Therapist had evaluated the resident prior to the meeting on June 22, 2010. Continued interview with the Dietary Manager confirmed on June 22, 2010, the Dietary Manager recommended the resident be re-evaluated by the Speech Therapist due to the report by the POA the resident was choking. Continued interview with the Dietary Manager confirmed the POA requested the resident be provided soft foods, because of choking, and confirmed soft foods had not been provided as requested by the POA. Interview on August 24, 2010, at 1:05 p.m., in the office, with the Director of Nursing confirmed the facility failed to ""follow up"" on the recommendation made by the Dietary Manager on June 22, 2010, for speech therapy to evaluate the resident and failed to provide soft food to the resident as requested by the POA on June 22, 2010. C/O #",2014-01-01
14307,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2010-09-02,309,D,,,3DE411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to assess and investigate the cause of skin tears for one (#1) of eighteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; had periods of restlessness and repetitive physical movements; had physically abusive behavioral symptoms and resisted care; was totally dependent on staff for all activities of daily living; and had no skin tears. Medical record review of a weekly skin assessment dated [DATE], revealed, ""...Scratch on (R) (right) (lower) extremity..."" Medical record review of a weekly skin assessment dated [DATE], revealed, ""...Scratch to RLE (right lower extremity)..."" Medical record review of a physician's orders [REDACTED]. Medical record review of nurses' notes dated June 15, 2010, (admission) through July 8, 2010, (date of discharge from the facility) and the treatment record dated July 2010, revealed no documentation as to when the skin tears developed and no documentation of the size of the skin tears, drainage, condition of the surrounding skin or the cause of the skin tears. Review of the facility's policy for skin tears revealed, ""...When a skin tear is discovered, complete an incident report...Evaluate possible cause and determine preventive measures...The following information should be recorded in the resident's medical record:...site and description of the skin tear or wound...date and time the skin tear was discovered...All assessment data...bleeding, size of wound...obtained when inspecting the wound..."" Interview on August 24, 2010, at 10:45 a.m., in the office, with the Registered Nurse/Treatment Nurse confirmed the resident had skin tears on the right leg which ""wasn't healing."" Continued interview with the Treatment Nurse confirmed orders for treatment of [REDACTED]. Interview on August 26, 2010, at 8:50 a.m., in the office, with the Assistant Director of Nursing (ADON)/Incident/Accident Coordinator confirmed an incident report related to the skin tears was not completed, and the date the skin tears occurred was not known. Interview on August 26, 2010, at 9:10 a.m., in the office, with the Treatment Nurse confirmed the resident had two skin tears on the lower right leg and confirmed the size of the skin tears had not been measured. C/O #",2014-01-01
14308,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2010-09-02,514,D,,,3DE411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow facility policy for documentation related to skin tears for one resident (#1) of eighteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills. Medical record review of a physician's orders [REDACTED]. Medical record review of nurses' notes dated June 15, 2010, (admission) through July 8, 2010 (date of discharge from the facility) and the treatment record dated July 2010, revealed no documentation as to when the skin tears developed and no documentation of the size of the skin tears, drainage, condition of the surrounding skin or the cause of the skin tears. Review of the facility's policy for skin tears revealed, ""...The following information should be recorded in the resident's medical record:...site and description of the skin tear or wound...date and time the skin tear was discovered...All assessment data...bleeding, size of wound...obtained when inspecting the wound..."" Interview on August 24, 2010, at 10:45 a.m., in the office, with the Registered Nurse/Treatment Nurse confirmed the resident had two skin tears on the right leg. Interview on August 26, 2010, at 9:10 a.m., in the office, with the Treatment Nurse confirmed no documentation of the size of the skin tears and no documentation related to drainage or the condition of the skin surrounding the skin tears. Continued interview with the Treatment Nurse confirmed the facility's policy for documentation of skin tears was not followed. C/O #",2014-01-01
14309,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2010-09-02,157,D,,,3DE411,"**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 recommendation by the Dietary Manager for a speech evaluation for one (#1) of eighteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living; had no chewing or swallowing problems and had no weight loss. Medical record review of documentation by the Speech Therapist dated June 16, 2010, revealed, ""...Eval (Evaluation) not indicated...No report or C/O (complaint) pt (resident) having difficulty...swallowing. Deficits in self-feeding reported to OT (Occupational Therapy)..."" Review of documentation of a ""Post Admit Meeting"" with the resident's Power of Attorney (POA-family member), dated June 22, 2010, revealed, ""...Softer foods...POA says (resident) having trouble eating/speech to eval...Discussed current diet. Resident choking. Recommend ST (Speech Therapy) to evaluate..."" Medical record review revealed no documentation speech therapy re-evaluated the resident after the POA reported the resident was having swallowing difficulty. Review of the POS [REDACTED]. Continued interview with the Dietary Manager confirmed on June 22, 2010, the Dietary Manager recommended the resident be re-evaluated by the Speech Therapist due to the report by the POA the resident was choking. Interview on August 24, 2010, at 1:05 p.m., in the office, with the Director of Nursing confirmed the facility failed to ""follow up"" with the physician on the recommendation made by the Dietary Manager on June 22, 2010, for speech therapy to evaluate the resident. C/O #",2014-01-01
14310,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2009-12-16,314,D,,,4T7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow dietary recommendations and obtain physician orders for a pressure area for one (#1) of twenty-three residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems with severely impaired cognitive skills and required assistance with all activities of daily living. Medical record review revealed the resident was receiving daily treatment for [REDACTED]. Medical record review of a dietary recommendation dated November 24, 2009, revealed, ""Recommend, Restart Prostat 30 ml. BID (twice daily)."" Medical record review revealed the Nurse Practitioner signed the recommendation on November 24, 2009, but no physician's order was written. Observation with the Unit Manager while performing a dressing change, in the resident's room, on December 15, 2009, at 12:30 p.m., revealed a healing Stage II pressure area 2.0 x (by) 2.0 x less than 0.1 cm. on the resident's left buttock. Interview with the Nurse Practitioner in the nursing office on December 16, 2009, at 10:30 a.m., confirmed the recommendation were noted however, the Nurse Practitioner failed to write a physician's order.",2014-01-01
14311,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2009-12-16,281,D,,,4T7Z11,"**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 [REDACTED]. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the Daily Skilled Nurse ' s Notes revealed the following blood pressure readings: on December 9, 2009, 101/62; (normal 120/80); on December 11, 2009, 102/62; and on December 13, 2009, 110/54. Interview with the Director of Nursing on December 15, 2009, at 10:15 a.m., in the Director of Nursing 's office confirmed, per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order dated December 9, 2009, for decreasing [MEDICATION NAME] to 2.5 mg was not followed.",2014-01-01
14312,TRI STATE HEALTH AND REHABILITATION CENTER,445263,600 SHAWANEE RD,HARROGATE,TN,37752,2010-03-31,151,D,,,J54J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to honor the rights of one resident (#12) of twenty-three residents reviewed. The finding's included: Resident # 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was independent in decision making and had no short or long term memory problems. Observation and interview on March 29, 2010, at 11:45 a.m., and March 30, 2010, at 8:15 a.m., in the resident's room revealed the resident awake and resting in bed with bilateral half side rails in the down position. Continued observation and interview with resident on these dates revealed, the resident wished to have the side rails up for increased safety but had been told by Licensed Practical Nurse (LPN) #1 that side rails in the up position were illegal. Interview on March 30, 2010, at 8:20 a.m., in the resident's room, with LPN #2 confirmed it was the resident right to have side rails in the up position. Interview on March 30, 2010, at 8:32 a.m., with LPN #1 on the 200 hall revealed, LPN #1 told the resident that, side rails could be up when Certified Nursing Assistants (CNA's) were in the room but side rails were to be down when staff were not in the room. Continued interview with LPN #1 revealed, the facility's Risk Manager had informed LPN #1 of the above. Interview on March 30, 2010, at 8:45 a.m., with the facility's Risk Manager, in the Risk Manager's office revealed, the Risk Manager had told LPN #1 that the resident was to have side rails when CNA's were in the room to assist in turning; but was not to have the side rails in place in the up position when staff was not in room. Continued interview confirmed, that it was the resident right to have side rails in the up position.",2014-01-01
14313,TRI STATE HEALTH AND REHABILITATION CENTER,445263,600 SHAWANEE RD,HARROGATE,TN,37752,2010-03-31,272,D,,,J54J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to complete a side rail assessment for one (#12) of twenty-three residents reviewed. The finding's included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation and interview on March 29, 2010, at 11:45 a.m., and March 30, 2010, at 8:15 a.m., in the resident's room revealed the resident awake and resting in bed with bilateral half side rails in the down position. Continued observation and interview with resident on these dates revealed, the resident wished to have the side rails up for increased safety but had been told by Licensed Practical Nurse (LPN) #1 that side rails in the up position were illegal. Medical record review of a Side Rail assessment dated [DATE], revealed the Side Rail Assessment had not been completed. Interview on March 30, 2010, at 8:45 a.m., with the facility Risk Manager, in the Risk Manager office confirmed, the facility failed to assure the assessment for side rails was completed to determine the necessity of side rails.",2014-01-01
14314,TRI STATE HEALTH AND REHABILITATION CENTER,445263,600 SHAWANEE RD,HARROGATE,TN,37752,2010-03-31,164,D,,,J54J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to ensure privacy was provided during personal care for one resident (#13) of twenty-three residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident had short and long term memory deficits; had severely impaired judgment; was incontinent of bowel and bladder; and required total staff assistance with all activities of daily living. Observation in the resident's room on March 30, 2010, at 8:45 a.m., revealed, upon opening the door 6 inches after knocking, Certified Nursing Assistant (CNA) #1 and CNA #2 were providing incontinence care to the resident. Continued observation revealed the resident was in the bed on the far side of the room; the privacy curtain was not pulled and the resident's genitals were visible from the door and the resident's roommate was in a wheelchair eating breakfast by the bed closest to the door. Interview in the resident's room on March 30, 2010, at 8:50 a.m., with CNA #1 and CNA #2 confirmed the privacy curtain was not in use to provide for the resident's privacy during incontinence care; the resident was not covered to provide for the resident's privacy; and the roommate and anyone entering the room had full view of the exposed resident while the CNA's were providing incontinence care. Review of the facility policy Resident's Rights revealed ""...9. Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and care in his personal..."" Interview with the Administrator in the office of the Administrator on March 30, 2010, at 3:10 p.m., confirmed the privacy of the residents is to be protected by utilizing the privacy curtain to prevent exposure during personal care.",2014-01-01
14315,WILLOWS AT WINCHESTER CARE & REHABILITATION CENTER,445319,32 MEMORIAL DRIVE,WINCHESTER,TN,37398,2010-09-29,323,D,,,6R7P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to supervise to ensure staff used a proper transfer device when transferring one resident (#9) of eleven residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory deficit, required extensive assist for transfers and was non ambulatory. Medical record review of the care plan dated October 6, 2009, revealed the resident was to be transferred using the sit to stand mechanical lift. Review of a facility investigation dated December 9, 2009, revealed the resident was manually transferred to a bedside commode on November 23, 2009, and after staff members placed resident back in bed, the resident complained of leg pain. Continued review of the facility's investigation revealed the resident continued to complain of pain and pain medication was given through out the night. Medical record review revealed the resident was sent to the local hospital on November 24, 2009 and an Xray revealed a fracture of right femur. Interview with CNA#2 (one of the CNAs who were involved in transferring the resident on November 23, 2009) on September 28, 2010 at 12:45 p.m. in the conference room, revealed two CNAs transferred the resident to the bedside commode without using the mechanical lift but the resident did not fall or hurt their leg during this transfer. The CNA stated they stayed with the resident while the resident was on the commode and the resident did not specifically say their leg was hurting until the resident was assisted back to the bed. The CNA stated the resident's voiced pain was reported to the nurse. Interview with LPN #1 (Licensed Practical Nurse) on September 28, 2010, at 1:00 p.m., in the conference room, revealed the nurse had assessed the resident the evening of November 23, 2009, and had not noticed anything abnormal with the resident. Continued interview revealed the resident would complain of pain but would not specify an area of pain. Interview with the Director of Nursing (DON) on September 28, 2010, at 1:50 p.m., in the DON's office, confirmed the facility had failed to use lift for the resident for the transfer on November 23, 2009. Interview with the resident's doctor on September 29, 2010 at 8:00 a.m. revealed ""Hard to tell"" if the transfer without the lift could have caused the resident's fracture. C/O # , #",2014-01-01
14316,WILLOWS AT WINCHESTER CARE & REHABILITATION CENTER,445319,32 MEMORIAL DRIVE,WINCHESTER,TN,37398,2010-09-29,281,D,,,6R7P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to follow the care plan for one resident (#5); and failed to follow physician's orders for one resident (#8) of eleven residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was ""...total dependence..."" for transfers. Medical record review of the Care Plan dated June 4, 2010, revealed ""...use lift for transfers with assistance of two."" Review of a facility investigation dated July 16, 2010, revealed ""...manually lifted resident to shower chair..."" Interview on September 28, 2010, at 12:30 p.m., with Certified Nursing Assistant #1, at the nurse's station, revealed ""...lifted resident manually with help...did not use the full lift..."" Interview on September 28, 2010, at 2:30 p.m., with the ADON (Assistant Director of Nursing) in the ADON's office, confirmed the facility failed to follow the care plan for proper transfer of the resident. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's order revealed the resident was to have a weekly BMP (Basic Metabolic Panel) . Review of the laboratory report revealed the last BMP lab was completed August 17, 2009. Interview with Director of Nursing on [DATE], at 2:50 p.m., in the conference room, confirmed the last BMP lab was August 17, 2009.",2014-01-01
14317,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2010-01-21,157,D,,,IMBG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to update family contact information for one (#10) of fifteen residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes revealed the licensed nurse attempted to call the resident's brother on October 29, 2009, after the resident fell , and the brother's phone number was disconnected. Continued review revealed resident #10 fell again on November 12, 2009, and no contact number was available, so the resident's brother was not notified of the fall. Interview with the Social Services Director (SSD) and Case Manager (CM) #1 on January 21, 2010, at 9:35 a..m, in the Social Services Director's office, revealed the SSD and CM #1 were unaware the resident's brother's phone had been disconnected, and confirmed updated contact information was not available until January 21, 2010, at 1:00 p.m.",2014-01-01
14318,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2010-01-21,441,D,,,IMBG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, and interview, the staff failed to wash the hands, during a dressing change for two (#8, #1) of fifteen residents reviewed. The findings included: Observation on January 19, 2010, at 2:01 p.m., revealed Licensed Practical Nurse (LPN) #4 providing wound care to resident #8. Observation revealed LPN #4 donned gloves and removed soiled dressings from the right and left lower legs. Observation revealed without changing the gloves or washing the hands, LPN #4 cleansed two open wounds on the right lower leg, and three wounds on the left leg, with wound cleanser and gauze pads. Continued observation revealed without changing the gloves or washing the hands, LPN #4 applied Triple Antibiotic Ointment to each of LPN #4's gloved fingers, and then used each of the five fingers to individually apply the Triple Antibiotic Ointment to the five wounds on the lower legs. Continued observation revealed without changing the gloves or washing the hands, LPN #4 applied dressings to the five wounds. Review of the facility's policy Skin Integrity Program revealed ""...Put on gloves...Remove soiled dressing...Cleanse wound with wound cleanser...Remove gloves and complete hand hygiene...Put on new gloves...Apply prescribed ointments if indicated...If you are dressing more than one site on a resident, hand hygiene must be done between each site..."" Interview on January 20, 2010, at 11:10 a.m., with LPN #4, in the Assistant Director of Nursing's office, confirmed the gloves were not changed and the hands were not washed during the wound care provided to resident #8 on January 19, 2010, at 2:01 p.m. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on January 20, 2010, at 9:20 a.m., in resident #1's room, of LPN #4 provide treatment to a open wound on the resident's right fifth toe. Observation revealed: LPN #4 applied gloves; removed the resident's sock; a Certified Nurse Assistant entered the room and handed LPN #4 a tube of ointment for another resident (contaminated) and LPN #4 put the other resident's tube of ointment into the uniform pocket; without removing the contaminated gloves or sanitizing the hands LPN #4 removed the soiled dressing on the resident's foot; removed the soiled gloves and without washing or sanitizing the hands applied clean gloves; cleansed the wound with wound cleanser and dried it with gauze pads; without washing or sanitizing the hands applied [MEDICATION NAME] ointment with a cotton swab using the cotton end, then turned the cotton swab around and used the contaminated wooden end to smooth the ointment onto the wound; without washing or sanitizing the hands applied the dressing to the wound; reapplied the resident's sock; put soiled items including the soiled gloves into a bag; disposed of the bag in the the trash compartment on the treatment cart; and without washing or sanitizing the hands placed the wound cleanser bottle and the jar of [MEDICATION NAME] in the treatment cart. Interview with LPN #4 on January 20, 2010, at 9:35 a.m., in the hallway outside of resident #1's door, revealed the hands were sanitized prior to assembling the bottle of wound cleanser, gauze, jar of [MEDICATION NAME], cotton swab, and the dressing, and confirmed the hands were not washed or sanitized until all items were replaced in the treatment cart.",2014-01-01
14319,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2010-01-21,505,D,,,IMBG11,"**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 laboratory results for two (#8, #7) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the December 2009, physician's recapitulation orders revealed the resident was receiving [MEDICATION NAME] (anticoagulant) 4mg (milligrams) daily, and a PT/INR (laboratory test to measure blood coagulation) was to be completed every month. Medical record review of a PT/INR laboratory report dated December 22, 2009, revealed PT 25.1 (reference range 11.9-14.4) and INR 2.2 (reference range 2.0-3.5). Medical record review of the same PT/INR laboratory report revealed the laboratory report was faxed to the physician on December 23, 2009, however, medical record review revealed no documentation the physician had received/reviewed the laboratory report. Interview on January 21, 2010, at 9:35 a.m., with the Assistant Director of Nursing, in the conference room, confirmed there was no documentation the physician was notified of the results of the laboratory report. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapulation orders revealed: ""...December 24, 2008, [MEDICATION NAME] level every 3 months ...March 24, 2009, PT/INR (measures how fast blood clots), Potassium, Liver Function every month ...August 21, 2009, BMP (Basic Metabolic Function) HEP (liver) function once a month ..."" Medical record review of the laboratory report dated September 10, 2009, revealed ""[MEDICATION NAME] 0.1 (L) (reference range 0.8-2.0 ng/mg) faxed...9/11/09 ..."" Medical record review revealed no documentation the physician had received/reviewed the laboratory report. Medical record review of the laboratory report dated September 22, 2009, revealed Hepatic Function Panel Total Protein 5.2 (L)...(reference range 6.2-8.0 g/dl)... [MEDICATION NAME] 1.9 (L)(reference range 2.1- 3.7 g/dl)[MEDICATION NAME] time (PT) 15.0 (H) (reference range 11.9-14.4 seconds) INR 1.2 (L) (reference range 2.0-3.5 seconds) faxed ...9/23/09 ..."" Medical record review revealed no documentation the physician had received/reviewed the laboratory report. Medical record review of the laboratory report dated September 24, 2009, revealed "" [MEDICATION NAME] 0.4 (L)(reference range 0.8-2.0 ng/mg)...faxed to M.D. 9/25 ... Medical record review revealed no documentation the physician had received/reviewed the laboratory report. Medical record review of the laboratory report dated October 20, 2009, revealed "" [MEDICATION NAME] 0.3 (L) (reference range 0.8-2.0 ng/mg)[MEDICATION NAME] time (PT) 15.5 (H) (reference range 11.9-14.4 seconds) INR 1.2 (L) (reference range 2.0-3.5 seconds) faxed to M.D. 10-21-09 ... Medical record review revealed no documentation the physician had received/reviewed the laboratory report. Medical record review of the laboratory report dated December 3, 2009, revealed "" [MEDICATION NAME] 0.3 (L) (reference range 0.8-2.0 ng/mg)[MEDICATION NAME] time (PT) 15.3 (H) (reference range 11.9-14.4 seconds) INR 1.2 (L) (reference range 2.0-3.5 seconds) faxed 12-/4/09 ... Medical record review revealed no documentation the physician had received/reviewed the laboratory report. Medical record review of the laboratory report dated January 5, 2010, revealed "" ...INR 1.0 (L) (reference range 2.0-3.5 seconds) Basic Metabolic Panel Glucose 138 (H) (reference range 73-107 hd/dl) ...Calcium 8.6 (L) ... (reference range 8.7-10.4 mg/dl) ...Hepatic Function Panel Total Protein 5.3 (L) (reference range 6.2-8.0g/dl) [MEDICATION NAME] 2.0 (L) (reference range 2.1-3.7 g/dl) ...faxed to MD 1/7/10 ... Medical record review revealed no documentation the physician had received/reviewed the laboratory report. Interview on January 21, 2010, at 9:10 a.m., with the Assistant Director of Nursing in the conference room revealed the physician was notified January 21, 2010, before the interview and the physician confirmed ... was unaware of the results and ordered the resident's dosage of [MEDICATION NAME] to be changed from 4mg daily to 6mg daily.",2014-01-01
14320,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2010-01-21,280,D,,,IMBG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the care plan was revised when a behavior modification program was initated for one (#14) of fifteen residents reviewed. The findings included: Resident # 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes revealed a Weekly Summary, dated July 10, 2009, ""Resident allowed to use...personal cell phone if meds taken as scheduled. Resident likes to call...sister (name) on...cell phone."" Medical record review of the current care plan, revealed the use of the cell phone to modify the resident's behavior was not addressed on the care plan. Interview with the Social Services Director and Case Manager #1 on January 21, 2010, at 9:10 a.m., in the SSD's office, revealed the resident was allowed to use the cell phone, if...took medications as scheduled, at the request of the resident's conservator. Continued interview confirmed the use of the cell phone was utilized to encourage the resident to take medications as scheduled, and confirmed the cell phone program was not addressed on the comprehensive care plan.",2014-01-01
14321,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2010-01-21,514,D,,,IMBG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the medical record was accurate for two (#12, #14) of fifteen residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Consultant Pharmacist Communication to the Physician dated July 15, 2009, revealed ""...Antipsychotic Gradual Dose Reduction (GDR) [MEDICATION NAME] (antipsychotic) 4mg (milligrams) qHS (every hour of sleep)...Based on a review of the MDS (Minimum Data Set), progress notes and nursing record, it was felt by this reviewer that a GDR could be attempted. Please consider the following trial dose reduction: decrease [MEDICATION NAME] to 3mg qHS..."" Medical record review of a physician's orders [REDACTED]. Medical record review of the Mental Health Notes, completed by the Psychiatric Nurse Practitioner, dated August 4, 2009, September 21, 2009, November 30, 2009, and January 18, 2010, revealed the Psychiatric Nurse Practitioner documented the resident continued to receive [MEDICATION NAME] 4mg at hour of sleep, after the [MEDICATION NAME] was decreased to 3mg on July 20, 2009. Interview on January 21, 2010, at 11:20 a.m., with the Director of Nursing (DON), in the DON's office, confirmed the Mental Health Notes/medical record was not accurate. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Mental Health Notes, completed by the Psychiatric Nurse Practitioner, dated August 24, 2009, revealed the resident received [MEDICATION NAME] (antipsychotic) 5 mg one time a day. Medical record review of physician's orders [REDACTED]. Medical record review of the Mental Health Notes, completed by the Psychiatric Nurse Practitioner, dated July 27, 2009, revealed the resident received [MEDICATION NAME] 5 mg 1 every day. Medical record review of the physician's orders [REDACTED]. Interview with the Director of Nursing in the Social Services Director's office on January 21, 2010, at 9:15 a.m., confirmed the Mental Health Notes were inaccurate.",2014-01-01
14322,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2010-01-21,323,D,,,IMBG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent a fall for one (#8) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had moderately impaired cognitive skills, required extensive assistance with transfers/ambulation, and had fallen in the past thirty days. Medical record review of the Fall Risk assessment dated [DATE], and December 14, 2009, revealed the resident was at high risk for falls. Medical record review of a nursing note dated November 18, 2009, at 8:00 a.m., revealed ""This res (resident) found sitting in floor at...bedside. Assessment revealed (no) injuries...Fall was unwitnessed..."" Medical record review of a Fall Care Plan dated November 18, 2009, revealed ""...Resident will not be left in hallway or alone in room in w/c (wheelchair). Take resident from dining room directly to...room & assist to bed. "" Medical record review of a nursing note dated November 22, 2009, at 1:40 p.m., revealed ""Attempted to get into bed et slid into floor. (no) injuries noted..."" Observation on January 20, 2010, at 8:13 a.m., revealed the resident lying on the bed. Interview on January 20, 2010, at 11:45 a.m., with the Director of Nursing, in the conference room, confirmed the resident was unattended at the time of the fall on November 22, 2009, and the Fall Care Plan was not followed.",2014-01-01
14323,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2010-01-21,309,D,,,IMBG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure physician's orders were followed for two (#14, #1) of fifteen residents reviewed. The findings included: Resident #14 was admitted to the facility on December 22, 2008, with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged to another facility on November 13, 2009. Medical record review of physician's orders revealed a telephone order, dated January 13, 2009, for [MEDICATION NAME] (antipsychotic) 5 mg (milligrams) one every morning and 5 mg one at bedtime ""may give IM (intramuscular) if won't take PO (orally)"". Continued review of physician's orders revealed when the [MEDICATION NAME] was increased to 10 mg 1 po bid (twice a day) ""may give IM if refuses PO."" Medical record review of physician's orders revealed the [MEDICATION NAME] was discontinued on August 19, 2009. Medical record review of nurse's notes revealed resident #14 spit out meds as follows March 5, 2009 at 1000; March 24, 2009, at 0730; April 28, 2009, at 0830; and July 27, 2009, at 2100, ""spit out meds in BR (bathroom)."" Medical record review of nurse's notes and the Mediaction Administration Records (MARS) from March, 2009, thru July, 2009, revealed the resident did not receive Zyprex via injection, as ordered, on any of the above dates. Medical record review of physician's orders and MARS from March, 2009, thru July, 2009, revealed on March 1, 2009, resident #14 was receiving [MEDICATION NAME] 5 mg every morning and 10 mg at bedtime (total of 15 mg). Continued review revealed on July 1, 2009, [MEDICATION NAME] was increased to 10 mg twice a day (total of 20 mg). Medical record review of physician's orders and MARS for July, 2009, revealed the [MEDICATION NAME] was again increased, with a 2:00 p.m., dose of 5 mg added (total of 25 mg). Interview with the Assistant Director of Nursing, in the conference room, on January 21, 2010, at 11:30 a.m., revealed the injection was to be given when the resident refused to take the [MEDICATION NAME] or later spit the [MEDICATION NAME] out. Continued interview with the ADON confirmed the physician's order was not followed four times between March 5, 2009, and July 27, 2009. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the December 2009, physician's recapulation orders revealed ""...apply black TED hose (compression stockings) before rising in the morning and remove at bedtime..."" Medical record review of the Podiatrist's progress note dated December 11, 2009, revealed ""...treatment plan: Observation on January 20, 2010, at 8:30 a.m., and 12:40 p.m., in the resident's room, revealed the resident with white cotton socks on both feet. Observation and interview on January 21, 2010, at 10:40 a.m., with the Director of Nursing (DON) and the resident in the resident's room revealed the resident lying on the bed with white cotton socks on both feet. Interview with the resident revealed the staff frequently does not offer to apply the black TED hose for the resident, and the resident is unable to apply the black TED hose to the feet. Interview with the DON confirmed the resident's black TED hose had not been applied. Observation and interview with Licensed Practical Nurse (LPN) #6 on January 21, 2010, at 11:25 a.m., in the resident's room revealed the resident had [MEDICAL CONDITION] in both feet. Interview with LPN #6, confirmed the physician's order was not implemented.",2014-01-01
14324,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2010-01-21,508,D,,,IMBG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure radiology services were obtained as ordered for one (#4) of fifteen residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of physician's progress notes revealed on November 23, 2009, a chest xray was obtained due to resident #4's complaints of congestion and wheezing. Continued review revealed the physician ordered [MEDICATION NAME] (antibiotic) once a day for seven days, and a repeat chest xray in three weeks. Medical record review of radiology reports revealed a repeat chest xray was not obtained until January 20, 2010. Interview with the Assistant Director of Nursing on January 20, 2010, at 2:10 p.m., in the conference room, confirmed the physician's orders [REDACTED].",2014-01-01
14325,"ADAMSPLACE, LLC",445392,1927 MEMORIAL BOULEVARD,MURFREESBORO,TN,37129,2013-11-20,246,D,,,GOZW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to maintain a call light within reach for one resident (#223) of twenty residents reviewed. The findings included: Resident #223 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated November 11, 2013, revealed the resident had a potential for falls/injury related to history of falls, decreased mobility, weakness, with the approach to keep the call light within reach. Observation and interview with the resident, on November 19, 2013, at 8:26 a.m. revealed the resident seated in a wheelchair in the resident's room with the breakfast tray on the over bed table in front of the resident. Further observation revealed the call light was on the bed side table directly behind the wheelchair and out of reach of the resident. Interview with the resident revealed the resident was not able to reach the call light. Interview on November 20, 2013, at 8:30 a.m., with the resident's direct care Certified Nurse Aide #1, in the resident's room, confirmed the resident was capable of using the call light. Further interview confirmed the call light was not in reach of the resident.",2014-01-01
14326,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,323,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility failed to ensure the environment was safe and free of accident hazards, residents received adequate supervision for behaviors and implement interventions to prevent falls for 4 of 32 (Residents #66, #118, #64 and 129) sampled residents in Stage 1 and Stage 2. The facility failed to adequately assess, implement interventions and supervision to ensure the environment was safe and free of accident hazards and notify the physician of conditions resulted in an immediate jeopardy when Resident #66 continued to exhibit behaviors, falls and deterioration of condition. The findings included: 1. Review of the facility's ""Behavior Management Plan"" policy documented, ""The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... The following four-step plan provides the methods of problem solving needed to deal with behavioral symptoms in a quick and consistent way... 1. Immediate Action to control a threatening or dangerous behavioral symptom. 2. Behavior assessment to observe and describe the behavior. 3. Medical evaluation to look for medical or other causes of the behavioral symptom that need treatment... Psychiatric evaluation may be needed. 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the administrator, and the mental health consultant... Residents will be immediately transported to a designated or requested acute care facility for evaluation..."" Review of the facility's ""Accidents/Incidents/Unusual Circumstances"" policy documented, ""It is the policy of this facility to provide residents with adequate supervision to minimize the risk of accidents... The facility will identify residents at risk for falls and implement interventions to minimize the occurrence of falls for those at risk... Residents will be assessed for Fall Risk routinely on admission, quarterly, following a fall and with a significant change... Based on assessment findings, appropriate interventions are identified and implemented... Care plans are updated and revised at every fall or incident..."" Review of the MSDS sheets for the two moisture barrier creams used in the facility revealed the following: a. MSDS for Secura Extra Protective Cream ""...ACUTE HEALTH HAZARDS... INGESTION... GASTROINTESTINAL IRRITATION. INGESTION OF LARGE QUANTITIES CAN BE HAZARDOUS. SYMPTOMS OF INTOXICATION... Contact a poison control center for instructions... After first aid, get appropriate in-plant, paramedic, or community medical support... EYES... may cause eye irritation... Avoid eye contact."" b. MSDS for Secura Dimethicone Protectant ""...ACUTE HEALTH HAZARDS... Ingestion: Large doses may cause gastric upset, dangerous upon ingestion. First Aid Measures... Ingestion: not known... After first aid, get appropriate in-plant, paramedic, or community medical support.... EYES: May cause irritation with redness and pain... Flush eyes (including under lids) with copious amounts of water for at least 15 minutes."" Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses note documented the following: a. [DATE] - ""Resident scratches himself and has scabs all over body. Hospital staff stated this is his behavior... resident's decisions are poor; cues/supervision required... "" b. [DATE] at 3:50 AM - "" ...Ativan... Tablet given for anxiety restless... stating that he can't sleep without medication..."" [DATE] at 4:45 - ""...observed on floor... minor injury moves all extremities laceration to right elbow immediately applied, steristrips... 02 (oxygen) Saturation: 84% (percent) on 02."" c. [DATE] at 7:47 AM - ""...Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed and put oxygen on 02 sat (saturation) checked ,[DATE]% on room air..."" [DATE] at 2:32 PM - ""...Resident noted to be very anxious this shift... proceeded to take a family members milkshake and was going to drink it but ended up dumping it onto the floor, nurse entered room and reminded resident that he is a diabetic and is not to have such items and also that it was inappropriate to take things from other residents... At approximately 1030 his nurse was called to resident's room by CNT (certified nursing technician)... Resident noted sitting on side of bed, snorting a white powdery substance off of a paper located on bedside table using a temperature probe cover with the once closed end open with jagged edges. Also noted on table were a bread knife and credit card. When resident noticed that staff had entered the room he immediately stopped and started apologizing. Substance and paper were taken from resident and placed in zip-lock bag. Resident asked what he was doing and stated that he had found a round, white pill on the floor, crushed it up, and started snorting it because he knew it would get into his system faster... it looked like an Ativan..."" [DATE] at 5:21 PM - ""...Resident seen getting out of wheelchair and attempting to transfer without assist... falling onto his bottom and then onto back hitting the back of his head on the floor..."" d. [DATE] at 8:41 AM - ""resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given Ativan 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..."" [DATE] at 7:48 PM - ""resident is rummaging around, invading other's space, he is non-compliant with staying in his w/c (wheelchair), he gets up and wanders around his room he approaches any and every one in his path, he's making unreasonable request, asking for things that he doesn't have ordered, he refuses to listen to any reasoning, he is obnoxious to staff when he's asked to scoot back out of the personal space he's invaded, he repeats his self over and over again, state's that he can't stop talking, he is anxious and makes those around him uncomfortable per other residents that are trying to walk and get exercise he has absolutely no respect for others, he manipulates staff's time, visitors to other residents time and space, makes request of visitors that are inappropriate asking for phone numbers so he can contact them if he has an emergency, these are not his visitors, medication is not helpful in getting him to calm down."" e. [DATE] at 6:56 AM - ""...noted his lower leg with feet swollen and respirations slightly dyspnic (dyspneic). He was asked to (go) back in bed for leg elevation and put Oxygen nasal cannula on but he was not follow the directions... At 6:41 am, observed resident getting out of wheelchair and starting to walk without staff assistance. Before staff reached him to hold his body, he lost his balance and stepped backward then fell down on his bottom..."" f. [DATE] at 5:44 AM - ""...PRN (as needed) MED (medication) GIVEN; ATIVAN FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... VERY UNSTEADY ON FEET... FREQUENTLY REMOVING OXYGEN... SAT% 84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... TEMP (temperature) 102.8... a little later, found resident eating skin protectant paste. Noted white ointment in full of his mouth and he spread that cream on his glasses... Noted resident's lower extremities edematous..."" g. [DATE] at 3:37 AM - ""...Ativan... given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance... LUNG SOUNDS: crackles heard, lower bilateral lobes... pale, cool..."" h. [DATE] at 8:48 AM - ""Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655am..."" Review of a falls risk assessment completed on [DATE] documented the resident was a high risk for falls. A 5 day Minimum Data Set ((MDS) dated [DATE] documented the brief interview for mental status (BIMS) score was 11, had no behaviors, no wandering and no rejection of care. The care plan dated [DATE] did not address the residents behaviors of drug seeking, snorting, eating the moisture barrier and taking items that are not his. During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, ""Yes I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..."" The physician was asked if he was notified of Resident #66's repeated falls. The physician stated, ""...want to say yes, nurses are good about letting me know about falls, can't say for sure without looking into the ECS (electronic charting system) system, they document incidents in there and I review them in there..."" The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, rummaging, wandering, resisting care, refusing oxygen, refusing to go to bed, being up all hours, constantly talking, eating and drinking everything. The physician stated, ""...am aware of some of his behaviors, told in a couple of conversations..."" When asked if he was informed about the incident of the resident eating the moisture barrier cream. The physician stated, ""No, I don't know anything about him eating the barrier cream..."" When he was asked if he was notified of the residents symptoms of feet and legs swelling, elevated temperature, low oxygen saturations, lung sounds."" The physician stated, ""...No, can't say I know about the elevated temp, they have a protocol for that, 101 and above to call me... I know he had problems, wasn't there very long, don't remember being told he was not using oxygen, I do remember the powder incident and some of the behaviors."" During an interview in the ADON's office on [DATE] at 7:00 PM, the Director of Nursing (DON) stated, ""...yes, I would expect nurses to notify and document the physician was made aware of behaviors, change in condition of residents."" During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, ""...this guy (Resident #66) was aware but not reliable, had diastolic heart failure, not ambulatory, had back pain, people on these drugs need pain clinic, I did not see where behavioral health saw patient, normally would need psychiatric evaluation and care, if I had known just one day of those (documented behaviors) I would have sent him out. He needed to go back to the hospital... I know I would have called psych (psychiatry) in if I had known..."" There was no documentation that the physician was notified of Resident #66's repeated behaviors, anxiety and agitation. There was no documentation of a behavior assessment completed per facility protocol. There was no documentation that the physician was notified of the resident's repeatedly low oxygen saturation results or of the resident being noncompliant with using the oxygen. There was no documentation that the physician was notified of the resident eating the moisture barrier cream. There was no documentation of any medical care given after the resident was found eating the moisture barrier cream. There was no documentation of any new interventions put in place after the second and third falls. There was no documentation of a fall risk assessment completed after the [DATE] fall per facility protocol. There was no incident report completed for the behavior of snorting the white powdery substance or eating the barrier cream. The facility failed to adequately assess, provide interventions and supervision to ensure the environment was safe and free of accident hazards resulted in an immediate jeopardy when Resident #66 continued to exhibit behaviors, falls and deterioration of condition. 2. Medical record review for Resident #118 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The Initial MDS dated [DATE] documented the resident had no falls. Fall risk assessments documented on [DATE] a score of 18, on [DATE] a score of 13 and on [DATE] a score of 17, all indicating the resident was a high risk for falls. Nurses notes documented falls as followed: a. [DATE] - fall with no injury with interventions to make sure the bed is in the lowest position and initiate high wing mattress. b. [DATE] - a fall with no injury and intervention to ""continue to observe."" There was no new intervention implemented after the fall on [DATE]. The care plan dated [DATE] was not revised to include fall and interventions to prevent further falls. 3. Medical record review for Resident #64 documented an admission of [DATE] from a psychiatric hospital, with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] documented a score of 17 indicating the resident was a high risk for falls. Nurses notes documented the following: a. [DATE] - a fall with no injury and an intervention ""instructed to use call light."" b. [DATE] - a witnessed fall ""resident leaned forward and fell head first to ground WITH [DIAGNOSES REDACTED] TO FRONTAL LOBE."" The intervention was ""resident to be placed in a chair with arm rests."" c. [DATE] at 3:00 AM - ""found on floor, fall from bed, sent to ER (emergency room ) for evaluation... Intervention neuro checks."" The care plan dated [DATE] was not revised to include the interventions implemented after the [DATE] and [DATE] falls. There was no documentation of any new interventions to address the fall sustained on [DATE]. 4. Review of the MSDS for Dermal Wound Cleanser documented that it could potentially cause eye irritation and that ingestion can be hazardous due to presence of Benzethonium Chloride. First aid measures, ""...Flush eyes with copious amounts of water for at least 15 minutes... Dilute by drinking water... After first aid, get appropriate in-plant, paramedic, or community medical support..."" Observations at the treatment cart on [DATE] at 11:35 AM, revealed Nurse #5 gathered the wound care supplies and placed them on top of the cart. Nurse #5 left the Dermal Wound Cleanser and the Dakins solution on top of the cart and the cart unlocked and walked down the hall to the nurses' station. Nurse # 5 returned to the cart and Resident #129 approached the cart. Resident #129 has a [DIAGNOSES REDACTED]. Resident #129 reached out toward the cart. Nurse #5 unsuccessfully, verbally tried to redirect the resident's behavior. Another facility staff member had to physically remove Resident #129 away from the treatment cart. Observations in room 109B on [DATE] at 12:15 PM, Resident #129 entered the room, while Nurse #2 was administering medication to the resident residing in room 109B. Room 109B was not Resident #129's room. During an interview in room 109B on [DATE] at 12:15 PM, Nurse #2 stated that Resident #129 goes into the rooms of other residents and drinks their water from their water pitchers on their overbed tables. During an interview in the Director of Nursing's (DON) office on [DATE] at 2:45 PM, the DON was asked if treatment supplies should be left unattended. The DON stated, ""No ma'am."" 5. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F323 with a scope and severity of a ""J"". The facility's failure to provide an environment that remains as free from accident hazards as possible and failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed the facility in immediate jeopardy due to these failures. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON) and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. Inservicing 100 percent (%) of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Fall Interventions. b. Fall and Incident reporting. c. Verbal questions and answers with staff. d. Fall interventions. e. Physician notification and Responsible Party notification. f. Change of Condition. g. Recognizing signs/symptoms of respiratory and cardiac distress. h. Behavior Management. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 2. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Behavior Quality Assurance/ Performance Improvement (QA/PI) tool. b. Weekly At Risk QA/PI Log. c. Nursing Notes Audit For Change of Condition. d. Alert Charting Log. e. Event Log. 3. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 4. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices for fall interventions, fall and accident reporting, physician notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and behavior management and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""D"" level for F323 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14327,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,156,D,,,LH9611,"Based on record review and interview, it was determined the facility failed to provide 2 of 3 (Residents #9 and 105) residents with an advanced beneficiary notice as required by law. The findings included: Review of advanced beneficiary notices on 5/14/12 at 1:05 PM, the facility was unable to provide an advanced beneficiary notices for Residents #9 and #105. During an interview in the Assistant Director of Nursing's (ADON) office on 5/14/12 at 1:05 PM, the Social Worker stated, ""We did not start giving them (advanced beneficiary notice) until April (2012).""",2014-01-01
14328,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,157,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of material safety data sheets (MSDS), medical record review and interview, it was determined the facility failed to notify the physician of a deterioration in health, mental and psychosocial status of the resident's repeated behaviors, anxiety, agitation, repeatedly low oxygen saturation results, resident's noncompliance with using oxygen, symptoms of swelling, dyspnea, coolness, paleness and abnormal lung sounds and elevated temperature for 1 of 32 (Resident #66) sampled residents in Stage 1 and Stage 2. Failure of the facility to assess the resident's status and notify the physician of these conditions placed Resident #66 in immediate jeopardy. The findings included: Review of the facility's ""Pulse Oximetry, Monitoring of Residents"" policy documented, ""...Obtain physician order [REDACTED]. Review of the facility's ""Change in Condition"" policy documented, ""...A resident's physician... must be notified of a change in the resident's condition... Documentation of the Change in Condition will be made in the appropriate condition system folder in the Electronic Medical Record... Situations in which a physician... should be notified Immediately of a change in a resident's condition include... any accident / incident with suspected or actual injury... significant and unexpected change/decline in a resident's physical, mental and/or psychosocial status..."" Review of the MSDS sheets for the two moisture barrier creams used in the facility revealed the following: a. MSDS for [MEDICATION NAME] Extra Protective Cream ""...ACUTE HEALTH HAZARDS... INGESTION... GASTROINTESTINAL IRRITATION. INGESTION OF LARGE QUANTITIES CAN BE HAZARDOUS. SYMPTOMS OF INTOXICATION... Contact a poison control center for instructions... After first aid, get appropriate in-plant, paramedic, or community medical support... EYES... may cause eye irritation... Avoid eye contact."" b. MSDS for [MEDICATION NAME] Dimethicone Protectant ""...ACUTE HEALTH HAZARDS... Ingestion: Large doses may cause [MEDICAL CONDITION] upset, dangerous upon ingestion. First Aid Measures... Ingestion: not known... After first aid, get appropriate in-plant, paramedic, or community medical support.... EYES: May cause irritation with redness and pain... Flush eyes (including under lids) with copious amounts of water for at least 15 minutes."" Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses notes documented the following: a. [DATE] - ""Resident scratches himself and has scabs all over body. Hospital staff stated this is his behavior... resident's decisions are poor; cues/supervision required..."" b. [DATE] at 3:50 AM - ""[MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..."" [DATE] at 4:45 AM - ""...observed on floor... minor injury moves all extremities laceration to right elbow immediately applied, steristrips... 02 (oxygen) Saturation: 84% (percent) on 02."" c. [DATE] at 7:47 AM - ""..Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed and put oxygen on 02 sat (saturation) checked ,[DATE]% on room air..."" [DATE] at 2:32 PM - ""...Resident noted to be very anxious this shift... proceeded to take a family members milkshake and was going to drink it but ended up dumping it onto the floor, nurse entered room and reminded resident that he is a diabetic and is not to have such items and also that it was inappropriate to take things from other residents... At approximately 1030 his nurse was called to resident's room by CNT (certified nursing technician)... Resident noted sitting on side of bed, snorting a white powdery substance off of a paper located on bedside table using a temperature probe cover with the once closed end open with jagged edges. Also noted on table were a bread knife and credit card. When resident noticed that staff had entered the room he immediately stopped and started apologizing. Substance and paper were taken from resident and placed in zip-lock bag. Resident asked what he was doing and stated that he had found a round, white pill on the floor, crushed it up, and started snorting it because he knew it would get into his system faster... it looked like an [MEDICATION NAME]"" [DATE] at 5:21 PM - ""...Resident seen getting out of wheelchair and attempting to transfer without assist... falling onto his bottom and then onto back hitting the back of his head on the floor..."" d. [DATE] at 8:41 AM - ""resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given [MEDICATION NAME] 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..."" [DATE] at 7:48 PM - ""resident is rummaging around, invading other's space, he is non-compliant with staying in his w/c (wheelchair), he gets up and wanders around his room he approaches any and every one in his path, he's making unreasonable request, asking for things that he doesn't have ordered, he refuses to listen to any reasoning, he is obnoxious to staff when he's asked to scoot back out of the personal space he's invaded, he repeats his self over and over again, state's that he can't stop talking, he is anxious and makes those around him uncomfortable per other residents that are trying to walk and get exercise he has absolutely no respect for others, he manipulates staff's time, visitors to other residents time and space, makes request of visitors that are inappropriate asking for phone numbers so he can contact them if he has an emergency, these are not his visitors, medication is not helpful in getting him to calm down."" e. [DATE] at 6:56 AM ""...noted his lower leg with feet swollen and respirations slightly dyspnic (dyspneic). He was asked to (go) back in bed for leg elevation and put Oxygen nasal cannula on but he was not follow the directions... At 6:41 am, observed resident getting out of wheelchair and starting to walk without staff assistance. Before staff reached him to hold his body, he lost his balance and stepped backward then fell down on his bottom..."" f. [DATE] at 5:44 AM - ""...PRN (as needed) MED (medication) GIVEN; [MEDICATION NAME] FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... VERY UNSTEADY ON FEET... FREQUENTLY REMOVING OXYGEN... SAT%84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... TEMP (temperature) 102.8... a little later, found resident eating skin protectant paste. Noted white ointment in full of his mouth and he spread that cream on his glasses... Noted resident's lower extremities [MEDICAL CONDITION]"" g. [DATE] at 3:37 AM - ""[MEDICATION NAME] given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance... LUNG SOUNDS: crackles heard, lower bilateral lobes...pale, cool..."" h. [DATE] at 8:48 AM - ""Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655am..."" During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, ""Yes I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..."" The physician was asked about notification of repeated falls. The physician stated, ""...want to say yes, nurses are good about letting me know about falls, can't say for sure without looking into the ECS (electronic charting system) system, they document incidents in there and I review them in there..."" The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, rummaging, wandering, resisting care, refusing oxygen, refusing to go to bed, being up all hours, constantly talking, eating and drinking everything. The physician stated, ""...am aware of some of his behaviors, told in a couple of conversations..."" When asked if he had been notified about the incident of the resident eating the moisture barrier cream. The physician stated, ""No, I don't know anything about him eating the barrier cream..."" When he was asked if he was notified of the residents symptoms of feet and legs swelling, elevated temperature, low oxygen saturations, lung sounds. The physician stated, ""...No, can't say I know about the elevated temp, they have a protocol for that, 101 and above to call me... I know he had problems, wasn't there very long, don't remember being told he was not using oxygen..."" During an interview in the ADON's office on [DATE] at 7:00 PM, the Director of Nursing (DON) stated, ""...yes, I would expect nurses to notify and document the physician was made aware of behaviors, change in condition of residents."" During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, ""...this guy (Resident #66) was aware but not reliable, had diastolic heart failure, not ambulatory, had back pain, people on these drugs need pain clinic, I did not see where behavioral health saw patient, normally would need psychiatric evaluation and care, if I had known just one day of those (documented behaviors) I would have sent him out, He needed to go back to the hospital... I know I would have called psych (psychiatry) in if I had known..."" The facility was unable to provide documentation of the physician being notified of the resident's repeated behaviors, anxiety, agitation, repeatedly low oxygen saturation results, resident's noncompliant with using the oxygen usage, symptoms of swelling, dyspnea, coolness, paleness, abnormal lung sounds and elevated temperature. There was no documentation that the physician was notified of the resident eating the moisture barrier cream. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F157 with a scope and severity of a ""J"". The facility's failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty and failure to notify the physician of these placed Resident #66 in immediate jeopardy. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON) and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. Inservicing 100 percent (%) of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Fall Interventions. b. Fall and Incident reporting. c. Verbal questions and answers with staff. d. Fall interventions. e. Physician notification and Responsible Party notification. f. Change of Condition. g. Recognizing signs/symptoms of respiratory and cardiac distress. h. Behavior Management. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 2. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Behavior Quality Assurance/ Performance Improvement (QA/PI) tool. b. Weekly At Risk QA/PI Log. c. Care Plan Audit. d. Oxygen orders and use. e. Nursing Notes Audit For Change of Condition. f. Alert Charting Log. g. Event Log. 3. The facility developed a ""Weekly at Risk QA/PI log"" that includes a change in condition/general decline audit to be completed by the DON, Administrator, ADON, and MDS weekly on residents. Audit results to be reported to the QA committee. 4. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 5. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, ADON, Regional Director of Operations, Vice President of Clinical Services and three Regional Nurse Consultants in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices for fall interventions, fall and accident reporting, physician notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and behavior management and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""D"" level for F157 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14329,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,170,C,,,LH9611,"Based on policy review and interview, it was determined the facility failed to ensure that residents' mail was sent and promptly received for 1 of 10 Random Resident (RR #5) and sampled residents interviewed. This potential affects all residents mailing or receiving mail on weekends, since the facility has the post office to hold the mail until Monday due to no one is in the front office on weekends. The findings included: Review of the facility's ""Resident Mail delivery and Distribution"" policy documented, ""...All resident mail is delivered unopened and postmarked (for outgoing mail) within 24 hours."" During an interview in RR #5's room on 5/10/12 at 9:00 AM, RR #5 was asked about receiving mail in the facility. RR #5 stated, ""Don't know if it (mail) is delivered on Saturdays."" During an interview in the Assistant Director of Nursing's office on 5/11/12 at 8:45 AM, the Activities Director stated, ""Mail is delivered Monday through Friday to front office, placed in our box and we deliver it to the residents. No mail delivery on weekends because there is no one in the front office. We are not able to get into front office on weekends. No mail delivery on Saturday, they (post office) wait till (until) Monday, Post office holds the mail till Monday because there is no one in the front office. Wished we could get it on weekends, have been incidents where residents have asked (on weekends) if they had any mail.""",2014-01-01
14330,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,223,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, medical record review, observation and interview, it was determined the facility failed to ensure 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 were free from verbal abuse. RR #1 and Resident #25 did not feel they were treated with respect and dignity. RR #1 and Resident #25 confirmed facility staff had yelled and been rude to them. The facility's failure to ensure that residents were free from verbal abuse placed RR #1 and Resident #25 in immediate jeopardy as evidenced by tearful emotional responses during the interviews. The findings included: 1. Review of the facility's ""Abuse Prevention"" policy documented, ""...""Abuse"" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in ""physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult..."" 2. Review of the facility's ""RESIDENT RIGHTS"" statement documented, ""...RESIDENT BEHAVIOR AND FACILITY PRACTICES... ABUSE... You have the right to be free from verbal, sexual, physical or mental abuse... STAFF TREATMENT... The facility must implement procedures that protect you from abuse, neglect or mistreatment..."" 3. Medical record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/30/12 documented, ""...PROBLEM (ADL's (activity of daily living) /FUNCTIONAL): Self Care Deficit needs ext (extensive) Bed Mobility Transfers Toilet Use... RELATED TO: [MEDICAL CONDITION], Decreased mobility Muscle weakness... MANIFESTED BY: Loss of independence, Incontinence... TOILETING: Extensive assist..."" Observations during a resident interview in RR #1's room on 5/8/12 at 2:50 PM, RR #1 began crying when talking about the way the staff spoke to her regarding her incontinence. During an interview in RR #1's room on 5/7/12 at 5:00 PM, RR #1 was asked a series of screening questions to determine if she was of a cognitive level so that she could be interviewed regarding the care and treatment she received at the facility. RR #1 stated she was here for wound care and therapy and planned to go home to her apartment after she was discharged from the facility. RR #1 was determined to be interviewable. During an interview in RR #1's room on 5/8/12 beginning at 2:50 PM, RR #1 was asked if she felt the staff treated her with respect and dignity. RR #1 stated that some of the Certified Nursing Technicians (CNT) had an ""...attitude... I have to use a pamper; and some times I don't ask them to change it because they are hateful... it's only the CNTs (mistreat me)... that has happened everyday since I've been here. They (CNTs) will change their attitude, like they are being so professional, when they get in front of their bosses and stuff. When they have to change my pamper they ask me if I know I'm going to the bathroom. I know I am but, can't get to the bathroom on time by myself..."" At 3:10 PM, RR #1 was asked if staff had yelled or been rude to her. RR #1 stated, ""...Yes, for using the bathroom on myself..."" RR #1 was asked if she knew the names of the staff that spoke to her in a demeaning way and if she had reported it. RR #1 stated, ""No."" During an interview outside RR #1's room on 5/9/12 at 4:45 PM, RR #1 was asked if she would talk with this surveyor further about the way she was being treated by the CNTs. RR #1 stated, ""...I'm not going to be here much longer and don't want to try to do anything about it (the behavior)..."" The surveyor asked RR #1 if she knew who to report mistreatment by staff or other residents to. RR #1 stated, ""...Yes, the nurse..."" During an interview in the Assistant Director of Nursing's office on 5/11/12 at 12:15 PM, the Director of Nursing confirmed that he expected the facility staff to treat the residents with dignity and respect. 4. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #25's room on 5/8/12 at 10:53 AM, revealed Resident #25 crying when talking about the way the staff treated her. During an interview in Resident #25's room on 5/8/12 at 11:06 AM, Resident #25 was asked, ""Has staff yelled or been rude to you?"" Resident #25 stated, ""Yes."" Resident #25 was observed to start crying and stated, ""rather not say cause when you leave, rather not say."" During an interview in Resident #25's room on 5/10/12 at 8:00 AM, Resident #25 stated, ""(Named CNT #4) on day shift sometimes she coming in slinging tray on the table, talk snappy to you... Half of them don't speak..."" During a telephone interview in the Assistant Director of Nursing's (ADON) office, with Resident #25's daughter, on 5/10/12 at 9:15 AM, the daughter stated, ""...The tech (CNT), don't know name, said to my mother, should call somebody to go to the bathroom and she (my mother) said she had urinated on herself because they were slow in coming. I took it as though they were reprimanding her. The tech did not know I had entered the room... I have mentioned it to the nurse evening shift... Asked her (Nurse #1) where are they (CNTs) and why are they so abrupt... I have talked to (named Nurse #1) at meetings..."" During an interview in the Minimum Data Set (MDS) office on 5/10/12 at 4:10 PM, Nurse # 1 stated she confirmed the daughter talked to her, but would not give names of staff. Nurse #1 stated, ""We tried to determine who the staff was. It was early part of year or end of last year. We investigated it, me the Social Worker, DON (Director of Nursing). It (investigation) would be in the DON files. From care conference would be (named Social Worker's) files."" During an interview in the ADON's office on 5/14/12 at 8:40 AM, the DON was asked if he found an investigation on staff being abrupt or rude to Resident #25. The DON stated, ""I don't have one."" 5. RR #1 and Resident #25 confirmed staff had yelled and been rude to them. The facility's failure to ensure that residents were free from verbal abuse placed RR #1 and Resident #25 in immediate jeopardy as evidenced by tearful emotional responses during the interviews. 6. On 5/7 through (-) 15/12 an annual re-certification survey was completed. The facility was cited with an IJ at F223 with a scope and severity of a ""J"". The facility's failure to protect residents from psychological harm and the failure to follow the facility policy of reporting and/or investigating allegations of abuse placed Resident #25 and Random Resident #1 in immediate jeopardy as evidenced by tearful, emotional responses during interviews concerning abuse. An extended survey was completed on 5/15/12. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on 5/10/12 at 7:35 PM and on 5/11/12 at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on 5/14/12 at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Social Services Director interviewed all 96 residents using the ""Resident Questionnaire Regarding Abuse"" form with the following results: a. Ninety residents denied any form of abuse. b. Three residents named a Certified Nursing Technician (CNT) - the CNT was terminated after investigation. c. Two residents alleged verbal abuse by staff - one was substantiated and the CNT was terminated, one was unsubstantiated. d. One allegation of misappropriation of medication - investigated and unsubstantiated. 2. Investigations were initiated utilizing the Vanguard Event Management process. 3. The Social Services Department will complete audits/interviews weekly for one month, monthly for three months, and then once a quarter and as needed. 4. The Social Service Director began one-on-one visits with each resident and/or responsible party defining abuse, how and when to report allegations of abuse and to inform of no retaliation from reporting alleged abuse on 5/12/12. 5. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention. b. Abuse Reporting. c. Staff questionnaire on abuse. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 6. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Weekly At Risk Quality Assurance /Performance Improvement (QA/PI) Log. b. Alert Charting Log. c. Event Log. 7. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 8. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on 5/15/12 at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on 5/10/12. The surveyors determined the IJ was abated on 5/15/12 at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of ""Resident Questionnaire Regarding Abuse"" for all residents, all staff inservices for abuse prevention and abuse reporting and review of findings on audit tools which were initiated on 5/11/12 and completed on 5/15/12. The IJ was abated as of 5/15/12. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""D"" level for F223 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14331,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,224,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, medical record review, observation and interview, it was determined the facility failed to ensure 1 of 10 (Random Resident (RR) #1) residents interviewed in the Stage 1 review was free from mistreatment and neglect by facility staff. RR #1 did not feel that she was treated with respect and dignity. RR #1 confirmed staff had yelled and been rude to her. The facility's failure to ensure that RR #1 was free from mistreatment and neglect placed RR #1 in immediate jeopardy as evidenced by the tearful emotional responses during an interview. The findings included: Review of the facility's ""Abuse Prevention"" policy documented, ""...""Abuse"" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in ""physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult..."" Review of the facility's ""RESIDENT RIGHTS"" statement documented, ""...RESIDENT BEHAVIOR AND FACILITY PRACTICES... ABUSE... You have the right to be free from verbal, sexual, physical or mental abuse... STAFF TREATMENT- The facility must implement procedures that protect your from abuse, neglect or mistreatment..."" Medical record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/30/12 documented, ""...PROBLEM (ADL's (activities of daily living) /FUNCTIONAL): Self Care Deficit needs ext (extensive) Bed Mobility Transfers Toilet Use... RELATED TO: [MEDICAL CONDITION], Decreased mobility Muscle weakness... MANIFESTED BY: Loss of independence, Incontinence... TOILETING: Extensive assist..."" Observations during an interview in RR #1's room on 5/8/12 at 2:50 PM, RR #1 was asked, ""Do you feel the staff treats you with respect and dignity?"" RR #1 stated, ""No."" RR #1 was asked, ""Has staff yelled or been been rude to you?"" RR #1 stated, ""Yes."" During the interview, RR #1 began crying when talking about the way the staff spoke to her regarding her incontinence. During an interview in RR #1's room on 5/7/12 at 5:00 PM, the resident was asked a series of screening questions to determine if she was of a cognitive level so that she could be interviewed regarding the care and treatment she received at the facility. RR #1 stated that she was here for wound care and therapy and planned to go home to her apartment after she was discharged from the facility. The resident was determined to be interviewable. During an interview in RR #1's room on 5/8/12 beginning at 2:50 PM, RR #1 was asked if she felt the staff treated her with respect and dignity? RR #1 stated that some of the Certified Nursing Technicians (CNT) had an ""...attitude... I have to use a pamper; and some times I don't ask them to change it because they are hateful... it's only the CNTs... that has happened everyday since I've been here. They (CNTs) will change their attitude, like they are being so professional, when they get in front of their bosses and stuff. When they have to change my pamper they ask me if I know I'm going to the bathroom. I know I am but, can't get to the bathroom on time by myself..."" At 3:10 PM, RR #1 was asked if staff had yelled or been rude to her. RR #1 stated, ""...Yes, for using the bathroom on myself..."" RR #1 was asked if she knew the names of the staff that spoke to her in a demeaning way and if she had reported it. RR #1 stated, ""No."" During an interview outside RR #1's room on 5/9/12 at 4:45 PM, RR #1 was asked if she would talk with this surveyor further about the way she was being treated by the CNTs. RR #1 stated, ""...I'm not going to be here much longer and don't want to try to do anything about it (the behavior)..."" The surveyor asked RR #1 if she knew who to report mistreatment by staff or other residents to. RR #1 stated, ""...Yes, the nurse..."" During an interview in the Assistant Director of Nursing's office on 5/11/12 at 12:15 PM, the Director of Nursing confirmed that he expected the facility staff to treat the residents with dignity and respect. On 5/7 through (-) 15/12 an annual re-certification survey was completed. The facility was cited with an IJ at F224 with a scope and severity of a ""J"". The facility's failure to ensure that RR #1 was free from mistreatment and neglect placed RR #1 in immediate jeopardy as evidenced by the tearful emotional responses during an interview concerning abuse and neglect. An extended survey was completed on 5/15/12. The Administrator (Adm), the Director of Nursing (DON) and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on 5/10/12 at 7:35 PM and on 5/11/12 at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on 5/14/12 at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Social Services Director interviewed all 96 residents using the ""Resident Questionnaire Regarding Abuse"" form with the following results: a. Ninety residents denied any form of abuse. b. Three residents named a Certified Nursing Technician (CNT) - the CNT was terminated after investigation. c. Two residents alleged verbal abuse by staff - one was substantiated and the CNT was terminated, one was unsubstantiated. d. One allegation of misappropriation of medication - investigated and unsubstantiated. 2. Investigations were initiated utilizing the Vanguard Event Management process. 3. The Social Services Department will complete audits/interviews weekly for one month, monthly for three months, and then once a quarter and as needed. 4. The Social Service Director began one-on-one visits with each resident and/or responsible party defining abuse, how and when to report allegations of abuse and to inform of no retaliation from reporting alleged abuse on 5/12/12. 5. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention. b. Abuse Reporting. c. Staff questionnaire on abuse. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 6. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Weekly At Risk Quality Assurance /Performance Improvement (QA/PI) Log. b. Nursing Notes Audit For Change of Condition. c. Alert Charting Log. d. Event Log. 7. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 8. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, ADON, Regional Director of Operations, Vice President of Clinical Services and three Regional Nurse Consultants in the therapy room on 5/15/12 at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on 5/10/12. The surveyors determined the IJ was abated on 5/15/12 at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of ""Resident Questionnaire Regarding Abuse"", all staff inservices for abuse prevention and abuse reporting and review of findings on audit tools which were initiated on 5/11/12 and completed on 5/15/12. The IJ was abated as of 5/15/12. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""D"" level for F224 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14332,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,226,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, medical record review, observation and interview, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed to investigate the reported abuse for Resident #25. The facility failed to implement procedures that protected RR #1 and Resident #25 from abuse or mistreatment, which resulted in immediate jeopardy as evidenced by displays of emotions due to mental anguish when both residents became tearful when discussing demeaning remarks and actions of staff related to their need for assistance with incontinent care. The findings included: 1. Review of the Abuse Protocol documented ""1. Defining... ""Abuse"" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in ""physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult..."" 2. Review of the facility's ""RESIDENT RIGHTS"" statement documented, ""...RESIDENT BEHAVIOR AND FACILITY PRACTICES... ABUSE... You have the right to be free from verbal, sexual, physical or mental abuse... STAFF TREATMENT... The facility must implement procedures that protect you from abuse, neglect or mistreatment..."" 3. Medical record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/30/12 documented, ""...PROBLEM (ADL's (activity of daily living) /FUNCTIONAL): Self Care Deficit needs ext (extensive) Bed Mobility Transfers Toilet Use... RELATED TO: [MEDICAL CONDITION], Decreased mobility Muscle weakness... MANIFESTED BY: Loss of independence, Incontinence... TOILETING: Extensive assist..."" Observations during a resident interview in RR #1's room on 5/8/12 at 2:50 PM, RR #1 began crying when talking about the way the staff spoke to her regarding her incontinence. During an interview in RR #1's room on 5/7/12 at 5:00 PM, RR #1 was asked a series of screening questions to determine if she was of a cognitive level so that she could be interviewed regarding the care and treatment she received at the facility. RR #1 stated that she was here for wound care and therapy and planned to go home to her apartment after she was discharged from the facility. RR #1 was determined to be interviewable. During an interview in RR #1's room on 5/8/12 beginning at 2:50 PM, RR #1 was asked if she felt the staff treated her with respect and dignity. RR #1 stated that some of the Certified Nursing Technicians (CNT) had an ""...attitude... I have to use a pamper; and some times I don't ask them to change it because they are hateful... it's only the CNTs (mistreat her)... that has happened everyday since I've been here. They (CNTs) will change their attitude, like they are being so professional, when they get in front of their bosses and stuff. When they (CNTs) have to change my pamper they ask me if I know I'm going to the bathroom. I know I am but, can't get to the bathroom on time by myself..."" At 3:10 PM, RR #1 was asked if staff had yelled or been rude to her. RR #1 stated, ""...Yes, for using the bathroom on myself..."" RR #1 was asked if she knew the names of the staff that spoke to her in a demeaning way and if she had reported it. RR #1 stated, ""No."" During an interview outside RR #1's room on 5/9/12 at 4:45 PM, RR #1 was asked if she would talk with this surveyor further about the way she was being treated by the CNTs. RR #1 stated, ""...I'm not going to be here much longer and don't want to try to do anything about it (the behavior)..."" The surveyor asked RR #1 if she knew who to report mistreatment by staff or other residents to. RR #1 stated, ""...Yes, the nurse..."" During an interview in the Assistant Director of Nursing's office on 5/11/12 at 12:15 PM, the Director of Nursing confirmed that he expected the facility staff to treat the residents with dignity and respect. 3. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #25's room on 5/8/12 at 10:53 AM, Resident #25 began crying when talking about the way the staff treated her. During an interview in Resident #25's room on 5/8/12 10:53 AM, Resident #25 stated, ""...they (staff) steal from you all time. Bloomer gone this morning, socks, magazines..."" During an interview in Resident #25's room on 5/8/12 at 11:06 AM, Resident #25 was asked if the staff had been rude to her. Resident #25 stated, ""Yes."" Resident #25 was asked, ""Has staff yelled or been rude to you?"" Resident #25 stated, ""Yes."" Resident #25 began crying and stated, ""rather not say cause when you leave, rather not say."" During an interview in Resident #25's room on 5/10/12 at 8:00 AM, Resident #25 stated, ""(Named CNT #4) on day shift, sometimes she coming in slinging tray on the table, talk snappy to you... Half of them don't speak..."" During a telephone interview in the Assistant Director of Nursing's (ADON) office on 5/10/12 at 9:15 AM, Resident #25's daughter stated, ""...The tech (CNT) don't know name, said to my mother should call somebody to go to the bathroom and she (my mother) said she had urinated on herself because they were slow in coming. I took it as though they were reprimanding her. The tech did not know I had entered the room... I have mentioned it to the nurse evening shift... Asked her (Nurse #1) where are they (CNTs) and why are they so abrupt... I have talked to (named Nurse #1) at meetings..."" During an interview in the Minimum Data Set (MDS) office on 5/10/12 at 4:10 PM, Nurse #1 confirmed that the daughter had talked to her but would not give names. Nurse #1 stated, ""We tried to determine who the staff was. It was early part of year or end of last year. We investigated it, me the Social Worker, DON (director of Nursing). It would be in the DON files. From care conference would be in (named Social Worker's) files."" During an interview in the ADON's office on 5/14/12 at 8:40 AM, the DON was asked if he found an investigation on staff being abrupt or rude to Resident #25. The DON stated, ""I don't have one."" 4. The facility failed to implement procedures that protected RR #1 and Resident #25 from abuse or mistreatment, which resulted in immediate jeopardy as evidenced by displays of emotions due to mental anguish when both residents became tearful when discussing demeaning remarks and actions of staff related to need for assistance with incontinent care. 5. On 5/7 through (-) 15/12 an annual re-certification survey was completed. The facility was cited with an IJ at F226 with a scope and severity of a ""J"". The facility's failure to protect residents from psychological harm and the failure to follow the facility policy of reporting and/or investigating allegations of abuse placed Resident #25 and Random Resident #1 at an immediate jeopardy as evidenced by tearful, emotional responses during interviews concerning abuse. An extended survey was completed on 5/15/12. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's office on 5/10/12 at 7:35 PM and on 5/11/12 at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on 5/14/12 at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Social Services Director interviewed all 96 residents using the ""Resident Questionnaire Regarding Abuse"" form with the following results: a. Ninety residents denied any form of abuse, b. Three residents named a Certified Nursing Technician (CNT) - the CNT was terminated after investigation c. Two residents alleged verbal abuse by staff - one was substantiated and the CNT was terminated, one was unsubstantiated. d. One allegation of misappropriation of medication - investigated and unsubstantiated 2. Investigations were initiated utilizing the Vanguard Event Management process 3. The Social Services Department will complete audits/interviews weekly for one month, monthly for three months and then once a quarter and as needed. 4. The Social Service Director began one-on-one visits with each resident and/or responsible party defining abuse, how and when to report allegations of abuse and to inform of no retaliation from reporting alleged abuse on 5/12/12. 5. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention b. Abuse Reporting c. Staff questionnaire on abuse The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 6. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention. b. Abuse Reporting. c. Staff questionnaire on abuse. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 7. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Weekly At Risk QA/PI Log b. Alert Charting Log c. Event Log 8. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 9. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on 5/15/12 at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on 5/10/12. The surveyors determined the IJ was abated on 5/15/12 at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of ""Resident Questionnaire Regarding Abuse"", all staff inservices for abuse prevention and abuse reporting and review of findings on audit tools which were initiated on 5/11/12 and completed on 5/15/12. The IJ was abated as of 5/15/12. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""D"" level for F226 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14333,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,241,G,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, medical record review, observation and interview, it was determined the facility failed to promote care for residents in a manner that maintained or enhanced each residents dignity and respect for 3 of 32 (Random Resident (RR) #1, Residents #25 and #118) sampled residents in Stage 1 and Stage 2 reviewed for dignity and respect; observations of residents (RR #2 and RR #6) during tour and the medication pass and during 1 of 2 (lunch meal on 5/7/12) dining observations. The facility's failure to ensure Resident #25 and RR #1 were treated with dignity and respect resulted in actual harm as evidenced by the residents being tearful when discussing abuse and mistreatment during interviews. The findings included: 1. Review of the facility's abuse protocol documented, ""...""Abuse"" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in ""physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult. ""...Verbal Abuse"" is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or with their hearing distance, regardless of their age, ability to comprehend, or disability... ""Mental abuse"" includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation... ""Neglect"" means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... only a single incident is necessary for a determination of neglect..."" 2. Review of the facility's ""RESIDENT RIGHTS"" statement documented, ""...RESIDENT BEHAVIOR AND FACILITY PRACTICES... ABUSE... You have the right to be free from verbal, sexual, physical or mental abuse... STAFF TREATMENT... The facility must implement procedures that protect you from abuse, neglect or mistreatment, and misappropriation of your property... All alleged violations must be thoroughly investigated and the results reported... QUALITY OF LIFE- The facility must care for you in a manner that enhances your quality of life. DIGNITY- The facility will treat you with dignity and respect in full recognition of your individuality..."" 3. Medical record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/30/12 documented, ""...PROBLEM (ADL's (activity of daily living) /FUNCTIONAL): Self Care Deficit needs ext (extensive) Bed Mobility Transfers Toilet Use... RELATED TO: [MEDICAL CONDITION], Decreased mobility Muscle weakness... MANIFESTED BY: Loss of independence, Incontinence... TOILETING: Extensive assist..."" Observations during a resident interview in RR #1's room on 5/8/12 at 2:50 PM, RR #1 began crying when talking about the way the staff spoke to her regarding her incontinence. During an interview in RR #1's room on 5/7/12 at 5:00 PM, RR #1 was asked a series of screening questions to determine if she was of a cognitive level so that she could be interviewed regarding the care and treatment she received at the facility. RR #1 stated that she was here for wound care and therapy and planned to go home to her apartment after she was discharged from the facility. RR #1 was determined to be interviewable. During an interview in RR #1's room on 5/8/12 beginning at 2:50 PM, RR #1 was asked if she felt the staff treated her with respect and dignity. RR #1 stated that some of the Certified Nursing Technicians (CNT) had an ""...attitude... I have to use a pamper; and some times I don't ask them to change it because they are hateful... it's only the CNTs (mistreat her)... that has happened everyday since I've been here. They (CNTs) will change their attitude, like they are being so professional, when they get in front of their bosses and stuff. When they have to change my pamper they ask me if I know I'm going to the bathroom. I know I am but, can't get to the bathroom on time by myself..."" At 3:10 PM, RR #1 was asked if staff had yelled or been rude to her. RR #1 stated, ""...Yes, for using the bathroom on myself..."" RR #1 was asked if she knew the names of the staff that spoke to her in a demeaning way and if she had reported it. RR #1 stated, ""...No..."" During an interview outside RR #1's room on 5/9/12 at 4:45 PM, RR #1 was asked if she would talk with this surveyor further about the way she was being treated by the CNTs. RR #1 stated, ""...I'm not going to be here much longer and don't want to try to do anything about it (the behavior)..."" The surveyor asked RR #1 if she knew who to report mistreatment by staff or other residents to. RR #1 stated, ""...Yes, the nurse..."" During an interview in the Assistant Director of Nursing's office on 5/11/12 at 12:15 PM, the Director of Nursing confirmed that he expected the facility staff to treat the residents with dignity and respect. 4. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #25's room on 5/8/12 at 10:53 AM, Resident #25 began crying when talking about the way the staff treated her. During an interview in Resident #25's room on 5/8/12 at 11:06 AM, Resident #25 was asked, ""Has staff yelled or been rude to you?"" Resident #25 stated, ""Yes."" Resident #25 was observed to start crying and stated, ""rather not say cause when you leave, rather not say."" During an interview in Resident #25's room on 5/10/12 at 8:00 AM, Resident #25 stated, ""(Named CNT #4) on day shift sometimes she coming in slinging tray on the table, talk snappy to you... Half of them don't speak..."" During a telephone interview in the Assistant Director of Nursing's (ADON) office on 5/10/12 at 9:15 AM, Resident #25's daughter stated, ""...The tech (CNT) don't know name said to my mother should call somebody to go to the bathroom and she (my mother) said she had urinated on herself because they were slow in coming. I took it as though they were reprimanding her. The tech did not know I had entered the room... I have mentioned it to the nurse evening shift... Asked her (Nurse #1) where are they and why are they (CNTs) so abrupt... I have talked to (named Nurse #1) at meetings..."" During an interview in the Minimum Data Set (MDS) office on 5/10/12 at 4:10 PM, Nurse # 1 stated she confirmed the daughter talked to her but would not give names. Nurse #1 stated, ""We tried to determine who the staff was. It was early part of year or end of last year. We investigated it, me the Social Worker, DON (Director of Nursing). It would be in the DON files. From care conference would be in (named Social Worker's) files."" During an interview in the ADON's office on 5/14/12 at 8:40 AM, the DON was asked if he found an investigation on staff being abrupt or rude to Resident #25. The DON stated, ""I don't have one."" 5. Medical record review for Resident #118 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/21/12 documented problems with related interventions for [MEDICAL CONDITION] and cognitive loss, alteration in vision, impaired communication, self care deficit, altered urine pattern, potential for social isolation, potential for depression, disruptive behavior physically, falls, unintended weight loss, fluid volume deficit and ineffective coping. Review of the MDS dated [DATE] documented, ""...Section C Cognitive Patterns... Summary Score 00 (impaired)..."" Observations on the 400 hall on 5/13/12 at 9:45 AM, revealed Resident #118 walking in the hall wearing only a hospital type gown that did not conceal her back and her diaper. Resident #118 was observed leaving her room and entering a room across the hall. Nurse #4 assisted Resident #118 back to her room. Further observation in the 400's hall at 9:55 AM, revealed Resident #118 wearing the open back gown and diaper again going from her room back to a room across the hall. Nurse #4 did not dress the cognitively impaired resident with known wandering behaviors into appropriate, more dignified clothing when the nurse took the resident back to her room after being found in the hall at 9:45 AM. 6. Medical record review for RR #2 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] documented, ""...Section B Hearing, Speech, Vision... B0600. Speech Clarity... No speech... B0800. Ability to Understand Others... Rarely/never understands... Section C Cognitive Patterns... Staff Assessment for Mental Status... Severely impaired... Section G Functional Status... Total dependence..."" Observations in RR #2's room on 5/9/12 at 4:55 PM, revealed Nurse #6 administering RR #2's medications via PEG tube. RR #2's privacy curtain was not pulled and the room door remained open while the medications were being administered. Observations in RR #2's room on 5/10/12 at 10:30 AM, revealed the door of the room open and the privacy curtain not pulled. RR #2 was lying in bed, exposed from the waist down with his sheet down around his feet. The urinary catheter tubing exited the right leg of his diaper and extended from inside of his diaper down his right leg. 7. Medical record review for RR #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations in RR #6's room on 5/13/12 at 11:55 AM, revealed Nurse #2 administering an insulin injection to RR #6. The privacy curtain between the A and B beds was not pulled. RR #6's roommate sat in a chair between the A and B beds and observed as RR #6 received his insulin. 8. Observations in the second floor dining room on 5/7/12 at 12:10 PM, revealed 3 residents at table #3 were served their meals, the 4th resident at table #3 was not served their meal until 12:20 PM, at which time the other 3 resident had already finished their meals. Observations in the second floor dining room on 5/7/12 at 12:12 PM, one resident at table #4 was served their meal. The first resident at table #4 was finished eating when the last resident was served their meal at 12:26 PM.",2014-01-01
14334,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,242,D,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure the right of residents to make choices about aspects of their life in the facility that are significant to them were respected for 2 of 10 (Resident #33 and Random Resident (RR) #5) sampled residents interviewed in Stage 1 and Stage 2. The findings included: 1. Medical record review for Resident #33 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] documented the resident's activity preferences that were very important to her such as books, newspapers, magazines, listen to music you like, keep up with the news, do things with groups of people, do your favorite activities, go outside and religious services/events. Review of the current care plan documented, ""...Strength (Activities) content with her present activity choice, having no complaints about activity choices, staying busy with room activities of choice. Assess interests/strengths. Invite and assist to activities Avoid fatigue Activity..."" The care plan did not include the individualized activities and preferences of Resident #33. Observations in Resident #33's room on 5/9/12 at 12:10 PM, revealed Resident #33 watching TV and a bible laying on the overbed table. Observations on the front porch on 5/9/12 at 2:40 PM, revealed Resident #33 seated outside smoking and visiting with other residents. Observations on the front porch on 5/12/12 at 2:00 PM, revealed Resident #33 sitting outside on porch with a group of other residents while smoking. During an interview in Resident #33's room on 5/8/12 at 8:50 PM, Resident #33 was asked if she could go outside if she liked. Resident #33 stated, ""...No. I took up smoking so I could go outside..."" 2. During an interview in RR #5's room on 5/10/12 at 9:00 AM, RR #5 was asked if the rights of residents were respected and encouraged. RR #5 stated, ""most of time... we have to have someone with us and get permission to go outside.""",2014-01-01
14335,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,250,D,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to document social progress notes and discharge planning for 1 of 3 (Resident #121) sampled residents in Stage 2. The findings included: Medical record review for Resident #121 documented an admission date of [DATE] from hospital with [DIAGNOSES REDACTED]. A social history completed on 1/23/12 documented the resident lived in an apartment with a friend prior to hospital stay due to a stroke. There were no social work progress notes in the medical record. There was no documentation of any discharge planning. The care plan did not address discharge planning. During an interview in the Assistant Director of Nursing's office on 5/12/12 at 9:10 AM, the Director of Nursing (DON) stated, ""She (Resident #121) is currently getting restorative treatments, therapy has been discontinued.""",2014-01-01
14336,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,253,F,,,LH9611,"Based on policy review, observation and interview, it was determined the facility failed to provide effective maintenance and housekeeping services to maintain a sanitary, orderly and comfortable interior as evidenced by baseboards peeling from the wall, cracked and missing floor tiles, cracked and torn sheet rock, sheet rock in need of cleaning and/or painting, holes in the walls, air units that were not sealed and flush with the wall and/or with cracked and/or missing vent covers and a missing dial, privacy curtains missing pegs and/or dangling from the curtain's ceiling track, dirty floor tiles, blackened caulking at the base of toilets, a broken toilet seat, broken light fixture covers, a light socket behind a bed with the sheet rock cracked and busted leaving the socket box loose in the wall in 44 of 44 (Resident rooms #101, 102, 103, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 201, 202, 203, 204, 205, 206, 207, 208, 209, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223 and 224) resident rooms observed, 300 hall, 200 hall shower room, assisted bath, clean linen closet, physical therapy, nurses bathroom, front office, oxygen room, nurses clean utility room, 1st floor supply room, janitor closet, dining room, 100 hall, 200 hall, Director of Nursing's (DON) office, the Minimum Data Set office and 200 hall shower room. The facility's failure to provide effective maintenance and housekeeping services to maintain a sanitary, orderly and comfortable environment resulted in substandard quality of care. The findings included: 1. Review of the facility's clinical equipment policy documented, ""Purpose: To provide clean clinical equipment and help promote sanitary environment. Policy: For all clinical equipment, the manufacturer's recommendations for cleaning or disinfecting are followed... Wheelchairs, geri-chairs and other specialty chairs are cleaned on a monthly schedule and as needed... IV (intravenous medication) poles... are cleaned weekly and as needed using germicidal agent that is approved for housekeeping to use..."" Review of the facility's maintenance department policy documented, ""Purpose: To assure proper maintenance of the physical plant... The department will do ongoing monitoring of the facility for areas needing repair..."" 2. Observations during tour of the facility on 5/9/12 beginning at 3:50 PM, revealed the following: a. Room 101 - bathroom floor tile missing, tile dirty 2 to 3 inches out from the wall, bedroom has spackling on the wall with no paint and a separation of the sheet rock over the air unit and the unit itself. b. Room 102 - dirt around floor of bathroom, edge of ceiling cracked approximately 1 foot and discolored like wet, glue peeling around the baseboard in the wall by air conditioner. c. Room 103 - brown drainage by the bathroom, chipped paint on the closet, spackling around the lower wall not painted, hole and peeling paint approximately 2 feet over the air conditioner and broken light fixture over the bed. d. Room 106 - spackling inside the door covering the hole and not painted, peeling paint inside the door, broken tile in the bathroom and loose tile behind the toilet. e. Room 107 - crack approximately 1/4 inch wide and approximately a foot long in the wall under the window and cracked peeling paint. f. Room 108 - hole in the ceiling tile around 3 edges, rust under the air conditioner, old glue and spackling around the wall, dirty, stained and chipped floor tile. g. Room 109 - peeling paint on the wall. h. Room 110 - brown splatter on the ceiling approximately 16 by (x) 8 inches wide, unpainted spackling around the bottom of the wall by the air conditioner. The air conditioner was separated from the window and outside light could be seen. Brown stain by the air conditioner, dusty and dirty floor tile, dirty bathroom floor and rusty door facings. i. Room 111 - brown splatter on 5 ceiling tile, brown splatter on the curtain track, broken ceiling tile, broken dry wall, brown-black material by air the conditioner and spackling on the wall by the air conditioner. j. Room 112 - dried plaster on the wall, hole in the wall to the right side of the window, the right side of the air conditioner unit, near the floor, the wood was crumbled and the base board was unattached from the wall, laminate was missing from both corners of the dresser, the privacy curtain would not pull to close, six hooks were missing from the privacy curtain, paint was chipped off the bathroom door and door facing, missing bathroom floor tiles and door to the room had chipped paint. The administrator stood in a chair in the room to try and pull the privacy curtain closed. The curtain would not pull. During an interview in room 112 on 5/9/12 at 3:53 PM, the Administrator stated, ""It won't close at all. That needs to be turned in and fixed."" k. Room 113 - the geri-chair in the room had tears in both arms, the tube feeding pump pole had a dried, brown substance on the base of the pole and the dresser had chipped laminate in the middle of the dresser and on the right edge, chipped paint on the wall in front of the A bed, the plaster around the light fixture above B bed was peeling, bathroom floor tiles were missing, chipped paint on the closet doors, the door to the room was scuffed and had chipped paint. During an interview in room 113 on 5/9/12 at 3:55 PM, the Administrator was asked how often are the poles cleaned. The Administrator stated, ""Cleaned every day."" The housekeeping supervisor was asked if the pole had been cleaned every day. The housekeeper stated, ""I wouldn't say so."" l. Room 114 - both arms of the geri-chair were torn, chipped tile in the right corner of the room, the left corner of the room near the window was chipped with broken floor tiles, baseboard around the room was loose and dirty, a hole in the wall behind the room door and the door had chipped paint and threshold at the entry doorway was black with dirty buildup. During an interview in room 114 on 5/9/12 at 4:00 PM, the housekeeping supervisor was asked what was the black substance on the threshold. The housekeeper stated, ""It's black. Feels like rubber. I guess it would be wax buildup and dirt."" Room 114 - the right side of the toilet seat was broken with rough edges exposed. During an interview in room 114 on 5/9/12 at 4:39 PM, the Administrator was asked if a report had been given for this seat to be repaired. The Administrator stated, ""Oh my gosh! Let me go get (named the maintenance man) right now."" m. Room 115 - the sheetrock was peeled from the lower wall around the entire room. During an interview in room 115 on 5/9/12 at 4:05 PM, the Administrator was asked what happened to the wall. The Administrator stated, ""They replaced the baseboard and when they removed it they peeled off the wall covering and haven't replaced it."" Room 115 - privacy curtain had 3 hooks that were not attached to the track, over-bed table had dried food particles and dried brown substances on the base. During an interview in room 115 on 5/9/12 at 4:05 PM, the housekeeping supervisor was asked how often the over-bed tables were cleaned. The housekeeping supervisor stated, ""Lately we had turnover in staff and haven't deep cleaned the rooms... I could tell you that has not been cleaned. Part of that is rust because it hasn't been cleaned. It was supposed to be cleaned today."" The Administrator stated, ""Some of it is rust, but some is dirt."" n. Room 116 - chipped paint on the wall near the window, three hooks in the privacy curtain were not attached to the track, chipped paint on the closet door and a white substance on the carpet in the right corner of the room near the window. During an interview in room 116 on 5/9/12 at 4:12 PM, the Administrator was asked what the white substance was. The Administrator stated, "" ...don't know what that is. Maybe something spilled or they might have sanded the wall and didn't clean it up."" o. Room 117 - chipped paint from the corner of the wall near the window, laminate was off the dresser corner for B bed, chipped paint on the closet door, chipped paint on the door and door frame. p. Room 118 - B Bed - cracked tile in front of the toilet, plaster on the wall on the right side of the door, privacy curtain had a dried brown smear approximately 4 inches in length across the curtain and over-bed table base was dirty. During an interview in room 118 on 5/9/12 at 4:17 PM, the Administrator was asked if the over-bed table had been cleaned. The Administrator stated, ""Yeah, I see it."" The Housekeeping Supervisor was asked what the brown substance on the curtain was. The housekeeping supervisor stated, ""Looks like BM (bowel movement) to me."" q. Room 119 - A bed- there were 3 hooks not attached to the track to the privacy curtain and 5 hooks missing from the privacy curtain. B bed - left corner of the room the baseboard was off and there was a hole in the wall, dirt buildup on the baseboard in the right corner of the room, laminate missing from the corner of the dresser, bathroom door had chipped paint and a black buildup across the entire threshold to the bathroom. During an interview in room 119 on 5/9/12 at 4:27 PM, the housekeeping supervisor stated, ""That's dirt. That's what it is. They haven't mopped that right."" r. Room 120 - A bed - privacy curtain would not close. The Administrator tried to close the privacy curtain and stated, ""It shouldn't be like that."" The bottom of the closet near the A bed had loose wood board that was pulled away from the closet, a hole in the wall at the corner of the bathroom door, bathroom door had chipped paint, room door and door frame had chipped paint. s. Room 121 - the right side wall behind the door had peeling sheetrock, closet door had chipped paint, entry doorframe had chipped paint and was covered with a clear plastic guard that was loose, chipped paint on the room door, sheetrock pulled away from baseboard at the corner of the room near the window, right side of the air unit had a black substance on the baseboard and covered the block of cement at the end of the air unit, tube feeding pump pole base had a thick brown dried substance, threshold to the bathroom and the floor near the threshold was black. During an interview in room 121 on 5/9/12 at 4:45 PM, the housekeeping supervisor stated, ""Tube feeding. That's what it is. Spilled on the pole and dried... That's wax buildup (referring to the black substance at the threshold to the bathroom)."" t. Room 122 - the tube feeding pump pole base was dirty with a dried brown substance, laminate was off the corners of the dresser for A bed, door had chipped paint, multiple areas of dried plaster on the wall above the dresser and closet door hinges were not secured on B bed closet. During an interview in room 122 on 5/9/12 at 4:50 PM, the Administrator stated, ""The hinges aren't attached like they should be."" u. Room 123 - there was cracked floor tile near the air unit, caulking above the air unit was black, privacy curtain was dirty with brown stains and bathroom threshold had dirty buildup. During an interview in room 123 on 5/9/12 at 4:53 PM, the Administrator stated, ""Looks like it has gotten wet and is rusty buildup from the water."" v. Room 201 - brown stains around the toilet, bathroom door threshold and facing with dirt buildup, all room walls have scuffed areas with sheet rock peeling, 7 ceiling tiles have brown stains, bathroom and room doors are scuffed, 201A - over-bed light cover broken and jagged. w. Room 202 - bathroom has several tiles missing under the toilet causing the toilet to rock, there is brown stained and missing grout, the wall behind and above toilet circled and peeling, bathroom threshold and door jam with dirt buildup, baseboards in the room with dirt buildup and loose baseboard under the vanity. 202B - bedside table had chipped and rough edges, privacy curtain stuck in the ceiling track and does not pull far enough to ensure full privacy and the bathroom and room doors are scuffed. x. Room 203 - loose baseboards under the vanity, vanity corners chipped and rough, dirt buildup around baseboards, brown stains on tiles around the ceiling light, walls scuffed, sheet rock rough, bathroom and room doors scuffed. y. Room 204 - toilet bowl with brown stains, walls scuffed and torn, baseboards are loose and missing under the closet area, there is a hole in the sheet rock behind the B and D beds, the bathroom threshold has a dirt buildup, the bathroom and room doors are scuffed and have chipped paint. z. Room 205 - bathroom has strong urine odor, room walls scuffed and sheet rock chipped behind the beds, room and bathroom corners are chipped, room baseboards with a dirt buildup, bathroom threshold stained with a dirt buildup and room door scuffed with paint chipping. aa. Room 206 - brown stains around the toilet and baseboard, a buildup of dirt around the bathroom door threshold, urine odor in bathroom, walls behind beds scuffed and paint chipped, corners have chipped sheet rock, dirt buildup around baseboards, bathroom and room doors scuffed with paint chipped. bb. Room 207 - room and bathroom threshold with brown buildup, room walls are scuffed with paint chipping around the beds, baseboards have dirt buildup, corners have chipped sheet rock, bathroom and room doors are scuffed with paint chipped. cc. Room 208 - bathroom grout around toilet had brown stain and dirt buildup, dirt buildup around baseboards, bathroom and room doors are scuffed and paint is chipped. dd. Room 209 - dirt buildup around baseboards, bathroom and room doors are scuffed, paint is chipped, threshold stained with a dirt buildup, loose baseboards loose around B bed, sheet rock at B bed has an area approximately 3 feet long that is chipped away, vanity corner is chipped and rough, there is a hole in the wall behind the door with blue tape over it. ee. Room 211 - dirt buildup around baseboard and bathroom threshold, bathroom and room doors are scuffed with chipped paint. ff. Room 212 - bathroom - adjoins 213 - missing floor tile at the entry to the bathroom, grimy tile around baseboard and toilet, and bottom of door frame rusty with peeling paint, 212A - privacy curtain - 13 curtain pegs missing, curtain dangling from ceiling tract and room air unit with broken vents. gg. Room 213 - bottom of bathroom door frame rusty with peeling paint, sheet rock missing from the right corner between room entrance and bathroom entrance, 213B - privacy curtain - 4 pegs missing from privacy curtain and curtain dangled from the ceiling tract. hh. Room 214 - bathroom - adjoins 215 - bottom of bathroom door frame rusty with peeling paint, grimy floor tiles around baseboard, caulking and tile grout blackened at base of toilet, strong odor of urine, scuffed sheet rock on right wall at entrance to room. 214A - cracked sheet rock, about 1 foot long behind the headboard. 214B - curtain pegs missing from privacy curtain; air unit with broken and missing vents. ii. Room 215 - bottom of bathroom door frame rusty with peeling paint, 215A - privacy curtain sticks in ceiling track - difficult to pull and 215B - privacy curtain missing pegs. jj. Room 216 - bathroom - adjoins 217 - bottom of bathroom door frame rusty with peeling paint, grimy floor tile around baseboard and toilet, bathroom door had solid black scuff marks knee high from the floor, corner of the entrance wall and bathroom had chipped sheet rock and missing paint. 216A - no privacy curtain and 216B wall and base boards at foot of bed with multiple drip marks, a hole in the dry wall behind the bed measured approximately 8 to 9 inches in diameter and room air unit adjustment dial missing. kk. Room 217 - bottom of bathroom door frame rusty with peeling paint, 217A dirty baseboard with it coming away from wall, over-bed light cover held together with tape, privacy curtain - missing pegs and sticks in the ceiling tract, 217B baseboards peeling away from the wall, room air unit - front panel loose from unit and open crack between the back top of the unit and the wall. ll. Room 218 - bathroom - adjoins 219 - bottom of bathroom door frame rusty with peeling paint, grimy floor tiles around the baseboard, blackened caulking and tiles around base of the toilet, missing floor tile behind the toilet. 218B - cracked and busted out sheet rock approximately 1 foot high by 3 feet wide behind head board of the bed, electrical socket box loose in the wall and the wall missing from the bottom half of the box, privacy curtain - an extra 6 pegs in the ceiling track jammed the curtain in the track therefore the curtain could not be pulled around the bed for full privacy. mm. Room 219 - bottom of bathroom door frame rusty with peeling paint, dust particles dangled from the ceiling tiles across the expanse of the room, three ceiling tiles with dark brown stains, room air unit - open crack between the back top of the unit and the wall. nn. Room 220 - bathroom - adjoins room 221 - bottom of bathroom door frame rusty with peeling paint, grimy floor tiles around baseboard, blackened caulking and tiles around the base of the toilet, privacy curtains - 220A missing pegs and pegs out of the ceiling track, curtain could not be pulled around the bed for full privacy, 220B missing pegs from curtain did not close around the bed and room air unit - vents broken and missing. oo. Room 221 - bottom of bathroom door frame rusty with peeling paint, grimy floor tiles around baseboard and 221A privacy sticking in ceiling track could not be pulled around the bed for full privacy. pp. Room 222 - bottom of bathroom door frame rusty with peeling paint, grimy floor tiles around baseboard and toilet, and 222B multiple scuff marks were on the walls with multiple stained drip marks and small nail holes. qq. Room 223 - brown stains around toilet, bathroom thresholds for room 223 and 224 have a buildup of dirt, bathroom has urine odor, room baseboards have dirt buildup, sheet rock is torn at entrance to room. rr. On the 300 hall between room 204 and the clean linen room, the sheet rock wall has a hole where the sheet rock is crumbling. ss. The 200 hall shower room has puddles of water in front of all 3 shower stalls and there are no warning signs in the room. tt. Assisted Bath - rust and a dark black buildup around the edge of the shower which the assistant maintenance person confirmed to be mold around 2 showers and dirt around and on the exhaust vent. uu. Clean linen closet - water damage by air conditioner return. vv. Physical Therapy - dirt on the top of the air conditioner, water damage on the wall by the air conditioner, chipped tile and dirt in the therapy bathroom and a cracked ceiling where the assistant maintenance person stated was from a commode that overflowed in the room above this bathroom. ww. Nurses bathroom - peeling paint on door facing and inside facing, floor tile with dirt colored material brown. xx. Front office - dirty door, scraped paint approximately 8 feet long size verified by assistant maintenance person, water damage by air conditioner unit in front office on front wall by window. yy. Oxygen room - water damage in the ceiling with a brown hole in the center, brown material on the floor. zz. Nurses clean utility room - 2 broken light fixtures, separating chipping corner wall, and missing tile from baseboard. aaa. First Floor Supply room - brown material on the floor, material looking like hair on the floor, chipped paint on the door. bbb. Janitor closet - dirty rag, dirty sink, hole in the wall, broken wall tile, dirty cracked floor tile. ccc. Dining room - hole in the wall by the ice machine, leaking water from dish machine ran over the kitchen threshold into the dining room and left a puddle of water on the floor, peeling scuffed wall in the dining room approximately 3 feet and peeling paint on the dining room doors. ddd. 100 and 200 hall - peeling paint outside all doors. eee. Director of Nursing office - gap in the baseboard by air conditioner. fff. Minimum data set office - mold on that carpet and the air unit had a wooden bi-fold in front of it that had decaying wood at the corner, corner of the ceiling behind the door had a ceiling tile with a hole around 3 sides. During an interview in the minimum data set office on 5/9/12 at 5:05 PM, Nurse #3 stated, ""Look at the mold on that carpet. It's embarrassing when families come in here."" The Maintenance assistant stated, ""That's water damage to the door. There should be a physical wall but they put up this bi-fold wall to hide the unit. It's (the air unit) supposed to be behind a wall."" The Maintenance assistant was asked what the stain on the carpet was. The Maintenance assistant stated, ""That's water damage from the unit and that's mold."" The Maintenance assistant stated, ""It has a hole because it was cut too small."" ggg. 200 hall shower room - a hole in the wall above the baseboard of the first stall and circle of black substance on the ceiling above the toilet in the first stall. The housekeeping supervisor stated, ""That's mildew on the ceiling. It's probably leaking from the 2nd floor down."" The 2nd stall had a brown and black substance above the baseboard around the stall. The housekeeping supervisor stated, ""That's mildew."" There was loose dirt on the floor throughout the shower room. The housekeeper stated, ""Yep, needs a good cleaning."" During an interview in the Assistant Director of Nursing's (ADON) office on 5/9/11 at 4:50 PM, the ADON and the Director of Nursing (DON) were asked if they were aware of the state of the facility's interior environment. The ADON stated, ""Yes, there are holes in the walls. Yes, the 300 hall has an area of broken plaster. The shower room has puddles in the floor in front of the showers."" The DON stated, ""We had a mock survey about a month ago. They used blue tape on areas they found concerns, that is what they marked environmental issues with, the blue tape."" During an interview in the ADON's office on 5/10/12 starting at 11:30 AM, the Director of Maintenance was asked how often he or the maintenance assistant was in the resident rooms and if he was aware of their appearance and condition. The Director of Maintenance stated that he and/or the assistant were in each resident's room and the common areas at least monthly for scheduled maintenance and on top of that, for needed repairs that were reported to the maintenance department by staff or residents. During an interview in the DON's office on 5/14/12 at 2:30 PM, the housekeeping supervisor was asked what the housekeeping staff was expected to do on a daily basis. The housekeeping supervisor stated that every resident's room was cleaned daily and this included: the bathroom floors are mopped and the toilet and sink cleaned, the beds are suppose to be pulled away from the walls, the bed side and over-bed tables. The housekeeping supervisor was asked if the housekeeping staff was reporting needed repairs to the maintenance department. The housekeeping supervisor stated, "" ...I don't have the employees to do what I want... I've told them they need to write it (identified repair needs) down and keep a copy... No, they aren't doing it (reporting what they are finding). I've told them (maintenance) they need to take the toilets up and put new caulking around the toilets. The tiles and the door jams are dirty looking but that is old built up wax... each room gets housekeeping every day...""",2014-01-01
14337,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,272,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of dental contract, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility failed to ensure a complete and accurate assessment was completed for 6 of 32 (Residents #66, #138, #14, #19, #106 and #100) sampled residents reviewed in Stage 1 and Stage 2. The failure of the facility to accurately and completely assess behaviors, falls, accident hazards, oxygen therapy and change in conditions placed Resident #66 in an immediate jeopardy. The failure of the facility to assess and provide treatments to pressure ulcers resulted in actual harm to Resident #138. The findings included: 1. Review of the facility's ""Behavior Management Plan"" policy documented, ""The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... The following four-step plan provides the methods of problem solving needed to deal with behavioral symptoms in a quick and consistent way... 1. Immediate Action to control a threatening or dangerous behavioral symptom. 2. Behavior assessment to observe and describe the behavior. 3. Medical evaluation to look for medical or other causes of the behavioral symptom that need treatment... Psychiatric evaluation may be needed. 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the administrator, and the mental health consultant... Residents will be immediately transported to a designated or requested acute care facility for evaluation..."" Review of the facility's ""Accidents/ Incidents/ Unusual Circumstances"" policy documented, ""It is the policy of this facility to provide residents with adequate supervision to minimize the risk of accidents... The facility will identify residents at risk for falls and implement interventions to minimize the occurrence of falls for those at risk... Residents will be assessed for Fall Risk routinely on admission, quarterly, following a fall and with a significant change... Based on assessment findings, appropriate interventions are identified and implemented... Care plans are updated and revised at every fall or incident..."" Review of the facility's ""Oxygen, Administration"" policy documented, ""...To provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident... Document all appropriate information in the clinical record... Oxygen is a drug and, as such, there must be a physician's order for its use... Signs and Symptoms of Respiratory Distress... shortness of breath, confusion... gurgling, wheezing, or [MEDICATION NAME] sounds, fever..."" Review of the facility's ""Pulse Oximetry, Monitoring of Residents"" policy documented, ""...Obtain physician order for [REDACTED]. Review of the facility's ""Change in Condition"" policy documented, ""...A resident's physician and legal representative or responsible party must be notified of a change in the resident's condition... Documentation of the Change in Condition will be made in the appropriate condition system folder in the Electronic Medical Record... Situations in which a physician and legal representative or responsible party should be notified Immediately of a change in a resident's condition include... any accident/incident with suspected or actual injury... significant and unexpected change/decline in a resident physical, mental and/or psychosocial status..."" Review of the MSDS sheets for the two moisture barrier creams used in the facility revealed the following: a. MSDS for [MEDICATION NAME] Extra Protective Cream ""...ACUTE HEALTH HAZARDS... INGESTION... GASTROINTESTINAL IRRITATION. INGESTION OF LARGE QUANTITIES CAN BE HAZARDOUS. SYMPTOMS OF INTOXICATION... Contact a poison control center for instructions... After first aid, get appropriate in-plant, paramedic, or community medical support... EYES... may cause eye irritation... Avoid eye contact."" b. MSDS for [MEDICATION NAME] Dimethicone Protectant ""...ACUTE HEALTH HAZARDS... Ingestion: Large doses may cause [MEDICAL CONDITION] upset, dangerous upon ingestion. First Aid Measures... Ingestion: not known... After first aid, get appropriate in-plant, paramedic, or community medical support... EYES: May cause irritation with redness and pain... Flush eyes (including under lids) with copious amounts of water for at least 15 minutes."" Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses note documented the following: a. [DATE] - ""Resident scratches himself and has scabs all over body. Hospital staff stated this is his behavior... resident's decisions are poor; cues/supervision required... "" b. [DATE] at 3:50 AM - ""[MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..."" [DATE] at 4:45 - ""...observed on floor... minor injury moves all extremities laceration to right elbow immediately applied, steristrips... 02 (oxygen) Saturation: 84% (percent) on 02."" c. [DATE] at 7:47 AM - ""..Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed and put oxygen on 02 sat (saturation) checked ,[DATE] (to) room air..."" [DATE] at 2:32 PM - ""...Resident noted to be very anxious this shift... proceeded to take a family members milkshake and was going to drink it but ended up dumping it onto the floor, nurse entered room and reminded resident that he is a diabetic and is not to have such items and also that it was inappropriate to take things from other residents... At approximately 1030 his nurse was called to resident's room by CNT (certified nursing technician)... Resident noted sitting on side of bed, snorting a white powdery substance off of a paper located on bedside table using a temperature probe cover with the once closed end open with jagged edges. Also noted on table were a bread knife and credit card. When resident noticed that staff had entered the room he immediately stopped and started apologizing. Substance and paper were taken from resident and placed in zip-lock bag. Resident asked what he was doing and stated that he had found a round, white pill on the floor, crushed it up, and started snorting it because he knew it would get into his system faster... it looked like an [MEDICATION NAME]"" [DATE] at 5:21 PM - ""...Resident seen getting out of wheelchair and attempting to transfer without assist... falling onto his bottom and then onto back hitting the back of his head on the floor..."" d. [DATE] at 8:41 AM - ""resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given [MEDICATION NAME] 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..."" [DATE] at 7:48 PM - ""resident is rummaging around, invading other's space, he is non-compliant with staying in his w/c (wheelchair), he gets up and wanders around his room he approaches any and every one in his path, he's making unreasonable request, asking for things that he doesn't have ordered, he refuses to listen to any reasoning, he is obnoxious to staff when he's asked to scoot back out of the personal space he's invaded, he repeats his self over and over again, state's that he can't stop talking, he is anxious and makes those around him uncomfortable per other residents that are trying to walk and get exercise he has absolutely no respect for others, he manipulates staff's time, visitors to other residents time and space, makes request of visitors that are inappropriate asking for phone numbers so he can contact them if he has an emergency, these are not his visitors, medication is not helpful in getting him to calm down."" e. [DATE] at 6:56 AM - ""...noted his lower leg with feet swollen and respirations slightly dyspnic (dyspneic). He was asked to (go) back in bed for leg elevation and put Oxygen nasal cannula on but he was not follow the directions... At 6:41 am, observed resident getting out of wheelchair and starting to walk without staff assistance. Before staff reached him to hold his body, he lost his balance and stepped backward then fell down on his bottom..."" f. [DATE] at 5:44 AM - ""...PRN (as needed) MED (medication) GIVEN; [MEDICATION NAME] FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... VERY UNSTEADY ON FEET... FREQUENTLY REMOVING OXYGEN... SAT% 84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... TEMP (temperature) 102.8... a little later, found resident eating skin protectant paste. Noted white ointment in full of his mouth and he spread that cream on his glasses... Noted resident's lower extremities [MEDICAL CONDITION]"" g. [DATE] at 3:37 AM - ""[MEDICATION NAME] given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance... LUNG SOUNDS: crackles heard, lower bilateral lobes... pale, cool.. "" h. [DATE] at 8:48 AM - ""Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655am..."" Review of a falls risk assessment completed on [DATE] documented the resident was at a high risk for falls. A 5 day Minimum Data Set ((MDS) dated [DATE] documented the brief interview for mental status (BIMS) score was 11, had no behaviors, no wandering and no rejection of care. During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, ""Yes I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..."" The physician was asked if he was notified of Resident #66's repeated falls. The physician stated, ""...want to say yes, nurses are good about letting me know about falls, can't say for sure without looking into the ECS (electronic charting system) system, they document incidents in there and I review them in there..."" The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, rummaging, wandering, resisting care, refusing oxygen, refusing to go to bed, being up all hours, constantly talking, eating and drinking everything. The physician stated, ""...am aware of some of his behaviors, told in a couple of conversations..."" When asked if he was informed about the incident of the resident eating the moisture barrier cream. The physician stated, ""No, I don't know anything about him eating the barrier cream..."" When he was asked if he was notified of the residents symptoms of feet and legs swelling, elevated temperature, low oxygen saturations, lung sounds."" The physician stated, ""...No, can't say I know about the elevated temp, they have a protocol for that, 101 and above to call me... I know he had problems, wasn't there very long, don't remember being told he was not using oxygen, I do remember the powder incident and some of the behaviors."" During an interview in the ADON's office on [DATE] at 7:00 PM, the Director of Nursing (DON) stated, ""...yes, I would expect nurses to notify and document the physician was made aware of behaviors, change in condition of residents."" During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, ""...this guy (Resident #66) was aware but not reliable, had diastolic heart failure, not ambulatory, had back pain, people on these drugs need pain clinic, I did not see where behavioral health saw patient, normally would need psychiatric evaluation and care, if I had known just one day of those (documented behaviors) I would have sent him out. He needed to go back to the hospital... I know I would have called psych (psychiatry) in if I had known..."" There was no documentation of a behavior assessment completed per facility protocol. There was no documentation of any new interventions put in place after the second and third falls. There was no documentation of a fall risk assessment completed after the [DATE] fall per facility protocol. There was no incident report completed for the behavior of snorting the white powdery substance or eating the barrier cream. The failure of the facility to accurately and completely assess behaviors, falls, accident hazards, oxygen therapy and change in condition placed Resident #66 in an immediate jeopardy. 2. Medical record review for Resident #138 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A nurses note dated [DATE] documented pressure ulcer to ""right heel - unstageable, 2x (by) 3cm (centimeters), painful to touch, left heel - unstageable, 4.25x7.25cm, painful to touch, abdominal incision 21x< (less than) 1cm surgical wound, and coccyx- stage 1, reddened, 4x4cm."" The initial MDS dated [DATE] documented the resident as cognitive - 3 severely impaired, had no behaviors, had 2 unstageable pressure sores, had a surgical wound. The 14 day MDS dated [DATE] documented the resident as cognitive - 3 severely impaired, had no behaviors, inaccurately documented the resident had a stage 4 - that measured 0.2x0.3x0.6cm pressure ulcer, had a surgical wound, and inaccurately documented the resident had [MEDICAL CONDITION]. A nurses note dated [DATE] documented the physician assessed the resident and sent him to the hospital on [DATE] and he returned back to the facility on [DATE]. A nurses note dated [DATE] documented the resident dislodged a tube and was sent back to the hospital on [DATE] and returned to the facility on [DATE]. The record contained a wound treatment log that documented a wound assessment dated [DATE] to ""right heel 3.5x6cm and unstageable, left heel 2x5cm and unstagable (unstageable)."" There was no assessment of the coccyx pressure ulcer. Observations in Resident #138's room on [DATE] at 7:30 AM, revealed Resident #138 in bed sleeping on a concave mattress, receiving oxygen at 2 liters per nasal cannula. Observations in Resident #138's room on [DATE] at 5:30 PM, revealed Resident #138 in bed position on the right side, receiving oxygen at 1.5 liters. Observations in Resident #138's room on [DATE] at 8:45 AM, revealed Resident #138 in bed receiving oxygen at 1.5 liters per nasal cannula. Observations in Resident #138's room on [DATE] at 12:00 PM, revealed Resident #138 in bed, was alert, responsive, denies any pain and has bilateral heelbos on feet. Observed an old dressing removed from the coccyx area dated [DATE] identified by Nurse #5 as a foam dressing. The left buttocks wound was approximately ,[DATE] dollar size, had pink center, red edges and open. The right buttock wound was approximately 2x3 inches, had a pink center, red edges and open. The nurse removed the old dressing, dated [DATE], from the left heel, there was no open area but a golf ball sized black hard area was present. Nurse #5 removed the old right heel dressing dated [DATE], the right outer heel area was nickel sized with a pink center, red edges and open. Medical record review revealed there was no physician order for [REDACTED].#138 returned to the facility on [DATE]. During an interview at the first floor nursing station on [DATE] at 11:40 AM, the Director of Nursing (DON) was asked about wound assessment and treatments since Resident #138 returned from the hospital on [DATE]. The DON stated, ""This is all I can find (he brought a copy of the wound treatment log dated [DATE] with assessment of left and right heels and abdominal incision site)."" The facility failed to assess and implement care resulting in actual harm when Resident #138's pressure ulcers deteriorated. 3. Medical record review for Resident #14 documented an admission date of [DATE] from hospital with [DIAGNOSES REDACTED]. The annual MDS dated [DATE], documented a BIMS 00, extensive assist with activities of daily living and no falls. Nurses' incident notes documented the following: a. [DATE] - resident ""found on floor at foot of bed."" b. [DATE] documented a ""fall."" c. [DATE] documented a ""fall."" The quarterly MDS dated [DATE] documented a BIMS 00, no behaviors and no falls. 4. Medical record review for Resident #19 admitted on [DATE] with [DIAGNOSES REDACTED]. The 14 day MDS dated [DATE] was blank in the dental area. The quarterly MDS dated [DATE] was blank in the dental area. During an interview in Resident #19's room on [DATE] at 10:23 AM, Resident #19 stated, ""No problems, had teeth, dropped and broke them, would like to have teeth."" Observation in Resident #19's room on [DATE] at 10:23 AM, confirmed Resident #19 was edentulous. During an interview in the Assistant Director of Nursing's office on [DATE] at 10:40 AM, the DON stated, ""...would get a dental consult for that, we had a dentist that came here, no longer comes here, I believe they stopped coming in December (2011)."" During an interview in the Assistant Director of Nursing's office on [DATE] at 4:40 PM, the DON stated, ""Need to clarify, we did lose dentist but just signed a new contract with one last week, currently getting list of names for him (dentist) to see, to be here in 2 weeks, Have put (named Resident #19) on the list."" Review of the facility's contract with Onecare Dental Solutions was signed on [DATE]. 5. Medical record review for Resident #106 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses' notes dated [DATE] documented, ""WEEKLY SKIN ASSESSMENT ASSESSMENT SKIN PROBLEMS... Has no skin problems or [MEDICAL CONDITION] present."" Observations in Resident #106 room on [DATE] at 8:01 AM, revealed Resident #106 had a red area with a scab on his nose and scabbed area on the left side of his temple. During an interview in the 100 hall on [DATE] at 10:00 AM, Nurse #2 was asked had she ever checked the area on Resident #106's nose. Nurse #2 stated, ""Yes... He does not have anything ordered for it... I had not noticed it until you asked me."" Nurse #2 was asked if she saw Resident #106 everyday. Nurse #2 confirmed she did. During an interview in Resident #106's room on [DATE] at 10:13 AM, Nurse #1 was asked about the area on Resident #106's nose. Nurse #1 stated, ""It looks like [MEDICAL CONDITION]. It is blanchable but is red with a scabbing and can feel nasal septal deformity. I am going to call doctor (nickname of doctor) and call his (Resident #106's) daughter."" During an interview at the nurses' station on [DATE] at 10:25 AM, Nurse #1 stated, ""...Talked to daughter who said he has had several [MEDICAL CONDITION] so the doctor is on his way to look at it."" During an interview at the first floor nurses' station on [DATE] at 3:00 PM, the physician stated, ""It was excoriated and with his history ([MEDICAL CONDITION]) with colon and [MEDICAL CONDITION], we are going to send him out."" During a telephone interview in the ADON's office on [DATE] at 9:45 AM, Resident #106's daughter confirmed Nurse #1 had called her Sunday ([DATE]) and she had called back with the name of the doctor and had to leave a message on the answering machine and no one had called her back yet."" The weekly skin assessment dated [DATE] (documenting no skin problems) was inaccurate since the surveyor had observed the lesion on the nose on [DATE]. 6. Medical record review for Resident #100 documented [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented the resident had no falls since admission or the prior assessment. The record contained a fall risk assessment dated [DATE] with a score of 4 and a fall risk assessment dated [DATE] with a score of 15, indicating a high risk for falls. A fall/incident note dated [DATE] documented ""on floor in her room, Stated going to BR (bathroom) and slid off bed. No injury INTERVENTION - Instructed resident on use of call light."" A fall/incident note dated [DATE] documented, ""on floor No injury INTERVENTION - instructed on safe use of assistive device."" The care plan was not revised with appropriate interventions after the fall on [DATE] or [DATE]. During an interview in the MDS office on [DATE] at 1:53 PM, the MDS Coordinator was asked if the MDS assessment on [DATE] included the fall since the prior assessment. MDS Coordinator stated, ""No, it's not there. Nothing I can say about that. It's not there."" 7. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F272 with a scope and severity of a ""J"". The facility's failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed Resident #66 in immediate jeopardy. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Adm, DON, ADON, Nurse Educator/ADON and Minimum Data Set (MDS) nurses began assessing all residents for signs and symptoms of respiratory and cardiac distress, and behavior assessments on [DATE] and reported any findings of signs and symptoms to the physician. 2. The facility developed a ""Nursing Notes Audit For Change of Condition"" tool to be used for auditing and continued monitoring for each resident. 3. Inservicing 100% of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Fall Interventions. b. Fall and Incident reporting. c. Verbal questions and answers with staff. d. Fall interventions. e. Physician notification and Responsible Party notification. f. Change of Condition. g. Recognizing signs/symptoms of respiratory and cardiac distress. h. Behavior Management. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 4. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Behavior Quality Assurance / Performance Improvement (QA/PI) tool. b. Weekly At Risk QA/PI Log. c. Care Plan Audit. d. Oxygen orders and use. e. Nursing Notes Audit For Change of Condition. f. Alert Charting Log. g. Event Log. 8. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 9. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices for fall interventions, fall and accident reporting, physician notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and behavior management and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of an ""E"" level for F272 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14338,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,279,E,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of dental contract, medical record review, observation and interview, it was determined the facility failed to develop a complete and accurate comprehensive care plan for 14 of 32 (Residents #3, #14, #19, #25, #33, #45, #64, #85, #106, #118, #121, #129, #137 and #138) sampled residents in Stage 1 and Stage 2. The findings included: 1. Review of the facility's ""The Care Plan"" policy documented, "" The Comprehensive Care Plan is completed within seven (7) days after the MDS (minimum data set) is completed... and reviewed quarterly thereafter... If modification, deletions, additions are necessary, changes should be made at the time of the occurrence."" Review of the facility's ""Accidents/ Incidents/ Unusual Circumstances"" policy documented, ""It is the policy of this facility to provide residents with adequate supervision to minimize the risk of accidents... The facility will identify residents at risk for falls and implement interventions to minimize the occurrence of falls for those at risk... Care plans are updated and revised at every fall or incident..."" 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented in Section G that the resident was assessed with [REDACTED]. Review of the care plan dated 2/9/12 did not include ROM exercises. Observations in Resident #3's room on 5/9/12 at 7:41 AM, revealed Resident #3 had left sided contractures. He held his left arm up bent at the elbow against his chest and his left foot pedal of his wheelchair was elevated and extended and supported his left foot and leg. During an interview in Resident #3's room on 5/8/12 at 9:53 AM, Nurse #8 confirmed Resident #3 had contractures on his left side on both the upper and lower extremities. During an interview at the second floor nurses' station on 5/14/12 at 2:35 PM, the restorative certified nursing technician (CNT) #2 was asked if Resident #3 had a restorative plan of care and did he received ROM exercises. CNT #2 stated, ""...He is not in the restorative program at the time... the nursing staff on the unit are responsible for his care and treatment..."" During an interview on the 200 hall on 5/14/12 at 2:40 PM, CNT #3 (who was assigned to care for Resident #3) was asked if she performed scheduled ROM exercises or ROM exercises with the resident while giving his daily personal care. CNT #3 stated, ""No."" 3. Medical record review for Resident #14 documented an admission date of [DATE] from the hospital with [DIAGNOSES REDACTED]. Nurses' incident notes documented the following: a. 1/28/12 - ""found on floor at foot of bed."" b. 2/27/12 - ""fall."" c. 4/16/12 - ""fall."" The quarterly MDS dated [DATE] was not coded to reflect falls. The care plan updated on 4/18/12 did not address falls. 4. Medical record review for Resident #19 admitted on [DATE] with [DIAGNOSES REDACTED]. The 14 day MDS dated [DATE] was blank in the dental area. The quarterly MDS dated [DATE] was blank in the dental area. The care plan dated 4/30/12 did not address the resident's dental issues. During an interview in Resident #19's room on 5/8/12 at 10:23 AM, Resident #19 stated, ""No problems, had teeth, dropped and broke them, would like to have teeth."" Observation during that interview in Resident #19's room on 5/8/12 at 10:23 AM, confirmed Resident #19 was edentulous. During an interview in the Assistant Director of Nursing's (ADON) office on 5/8/12 at 10:40 AM, the Director of Nursing (DON) stated, ""...would get a dental consult for that, we had a dentist that came here, no longer comes here, I believe they stopped coming in December (2011)."" During an interview in the ADON's office on 5/8/12 at 4:40 PM, the DON stated, ""Need to clarify, we did lose dentist but just signed a new contract with one last week, currently getting list of names for him (dentist) to see, to be here in 2 weeks. Have put (named Resident #19) on the list."" The facility contract with Onecare Dental Solutions was documented as signed on March 1, 2012. 5. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] documented in Section L Oral/Dental Status that the resident had, ""...obvious or likely cavity or broken natural teeth..."" There was no care plan for dental problems. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview in Resident #25's room on 5/8/12 at 6:59 AM, Resident #25 was asked about chewing or eating problems. Resident #25 stated, ""Yes, when I eat certain things it hurts and I throw up... and confirmed she had toothaches."" 6. Medical record review for Resident #33 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] documented the resident's activity preferences that were very important to her were books, newspapers, magazines, music, keep up with the news, do things with groups of people, do your favorite activities, go outside and attend religious services/events. Review of the current care plan documented, ""...Strength (Activities) content with her present activity choice, having no complaints about activity choices, staying busy with room activities of choice. Assess interests/strengths. Invite and assist to activities Avoid fatigue Activity..."" The care plan did not include individualized activities and preferences for Resident #33. Observations in Resident #33's room on 5/9/12 at 12:10 PM, revealed the resident watching TV and a bible on the overbed table. Observations on the front porch on 5/9/12 at 2:40 PM, revealed Resident #33 seated outside smoking and visiting with other residents. Observations on the front porch on 5/12/12 at 2:00 PM, revealed Resident #33 sitting outside on porch with a group of other residents while smoking. During an interview in Resident #33's room on 5/8/12 at 8:50 PM, Resident #33 was asked if she could go outside if she liked. Resident #33 stated, ""...No. I took up smoking so I could go outside..."" 7. Medical record review for Resident #45 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] documented, ""...Section L Oral/Dental Status L0200... Check all that apply... (checked) D. Obvious or likely cavity or broken natural teeth..."" Review of the resident's current care plan did not include oral hygiene or dental problems. Observations in Resident #45's room on 5/8/12 at 2:30 PM, revealed Resident #45 had several missing teeth. 8. Medical record review for Resident #64 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview Mental Status (BIMS) 0, indicating cognitive impairment and total care for hygiene. The care plan dated 2/29/12 did not address grooming/hygiene issues. Observations in Resident #64's room on 5/7/12 at 4:12 PM and on 5/9/12 at 4:15 PM, revealed Resident #64 with chin hair present. During an interview at second floor nursing station on 5/11/12 at 5:30 PM, Certified Nursing Assistant #2 stated, ""Residents get shower every other day, suppose to shave chin hair on those days..."" 9. Medical record review for Resident #85 documented [DIAGNOSES REDACTED]. Review of an incident report note dated 4/28/12 documented, ""Fall time of incident 6:25 PM in hallway, another resident had her feet stuck out in the hallway, laceration to right dorsal side of wrist, bruising noted to left ventral side of thumb, hematoma noted to right frontal / temporal side of head. transferred to ER (emergency room )... INTERVENTION - keep residents from [DIAGNOSES REDACTED] hallway and go to a better appropriate place to sit & (and) mingle."" The care plan dated 5/10/12 did not address the fall. 10. Medical record review for Resident #106 documented and admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurse notes dated 5/9/12 documented, ""WEEKLY SKIN ASSESSMENT ASSESSMENT SKIN PROBLEMS... Has no skin problems or [MEDICAL CONDITION] present."" There was no care plan for care of the lesion on Resident #106's nose. Observations in Resident #106 room on 5/8/12 at 8:01 AM, revealed Resident #106 had a red area with a scab on his nose and scabbed area on left side of his temple. During an interview in the 100 hall on 5/13/12 at 10:00 AM, Nurse #2 was asked had she ever checked the area on Resident #106's nose. Nurse #2 stated, ""Yes... He does not have anything ordered for it... I had not noticed it until you asked me. When asked if she saw him everyday, she confirmed she did."" During an interview in Resident #106's room on 5/13/12 at 10:13 AM, when asked about the area on Resident #106's nose. Nurse #1 stated, ""It looks like [MEDICAL CONDITION]. It is blanchable but is red with a scabbing and can feel nasal septal deformity. I am going to call doctor... and call his daughter. During an interview at the nurses station on 5/13/12 at 10:25 AM, Nurse #1 stated, ""...Talked to daughter who said he has had several [MEDICAL CONDITION] so the doctor is on his way to look at it."" During an interview at the first floor nurses station on 5/13/12 at 3:00 PM, the physician stated, ""It was excoriated and with his history ([MEDICAL CONDITION]) with colon and [MEDICAL CONDITION], we are going to send him out."" During a telephone call on 5/15/12 at 9:45 AM, Resident #106's daughter confirmed Nurse #1 had called her Sunday and she had called back with the name of the doctor and had had to leave a message on the answering machine and no one had called her back yet. 11. Medical record review for Resident #118 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The Initial MDS dated [DATE] documented the resident had no falls. Fall risk assessments documented on 3/29/12 a score of 18, on 4/14/12 a score of 13 and on 5/13/12 a score of 17, all indicating the resident was a high risk for falls. Nurses notes documented falls as followed: a. 4/20/12 - fall with no injury with interventions to make sure the bed is in the lowest position and initiate high wing mattress. b. 5/4/12 - a fall with no injury and intervention to ""continue to observe."" There was no new intervention implemented after the fall on 5/4/12. The care plan dated 3/21/12 did not address falls. 12. Medical record review for Resident #121 documented an admission date of [DATE] from hospital with [DIAGNOSES REDACTED]. A social history completed on 1/23/12 documented the resident lived in an apartment with a friend prior to hospital stay due to a stroke. There were no social work progress notes in the medical record. There was no documentation of any discharge planning. The care plan did not address discharge planning. During an interview in the Assistant Director of Nursing's office on 5/12/12 at 9:10 AM, the Director of Nursing (DON) stated, ""She (Resident #121) is currently getting restorative treatments, therapy has been discontinued."" 13. Medical record review for Resident #129 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the dietary assessment dated [DATE] recommended add Multivitamin with minerals daily, add fortified foods with meals, add house supplement 4 ounces three times daily for 4 weeks. Review of the weight log for Resident #129 documented a weight on 4/11/12 - 107 pounds (#) and a weight on 5/7/12 - 101#. There was no care plan that addressed nutritional needs or weight loss. During an interview in the MDS office on 5/14/12 at 3:24 PM, Nurse #3 was asked if the Resident #129 had a care plan for nutrition / weight loss. Nurse #3 reviewed the care plan and stated, ""No."" 14. Medical record review for Resident #137 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/27/12 documented, ""...PROBLEM (ACTIVITIES): Potential for Social isolation... GOAL Indicates satisfaction with leisure time Satisfied with level of social interaction... Nurses - Assure adequate pain control Assure adequate nutrition and hydration... Nurse Aide - Report change in ability Report pain indicators to nurse..."" The care plan that was developed under the problem of ""Activities"" does not address activities, instead, the care plan addresses pain. A care plan related to activities and potential for social isolation was not developed for Resident #137. 15. Medical record review for Resident #138 documented an admitted 4/26/12 with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].>(greater than) 92% (percent)."" The care plan dated 4/27/12 did not address oxygen use or need for oxygen saturation monitoring. Observations in Resident #138's room revealed the following times when Resident #138 was not receiving oxygen at the rate prescribed by the physician: a. 5/11/12 at 7:30 AM, oxygen at 2 liters per nasal cannula. b. 5/11/12 at 5:30 PM, oxygen at 1.5 liters. c. 5/12/12 at 8:45 AM, oxygen at 1.5 liters per nasal cannula. d. 5/13/12 at 12:00 PM, oxygen at 1.5 liters per nasal cannula. During an interview in the ADON's office on 5/14/12 at 9:00 AM, the Director of Nursing stated, ""Would expect nurses to have the correct oxygen rate and to do the oxygen sats as ordered.""",2014-01-01
14339,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,280,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of dental contract, medical record review, observation and interview, it was determined the facility failed to revise the comprehensive care plan for 9 of 32 (Residents #66, #138, #118, #19, #64, #89, #100, #106 and #128) sampled residents in Stage 1 and Stage 2. The failure of the facility to accurately and completely assess and revise the care plan to address behaviors, falls, accident hazards, oxygen therapy and change in condition placed Resident #66 in an immediate jeopardy. The failure of the facility to assess and provide treatments resulted in deterioration of pressure ulcers resulting in actual harm to Resident #138. The failure of the facility to implement recommendations resulted in actual harm when Resident #118 sustained a significant weight loss. The findings included: 1. Review of the facility's ""Behavior Management Plan"" policy documented, ""The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... "" Review of the facility's ""Accidents/ Incidents/ Unusual Circumstances"" policy documented, ""It is the policy of this facility to provide residents with adequate supervision to minimize the risk of accidents... Care plans are updated and revised at every fall or incident..."" Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses note documented the following: a. [DATE] - ""Resident scratches himself and has scabs all over body. Hospital staff stated this is his behavior... resident's decisions are poor; cues/supervision required... "" b. [DATE] at 3:50 AM - "" [MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..."" [DATE] at 4:45 - ""...observed on floor... minor injury moves all extremities laceration to right elbow immediately applied, steristrips... 02 (oxygen) Saturation: 84% (percent) on 02."" c. [DATE] at 7:47 AM - ""..Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed and put oxygen on 02 sat (saturation) checked ,[DATE]% on room air..."" [DATE] at 2:32 PM - ""...Resident noted to be very anxious this shift... proceeded to take a family members milkshake and was going to drink it but ended up dumping it onto the floor, nurse entered room and reminded resident that he is a diabetic and is not to have such items and also that it was inappropriate to take things from other residents... At approximately 1030 his nurse was called to resident's room by CNT (certified nursing technician)... Resident noted sitting on side of bed, snorting a white powdery substance off of a paper located on bedside table using a temperature probe cover with the once closed end open with jagged edges. Also noted on table were a bread knife and credit card. When resident noticed that staff had entered the room he immediately stopped and started apologizing. Substance and paper were taken from resident and placed in zip-lock bag. Resident asked what he was doing and stated that he had found a round, white pill on the floor, crushed it up, and started snorting it because he knew it would get into his system faster... it looked like an [MEDICATION NAME]"" [DATE] at 5:21 PM - ""...Resident seen getting out of wheelchair and attempting to transfer without assist... falling onto his bottom and then onto back hitting the back of his head on the floor..."" d. [DATE] at 8:41 AM - ""resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given [MEDICATION NAME] 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..."" [DATE] at 7:48 PM - ""resident is rummaging around, invading other's space, he is non-compliant with staying in his w/c (wheelchair), he gets up and wanders around his room he approaches any and every one in his path, he's making unreasonable request, asking for things that he doesn't have ordered, he refuses to listen to any reasoning, he is obnoxious to staff when he's asked to scoot back out of the personal space he's invaded, he repeats his self over and over again, state's that he can't stop talking, he is anxious and makes those around him uncomfortable per other residents that are trying to walk and get exercise he has absolutely no respect for others, he manipulates staff's time, visitors to other residents time and space, makes request of visitors that are inappropriate asking for phone numbers so he can contact them if he has an emergency, these are not his visitors, medication is not helpful in getting him to calm down."" e. [DATE] at 6:56 AM - ""...noted his lower leg with feet swollen and respirations slightly dyspnic (dyspneic). He was asked to (go) back in bed for leg elevation and put Oxygen nasal cannula on but he was not follow the directions... At 6:41 am, observed resident getting out of wheelchair and starting to walk without staff assistance. Before staff reached him to hold his body, he lost his balance and stepped backward then fell down on his bottom..."" f. [DATE] at 5:44 AM - ""...PRN (as needed) MED (medication) GIVEN; [MEDICATION NAME] FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... VERY UNSTEADY ON FEET... FREQUENTLY REMOVING OXYGEN... SAT% 84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... TEMP (temperature) 102.8... a little later, found resident eating skin protectant paste. Noted white ointment in full of his mouth and he spread that cream on his glasses... Noted resident's lower extremities [MEDICAL CONDITION]"" g. [DATE] at 3:37 AM - ""[MEDICATION NAME] given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance... LUNG SOUNDS: crackles heard, lower bilateral lobes... pale, cool.."" h. [DATE] at 8:48 AM - ""Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655am..."" Review of a falls risk assessment completed on [DATE] documented the resident was at a high risk for falls. A 5 day Minimum Data Set ((MDS) dated [DATE] documented the brief interview for mental status (BIMS) score was 11, inaccurately assessed the resident with having no behaviors, no wandering and no rejection of care. The care plan dated [DATE] was not revised to address the residents behaviors of drug seeking, snorting, eating the moisture barrier, taking items that were not his, [MEDICAL CONDITION] of legs and feet, low oxygen saturations, abnormal lung sounds, elevated temperature or falls. During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, ""Yes, I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..."" The physician was asked if he was notified of Resident #66's repeated falls. The physician stated, ""...want to say yes, nurses are good about letting me know about falls, can't say for sure without looking into the ECS (electronic charting system) system, they document incidents in there and I review them in there..."" The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, rummaging, wandering, resisting care, refusing oxygen, refusing to go to bed, being up all hours, constantly talking, eating and drinking everything. The physician stated, ""...am aware of some of his behaviors, told in a couple of conversations..."" When asked if he was informed about the incident of the resident eating the moisture barrier cream. The physician stated, ""No, I don't know anything about him eating the barrier cream..."" When he was asked if he was notified of the residents symptoms of feet and legs swelling, elevated temperature, low oxygen saturations, lung sounds."" The physician stated, ""...No, can't say I know about the elevated temp, they have a protocol for that, 101 and above to call me... I know he had problems, wasn't there very long, don't remember being told he was not using oxygen, I do remember the powder incident and some of the behaviors."" During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, ""...this guy (Resident #66) was aware but not reliable, had diastolic heart failure, not ambulatory, had back pain, people on these drugs need pain clinic, I did not see where behavioral health saw patient, normally would need psychiatric evaluation and care, if I had known just one day of those (documented behaviors) I would have sent him out. He needed to go back to the hospital... I know I would have called psych (psychiatry) in if I had known..."" The failure of the facility to accurately and completely assess and revise the care plan to address behaviors, falls, accident hazards, oxygen therapy and change in condition placed Resident #66 in an immediate jeopardy. 2. Review of the facility's ""Wounds Care / Treatment Guidelines"" policy documented ""...weekly assessment is completed on all wounds. This should include measurement and a description... There must be a specific order for the treatment. Documentation of the treatment should be done immediately after the treatment. The care plan should reflect the current status of the wound and appropriate goals."" Medical record review for Resident #138 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A nurses' note dated [DATE] documented pressure ulcer to ""right heel- unstageable, 2x (by) 3cm (centimeters), painful to touch, left heel - unstageable, 4.25x7.25cm, painful to touch, abdominal incision 21x< (less than) 1cm surgical wound, and coccyx- stage 1, reddened, 4x4cm."" A nurses note dated [DATE] documented the physician assessed the resident and sent him to the hospital on [DATE] and he returned back to the facility on [DATE]. A nurses note dated [DATE] documented the resident dislodged a tube and was sent back to the hospital on [DATE] and returned to the facility on [DATE]. The initial Minimum Data Set ((MDS) dated [DATE] documented the resident as cognitive - 3 severely impaired, had no behaviors, had 2 unstageable pressure sores, had a surgical wound. The 14 day MDS dated [DATE] documented the resident as cognitive - 3 severely impaired,had no behaviors, inaccurately documented the resident had a stage 4 - that measured 0.2x0.3x0.6cm pressure ulcer, had a surgical wound, and inaccurately documented the resident had [MEDICAL CONDITION]. The record contained a wound treatment log that documented a wound assessment dated [DATE] to ""right heel 3.5x6cm and unstageable, left heel 2x5cm and unstagable"". There was no assessment of the coccyx pressure ulcer. Observations in Resident #138's room on [DATE] at 12:00 PM, revealed Resident #138 in bed positioned on the right side laying on a concave mattress with the head of the bed elevated, receiving oxygen at 1 ,[DATE] liters per nasal cannula and [MEDICATION NAME] 1.2 at 40 cubic centimeters per hour (cc/hr) per percutaneous endsoscopy gastrostomy (peg) tube. The resident was alert, responsive, denies any pain and has bilateral heelbos on feet. Observed an old dressing removed from the coccyx area dated [DATE] identified by Nurse #5 as a foam dressing. The left buttocks wound was approximately ,[DATE] dollar size, had pink center, red edges and open. The right buttock wound was approximately 2x3 inches, had a pink center, red edges and open. The nurse removed the old dressing dated [DATE], from the left heel, there was no open area but a golf ball sized black hard area was present. Nurse #5 removed the old right heel dressing dated [DATE], the right outer heel area was nickel sized with a pink center, red edges and open. Medical record review revealed there was no physician's order for wound care for the coccyx or heel wounds until [DATE]. There was no assessment of the coccyx pressure ulcer and no documentation of any wound care treatments done since the resident returned to the facility on [DATE] until [DATE]. During an interview at the first floor nursing station on [DATE] at 11:40 AM, the Director of Nursing (DON) was asked about wound assessment and treatments since Resident #138 returned from the hospital on [DATE]. The DON stated, ""This is all I can find (he brought a copy of the wound treatment log dated [DATE] with assessment of left and right heels and abdominal incision site)."" The care plan dated [DATE] was not revised to address the deterioration of the pressure ulcers. The failure of the facility staff to assess, care plan and implement treatments, caused actual harm when Resident #138's pressure ulcers deteriorated following return to the facility. 3. Review of the facility's ""Weight Loss / Underweight"" policy documented, ""...Residents who have a significant, unchanged weight loss or who are 20% or more below their IBW (ideal body weight) or UBW (usual body weight) are considered to be at nutrition risk. Significant unchanged weight loss... should be addressed on the care plan... The resident's physician and the consultant dietitian are notified... include high calorie foods such as large portions, fortified cereals, and juices, house supplements in the diet... consider requesting a physician order for [REDACTED]. Medical record review for Resident #118 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the ""Monthly Weights"" for Resident #118 documented a weight of 134.6 pounds (#) on [DATE], a weight of 129.4 # on [DATE] and a weight of 125.6 # on [DATE], resulting in a significant weight loss of 7.5 percent in 2 months. Review of the RD assessments documented the following: a. [DATE] - ""weight 133 lbs... nutrition intake... requires assist with d/t (due to) [MEDICAL CONDITION] RD RECOMMENDATIONS: add MVI with minerals daily, add fortified food with breakfast."" b. [DATE] - ""...weight loss... 129lbs... RD RECOMMENDATIONS: add house supp (supplement) 4 oz (ounces) bid (twice a day), add fortified foods with meals, cont (continue) weekly wts(weights) x (for) 4 weeks, add MVI with min (minerals) daily."" A physician's order for the RD recommendations was not obtained until [DATE]. The order was documented as ""MVI with minerals daily, House Supplement 4 oz bid, regular fortified food items."" Review of the May, 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation of any interventions implemented from [DATE] until [DATE]. The care plan dated [DATE] was not revised to address the weight loss. Observations in the second floor dining room on [DATE] at 5:00 PM, revealed Resident #118 was thin, getting up and down, and wandering around the room. The staff redirected her back to her meal, she ate ,[DATE] of her meal, then followed a staff member around room and out to hallway. During an interview in the ADON's office on [DATE] at 5:20 PM, the Director of Nursing (DON) stated, ""RD makes her recommendations and puts them in the managers box for follow up, don't know why there is a gap there."" The facility failed to timely implement weight loss recommendations resulting in a significant weight loss and actual harm to Resident #118. 4. Medical record review for Resident #19 documented an admission on [DATE] with [DIAGNOSES REDACTED]. The 14 day MDS dated [DATE] was blank in the dental area. The quarterly MDS dated [DATE] was blank in the dental area. The care plan dated [DATE] was not revised to address the residents dental status. During an interview in Resident #19's room on [DATE] at 10:23 AM, Resident #19 stated, ""No problems, had teeth, dropped and broke them, would like to have teeth."" Observation during the interview in Resident #19's room on [DATE] at 10:23 AM, confirmed the resident was edentulous. During an interview in the ADON's office on [DATE] at 10:40 AM, the DON stated, ""...would get a dental consult for that, we had a dentist that came here, no longer comes here, I believe they stopped coming in December (2011)."" During an interview in the ADON's office on [DATE] at 4:40 PM, the DON stated, ""Need to clarify, we did lose dentist but just signed a new contract with one last week, currently getting list of names for him (dentist) to see, to be here in 2 weeks, Have put (named Resident #19) on the list."" Review of the facility contract with Onecare Dental Solutions revealed the contract was signed on [DATE]. 5. Medical record review for Resident #64 documented an admission of [DATE] from a psychiatric hospital, with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] documented a score of 17 indicating the resident was a high risk for falls. Nurses' note documented the following: a. [DATE] - a fall with no injury and an intervention of ""instructed to use call light."" b. [DATE] - a witnessed fall of ""resident leaned forward and fell head first to ground WITH [DIAGNOSES REDACTED] TO FRONTAL LOBE."" The intervention was ""resident to be placed in a chair with arm rests."" c. [DATE] at 3:00 AM - ""found on floor, fall from bed, sent to ER (emergency room ) for evaluation... Intervention neuro checks."" The care plan dated [DATE] was not revised to include the interventions implemented after the [DATE] and [DATE] falls. There was no documentation of any new interventions to address the fall sustained on [DATE]. 6. Medical record review for Resident #89 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders for [DATE] documented wound treatment orders to the resident's right trochanter wound, left trochanter wound, sacral wound, and left ischium wound. Review of the care plan dated [DATE] AND UPDATED [DATE] documented, ""...PROBLEM... PRESSURE ULCER... MANIFESTED BY: Multiple pressure wounds located on (L) (left) Ischium & (and) (R) (right) and (L) Trochanter..."" The care plan was not updated to address the additional sacral wound. During an interview at the first floor nurses' station on 5/ ,[DATE] at 2:37 PM, Nurse #9 was asked if the resident currently had one or more pressure ulcers. Nurse #9 confirmed the presence of wounds located on Resident #89's Left Ishium, Left Trochanter, Right Trochanter and his Sacrum. 7. Medical record review for Resident #100 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the weight records documented a weight of 215 on [DATE], a weight of 205 on [DATE] and a weight of 181 on [DATE]. The resident lost 11.71% from the first weight to the second weight and 15.81% from the first weight to the third weight. The care plan dated [DATE] documented, ""PROBLEM (ADLs (Activities of Daily Living) /FUNCTIONAL)... Dietary--- Provide ordered diet, Identify likes/dislikes Dietary consult..."" The care plan did not address the weight loss and was not revised to include the additional ""...hs (bedtime) snack."" During an interview in the dining room on [DATE] 1:24 PM, the Dietary Manager stated, ""We discuss the residents in PAR (patients at risk) meeting and any changes are passed on to (named Nurse #1) and (named Nurse #3). They should have it on the care plan."" During an interview on [DATE] at 1:31 PM, Nurse #1 was asked if the bedtime snack was included on the care plan. Nurse #1 reviewed the care plan and stated, ""No. The snack is not on there."" 8. Medical record review for Resident #106 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurse notes dated [DATE] documented, ""WEEKLY SKIN ASSESSMENT ASSESSMENT SKIN PROBLEMS... Has no skin problems or [MEDICAL CONDITION] present."" The plan of care had not been revised to address the lesion on Resident #106's nose. Observations in Resident #106 room on [DATE] at 8:01 AM, revealed a red area with a scab on his nose and scabbed area on left side of his temple. During an interview in the 100 hall on [DATE] at 10:00 AM, Nurse #2 was asked had she ever checked the area on Resident #106's nose. Nurse #2 stated, ""yes... He does not have anything ordered for it... I had not noticed it until you asked me."" Nurse #2 was asked if she saw him everyday. Nurse #2 confirmed she did. During an interview in Resident #106 room on [DATE] at 10:13 AM, Nurse #1 was asked about the area on Resident #106's nose. Nurse #1 stated, ""It looks like [MEDICAL CONDITION]. It is blanchable but is red with a scabbing and can feel nasal septal deformity. I am going to call doctor... and call his daughter."" During an interview at the nurses' station on [DATE] at 10:25 AM, Nurse #1 stated, ""...Talked to daughter who said he has had several [MEDICAL CONDITION] so the doctor is on his way to look at it."" During an interview at the first floor nurses station on [DATE] at 3:00 PM, the physician stated, ""It was excoriated and with his history ([MEDICAL CONDITION]) with colon and [MEDICAL CONDITION], we are going to send him out."" During a telephone call in the ADON's office on [DATE] at 9:45 AM, Resident #106's daughter confirmed Nurse #1 had called her Sunday and she had called back with the name of the doctor and had to leave a message on the answering machine and no one had called her back yet. 9. Medical record review for Resident #128 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] documented, ""...Section C Cognitive Status... C0500. Summary Score... 15 (cognitively intact)..."" Review of the Interdisciplinary fall risk meeting dated [DATE] documented, ""...Found in floor beside her bed [DATE]... Intervention... Bed alarm..."" Review of the care plan dated [DATE] document, ""...FALLS... GOAL... Minimal injury from falls... Request therapy assessment... Transfer with assistance, assist with ambulating, transferring, toileting, report pain indicators..."" The care plan was not updated to include the intervention of the bed alarm. Observations in Resident #128's room on [DATE] at 2:45 PM, revealed the bed alarm was on the bed and the light was blinking on the alarm box. During an interview in Resident #128's room on [DATE] at 3:00 PM, Nurse #7 was asked if the resident had a bed alarm and was it working. Nurse #7 stated, ""...Yes, that is a bed alarm, the light is flashing. It appears to be working..."" 10. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F280 with a scope and severity of a ""J"". The facility's failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed the facility in immediate jeopardy. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. On [DATE] the DON, Adm, ADON, and MDS nurses began reviewing all care plans for accuracy, correcting any interventions as needed, and reporting their findings using the ""Care Plan Audit"" tool. 2. Inservicing 100% of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Fall Interventions. b. Fall and Incident reporting. c. Verbal questions and answers with staff. d. Fall interventions. e. Physician notification and Responsible Party notification. f. Change of Condition. g. Recognizing signs/symptoms of respiratory and cardiac distress. h. Behavior Management i. Individualized Care Planning. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 3. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the Quality Assurance / Performance Improvement (QA/PI) committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 4. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices for fall interventions, fall and accident reporting, physician notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and behavior management and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of an ""E"" level for F280 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14340,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,282,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to provide care according to the care plan for 1 of 32 (Resident #66) sampled residents in Stage 1 and Stage 2. The failure of the facility to provide care according to the care plan to address behaviors and falls resulted in immediate jeopardy to Resident #66. The findings included: Review of the facility's ""Behavior Management Plan"" policy documented, ""The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the administrator, and the mental health consultant... Residents will be immediately transported to a designated or requested acute care facility for evaluation..."" Review of the facility's ""Accidents/ Incidents/ Unusual Circumstances"" policy documented, ""It is the policy of this facility to provide residents with adequate supervision to minimize the risk of accidents... The facility will identify residents at risk for falls and implement interventions to minimize the occurrence of falls for those at risk... Residents will be assessed for Fall Risk routinely on admission, quarterly, following a fall and with a significant change... Based on assessment findings, appropriate interventions are identified and implemented... Care plans are updated and revised at every fall or incident..."" Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses note documented the following: a. [DATE] - ""Resident scratches himself and has scabs all over body. Hospital staff stated this is his behavior... resident's decisions are poor; cues/supervision required... "" b. [DATE] at 3:50 AM - "" [MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..."" [DATE] at 4:45 - ""...observed on floor... minor injury moves all extremities laceration to right elbow immediately applied, steristrips..."" c. [DATE] at 7:47 AM - ""..Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed..."" [DATE] at 2:32 PM - ""...Resident noted to be very anxious this shift... proceeded to take a family members milkshake and was going to drink it but ended up dumping it onto the floor, nurse entered room and reminded resident that he is a diabetic and is not to have such items and also that it was inappropriate to take things from other residents... At approximately 1030 his nurse was called to resident's room by CNT (certified nursing technician)... Resident noted sitting on side of bed, snorting a white powdery substance off of a paper located on bedside table using a temperature probe cover with the once closed end open with jagged edges. Also noted on table were a bread knife and credit card. When resident noticed that staff had entered the room he immediately stopped and started apologizing. Substance and paper were taken from resident and placed in zip-lock bag. Resident asked what he was doing and stated that he had found a round, white pill on the floor, crushed it up, and started snorting it because he knew it would get into his system faster... it looked like an [MEDICATION NAME]"" [DATE] at 5:21 PM - ""...Resident seen getting out of wheelchair and attempting to transfer without assist... falling onto his bottom and then onto back hitting the back of his head on the floor..."" d. [DATE] at 8:41 AM - ""resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given [MEDICATION NAME] 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..."" [DATE] at 7:48 PM - ""resident is rummaging around, invading other's space, he is non-compliant with staying in his w/c (wheelchair), he gets up and wanders around his room he approaches any and every one in his path, he's making unreasonable request, asking for things that he doesn't have ordered, he refuses to listen to any reasoning, he is obnoxious to staff when he's asked to scoot back out of the personal space he's invaded, he repeats his self over and over again, state's that he can't stop talking, he is anxious and makes those around him uncomfortable per other residents that are trying to walk and get exercise he has absolutely no respect for others, he manipulates staff's time, visitors to other residents time and space, makes request of visitors that are inappropriate asking for phone numbers so he can contact them if he has an emergency, these are not his visitors, medication is not helpful in getting him to calm down."" e. [DATE] ""...At 6:41 am, observed resident getting out of wheelchair and starting to walk without staff assistance. Before staff reached him to hold his body, he lost his balance and stepped backward then fell down on his bottom..."" f. [DATE] at 5:44 AM - ""...PRN (as needed) MED (medication) GIVEN; [MEDICATION NAME] FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... VERY UNSTEADY ON FEET... FREQUENTLY REMOVING OXYGEN... SAT% 84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... a little later, found resident eating skin protectant paste. Noted white ointment in full of his mouth and he spread that cream on his glasses..."" g. [DATE] at 3:37 AM - ""[MEDICATION NAME] given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance..."" h. [DATE] at 8:48 AM - ""Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655am..."" Review of a falls risk assessment completed on [DATE] documented the resident was at a high risk for falls. A 5 day Minimum Data Set ((MDS) dated [DATE] documented the brief interview for mental status (BIMS) score was 11, had no behaviors, no wandering and no rejection of care. The care plan dated [DATE] documented the following: ""Potential for Trauma- Falls injury... Nurses--- Request psych (psychiatric) consult Request therapy assessment..."" During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, ""Yes I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..."" The physician was asked if he was notified of Resident #66's repeated falls. The physician stated, ""...want to say yes, nurses are good about letting me know about falls, can't say for sure without looking into the ECS (electronic charting system) system, they document incidents in there and I review them in there..."" The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, rummaging, wandering, resisting care, refusing oxygen, refusing to go to bed, being up all hours, constantly talking, eating and drinking everything. The physician stated, ""...am aware of some of his behaviors, told in a couple of conversations..."" When asked if he was informed about the incident of the resident eating the moisture barrier cream. The physician stated, ""No, I don't know anything about him eating the barrier cream..."" When he was asked if he was notified of the residents symptoms of feet and legs swelling, elevated temperature, low oxygen saturations, lung sounds."" The physician stated, ""...I know he had problems, wasn't there very long, don't remember being told he was not using oxygen, I do remember the powder incident and some of the behaviors."" During an interview in the ADON's office on [DATE] at 7:00 PM, the Director of Nursing (DON) stated, ""...yes, I would expect nurses to notify and document the physician was made aware of behaviors, change in condition of residents."" During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, ""...this guy (Resident #66) was aware but not reliable, had diastolic heart failure, not ambulatory, had back pain, people on these drugs need pain clinic, I did not see where behavioral health saw patient, normally would need psychiatric evaluation and care, if I had known just one day of those (documented behaviors) I would have sent him out. He needed to go back to the hospital... I know I would have called psych (psychiatry) in if I had known..."" There was no documentation of a behavior assessment completed per facility protocol. There was no documentation of a fall risk assessment completed after the [DATE] fall per facility protocol. There was no documentation of a psychiatric consultation or therapy consultation requested per care plan. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F282 with a scope and severity of a ""J"". The facility's failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed the facility at an immediate jeopardy. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The facility developed a ""Behavior QA (Quality assurance) /PI (Performance Improvement)"" tool for auditing and continued monitoring to be completed by Social Services. The tool included: a. Behaviors captured on MDS. b. Behavior Management Plan available. c. Targeted behaviors monitored. d. Care Plan appropriate with problem/interventions. e. Psychiatric services in-house or out patient. f. Non-pharmacological interventions. g. Behaviors: Verbal or physical aggression, socially inappropriate, resisting care, harm to self or others, wandering/elopement. 2. Inservicing 100% of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Fall Interventions. b. Fall and Incident reporting. c. Verbal questions and answers with staff. d. Fall interventions. e. Physician notification and Responsible Party notification. f. Change of Condition. g. Recognizing signs/symptoms of respiratory and cardiac distress. h. Behavior Management i. Individualized Care Planning. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 3. On [DATE] the DON, Adm, ADON, and MDS nurses began reviewing all care plans for accuracy, correcting any interventions as needed, and reporting their findings using the ""Care Plan Audit"" tool. 4. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 5. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices for abuse prevention, abuse reporting, fall interventions, fall and accident reporting, physician notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and behavior management and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of an ""E"" level for F282 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14341,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,309,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for 2 of 32 (Residents #66 and #106) sampled residents in Stage 1 and Stage 2. The facility was unable to provide documentation of the physician being notified of the resident's repeated behaviors, anxiety, agitation, repeatedly low oxygen saturation results, resident's noncompliance with using the oxygen, symptoms of swelling, dyspnea, coolness, paleness, abnormal lung sounds and elevated temperature. There was no documentation that the physician was notified of the resident eating the moisture barrier cream. Failure of the facility to assess the residents status, notify the physician of these conditions and implement a plan of care placed Resident #66 in immediate jeopardy. The findings included: 1. Review of the facility's ""Behavior Management Plan"" policy documented, ""The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... The following four-step plan provides the methods of problem solving needed to deal with behavioral symptoms in a quick and consistent way... 1. Immediate Action to control a threatening or dangerous behavioral symptom. 2. Behavior assessment to observe and describe the behavior. 3. Medical evaluation to look for medical or other causes of the behavioral symptom that need treatment... Psychiatric evaluation may be needed. 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the administrator, and the mental health consultant... Residents will be immediately transported to a designated or requested acute care facility for evaluation..."" Review of the facility's ""Accidents/ Incidents/ Unusual Circumstances"" policy documented, ""It is the policy of this facility to provide residents with adequate supervision to minimize the risk of accidents... The facility will identify residents at risk for falls and implement interventions to minimize the occurrence of falls for those at risk... Residents will be assessed for Fall Risk routinely on admission, quarterly, following a fall and with a significant change... Based on assessment findings, appropriate interventions are identified and implemented... Care plans are updated and revised at every fall or incident..."" Review of the facility's ""Oxygen, Administration"" policy documented, ""...To provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident... Document all appropriate information in the clinical record... Oxygen is a drug and, as such, there must be a physician's orders [REDACTED]. Review of the facility's ""Pulse Oximetry, Monitoring of Residents"" policy documented, ""...Obtain physician order [REDACTED]. Review of the facility's ""Change in Condition"" policy documented, ""...A resident's physician and legal representative or responsible party must be notified of a change in the resident's condition... Documentation of the Change in Condition will be made in the appropriate condition system folder in the Electronic Medical Record... Situations in which a physician and legal representative or responsible party should be notified Immediately of a change in a resident's condition include... any accident/incident with suspected or actual injury... significant and unexpected change/decline in a resident physical, mental and/or psychosocial status..."" Review of the MSDS sheets for the two moisture barrier creams used in the facility revealed the following: a. MSDS for [MEDICATION NAME] Extra Protective Cream ""...ACUTE HEALTH HAZARDS... INGESTION... GASTROINTESTINAL IRRITATION. INGESTION OF LARGE QUANTITIES CAN BE HAZARDOUS. SYMPTOMS OF INTOXICATION... Contact a poison control center for instructions... After first aid, get appropriate in-plant, paramedic, or community medical support... EYES... may cause eye irritation... Avoid eye contact."" b. MSDS for [MEDICATION NAME] Dimethicone Protectant ""...ACUTE HEALTH HAZARDS... Ingestion: Large doses may cause [MEDICAL CONDITION] upset, dangerous upon ingestion. First Aid Measures... Ingestion: not known... After first aid, get appropriate in-plant, paramedic, or community medical support.... EYES: May cause irritation with redness and pain... Flush eyes (including under lids) with copious amounts of water for at least 15 minutes."" Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses note documented the following: a. [DATE] - ""Resident scratches himself and has scabs all over body. Hospital staff stated this is his behavior... resident's decisions are poor; cues/supervision required... "" b. [DATE] at 3:50 AM - "" [MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..."" [DATE] at 4:45 - ""...observed on floor... minor injury moves all extremities laceration to right elbow immediately applied, steristrips... 02 (oxygen) Saturation: 84% (percent) on 02."" c. [DATE] at 7:47 AM - ""..Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed and put oxygen on 02 sat (saturation) checked ,[DATE]% on room air..."" [DATE] at 2:32 PM - ""...Resident noted to be very anxious this shift... proceeded to take a family members milkshake and was going to drink it but ended up dumping it onto the floor, nurse entered room and reminded resident that he is a diabetic and is not to have such items and also that it was inappropriate to take things from other residents... At approximately 1030 his nurse was called to resident's room by CNT (certified nursing technician)... Resident noted sitting on side of bed, snorting a white powdery substance off of a paper located on bedside table using a temperature probe cover with the once closed end open with jagged edges. Also noted on table were a bread knife and credit card. When resident noticed that staff had entered the room he immediately stopped and started apologizing. Substance and paper were taken from resident and placed in zip-lock bag. Resident asked what he was doing and stated that he had found a round, white pill on the floor, crushed it up, and started snorting it because he knew it would get into his system faster... it looked like an [MEDICATION NAME]"" [DATE] at 5:21 PM - ""...Resident seen getting out of wheelchair and attempting to transfer without assist... falling onto his bottom and then onto back hitting the back of his head on the floor..."" d. [DATE] at 8:41 AM - ""resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given [MEDICATION NAME] 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..."" [DATE] at 7:48 PM - ""resident is rummaging around, invading other's space, he is non-compliant with staying in his w/c (wheelchair), he gets up and wanders around his room he approaches any and every one in his path, he's making unreasonable request, asking for things that he doesn't have ordered, he refuses to listen to any reasoning, he is obnoxious to staff when he's asked to scoot back out of the personal space he's invaded, he repeats his self over and over again, state's that he can't stop talking, he is anxious and makes those around him uncomfortable per other residents that are trying to walk and get exercise he has absolutely no respect for others, he manipulates staff's time, visitors to other residents time and space, makes request of visitors that are inappropriate asking for phone numbers so he can contact them if he has an emergency, these are not his visitors, medication is not helpful in getting him to calm down."" e. [DATE] at 6:56 AM - ""...noted his lower leg with feet swollen and respirations slightly dyspnic (dyspneic). He was asked to (go) back in bed for leg elevation and put Oxygen nasal cannula on but he was not follow the directions... At 6:41 am, observed resident getting out of wheelchair and starting to walk without staff assistance. Before staff reached him to hold his body, he lost his balance and stepped backward then fell down on his bottom..."" f. [DATE] at 5:44 AM - ""...PRN (as needed) MED (medication) GIVEN; [MEDICATION NAME] FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... VERY UNSTEADY ON FEET... FREQUENTLY REMOVING OXYGEN... SAT% 84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... TEMP (temperature) 102.8... a little later, found resident eating skin protectant paste. Noted white ointment in full of his mouth and he spread that cream on his glasses... Noted resident's lower extremities [MEDICAL CONDITION]"" g. [DATE] at 3:37 AM - ""[MEDICATION NAME] given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance... LUNG SOUNDS: crackles heard, lower bilateral lobes... pale, cool..."" h. [DATE] at 8:48 AM - ""Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655am..."" Review of a falls risk assessment completed on [DATE] documented the resident was at a high risk for falls. A 5 day Minimum Data Set ((MDS) dated [DATE] documented the brief interview for mental status (BIMS) score was 11, had no behaviors, no wandering and no rejection of care. The care plan dated [DATE] did not address the residents behaviors of drug seeking, snorting, eating the moisture barrier, taking items that are not his, [MEDICAL CONDITION] of legs and feet, low oxygen saturations, lung sounds or elevated temperature. During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, ""Yes I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..."" The physician was asked if he was notified of Resident #66's repeated falls. The physician stated, ""...want to say yes, nurses are good about letting me know about falls, can't say for sure without looking into the ECS (electronic charting system) system, they document incidents in there and I review them in there..."" The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, rummaging, wandering, resisting care, refusing oxygen, refusing to go to bed, being up all hours, constantly talking, eating and drinking everything. The physician stated, ""...am aware of some of his behaviors, told in a couple of conversations..."" When asked if he was informed about the incident of the resident eating the moisture barrier cream. The physician stated, ""No, I don't know anything about him eating the barrier cream..."" When he was asked if he was notified of the residents symptoms of feet and legs swelling, elevated temperature, low oxygen saturations, lung sounds."" The physician stated, ""...No, can't say I know about the elevated temp, they have a protocol for that, 101 and above to call me... I know he had problems, wasn't there very long, don't remember being told he was not using oxygen, I do remember the powder incident and some of the behaviors."" During an interview in the ADON's office on [DATE] at 7:00 PM, the Director of Nursing (DON) stated, ""...yes, I would expect nurses to notify and document the physician was made aware of behaviors, change in condition of residents."" During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, ""...this guy (Resident #66) was aware but not reliable, had diastolic heart failure, not ambulatory, had back pain, people on these drugs need pain clinic, I did not see where behavioral health saw patient, normally would need psychiatric evaluation and care, if I had known just one day of those (documented behaviors) I would have sent him out. He needed to go back to the hospital... I know I would have called psych (psychiatry) in if I had known..."" There was no documentation that the physician was notified of Resident #66's repeated behaviors, anxiety and agitation. There was no documentation of a behavior assessment completed per facility protocol. There was no documentation that the physician was notified of the resident's repeatedly low oxygen saturation results or of the resident being noncompliant with using the oxygen. There was no documentation that the physician was notified of the resident eating the moisture barrier cream. There was no documentation of any medical care given after the resident was found eating the moisture barrier cream. There was no documentation that the poison control center had been contacted per MSDS recommendations. There was no documentation of any new interventions put in place after the second and third falls. There was no documentation of a fall risk assessment completed after the [DATE] fall per facility protocol. There was no incident report completed for the behavior of snorting the white powdery substance or eating the barrier cream. The facility was unable to provide documentation of the physician being notified of the resident's repeated behaviors, anxiety, agitation, repeatedly low oxygen saturation results, resident's noncompliant with using the oxygen usage, symptoms of swelling, dyspnea, coolness, paleness, abnormal lung sounds and elevated temperature. There was no documentation that the physician was notified of the resident eating the moisture barrier cream. Failure of the facility to assess the residents status, notify the physician of these conditions and implement a plan of care placed Resident #66 in an immediate jeopardy. 2. Medical record review for Resident #106 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurse notes dated [DATE] documented, ""WEEKLY SKIN ASSESSMENT ASSESSMENT SKIN PROBLEMS... Has no skin problems or [MEDICAL CONDITION] present."" Observations in Resident #106's room on [DATE] at 8:01 AM, revealed Resident #106 had a red area with a scab on his nose and scabbed area on left side of his temple. During an interview on the 100 hall on ,[DATE] at 10:00 AM, Nurse #2 was asked had she ever checked the area on Resident #106's nose. Nurse #2 stated, ""Yes... He does not have anything ordered for it... I had not noticed it until you asked me."" Nurse #2 was asked if she saw him everyday, she confirmed she did. During an interview in Resident #106's room on [DATE] at 10:13 AM, Nurse #1 was asked about the area on Resident #106's nose. Nurse #1 stated, ""It looks like [MEDICAL CONDITION]. It is blanchable but is red with a scabbing and can feel nasal septal deformity. I am going to call doctor... and call his daughter."" During an interview at the nurses station on [DATE] at 10:25 AM, Nurse #1 stated, ""...Talked to daughter who said he has had several [MEDICAL CONDITION] so the doctor is on his way to look at it."" During an interview at the first floor nurses' station on [DATE] at 3:00 PM, the physician stated, ""It was excoriated and with his history ([MEDICAL CONDITION]) with colon and [MEDICAL CONDITION], we are going to send him out."" During a telephone interview in the ADON's office on [DATE] at 9:45 AM, Resident #106's daughter confirmed Nurse #1 had called her Sunday and she had called back with the name of the doctor and had to leave a message on the answering machine and none had called her back yet. During an interview in the ADON's office on [DATE] at 10:30 AM, the DON was asked what he would expect if a sore had been on the resident's nose for the last 7 days. The DON stated, ""I would have expected her to have noted it somewhere and notified me, the family and the physician."" 3. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F309 with a scope and severity of a ""J"". The facility's failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed Resident #66 in immediate jeopardy. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. Inservicing 100 percent (%) of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Fall Interventions. b. Fall and Incident reporting. c. Verbal questions and answers with staff. d. Fall interventions. e. Physician notification and Responsible Party notification. f. Change of Condition. g. Recognizing signs/symptoms of respiratory and cardiac distress. h. Behavior Management. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 2. Auditing/Monitoring tools developed will be used for follow-up and continued monitoring for the following areas: a. Behavior Quality Assurance /Performance Improvement (QA/PI) tool. b. Weekly At Risk QA/PI Log. c. Care Plan Audit. d. Oxygen orders and use. e. Nursing Notes Audit For Change of Condition. f. Alert Charting Log. g. Event Log. 3. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 4. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices for fall interventions, fall and accident reporting, physician notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and behavior management and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""D"" level for F309 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14342,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,312,D,,,LH9611,"**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 provide grooming for 1 of 26 (Resident #64) sampled residents observed in Stage 1 and Stage 2. The findings included: Medical record review for Resident #64 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview Mental Status (BIMS) 0, indicating cognitive impairment and total care for hygiene. Observations in Resident #64's room on 5/7/12 at 4:12 PM and on 5/9/12 at 4:15 PM, revealed Resident #6 with chin hair present. During an interview at second floor nursing station on 5/11/12 at 5:30 PM, Certified Nursing Assistant #2 stated, ""Residents get shower every other day, suppose to shave chin hair on those days...""",2014-01-01
14343,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,314,G,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to provide assessments and treatments to pressure ulcers for 1 of 2 (Resident #138) sampled residents with pressure ulcers in Stage 1 and Stage 2. Failure of the facility to assess and provide care and treatments resulted in actual harm when Resident #138's pressure ulcers deteriorated. The findings included: Review of the facility's ""Wounds Care/Treatment Guidelines"" policy documented, ""...weekly assessment is completed on all wounds. This should include measurement and a description... The door must be closed and the curtains pulled... There must be a specific order for the treatment. Documentation of the treatment should be done immediately after the treatment..."" Medical record review for Resident #138 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A nurses note dated 4/27/12 documented pressure ulcer to ""right heel - unstageable, 2x (by) 3cm (centimeters), painful to touch, left heel - unstageable, 4.25x7.25cm, painful to touch, abdominal incision 21x< (less than) 1cm surgical wound, and coccyx- stage 1, reddened, 4x4cm."" The initial Minimum Data Set ((MDS) dated [DATE] documented the resident as cognitive - 3 severely impaired, had no behaviors, had 2 unstageable pressure sores, had a surgical wound. The 14 day MDS dated [DATE] documented the resident as cognitive - 3 severely impaired, had no behaviors, inaccurately documented the resident had a stage 4- that measured 0.2x0.3x0.6cm pressure ulcer, had a surgical wound, and inaccurately documented the resident had [MEDICAL CONDITION]. A nurses note dated 4/27/12 documented the physician assessed the resident and sent him to the hospital on [DATE] and he returned back to the facility on [DATE]. A nurses note dated 5/8/12 documented the resident dislodged a tube and was sent back to the hospital on [DATE] and returned to the facility on [DATE]. The medical record contained a wound treatment log that documented a wound assessment dated [DATE] to ""right heel 3.5x6cm and unstageable, left heel 2x5cm and unstageable."" There was no assessment of the coccyx pressure ulcer. Observations in Resident #138's room on 5/11/12 at 7:30 AM, revealed Resident #138 in bed sleeping on a concave mattress. Observations in Resident #138's room on 5/11/12 at 5:30 PM, revealed Resident #138 in bed position on the right side. Observations in Resident #138's room on 5/12/12 at 8:45 AM, revealed Resident #138 in bed. Observations in Resident #138's room on 5/13/12 at 12:00 PM, revealed Resident #138 in bed, was alert, responsive, denies any pain and has bilateral heelbos on feet. Observed an old dressing removed from the coccyx wound dated 5/11/12, identified by Nurse #5 as a foam dressing. The left buttocks area was approximately 1/2 dollar size, had pink center, red edges and open. The right buttock area was approximately 2x3 inches, had a pink center, red edges and open. The nurse removed the old dressing, dated 5/11/12, from the left heel, there was no open area but a golf ball sized black hard area was present. Nurse #5 removed the old right heel dressing dated 5/11/12, the right outer heel area was nickel sized with a pink center, red edges and open. The facility was unable to provide documentation of an assessment of the coccyx pressure ulcer or wound care treatments from 5/10/12, until 5/13/12. There was no physician order for [REDACTED]. During an interview at the first floor nurses' station on 5/13/12 at 11:40 AM, the Director of Nursing (DON)was asked about wound assessments and treatments since Resident #138 returned from the hospital on [DATE]. The DON stated, ""This is all I can find (he brought copy of the wound treatment log dated 5/11/12 with assessment of left and right heels and abdominal incision site.)"" The facility failed to assess, care plan and implement treatments, which resulted in actual harm when Resident #138's pressure ulcers deteriorated.",2014-01-01
14344,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,318,D,,,LH9611,"**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 provide appropriate treatment and services to ensure that a resident maintained the highest level of range of motion (ROM) for 1 of 1 (Resident #3) sampled residents with ROM needs in Stage 1 and Stage 2. The findings included: Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented in Section G that the resident was assessed with [REDACTED]. Review of the care plan dated 2/9/12 did not include ROM exercises. Observations in Resident #3's room on 5/9/12 at 7:41 AM, revealed Resident #3 had left sided contractures. He held his left arm up bent at the elbow against his chest and his left foot pedal of his wheelchair was elevated and extended and supported his left foot and leg. During an interview in Resident #3's room on 5/8/12 at 9:53 AM, Nurse #8 confirmed Resident #3 had contractures on his left side on both the upper and lower extremities. During an interview at the second floor nurses' station on 5/14/12 at 2:35 PM, the restorative certified nursing technician (CNT) #2 was asked if Resident #3 had a restorative plan of care and did he received ROM exercises. CNT #2 stated, ""...He is not in the restorative program at the time... the nursing staff on the unit are responsible for his care and treatment..."" During an interview on the 200 hall on 5/14/12 at 2:40 PM, CNT #3 (who was assigned to care for Resident #3) was asked if she performed scheduled ROM exercises or ROM exercises with the resident while giving his daily personal care. CNT #3 stated, ""No.""",2014-01-01
14345,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,319,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of material safety data sheets (MSDS), medical record review and interview, it was determined the facility failed to assess, notify the physician and provide appropriate treatment and services to address mental and psychosocial adjustment difficulties for 1 of 32 (Resident #66) sampled residents in Stage 1 and Stage 2. Failure of the facility to assess, implement interventions, adequately supervise and notify the physician of behaviors placed Resident #66 in immediate jeopardy. The findings included: Review of the facility's ""Behavior Management Plan"" policy documented, ""The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... The following four-step plan provides the methods of problem solving needed to deal with behavioral symptoms in a quick and consistent way... 1. Immediate Action to control a threatening or dangerous behavioral symptom. 2. Behavior assessment to observe and describe the behavior. 3. Medical evaluation to look for medical or other causes of the behavioral symptom that need treatment... Psychiatric evaluation may be needed. 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the administrator, and the mental health consultant... Residents will be immediately transported to a designated or requested acute care facility for evaluation..."" Review of the facility's ""Change in Condition"" policy documented, ""...A resident's physician and legal representative or responsible party must be notified of a change in the resident's condition... Documentation of the Change in Condition will be made in the appropriate condition system folder in the Electronic Medical Record... Situations in which a physician and legal representative or responsible party should be notified Immediately of a change in a resident's condition include... significant and unexpected change/decline in a resident physical, mental and/or psychosocial status..."" Review of the MSDS sheets for the two moisture barrier creams used in the facility revealed the following: a. MSDS for [MEDICATION NAME] Extra Protective Cream ""...ACUTE HEALTH HAZARDS... INGESTION... GASTROINTESTINAL IRRITATION. INGESTION OF LARGE QUANTITIES CAN BE HAZARDOUS. SYMPTOMS OF INTOXICATION... Contact a poison control center for instructions... After first aid, get appropriate in-plant, paramedic, or community medical support... EYES... may cause eye irritation... Avoid eye contact."" b. MSDS for [MEDICATION NAME] Dimethicone Protectant ""...ACUTE HEALTH HAZARDS... Ingestion: Large doses may cause [MEDICAL CONDITION] upset, dangerous upon ingestion. First Aid Measures... Ingestion: not known... After first aid, get appropriate in-plant, paramedic, or community medical support.... EYES: May cause irritation with redness and pain... Flush eyes (including under lids) with copious amounts of water for at least 15 minutes."" Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses' notes documented the following: a. [DATE] - ""Resident scratches himself and has scabs all over body. Hospital staff stated this is his behavior... resident's decisions are poor; cues/supervision required... "" b. [DATE] at 3:50 AM - "" [MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..."" [DATE] at 4:45 - ""...observed on floor... minor injury moves all extremities laceration to right elbow immediately applied, steristrips... 02 (oxygen) Saturation: 84% (percent) on 02."" c. [DATE] at 7:47 AM - ""..Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed and put oxygen on 02 sat (saturation) checked ,[DATE]% on room air..."" [DATE] at 2:32 PM - ""...Resident noted to be very anxious this shift... proceeded to take a family members milkshake and was going to drink it but ended up dumping it onto the floor, nurse entered room and reminded resident that he is a diabetic and is not to have such items and also that it was inappropriate to take things from other residents... At approximately 1030 his nurse was called to resident's room by CNT (certified nursing technician)... Resident noted sitting on side of bed, snorting a white powdery substance off of a paper located on bedside table using a temperature probe cover with the once closed end open with jagged edges. Also noted on table were a bread knife and credit card. When resident noticed that staff had entered the room he immediately stopped and started apologizing. Substance and paper were taken from resident and placed in zip-lock bag. Resident asked what he was doing and stated that he had found a round, white pill on the floor, crushed it up, and started snorting it because he knew it would get into his system faster... it looked like an [MEDICATION NAME]"" [DATE] at 5:21 PM - ""...Resident seen getting out of wheelchair and attempting to transfer without assist... falling onto his bottom and then onto back hitting the back of his head on the floor..."" d. [DATE] at 8:41 AM - ""resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given [MEDICATION NAME] 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..."" [DATE] at 7:48 PM - ""resident is rummaging around, invading other's space, he is non-compliant with staying in his w/c (wheelchair), he gets up and wanders around his room he approaches any and every one in his path, he's making unreasonable request, asking for things that he doesn't have ordered, he refuses to listen to any reasoning, he is obnoxious to staff when he's asked to scoot back out of the personal space he's invaded, he repeats his self over and over again, state's that he can't stop talking, he is anxious and makes those around him uncomfortable per other residents that are trying to walk and get exercise he has absolutely no respect for others, he manipulates staff's time, visitors to other residents time and space, makes request of visitors that are inappropriate asking for phone numbers so he can contact them if he has an emergency, these are not his visitors, medication is not helpful in getting him to calm down."" e. [DATE] at 6:56 AM - ""...noted his lower leg with feet swollen and respirations slightly dyspnic (dyspneic). He was asked to (go) back in bed for leg elevation and put Oxygen nasal cannula on but he was not follow the directions... At 6:41 am, observed resident getting out of wheelchair and starting to walk without staff assistance. Before staff reached him to hold his body, he lost his balance and stepped backward then fell down on his bottom..."" f. [DATE] at 5:44 AM - ""...PRN (as needed) MED (medication) GIVEN; [MEDICATION NAME] FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... VERY UNSTEADY ON FEET... FREQUENTLY REMOVING OXYGEN... SAT% 84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... TEMP (temperature) 102.8... a little later, found resident eating skin protectant paste. Noted white ointment in full of his mouth and he spread that cream on his glasses..."" g. [DATE] at 3:37 AM - ""[MEDICATION NAME] given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance... LUNG SOUNDS: crackles heard, lower bilateral lobes... pale, cool..."" h. [DATE] at 8:48 AM - ""Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655 am..."" Review of a 5 day Minimum Data Set ((MDS) dated [DATE] documented the brief interview for mental status (BIMS) score was 11, had no behaviors, no wandering and no rejection of care. The care plan dated [DATE] did not address the residents behaviors of drug seeking, snorting, eating the moisture barrier, taking items that are not his, low oxygen saturations, abnormal lung sounds or elevated temperature. During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, ""Yes I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..."" The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, rummaging, wandering, resisting care, refusing oxygen, refusing to go to bed, being up all hours, constantly talking, eating and drinking everything. The physician stated, ""...am aware of some of his behaviors, told in a couple of conversations..."" When asked if he was informed about the incident of the resident eating the moisture barrier cream. The physician stated, ""No, I don't know anything about him eating the barrier cream..."" When he was asked if he was notified of the residents symptoms of low oxygen saturations and lung sounds."" The physician stated, ""...I know he had problems, wasn't there very long, don't remember being told he was not using oxygen, I do remember the powder incident and some of the behaviors."" During an interview in the ADON's office on [DATE] at 7 PM, the Director of Nursing (DON) stated, ""...yes, I would expect nurses to notify and document the physician was made aware of behaviors, change in condition of residents."" During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, ""...this guy (Resident #66) was aware but not reliable, had diastolic heart failure, not ambulatory, had back pain, people on these drugs need pain clinic, I did not see where behavioral health saw patient, normally would need psychiatric evaluation and care, if I had known just one day of those (documented behaviors) I would have sent him out. He needed to go back to the hospital... I know I would have called psych (psychiatry) in if I had known..."" There was no documentation that the physician was notified of Resident #66's repeated behaviors, anxiety and agitation. There was no documentation of a behavior assessment completed per facility protocol. There was no documentation that the physician was notified of the resident's repeatedly low oxygen saturation results or of the resident being noncompliant with using the oxygen. There was no documentation that the physician was notified of the resident eating the moisture barrier cream. There was no documentation of any medical care given after the resident was found eating the moisture barrier cream. There was no documentation that the poison control center was consulted per MSDS recommendations. There was no incident report completed for the behavior of snorting the white powdery substance or eating the barrier cream. The facility failed to adequately assess, provide interventions and supervision to ensure that the psychosocial needs were treated which resulted in immediate jeopardy when Resident #66 continued to exhibit behaviors and deterioration of condition. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F319 with a scope and severity of a ""J"". The facility's failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed the Resident #66 in immediate jeopardy. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. Inservicing 100 percent (%) of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Verbal questions and answers with staff. b. Physician notification and Responsible Party notification. c. Change of Condition. d. Behavior Management. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 2. The facility developed an ""Alert Charting Log"" to document resident identification, reason for alert charting, start and end date of charting for nurses to use when documenting. 3. The facility developed an ""Event Log"" audit form that included physician notification, root cause, Plan of Correction (POC) update, interventions, fall risk update, alert charting done and neuro checks done to be audited, results communicated to Quality Assurance (QA) committee. 4. The facility developed an ""Oxygen orders and use audit form with results to be communicated to QA committee. 5. A ""Nursing Notes Audit for Change of Condition"" audit form was developed to audit nurse documentation, physician notification for residents with a change in condition. Results to be communicated to the QA committee. 6. The facility developed a Weekly At Risk QA/ Performance Improvement (PI) audit log that audits behaviors, events reported, new declines in activity of daily living (ADL)s, change of conditions/general decline conditions. Results to be communicated to the QA committee. 7. The facility developed at Behavior QA/PI tool to be completed by Social Services that included behaviors, resisting care, psychiatric services, alert charting, behaviors on MDS. This audit tool to be communicated to the QA committee. 8. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 9. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices physician notifications, condition changes and recognizing the possible need of behavior management and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""D"" level for F319 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14346,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,325,G,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to timely implement interventions recommended by the Registered Dietician (RD) for 1 of 7 (Resident #118) sampled residents experiencing a significant weight loss of the 32 sampled residents in Stage 1 and Stage 2. The facility failed to timely implement weight loss recommendations which resulted in a significant weight loss causing actual harm to Resident #118. The findings included: Review of the facility's ""Weight Loss / Underweight"" policy documented, ""...Residents who have a significant, unchanged weight loss or who are 20% (percent) or more below their IBW (ideal body weight) or UBW (usual body weight) are considered to be at nutrition risk. Significant unchanged weight loss... should be addressed on the care plan... The resident's physician and the consultant dietitian are notified... include high calorie foods such as large portions, fortified cereals, and juices, house supplements in the diet.... consider requesting a physician order [REDACTED]. Medical record review for Resident #118 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the ""Monthly Weights"" for Resident #118 documented a weight of 134.6 pounds (#) on 3/21/12, a weight of 129.4 # on 4/11/12 and a weight of 125.6 # on 5/7/12, resulting in a significant weight loss of 7.5 percent in 2 months. Review of the RD assessments documented the following: a. 3/30/12 - ""weight 133 lbs... nutrition intake... requires assist with d/t (due to) [MEDICAL CONDITION] RD RECOMMENDATIONS: add MVI with minerals daily, add fortified food with breakfast."" b. 4/25/12 - ""...weight loss... 129lbs... RD RECOMMENDATIONS: add house supp (supplement) 4 oz (ounces) bid (twice a day), add fortified foods with meals, cont (continue) weekly wts (weights) x (for) 4 weeks, add MVI with min (minerals) daily."" A physician's orders [REDACTED]. The order was documented as ""MVI with minerals daily, House Supplement 4 oz bid, regular fortified food items."" Review of the May, 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation of any interventions implemented for the weight loss from 3/21/12 until 5/8/12. The care plan dated 3/21/12 was not revised to address the weight loss. Observations in the second floor dining room on 5/9/12 at 5:00 PM, revealed Resident #118 was thin, getting up and down, and wandering around the room. The staff redirected her back to her meal, she ate 1/2 of her meal, then followed a staff member around room and out to hallway. During an interview in the Assistant Director of Nursing's office on 5/14/12 at 5:20 PM, the Director of Nursing (DON) stated, ""RD makes her recommendations and puts them in the managers box for follow up, don't know why there is a gap there.""",2014-01-01
14347,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,328,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure that proper respiratory treatment and services were provided for 2 of 32 (Residents #66 and #138) sampled residents of the 32 residents included in Stage 1 and Stage 2. The facility failed to adequately assess and notify the physician of behaviors, anxiety, agitation, repeatedly low oxygen saturation results and resident's noncompliance with using the oxygen placed Resident #66 in immediate jeopardy. The findings included: 1. Review of the facility's ""Oxygen, Administration"" policy documented, ""...To provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident... Document all appropriate information in the clinical record... Oxygen is a drug and, as such, there must be a physician's orders [REDACTED]. Review of the facility's ""Pulse Oximetry, Monitoring of Residents"" policy documented, ""...Obtain physician order [REDACTED]. Review of the facility's ""Change in Condition"" policy documented, ""...A resident's physician and legal representative or responsible party must be notified of a change in the resident's condition... Documentation of the Change in Condition will be made in the appropriate condition system folder in the Electronic Medical Record... Situations in which a physician... should be notified Immediately of a change in a resident's condition include... significant and unexpected change/decline in a resident physical, mental and/or psychosocial status..."" Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses' notes documented the following: a. [DATE] at 3:50 AM - "" [MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..."" [DATE] at 4:45 - 02 (oxygen) Saturation: 84% (percent) on 02."" b. [DATE] at 7:47 AM - ""..Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed and put oxygen on 02 sat (saturation) checked ,[DATE]% on room air..."" [DATE] at 2:32 PM - ""...Resident noted to be very anxious this shift..."" c. [DATE] at 8:41 AM - ""resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given [MEDICATION NAME] 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..."" d. [DATE] at 6:56 AM - ""...noted his lower leg with feet swollen and respirations slightly dyspnic (dyspneic). He was asked to back in bed for leg elevation and put Oxygen nasal cannula on but he was not follow the directions..."" e. [DATE] at 5:44 AM - ""...PRN (as needed) MED (medication) GIVEN; [MEDICATION NAME] FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... FREQUENTLY REMOVING OXYGEN... SAT% 84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... TEMP (temperature) 102.8..."" f. [DATE] at 3:37 AM - ""[MEDICATION NAME] given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance... LUNG SOUNDS: crackles heard, lower bilateral lobes... pale, cool..."" g. [DATE] at 8:48 AM - ""Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655am..."" The care plan dated [DATE] did not address the residents low oxygen saturations, lung sounds or elevated temperature. During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, ""Yes I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..."" The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, resisting care, and refusing oxygen. The physician stated, ""...am aware of some of his behaviors, told in a couple of conversations..."" When he was asked if he was notified of the residents symptoms of elevated temperature, low oxygen saturations and lung sounds."" The physician stated, ""...No, can't say I know about the elevated temp, they have a protocol for that, 101 and above to call me... I know he had problems, wasn't there very long, don't remember being told he was not using oxygen..."" During an interview in the ADON's office on [DATE] at 7 PM, the Director of Nursing (DON) stated, ""...yes, I would expect nurses to notify and document the physician was made aware of behaviors, change in condition of residents."" During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, ""...this guy (Resident #66) was aware but not reliable, had diastolic heart failure... if I had known just one day of those (documented behaviors) I would have sent him out. He needed to go back to the hospital..."" There was no documentation that the physician was notified of Resident #66's repeated behaviors, anxiety and agitation. There was no documentation that the physician was notified of the resident's repeatedly low oxygen saturation results or of the resident being noncompliant with using the oxygen. The facility failed to adequately assess and notify the physician of behaviors, anxiety, agitation, repeatedly low oxygen saturation results and resident's noncompliant with using the oxygen usage which placed Resident #66 in an immediate jeopardy. 2. Medical record review for Resident #138 documented an admitted [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].>(greater than) 92% (percent)."" Observations in Resident #138's room revealed the following times when Resident #138 was not receiving oxygen at the rate prescribed by the physician: a. [DATE] at 7:30 AM, oxygen at 2 liters per nasal cannula. b. [DATE] at 5:30 PM, oxygen at 1.5 liters. c. [DATE] at 8:45 AM, oxygen at 1.5 liters per nasal cannula. d. [DATE] at 12:00 PM, oxygen at 1.5 liters per nasal cannula. The care plan dated [DATE] did not address oxygen use or need for oxygen saturation monitoring. The facility was unable to provide documentation of oxygen saturation results. During an interview in the ADON's office on [DATE] at 9:00 AM, the Director of Nursing stated, ""Would expect nurses to have the correct oxygen rate and to do the oxygen sats as ordered."" 3. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F328 with a scope and severity of a ""J"". The facility's failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed the facility in immediate jeopardy due to these failures. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. Inservicing 100 percent (%) of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Verbal questions and answers with staff. b. Physician notification and Responsible Party notification. c. Change of Condition. d. Recognizing signs/symptoms of respiratory and cardiac distress. e. Behavior Management. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 2. Auditing/Monitoring tools developed will be used for follow-up and continued monitoring for the following areas: a. Behavior Quality Assurance /Performance Improvement (QA/PI) tool. b. Weekly At Risk QA/PI Log. c. Care Plan Audit. d. Oxygen orders and use. e. Nursing Notes Audit For Change of Condition. f. Alert Charting Log. g. Event Log. 3. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 4. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices for notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""D"" level for F328 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14348,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,332,E,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the ""GERIATRIC MEDICATION HANDBOOK"", medical record review, observation and interview, it was determined the facility failed to ensure that 3 of 4 (Nurses #2, 6 and 11) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 51 opportunities for error, resulting in a medication error rate of 5.9%. The findings included: 1. Review of the ""GERIATRIC MEDICATION HANDBOOK"" tenth edition, page 41 documented, ""DIABETES: INJECTABLE MEDICATIONS... Humalog... Rapid-Acting Insulin Analog... ONSET... 15 min (minutes)... TYPICAL ADMINISTRATION / COMMENTS 15 minutes prior to meals or immediately after eating..."" 2. Medical record review for Random Resident (RR) #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].d. (four times a day) 0800 1200 1600 and 2000... 241- (to) 300 = (amount of insulin to be administered) 9units..."" Observations in RR #6's room on 5/13/12 at 11:55 AM, Nurse #2 administered 9 units of Humalog insulin to RR #6. RR #6 did not get up to go to the dining room at lunch time and was not offered a tray or a substantial snack by the nurse until 1:30 PM. The administration of the insulin 1 hour and 35 minutes before a lunch tray or snack was served resulted in medication error #1. During an interview in the 100 hall on 5/13/12 at 1:30 PM, Nurse #2 was asked if RR #6 had been served a meal tray or had a snack. Nurse #2 stated, ""No. He'll get up and go to the dining room and get what he wants to eat. That's how he does..."" 3. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physicians orders dated 5/2012 documented, ""...HumaLOG 100UNIT/ML Solution injection sub-Q per sliding scale q.i.d. 0800 1200 1630 2100 ...181-210 = 6 units..."" Observations in the 200 hall on 5/9/12 at 5:30 PM, Nurse #6 prepared the insulin for administration. Observation of the insulin confirmed there was between 7 and 7.5 units of insulin in the syringe. Nurse #5 was asked to confirm the amount of insulin in the syringe and stated, ""...7 to 7.5 units"" of insulin in the syringe. Nurse #6 was asked to verify the amount a second time and adjusted the insulin to the correct dose prior to giving the resident the injection. The fact that Nurse #6 would have administered the 7 to 7.5 units of insulin to Resident #53 resulted in medication error #2. 4. Medical record review for RR #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].d 0800 (8:00 AM) 1200 (12:00 PM) 1600 (4:00 PM) 2000 (8:00 PM)... 161-180 blood sugar = 5 units (Humalog insulin)..."" Observations in RR #7's room on 5/7/12 at 11:30 AM, Nurse #11 administered 5 units of Humalog insulin to RR #7. RR #7 did not receive a meal tray until 12:15 PM. The administration of the insulin 45 minutes before lunch was served resulted in medication error #3. 5. During an interview in the Director of Nursing's (DON) office on 5/15/12 at 2:45 PM, the DON was asked how soon after receiving a fast acting insulin like Humalog would you expect the resident to receive a tray. The DON stated, ""Within 30 minutes.""",2014-01-01
14349,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,333,D,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the ""GERIATRIC MEDICATION HANDBOOK"", medical record review, observation and interview, it was determined the facility failed to ensure that residents were free of significant medication errors. The nursing staff failed to administer insulin within the proper time frame related to meals for 2 of 6 (Random Residents (RR) #6 and RR #7) and failed to prepare the correct dose of insulin for 1 of 6 (Resident #53) residents receiving insulin injections. The findings included: 1. Review of the ""GERIATRIC MEDICATION HANDBOOK"" tenth edition, page 41 documented, ""DIABETES: INJECTABLE MEDICATIONS... Humalog... Rapid-Acting Insulin Analog... ONSET... 15 min (minutes)... TYPICAL ADMINISTRATION / COMMENTS 15 minutes prior to meals or immediately after eating..."" 2. Medical record review for Random Resident (RR) #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].d. (four times a day) 0800 1200 1600 and 2000... 241- (to) 300 (blood sugar) = (amount of insulin to be administered) 9units..."" Observations in RR #6's room on 5/13/12 at 11:55 AM, Nurse #2 administered 9 units of Humalog insulin to RR #6. RR #6 did not get up to go to the dining room at lunch time and was not offered a tray or a substantial snack by the nurse until 1:30 PM. The administration of the insulin 1 hour and 35 minutes before a lunch tray or snack was served resulted in a significant medication error. During an interview in the 100 hall on 5/13/12 at 1:30 PM, Nurse #2 was asked if RR #6 had been served a meal tray or had a snack. Nurse #2 stated, ""No. He'll get up and go to the dining room and get what he wants to eat. That's how he does..."" 3. Medical record review for RR #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].d 0800 1200 1600 2000...61-180 blood sugar = 5 units..."" Observations in RR #7's room on 5/7/12 at 11:30 AM, Nurse #11 administered 5 units of Humalog insulin to RR #7. RR #7 did not receive a meal tray until 12:15 PM. The administration of the insulin 45 minutes before lunch was served resulted in a significant medication. 4. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physicians orders dated 5/2012 documented, ""...HumaLOG 100UNIT/ML Solution injection sub-Q per sliding scale q.i.d. 0800 1200 1630 2100 ...181-210 (blood sugar) = 6 units..."" Observations in the 200 hall on 5/9/12 at 5:30 PM, Nurse #6 prepared the insulin for administration. Observation of the insulin confirmed there was between 7 and 7.5 units of insulin in the syringe. Nurse #5 was asked to confirm the amount of insulin in the syringe and stated, ""...7 to 7.5 units"" of insulin in the syringe. Nurse #6 was asked to verify the amount a second time and adjusted the insulin to the correct dose prior to giving the resident the injection. The fact that Nurse #6 would have administered the 7 to 7.5 units of insulin to Resident #53 resulted in a significant medication. 5. During an interview in the Director of Nursing's (DON) office on 5/15/12 at 2:45 PM, the DON was asked how soon after receiving a fast acting insulin like Humalog would you expect the resident to receive a tray. The DON stated, ""Within 30 minutes.""",2014-01-01
14350,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,364,E,,,LH9611,"Based on recipe review, observation and interview, it was determine the facility failed to ensure food was done and palatability during 2 of 2 (5/7/12 and 5/9/12) dining observations. The findings included: 1. Observations in the second floor dining room during the noon meal on 5/7/12 at 12:05 PM and during the supper meal on 5/9/12 at 5:00 PM, revealed no ice in any of the glasses. During an interview in the second floor dining room on 5/9/12 at 5:15 PM, Certified Nursing Assistant #1 stated, ""Never any ice in glasses, don't know why?"" 2. Review of the recipe for Bread Pudding documented, ""Bake in oven at 325 (sign for degrees) F (Fahrenheit), or until inserted knife comes out clean. Observations in the kitchen on 5/9/12 at 12:15 PM, revealed the bread pudding that was placed into cups to be served was noted to be runny. During an interview in the kitchen on 5/9/12 at 12:30 PM, the dietary manager confirmed the bread pudding was not done. 3. Observations in the kitchen on 5/9/12 at 12:15 PM, revealed there was no ice in the glasses of tea. Observations in the kitchen on 5/9/12 at 5:10 PM, revealed no ice in drinks.",2014-01-01
14351,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,371,E,,,LH9611,"Based on recipe review, observation and interview, it was determined the facility failed to follow proper kitchen sanitation as evidence by food stored on the floor, juice connectors on the floor, mop and bucket in the clean dishwasher area, bread pudding not done, and staff touching the doors of the stove with mittens and gloves without changing prior to handling food and equipment on 4 of 9 days (5/7/12, 5/8/12, 5/10/12 and 5/12/12) of the survey. The findings included: 1. Review of the dietary service policy documented, ""...Food must be stored above floor level and away form walls. All staple food should be stored in a clean dry place 8"" (inches) to 12"" off the floor on food dollies or shelves... Food preparation: Use a sanitized thermometer to evaluate food temperatures... Food Service Using a properly sanitized thermometer, check the temperatures of hot and cold food prior to serving... Observe food storage rooms and food storage in the kitchen... Do staff handle and cook potentially hazardous foods..."" 2. Observations in the kitchen on 5/7/12 revealed the following: a. At 10:45 AM - boxes of canned good and elbow macaroni on the floor. b. At 10:49 AM - dispenser connector on the floor. c. At 11:42 AM - the backdoor had dirt all over it and the lock had a hole in it. Observations in the dining room on 5/7/12 revealed the following: a. At 11:45 AM - water in front of the ice machine coming from the dishwasher room. b. At 11:50 AM - the door to the dishwasher room with dirty brown material on the wall and rust by the edge of the door next to the floor. c. At 11:51 AM - the door to the kitchen had paint peeling and a crack in the wall. 3. Observation in dishwasher room on 5/8/12 at 5:00 PM, revealed a mop bucket and mop against the clean dish area which held clean dishes and a large trash can was sitting beside the mop bucket. During an interview in the dishwasher room on 5/8/12 at 5:00 PM, the dietary manager stated, ""I know they're (mop and mop bucket) not supposed to be there..."" Observations in the kitchen on 5/8/12 at 5:22 PM, revealed a juice connector on the floor. 4. Observations in the kitchen on 5/10/12 revealed the following: a. At 11:50 AM - the cook was holding the kitchen door open with a pot holder mitten, laid the mitten on an area of the 2 compartment sink, then picked it up, hung the glove up by the stove, then returned and got the mitten and used it again and put it back on the rack by stove. b. At 11:53 AM - dietary aide opened the door with gloved hand and brought ice back and spread it in a pan which held milk without changing her gloves. c. The tray line temperatures at 12:15 PM - the cook did not check the food temperatures prior to starting the tray line serving. During observation and interview in the kitchen on 5/10/12 at 12:15 PM, the cook was asked if he had checked the food temperatures. The cook stated, ""Got in a hurry (indicating the food temperatures were not checked prior to serving)."" The cook obtained a meat thermometer that went down to 120 degrees F. The cook was asked if he had calibrated the thermometer. The cook removed the thermometer and got ice water to check the thermometer. The cook was asked about using a thermometer that only went down to 120 degrees. The cook got another thermometer that went to 0. The cook then calibrated the correct thermometer and checked temperatures. Review of the bread pudding recipe documented, ""Bake in oven at 325 degrees... or until inserted knife comes out clean."" The recipe included eggs as an ingredient. Observation during tray line temperatures on 5/10/12 starting at 12:15 PM, revealed the bread pudding was very runny and not done, but was dipped up to serve. During an interview in the kitchen on 5/10/12 at 12:30 PM, the dietary manager verified the bread pudding was not done. 5. Observations in the kitchen on 5/12/12 at 11:07 AM revealed the following; a. Water dripping from the air conditioner vent with a puddle on the floor between the 2 compartment sink and storage table b. Five 12 inch tiles broken and one tile had a chip out in front of the stove. c. Rust on the pipe across the ceiling above the trayline. d. Thick brown particles beside the door on the wall as you leave the kitchen into dining room.",2014-01-01
14352,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,412,D,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of dental contract, medical record review, observation and interview, it was determined the facility failed to provide dental services for dental complaints and dental problems triggered on the Minimum Data Set (MDS) for 3 of 32 (Residents #19, #25 and #45) sampled residents of the 32 residents included in the Stage 2 sample. The findings included: 1. Review of the facility dental contract with Onecare Dental Solutions was signed on March 1, 2012. 2. Medical record review for Resident #19 admitted on [DATE] with [DIAGNOSES REDACTED]. The 14 day MDS dated [DATE] was blank in the dental area. The quarterly MDS dated [DATE] was blank in the dental area. During an interview in Resident #19's room on 5/8/12 at 10:23 AM, Resident #19 stated, ""No problems, had teeth, dropped and broke them, would like to have teeth."" Observation during that interview in Resident #19's room on 5/8/12 at 10:23 AM, confirmed Resident #19 was edentulous. During an interview in the Assistant Director of Nursing's (ADON) office on 5/8/12 at 10:40 AM, the Director of Nursing (DON) stated, ""...would get a dental consult for that, we had a dentist that came here, no longer comes here, I believe they stopped coming in December (2011)."" During an interview in the ADON's office on 5/8/12 at 4:40 PM, the DON stated, ""Need to clarify, we did lose dentist but just signed a new contract with one last week, currently getting list of names for him (dentist) to see, to be here in 2 weeks. Have put (named Resident #19) on the list."" 3. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] documented, ""L0200 D. Obvious or likely cavity or broken natural teeth. There was no care plan for dental problems. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview in Resident #25's room on 5/8/12 at 6:59 AM, Resident #25 was asked about chewing or eating problems. Resident #25 stated, ""Yes, when I eat certain things it hurts and I throw up... and confirmed she had toothaches."" 4. Medical record review for Resident #45 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] documented, ""...Section L Oral/Dental Status L0200... Check all that apply... (checked) D. Obvious or likely cavity or broken natural teeth..."" Review of the resident's current care plan did not include oral hygiene or dental problems. Observations in Resident #45's room on 5/8/12 at 2:30 PM, revealed Resident #45 had several missing teeth.",2014-01-01
14353,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,425,D,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure that pharmacy services were timely for 2 of 32 (Residents #33 and #100) sampled residents in Stage 1 and Stage 2. The findings included: 1. Medical record review for Resident #33 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].i.d. (twice daily) 0900 (9:00 AM) 2100 (9:00 PM) FOR: Pain..."" Review of the April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation in the nurse's charting under the exception tab documented, ""4/25/2012 09:49AM... Morphine Sulfate 15MG Tablet held med (medication) unavailable... 4/26/2012 09:03PM... Morphine Sulfate 15MG Tablet held REASON: Not available in Med Select 4/27/2012 10:09AM... Morphine Sulfate held med unavailable..."" During an interview in the 200's hall on 5/9/12 at 8:20 PM, Resident #33 stated that she did get her pain medication and that her pain was relieved..."" During an interview in the Assistant Director of Nursing's office on 5/14/12 at 9:00 AM, the Director of Nursing (DON) was asked what happened that the resident did not receive the Morphine Sulfate. The DON stated, ""I don't know what happened. I couldn't even make a guess as to what happened."" 2. Medical record review for Resident #100 documented a physician's orders [REDACTED].i.d..."" Review of the nurse charting exception tab dated 4/25/12 documented, ""...held REASON Medication not available."" The facility failed to ensure that the pharmacy timely delivered medications for Resident #33 and 100.",2014-01-01
14354,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,431,D,,,LH9611,"Based on observation and interview, it was determined the facility failed to ensure drugs were not stored past their expiration date in 1 of 6 (100 hall medication room) medication storage areas. The findings included: Review of the facility's medication storage policy documented, ""...13. Outdated, contaminated, or deteriorated medications... are immediately removed from stock, disposed of according to procedures for medication destruction..."" Observations in the 100 hall medication room on 5/13/12 at 3:50 PM, revealed the following drugs were stored past their expiration date: a. Three bottles of Enteric Coated (EC) Aspirin (ASA) 325 milligram (mg) tablets with an expiration date of 4/12. b. A bottle of Simethicone 80 mg tablets with an expiration date of 1/12. c. A bottle of Loperamide HCL 2 mg with an expiration date of 4/12. d. A bottle of Senna 8.6 mg with an expiration date of 4/12. e. A bottle of Promod Liquid Protein Fruit Punch with an expiration date of 12/1/11. f. A bottle of Geri Care Iron Supplement Elixir Ferrous Sulfate 220 mg with an expiration date of 11/11. g. Two Phenadoz Suppository with an expiration date of 4/6/12. During an interview in the first floor medication room on 5/13/12 at 3:50 PM, Nurse #5 was shown the medications as noted above and asked if the medications were out of date. Nurse #5 stated, ""Yes.""",2014-01-01
14355,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,441,E,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of infection control logs, observation and interview, it was determined the facility failed to establish and maintain an infection control program that provided a safe, sanitary and comfortable environment for the residents by failing to investigate and maintain records of incidents and corrective actions related to infections; failed to ensure that 2 of 5 (200 and 100 hall medication carts) medication carts and the treatment cart were clean; failed to ensure that 2 of 2 Random Residents (RR) #2 and #8) failed to clean feeding syringes; failed to prevent the catheter tubing and bag from dragging on the floor for 1 of 32 (Resident #98) sampled residents; failed to wash hands during 1 of 2 (noon meal on 5/7/12) dining observations or during medication administration on 3 or 4 (200, 300 and 400 halls) halls. The findings included: 1. Review of the facility's ""Vanguard Healthcare Services Infection Control Surveillance"" policy documented, ""...The Infection Control Practitioner does surveillance of healthcare-associated infections by... Healthcare-associated infections are reported monthly... Surveillance documentation is maintained on the... ECS (Electronic Charting System) QA (quality assurance) /Infection Control Folder... Infection Control Report (line listing of resident infections)... Log of Employee Infections..."" Review of 6 months of ""Infection Control Log"" documented, ""...infection control November 10 reported infections..., December 6 reported URI's (upper respiratory infections) on second floor seasonal, 5 UTI's (urinary tract infections)..., January (Jan)... 13 residents received antibiotics in Jan... February (Feb)... 9 residents received antibiotics in Feb..., and March... 6 residents an ATB (antibiotic) all for UTI... There was no documentation to identify the residents or staff involved in the infections, type of infection, symptoms, cultures / labs (laboratory) results, treatment/other actions, or if infections were healthcare or community acquired infections per facility policy."" During an interview in the Assistant Director of Nursing's (ADON) office on 5/14/12 at 9:00 AM, the Director of Nursing (DON) stated, ""Have not got infection control individual forms for those residents listed on the 6 month report, do not have those forms completed for the April (2012) report either."" 2. Observations on the 200 hall on 5/13/12 at 4:10 PM, revealed yellow stain on top of the 200 hall medication cart and brown dirt around the lower edge of the medication cart and wheels. Observations on the 200 hall on 5/13/12 at 4:10 PM, revealed a brown buildup on the treatment cart wheels. Observations on the 100 hall on 5/13/12 at 4:20 PM, revealed the 100 hall medication cart had dark gray material on the wheels. 3. Review of the facility's ""FEEDING SYRINGES"" policy documented, ""...The following procedures will be followed when using a piston syringe... (after administering medications) Rinse the syringe thoroughly removing all formula and medication residue; separate the piston from the barrel. Store the syringe separated on a clean surface to air dry, or place separated in a bag mounted to the feeding pump pole (the bag must not be air tight)..."" a. Observations during the medication pass in RR #2's room on 5/9/12 at 4:55 PM, revealed Nurse #6 administering medications via enteral tube. Nurse #6 took the piston syringe from a plastic bag hanging on the feeding pump pole and completed the medication administration, joined the piston and barrel of the syringe back together and placed it back in the plastic bag hanging from the pump pole. The syringe was not rinsed at any time during this observation. b. Observations during the medication pass in RR #8's room on 5/13/12 at 12:00 PM, revealed Nurse #2 administering medication via enteral tube. Nurse #2 took the piston syringe out of the plastic bag that was hanging from the tube feeling pump pole. A small amount of orange colored liquid could be seen at the tip and around the syringe plunger. Nurse #2 completed the medication administration, joined the piston and barrel of the syringe back together and placed it back in the plastic bag hanging from the pump pole. The syringe was not rinsed at any time during this observation. During an interview in the DON's office on 5/15/12 at 2:45 PM, the DON was asked if he expected the nurses giving medications via enteral tubes to wash, rinse and store the syringe parts separately. The DON stated, ""Yes."" 4. Review of the facility's ""URINARY CATHETERS"" policy documented, ""...To insure appropriate technique in the care and maintenance of indwelling catheters... Keep the collection bag off the floor..."" Observations on the 400 hall on 5/8/12 at 8:00 AM and on 5/12/12 at 4:15 PM and 5:00 PM, revealed Resident #98 seated in his wheelchair with his urinary catheter tubing dragging the floor under the wheelchair. Observations in Resident #98's room on 5/13/12 at 9:30 AM, revealed Resident #98 lying in his bed, the urinary catheter drainage bag was out of the privacy bag and laying directly on the floor. During an interview in Resident #98's room on 5/12/12 at 9:35 AM, Nurse #10 was asked if the catheter bag and tubing should be on the floor. Nurse #10 stated, ""...It shouldn't be there..."" 5. Review of the facility's hand hygiene policy documented, ""Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene. Policy: Hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections..."" a. Observations of the noon meal in the second floor dining room on 5/7/12 at 12:12 PM, revealed certified nursing assistant (CNA) #5 delivered a tray, set up the tray, moved a chair, sat down and started feeding a resident without washing her hands. On 5/7/12 at 12:20 PM, CNA #5 got another chair, adjusted a gerichair position, then fed the resident without washing her hands. b. Observations of the medication administration pass on the 200 hall on 5/9/12 at 5:32 PM, revealed Nurse #6 washed hands, applied gloves and performed an accucheck in room [ROOM NUMBER]A. The nurse removed the gloves, returned to the cart and prepared the insulin injection. Nurse #6 returned to room [ROOM NUMBER]A with the insulin and gave the injection without washing hands or applying gloves. The nurse returned to the cart and signed out the medication. Hand hygiene was not observed except at the start of this observation. c. Observations of the medication administration pass on the 300 hall on 5/7/12 at 11:30 AM, revealed Nurse #11 applied gloves and performed an accucheck in room [ROOM NUMBER]B. Nurse #11 nurse removed her gloves and returned to the cart. She applied gloves and cleaned the glucometer. Nurse #11 removed her gloves, took the insulin bottle out of the med cart, drew up the required insulin, applied gloves, gave the insulin injection to the resident and removed her gloves. Hand hygiene was not observed during this observation. d. Observations of the medication administration pass on the 400 hall on 5/14/12 at 9:15 AM, revealed Nurse #12 prepared and administered medications to the resident in 217A. Nurse #12 then prepared and administered medications to the resident in 217B. Hand hygiene was not observed between giving the resident in room [ROOM NUMBER]A and preparing and giving medications to the resident in 217B. e. During an interview in the DON's office on 5/15/12 at 2:45 PM, the DON was asked if he expected the nurses to perform hand hygiene before and after performing accuchecks and administering medications and if gloves were to be worn when giving injections. The DON stated, ""Yes Ma'am.""",2014-01-01
14356,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,456,D,,,LH9611,"Based on policy review, observation and interview, it was determined the facility failed to ensure that essential medical equipment was properly maintained as evidenced by 3 of 3 gerichairs observed with torn upholstery. The findings included: 1. Review of the facility's clinical equipment policy documented, ""Purpose: To provide clean clinical equipment and help promote sanitary environment. Policy: For all clinical equipment, the manufacturer's recommendations for cleaning or disinfecting are followed... geri-chairs and other specialty chairs are cleaned on a monthly schedule and as needed... are cleaned weekly and as needed using germicidal agent that is approved for housekeeping to use..."" 2. Observations on 5/9/12 beginning at 3:50 PM revealed the following: a. Room 113 - The geri-chair in the room had tears in both arms. b. Room 114 - Both arms of the geri-chair were torn. Observations in the 300 hall shower room on 5/14/12 at 4:37 PM, revealed a gerichair with the head rest upholstery torn. During an interview in the Assistant Director of Nursing's office on 5/10/12 starting at 11:30 AM, the Director of Maintenance was asked how often he or the maintenance assistant was in the resident rooms and if he was aware of their appearance and condition. The Director of Maintenance stated that ""he and/or the assistant were in each resident's room and the common areas at least monthly for scheduled maintenance and on top of that, for needed repairs that were reported to the maintenance department by staff or residents.""",2014-01-01
14357,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,463,D,,,LH9611,"Based on observation and interview, it was determined the facility failed to ensure the resident call system was functional for 1 of 32 (Resident #63) sampled residents reviewed in Stage 1 and Stage 2. The findings included: Observations in Resident #63's room (218 B) on 5/8/12 at 8:00 AM, revealed the call light was not functioning. Nurse #13 was observed to check the call light in room 218 B on 5/8/12 at 8:30 AM and confirmed it was not working. During an interview in room 218 B on 5/8/12 at 8:30 AM, Nurse #13 stated, ""Will have to get maintenance to check (call light)..."" Observations during an interview in room 218 on 5/8/12 at 9:25 AM, the Director of Maintenance replaced the call light cord and stated, ""Light functioning.""",2014-01-01
14358,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,490,J,,,LH9611,"Based on policy review, review of residents' rights, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility failed to be administered in a manner that ensured the environment was as free as possible from accident hazards; failed to maintain the highest practicable physical, mental, and psychosocial well being and failed to notify the physician of condition changes for 1 of 32 (Resident #66) sampled residents in the Stage 1 and 2 review. The facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed to investigate the reported abuse for Resident #25. residents interviewed in the Stage 1. The findings included: 1. The facility administration failed to ensure the environment was free from possible accident hazards, failed to ensure the staff assessed, provided the necessary care and services to address mental and psychosocial adjustment difficulties for Resident #66 as evidenced by not reporting non-compliance with oxygen therapy, low oxygen saturation levels not reported to physician, abnormal lung sounds that worsened, did not report fever to the physician, no fall management / prevention of multiple falls and did not address or report to the physician the repeated behaviors displayed. The facility's failure to assess and provide the necessary care and services and notify the physician of these conditions placed Resident #66 in immediate jeopardy. Refer to F157, F309, F319, F323 and F328. 2. The facility administration failed to ensure Resident #25 and RR #1 were free from verbal abuse; failed to effectively monitor staff interaction with residents; facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed to investigate the reported abuse for Resident #25. RR #1 and Resident #25 did not feel they were treated with respect and dignity. RR #1 and Resident #25 confirmed staff had yelled and been rude to them. This resulted in immediate jeopardy as evidenced by displays of emotions due to mental anguish when both residents were observed tearful when discussing demeaning remarks and actions of staff related to need for assistance with incontinent care. Refer to F223, F224, F225 and F226. 3. The Administrator failed to ensure there was effective maintenance and housekeeping services to maintain a sanitary, orderly and comfortable environment. Refer to F253. 4. The Administrator failed to ensure the Quality Assurance Committee established a method to identify concerns in the facility. Refer to F520. On 5/7 through (-) 15/12 an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F157, F272, F280, F282, F309, F319, F323, F328, F490 and F520 all with a scope and severity of a ""J"". The facility's failure to provide an environment that remains as free from accident hazards as possible and failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed Resident #66 in immediate jeopardy. The facility was cited with an IJ at F223, F224, F225, F226, F490 and F520 all with a scope and severity of a ""J"". The facility's failure to protect residents from psychological harm and the failure to follow the facility policy of reporting and/or investigating allegations of abuse placed Resident #25 and Random Resident #1 in immediate jeopardy as evidenced by tearful, emotional responses during interviews concerning abuse. An extended survey was completed on 5/15/12. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on 5/10/12 at 7:35 PM and on 5/11/12 at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on 5/14/12 at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Social Services Director interviewed all 96 residents using the ""Resident Questionnaire Regarding Abuse"" form with the following results: a. Ninety residents denied any form of abuse. b. Three residents named a Certified Nursing Technician (CNT) - the CNT was terminated after investigation. c. Two residents alleged verbal abuse by staff - one was substantiated and the CNT was terminated, one was unsubstantiated. d. One allegation of misappropriation of medication - investigated and unsubstantiated. 2. Investigations were initiated utilizing the Vanguard Event Management process. 3. The Social Services Department will complete audits/interviews weekly for one month, monthly for three months and then once a quarter and as needed. 4. The Social Service Director began one-on-one visits with each resident and/or responsible party defining abuse, how and when to report allegations of abuse and to inform of no retaliation from reporting alleged abuse on 5/12/12. 5. The Adm, DON, ADON, Nurse Educator and Minimum Data Set (MDS) nurses began assessing all residents for signs and symptoms of respiratory and cardiac distress on 5/11/12 and reported any findings of signs and symptoms to the physician. 6. The Adm, DON, ADON and MDS nurses began reviewing all care plans for accuracy, correcting any interventions as needed and reporting their findings using an audit tool beginning on 5/11/12. 7. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention. b. Abuse Reporting. c. Staff questionnaire on abuse. The inservicing was conducted by the Adm, DON, and the ADON. All new hires will be inserviced during orientation. 8. Inservicing 100% of the licensed nursing staff and Certified Nursing Assistants (CNA) began on 5/11/12 on the following topics: a. Fall Interventions. b. Fall and Incident reporting. c. Verbal questions and answers with staff. d. Fall interventions. e. Physician notification and Responsible Party notification. f. Change of Condition. g. Recognizing signs/symptoms of respiratory and cardiac distress. h. Behavior Management. The inservicing was conducted by the Adm, DON, and the ADON. All new hires will be inserviced during orientation. 9. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Behavior Quality Assurance/ Performance Improvement (QA/PI) tool. b. Weekly At Risk QA/PI Log. c. Care Plan Audit. d. Oxygen orders and use. e. Nursing Notes Audit For Change of Condition. f. Alert Charting Log. g. Event Log. 10. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 11. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, ADON, Regional Director of Operations, Vice President of Clinical Services and three Regional Nurse Consultants in the therapy room on 5/15/12 at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on 5/10/12. The surveyors determined the IJ was abated on 5/15/12 at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of ""Resident Questionnaire Regarding Abuse"", all staff inservices for abuse prevention, abuse reporting, fall interventions, fall and accident reporting, physician notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and behavior management and review of findings on audit tools which were initiated on 5/11/12 and completed on 5/15/12. The IJ was abated as of 5/15/12. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""F"" level for F490 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14359,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,516,D,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and observation, it was determined the facility failed to maintain confidentiality of a resident's private healthcare information during 1 of 2 (Resident #89) dressing change observations. The findings included: Medical record review for Resident #89 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of a dressing change in Resident #89's room on 5/13/12 at 11:30 AM, revealed Resident #89 lying in bed on his left side, the head of bed was elevated 30 degrees and 150 cubic centimeters (cc) of water was infusing per feeding tube. Nurse #5 was observed to gather supplies, removed the old dressing, performed wound care as ordered and disposed the dressing in a red bag. Nurse #5 left the computer open to Resident #89's Treatment Administration Record (TAR) as he walked down the hall to the nurses' station.",2014-01-01
14360,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,520,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility's administrative staff failed to identify and address quality of care issues such as failure to ensure adequate supervision of residents; failure to ensure adequate interventions were developed to manage and prevent falls; failure to provide necessary care and services for the management and treatment of [REDACTED].#66) sampled residents reviewed in the Stage 2 review. The facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed to investigate the reported abuse for Resident #25. The facility failed to assess and address the care and prevention of pressure ulcers for 1 of 2 (Resident #138) sampled residents observed with pressure ulcers. The facility failed to ensure the facility's protocol for monitoring nutrition was followed for 1 of 7 (Resident #118) sampled residents for nutrition in the Stage 2 review. The failure of the Quality Assurance and Assessment (QAA) Committee to identify and address these concerns resulted in the potential cause of death for Resident #66 as evidenced by repeated falls, no treatment and services for repeated behaviors and no physician notification of his deteriorating conditions. The failure of the QAA Committee to investigate and report the alleged abuse reported to the facility by Resident #25 and the failure to ensure RR #1 and Residents #25 were free from mistreatment and neglect placed these residents in immediate jeopardy as evidenced by tearful emotional responses when interviewed. The findings included: 1. During an interview in the Assistant Director of Nursing's (ADON) office on 5/15/12 at 2:00 PM, the Administrator, who coordinated the QAA Committee, did not identify any allegations of abuse, falls, behaviors, notification of physician and responsible party of accidents or condition changes, pressure ulcers, or weight loss as problems identified by the QAA Committee. The QAA Coordinator stated problems may be identified by anyone on the QAA Committee, but could not identify any resident care areas that had been through the QAA Committee. Refer to F223, F224, F225 , F226, F314 and F325. 2. During an interview in the ADON's office on 5/15/12 at 2:10 PM, the QAA Coordinator was asked if the QAA Committee had identified and addressed any concerns with notification of the physician when changes in condition of residents occurred. The QAA Coordinator stated, ""Nurses have said the doctor doesn't call back quick enough."" Refer to F157. 3. During an interview in the ADON's office on 5/15/12 at 2:10 PM, the QAA Coordinator was asked if the conditions of the resident environment, such as chipped paint, scuffed walls, cracked and missing tile and torn or broken equipment had been identified by the Committee. The QAA Coordinator stated, ""We have plans that are not always feasible."" Refer to F253. 4. On 5/7 through (-) 15/12 an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F157, F272, F280, F282, F309, F319, F323, F328, F490 and F520 all with a scope and severity of a ""J"". The facility's failure to provide an environment that remains as free from accident hazards as possible and failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed Resident #66 in immediate jeopardy. The facility was cited with an IJ at F223, F224, F225, F226, F490 and F520 all with a scope and severity of a ""J"". The facility's failure to protect residents from psychological harm and the failure to follow the facility policy of reporting and/or investigating allegations of abuse placed Resident #25 and Random Resident #1 in immediate jeopardy as evidenced by tearful, emotional responses during interviews concerning abuse. An extended survey was completed on 5/15/12. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on 5/10/12 at 7:35 PM and on 5/11/12 at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on 5/14/12 at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Social Services Director interviewed all 96 residents using the ""Resident Questionnaire Regarding Abuse"" form with the following results: a. Ninety residents denied any form of abuse. b. Three residents named a Certified Nursing Technician (CNT) - the CNT was terminated after investigation. c. Two residents alleged verbal abuse by staff - one was substantiated and the CNT was terminated, one was unsubstantiated. d. One allegation of misappropriation of medication - investigated and unsubstantiated. 2. Investigations were initiated utilizing the Vanguard Event Management process. 3. The Social Services Department will complete audits/interviews weekly for one month, monthly for three months and then once a quarter and as needed. 4. The Social Service Director began one-on-one visits with each resident and/or responsible party defining abuse, how and when to report allegations of abuse and to inform of no retaliation from reporting alleged abuse on 5/12/12. 5. The Adm, DON, ADON, Nurse Educator and Minimum Data Set (MDS) nurses began assessing all residents for signs and symptoms of respiratory and cardiac distress on 5/11/12 and reported any findings of signs and symptoms to the physician. 6. The Adm, DON, ADON and MDS nurses began reviewing all care plans for accuracy, correcting any interventions as needed and reporting their findings using an audit tool beginning on 5/11/12. 7. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention. b. Abuse Reporting. c. Staff questionnaire on abuse. The inservicing was conducted by the Adm, DON, and the ADON. All new hires will be inserviced during orientation. 8. Inservicing 100% of the licensed nursing staff and Certified Nursing Assistants (CNA) began on 5/11/12 on the following topics: a. Fall Interventions. b. Fall and Incident reporting. c. Verbal questions and answers with staff. d. Fall interventions. e. Physician notification and Responsible Party notification. f. Change of Condition. g. Recognizing signs/symptoms of respiratory and cardiac distress. h. Behavior Management. The inservicing was conducted by the Adm, DON, and the ADON. All new hires will be inserviced during orientation. 9. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Behavior Quality Assurance/ Performance Improvement (QA/PI) tool. b. Weekly At Risk QA/PI Log. c. Care Plan Audit. d. Oxygen orders and use. e. Nursing Notes Audit For Change of Condition. f. Alert Charting Log. g. Event Log. 10. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 11. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, ADON, Regional Director of Operations, Vice President of Clinical Services and three Regional Nurse Consultants in the therapy room on 5/15/12 at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on 5/10/12. The surveyors determined the IJ was abated on 5/15/12 at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of ""Resident Questionnaire Regarding Abuse"", all staff inservices for abuse prevention, abuse reporting, fall interventions, fall and accident reporting, physician notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and behavior management and review of findings on audit tools which were initiated on 5/11/12 and completed on 5/15/12. The IJ was abated as of 5/15/12. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""F"" level for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
14361,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,225,J,,,LH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to investigate and report 1 of 1 (Resident #25) sampled resident's allegation of abuse. The facility's failure to investigate and report the abuse allegation placed Resident #25 in immediate jeopardy as evidenced by her show of mental anguish by crying during an interview. The findings included: Review of the facility's abuse policy documented, ""1. Defining... ""Abuse"" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in ""physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult... Reporting and Response Notify the Administrator and/or Director of Nursing immediately. Do not wait until ""morning"" ...An accident /Incident Report is completed as soon as possible after an allegation of abuse or neglect is made... Report all alleged violations and all substantiated incidents to official agencies as required by State law..."" Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] documented, ""...Section C Cognitive Patterns Brief Interview for Mental Status...C0500. Summary Score...15 (cognitively intact)..."" Observations in Resident #25's room on 5/8/12 at 10:53 AM, Resident #25 began crying when talking about the way the staff treated her. During an interview in Resident #25's room on 5/8/12 10:53 AM, Resident #25 stated, ""...they (staff) steal from you all time. Bloomer gone this morning, socks, magazines..."" During an interview in Resident #25's room on 5/8/12 at 11:06 AM, Resident #25 was asked, ""Has staff yelled or been rude to you?"" Resident #25 stated, ""Yes."" Resident #25 was observed to start crying and stated, ""rather not say cause when you leave, rather not say."" During an interview in Resident #25's room on 5/10/12 at 8:00 AM, Resident #25 stated, ""(Named Certified Nursing Technician (CNT) #4) on day shift sometimes she coming in slinging tray on the table, talk snappy to you... Half of them don't speak..."" During a telephone interview in the Assistant Director of Nursing's (ADON) office, on 5/10/12 at 9:15 AM, Resident #25's daughter stated, ""...The tech (CNT) don't know name said to my mother should call somebody to go to the bathroom and she (my mother) said she had urinated on herself because they were slow in coming. I took it as though they were reprimanding her. The tech did not know I had entered the room... I have mentioned it to the nurse evening shift... Asked her (Nurse #1) where are they (CNTs) and why are they so abrupt... I have talked to (named Nurse #1) at meetings..."" During an interview in the MDS office on 5/10/12 at 4:10 PM, Nurse #1 confirmed that Resident #25's daughter had talked to her but would not give names of staff. Nurse #1 stated, ""We tried to determine who the staff was. It was early part of year or end of last year. We investigated it, me the Social Worker, DON (Director of Nursing). It would be in the DON files. From care conference would be in (named Social Worker's) files..."" During an interview in the ADON's office on 5/14/12 at 8:40 AM, the DON was asked if he found an investigation on staff being abrupt or rude to Resident #25. The DON stated, ""I don't have one."" Resident #25 confirmed staff had yelled and been rude to her. The facility was unable to provide documentation that the abuse allegation had been investigated or reported to the state agency as required by law. The facility's failure to ensure that all alleged violations involving abuse were thoroughly investigated and reported to the State survey and certification agency placed Resident #25 in immediate jeopardy as evidenced by her show of mental anguish when she began to cry during an interview. On 5/7 through (-) 15/12 an annual re-certification survey was completed. The facility was cited with an IJ at F225 with a scope and severity of a ""J"". The facility's failure to protect residents from psychological harm and the failure to follow the facility's policy of investigating and reporting allegations of abuse placed Resident #25 in immediate jeopardy as evidenced by tearful, emotional responses during interview concerning abuse. An extended survey was completed on 5/15/12. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON)office on 5/10/12 at 7:35 PM and on 5/11/12 at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on 5/14/12 at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Social Services Director interviewed all 96 residents using the ""Resident Questionnaire Regarding Abuse"" form with the following results: a. Ninety residents denied any form of abuse. b. Three residents named a Certified Nursing. Technician (CNT) - the CNT was terminated after investigation. c. Two residents alleged verbal abuse by staff - one was substantiated and the CNT was terminated, one was unsubstantiated. d. One allegation of misappropriation of medication - investigated and unsubstantiated. 2. Investigations were initiated utilizing the Vanguard Event Management process. 3. The Social Services Department will complete audits/interviews weekly for one month, monthly for three months, and then once a quarter and as needed. 4. The Social Service Director began one-on-one visits with each resident and/or responsible party defining abuse, how and when to report allegations of abuse and to inform of no retaliation from reporting alleged abuse on 5/12/12. 5. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention. b. Abuse Reporting. c. Staff questionnaire on abuse. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 6. Inservicing 100% of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention. b. Abuse Reporting. c. Staff questionnaire on abuse. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 7. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Weekly At Risk Quality Assurance /Performance Improvement (QA/PI) Log. b. Alert Charting Log. c. Event Log. 8. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 9. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, ADON, Regional Director of Operations, Vice President of Clinical Services and three Regional Nurse Consultants in the therapy room on 5/15/12 at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on 5/10/12. The surveyors determined the IJ was abated on 5/15/12 at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of ""Resident Questionnaire Regarding Abuse"", all staff inservices for abuse prevention and abuse reporting and review of findings on audit tools which were initiated on 5/11/12 and completed on 5/15/12. The IJ was abated as of 5/15/12. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a ""D"" level for F225 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag.",2014-01-01
11,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2020-01-02,580,D,1,0,14S411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to notify the physician in a timely manner of a malfunction of a Percutaneous Endoscopic Gastrostomy (PEG) tube (flexible feeding tube inserted through the abdominal wall and into the stomach for nutrition, fluids, and medications) for 1 resident (#2) of 3 residents reviewed for PEG tubes. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 5/9/19 revealed Resident #2 was care-planned for Infection Potential related to Feeding Tube, and Nutritional Status, Dependent on Tube Feed with interventions including (caloric, fiber fortified nutritional tube feeding) at 60 milliliters an hour for 18 hours, assess for changes in condition and notify medical staff, and MD (medical doctor) to replace PE[NAME] Medical record review of the Resident Progress Notes dated 9/1/19 at 1:38 PM, for Resident #2 revealed .in am, previous shift .nurse reported perforation to PEG tube. Noted large hole at end of catheter. Removed without difficulty and replace with new 24F (French) 20 cc (cubic centimeters) tube .restarted without concerns per supervisor .Husband updated, left message with NP (Nurse Practitioner) . Further review revealed no documentation the physician or the NP was made aware of the PEG tube perforation and the removal and reinsertion of a new PEG tube. Medical record review of the Physician's Orders on 9/1/19 revealed no documentation of an order to reinsert the PEG tube. Medical record review of an untitled typed letter, dated 10/14/19, and signed by the Unit Supervisor RN revealed .pt. (patient) had a removable gastric tube in place that had perforated and some of the balloon was visible from tube site entrance .nurse notified house supervisor .replaced with facility gastric tube . Interview with the Compliance Registered Nurse (RN) (former Unit House Supervisor) on 1/2/20 at 12:15 PM, in the Conference Room, confirmed she was the supervisor on duty on 9/1/19 when the Licensed Practical Nurse (LPN) (no longer employed at the facility), notified her of the perforated PEG tube. Continued interview confirmed she and the LPN removed the perforated PEG tube, reinserted a new PEG tube without notifying the physician. Interview with the Compliance RN, the Director of Nursing, and the Corporate Consulting RN on 1/2/20 at 1:50 PM, in the Conference Room, confirmed the facility did not notify the physician or NP of the PEG perforation and removal and reinsertion of the PEG tube.",2020-09-01
15,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-01-18,602,E,1,0,GSLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to prevent misappropriation of resident's medication for 5 residents (#1, #3, #4, #5, and #6) of 9 residents reviewed for abuse. The findings included: Review of the facility policy Resident Rights - Abuse of Residents revised [DATE] revealed, .any type of resident abuse .or misappropriation of resident property is strictly prohibited .misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of a resident's belonging or funds without the resident's consent . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Medical record review of Resident #1's Physicians Orders revealed an order dated [DATE] for [MEDICATION NAME] (pain medication) 0.25 milliliters (ML) sublingual (under the tongue) as needed (PRN) every 1 hour for pain. Continued review revealed the order was discontinued on [DATE]. Further review revealed an order dated [DATE] for [MEDICATION NAME] 0.5 ml sublingual PRN every 3 hours as needed for pain. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #3 was moderately cognitively impaired. Medical record review of the Physician Orders revealed an order for [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #4 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating Resident #4 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 2 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 2, indicating Resident #5 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML sublingual every 4 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #6 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 0 (zero), indicating Resident #6 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 4 hours as need for pain. Review of a facility investigation dated [DATE] revealed the facility became aware of a possible drug diversion at approximately 11:45 PM on [DATE]. Further review revealed during the narcotic count at shift change between 2nd and 3rd shift, Licensed Practical Nurse (LPN) #3 observed a vial of [MEDICATION NAME] prescribed for Resident #1, which appeared to have the tamper resistant seal altered. Continued review revealed the vial was full as if no medication had been administered. Further review revealed LPN #3 immediately notified LPN #2, the night shift supervisor, of her concern and at that time LPN #2 immediately notified the Director of Nursing (DON). Continued review revealed the vial of [MEDICATION NAME] was delivered to the facility the afternoon of [DATE] and Resident #1's Medication Administration Record [REDACTED]. Continued review revealed on [DATE] the DON began a facility wide investigation. Further review revealed during a narcotic audit the facility identified 3 additional residents' (#4, #5, and #6) vials of [MEDICATION NAME] were altered. Further review revealed, after reviewing the staffing assignment sheets and schedules, the facility was able to identify Registered Nurse (RN) #1 provided care to, and had access to, the residents' medications. Further review revealed on [DATE], during the facility's monthly narcotic waste, the DON and the Pharmacist found a vial of [MEDICATION NAME] prescribed for Resident #3, which had been placed in the narcotic waste bin after the order was discontinued on [DATE]. Continued review revealed the vial of [MEDICATION NAME] was noted to have been altered. Further review revealed the DON reviewed the staffing assignment sheets and RN #1 provided care to Resident #3 on [DATE], the day the [MEDICATION NAME] was discontinued. Review of the police report dated [DATE] revealed .responded to (facility) in reference to a theft of medication .advised (RN #1) .had stolen liquid [MEDICATION NAME] from four different residents at the facility. (RN #1) stole the medication .While on scene I observed a bottle of [MEDICATION NAME] that had been diluted .(RN #1) was subjected to a drug screen, in which the first sample showed invalid due to the temperature of the urine at the time. (RN #1) was subjected to a second drug screen, in which she tested positive for [MEDICATION NAME] . Continued review revealed RN #1 admitted to stealing the [MEDICATION NAME]. Review of the Urine Drug Screen Laboratory Report dated [DATE] revealed RN #1 was positive for [MEDICATION NAME]. Interview with RN #1 via phone on [DATE] at 10:33 AM, confirmed she had taken [MEDICATION NAME] from various residents over a two week period in (MONTH) (YEAR). Continued interview confirmed she was unable to identify the residents specifically. Interview with the DON on [DATE] at 9:16 AM, in the conference room, confirmed she was made aware of possible drug diversion on [DATE] at approximately 11:45 PM by LPN #2. Further interview confirmed LPN #2 reported the vial of [MEDICATION NAME] ordered for Resident #1 was delivered to the facility on [DATE], the tamper resistant seal showed signs of having been tampered with, and Resident #1's MAR indicated [REDACTED]. Continued interview confirmed during the course of their investigation the facility identified 4 additional residents (Residents #3, #4, #5, and #6) whose vials of [MEDICATION NAME] were altered. Further interview confirmed after reviewing the staffing assignment sheets and schedule, the facility was able to determine RN #1 provided care to the affected residents. Continued interview confirmed initially RN #1 denied having any knowledge of the altered [MEDICATION NAME] but eventually admitted to the misappropriation of the [MEDICATION NAME]. Further interview confirmed RN #1 was suspended on [DATE] and remained on suspension until being terminated on [DATE]. Interview with the DON on [DATE] at 10:10 AM, in the conference room, confirmed through the facility's investigation they were able to identify RN #1 had taken [MEDICATION NAME] from 5 residents (Residents #1, #3, #4, #5, and #6) and the facility had failed to prevent misappropriation of resident's medication.",2020-09-01
16,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2020-02-20,625,D,1,0,D8DU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to provide a bed hold notice for 1 resident (Resident #1) transferred to a psychiatric facility of 3 transferred residents reviewed. The findings included: Review of the facility's policy titled, Bed Hold Policy dated 10/19/2019 showed .Residents and/or responsible parties will be fully informed of options regarding the holding or releasing of a bed when the resident is temporarily transferred from the facility or is on a therapeutic leave.Upon admission to the facility the resident and/or their representative will be notified in writing of (named facility) Bed Hold Policy.In the event that the resident is transferred out of the facility temporarily, or the resident goes out on a therapeutic leave a copy of the Bed Hold Agreement will be given to the resident or their representative.This process will be followed for all transfers, regardless of payer type. A copy of the Bed Hold Agreement will be placed in the residents Business Office File and a copy of the bed hold agreement will be provided to the resident or their representative. Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to a psychiatric facility. Resident #1 was readmitted to the facility on [DATE], but was discharged again to the psychiatric facility on 7/24/2019 and did not return to the facility. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #1 had short and long term memory loss and exhibited physical and verbal behaviors directed towards others. Review of a Physician's Telephone Order dated 6/8/2020 showed .transfer to (named psychiatric facility).psych eval (psychiatric evaluation). Review of a Physician's Telephone Order dated 7/23/2020 showed .send to (named psychiatric facility) for evaluation + (and) tx (treatment). Medical record review showed no documentation a bed hold notice was provided to the resident or the resident's representative prior to the resident being transferred to the psychiatric facility on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 5:20 PM, the Administrator stated .I looked through the entire chart and could not find it.did not find a progress note.only thing we have is a resident agreement.does not mention bed hold.both times the resident was sent out to a psych facility.behaviors.combative.nothing for either transfer. The Administrator confirmed the facility did not give the resident or the resident representative a bed hold notification prior to the transfer on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 5:30 PM, the Nurse Manager confirmed a bed hold policy was not given to the family prior to transferring the resident on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 6:00 PM, the Social Worker confirmed a bed hold policy was not given to the resident or the resident's representative prior. During a telephone interview on 2/20/2020 at 6:30 PM, Resident #1's representative stated she was not made aware of the facility's bed hold policy either verbally or in writing.",2020-09-01
17,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-04-26,609,D,1,0,6SJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility investigation, observation, and interviews, the facility failed to report an injury of unknown origin for 1 resident (#3) of 5 residents reviewed. The findings included: Review of the facility policy Resident Rights Abuse of Residents dated 11/14/16 revealed .an injury of unknown origin .must be reported to the Executive Director .Resident Incidents must be reported immediately .not later than 24 hours if the events that cause the allegation do not involve abuse .to other officials (including law enforcement, state survey agency, and adult protective services) .in accordance with applicable law and regulations . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident had short and long term memory problems and was severely cognitively impaired for daily decision making skills. Further review revealed the resident required extensive to total assist for activities of daily living (ADL) with 1-2 person assist. Review of a facility investigation dated 3/28/18 revealed Certified Nurse Assistant (CNA) #1 noted bruising to Resident #3's left forehead, which was not present earlier in the day. Further review revealed CNA #1 reported the bruising to Licensed Practical Nurse (LPN) #5. Continued review revealed LPN #5 reported the injury to the Director of Nursing (DON). Interview with CNA #1 on 4/25/18 at 11:30 AM, in the 1 South Breakroom, revealed .I was on my way to lunch . (another CNA) was pushing her (Resident #3) out of the dining room .I brushed her (Resident #3's) hair back from her face and that is when I noticed the bruise .it was purple .reported to the nurse .got her (Resident #3) up and dressed that morning and did not see anything then . Interview with LPN #2 on 4/25/18 11:40 AM, in the 1 South Breakroom, revealed .immediately went and assessed her (Resident #3) .she had a hematoma to the top left of her hairline .the bruising was coming down toward her eye .notified the DON .the Nurse Practitioner was in the facility and came and assessed her .notified the family . Observation on 4/25/18 at 12:00 PM revealed Resident #3 was seated in her wheelchair in the dining room. Continued observation revealed the resident had a slight purplish discoloration from her hairline down the left side of her forehead. Interview with the Administrator on 4/26/18 at 1:30 PM, in his office, confirmed the injury of unknown origin was not reported to Adult Protective Services, Law Enforcement, or the Ombudsman and the facility failed to follow facility policy.",2020-09-01
18,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-04-26,656,D,1,0,6SJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interviews, the facility failed to ensure the comprehensive care plan was person centered for bathing for 2 residents (#1 and #2) of 5 residents reviewed. The findings included: Review of the facility policy Bathing dated 3/7/14 revealed .All Residents complete bathing needs will be met twice weekly, or at a schedule based on resident preference . Review of the facility policy Comprehensive Resident Centered Care Plan dated 11/2/16 revealed .The care plan incorporates the resident's strengths and abilities as well as areas requiring support . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's care plan dated 2/5/18 revealed .provide care as needed by the resident to complete his/her daily care needs . Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident required extensive assist with transfers, bathing, and dressing with 1-2 person assist. Continued review revealed the resident had a functional limitation of 1 upper and 1 lower extremity. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's care plan dated 3/22/18 revealed .provide care as needed by the resident to complete his/her daily care needs . Review of the admission MDS dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident required extensive assist for transfers, dressing with 2 person assist, and was totally dependent for personal hygiene and bathing with 1-2 person assist. Interview with Certified Nursing Assistant (CNA) #1 on 4/25/18 at 2:45 PM, on 1 South Household hallway, revealed .most residents get 2 showers a week unless they request more . Interview with Licensed Practical Nurse (LPN) #6 on 4/26/18 at 12:15 PM, in the therapy gym office, revealed . care plan should address the resident's preference and frequency of bathing . Interview with the Director of Nursing (DON) on 4/26/18 at 1:15 PM, in the DON's office, confirmed the care plans for Resident #1 and Resident #2 did not adequately reflect their bathing needs and were not person centered.",2020-09-01
19,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2019-05-02,609,D,1,0,ZMPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to ensure an allegation of abuse was reported immediately to the facility Administrator and to other officials (including the State Survey Agency and Adult Protective Services) for 1 resident (#1) of 4 residents reviewed for Abuse on 4 nursing units of 4 sampled residents. The findings included: Review of facility policy Resident Rights - Abuse of Residents revised 11/14/16 revealed .Reporting .1. Any witnessed or allegations of abuse .must be reported to the Executive Director, Administrator or Charge Nurse/Nurse Supervisor .a. Resident Incidents must be reported immediately .to other officials (including law enforcement, state survey agency, and adult protective services) in accordance with applicable law and regulations . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's 30 day MDS dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #3's annual MDS dated [DATE] revealed the resident was cognitively intact. Medical record review of a Psychiatric Progress Note for Resident #3 dated 4/10/19 revealed the resident was attention seeking and inappropriate verbally with staff related to sexuality. Review of a facility investigation dated 4/25/19 revealed Resident #3 reported he witnessed Resident #2 place his hand down the front of Resident #1's pants and Resident #3 told Resident #2 to stop. Continued review revealed Resident #2 replied .I was just checking to see if she (Resident #1) was wet to change . Further review revealed Resident #3 changed details of the alleged incident multiple times during the facility investigation and stated he was not able to see if Resident #2 put his hand under her blanket or inside Resident #1's pants. Continued review revealed Licensed Practical Nurse (LPN) #2 reported while she was feeding Resident #3 in his room on 4/22/19 or 4/23/19, Resident #3 reported the incident to her. Further review revealed Resident #3 also reported the incident to LPN #3 on 4/24/19. Interview with LPN #2 on 5/2/19 at 1:00 PM, in the Administrator's office, confirmed Resident #3 reported the alleged incident to her on 4/22/19 or 4/23/19. Further interview revealed she did not report the allegation because .in my mind .I thought it really didn't happen . Telephone interview with LPN #3 on 5/2/19 at 2:35 PM confirmed she did not report the allegation of abuse because she thought it was .old news . Further interview with LPN #3 confirmed she was aware she should have reported the allegation immediately, but failed to do so. In summary, Resident #3 reported an allegation of abuse to facility staff on 4/22/19 or 4/23/19, but the staff did not report the allegation to the Administrator or the State Survey Agency until 4/25/19.",2020-09-01
20,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,281,D,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Lippincott Manual of Nursing Practice, facility staffing files, facility policy, medical record review, and interview, the facility employed one Licensed Practical Nurse (LPN #9) with an expired license who administered insulin to 3 diabetic residents (#5, #16, and #14) of 17 residents reviewed. The findings included: Review of Lippincott Manual of Nursing Practice, Ninth Edition, chapter 2, revealed, .Licensure is granted by an agency of state government and permits individuals accountable for the practice of professional nursing to engage in the practice of that profession, while prohibiting all others from doing so legally . Review of the facility staff certification documents on [DATE] revealed LPN #9's license to practice nursing expired on [DATE]. Review of the facility's staffing files revealed LPN was hired on [DATE]. Medical record review of the facility's Insulin Administration Policy revised (MONTH) 2010 revealed, .Procedure .check blood glucose per physician order [REDACTED]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED].(increase) chemsticks (blood sugar testing) to AC/HS (before meals and bedtime) . Medical record review of Physician order [REDACTED].Humalog (fast-acting insulin for diabetics) 6 (units) with lunch and supper .hold if (blood glucose) (less than) 150 . Medical record review of Resident #5's electronic Medication Administration Record [REDACTED]. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 15 times out of 62 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 16 times out of 54 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar per physician order [REDACTED]. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (fast-acting insulin insulin for diabetics) .(6 units) .two times daily .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 10 times out of 27 opportunities. Medical record review of Resident #16's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 12 times out of 37 opportunities. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED].[MEDICATION NAME] .12 units .give extra 4 units if (blood glucose) (greater than 300)) . Medical record review of Resident #14's eMAR dated [DATE] at 1:00 PM revealed a blood sugar of 274 with documentation LPN #9 administered 10 units of insulin instead of the ordered 12 units. Continued review revealed the 5:30 PM blood sugar was 191, indicating Resident #14 continued to have high blood sugar. Interview with the DON on [DATE] at 2:35 PM, in the DON's office, confirmed nurses are to follow the physician's orders [REDACTED]. Interview with the Administrator and DON on [DATE] at 6:30 PM, confirmed, LPN #9 did not have a current license to practice nursing since the hire date in (MONTH) (YEAR). Continued interview confirmed since his employment, LPN #9 failed to follow physician's orders [REDACTED].",2020-09-01
21,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,282,E,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of Brunner and Suddarth's Textbook of Medical Surgical Nursing, medical record review, Review of Consultant Pharmacist Reports, and interview, the facility failed to administer insulin and follow diabetic care plans per the physicians orders for 8 residents (#1, #4, #6, #7, #13, #5, #16, #18) of 17 residents reviewed for insulin, of 24 residents reviewed. The facility's failure to follow diabetic care plans resulted in an insulin overdose and hospitalization for Resident #1. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on 7/27/17 at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .when PRN (as needed) medications are administered, the nurse must record .date and time administered .dosage .medications shall be administered as prescribed by the physician .must be administered with the written orders of the attending physician .nurses administering the medications must initial the resident's MAR .Should a drug be withheld .nurse must enter an explanatory note Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration (less than) 45 . by the level .causes of DKA (Diabetic Ketoacidosis, a serious complication of diabetes) .missed dose of insulin . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Continued review revealed the resident was transferred to the hospital on [DATE] after receiving an overdose of insulin. Review of the eMAR dated 9/12/16 at 9:00 PM, revealed a sliding scale (based on blood sugar results) for Humalog (short acting) insulin 100 units subcutaneous four times daily starting 8/25/16. Blood sugar 415 notify MD. Blood sugar is 0-150 (give) 0 units, Blood Sugar is 151-200 (give) 2 units Blood Sugar is 201-250 (give) 4 units Blood Sugar is 251-300 (give) 6 units Blood Sugar is 301-350 (give) 8 units Blood Sugar is 351-400 (give) 10 units Blood Sugar is 401-415 (give) 12 units Continued review revealed the blood sugar on 9/11/16 at 9:00 PM was 247 and 100 units of Humalog insulin instead of 4 units, was administered to the resident. Medical record review of Resident #1's care plan with a goal date of 12/8/16, revealed .Observe and record s/sx (signs and symptoms)of elevated blood sugar levels .Administer medication as ordered for elevated blood sugars .Observe for s/sx (signs and symptoms) of decreased blood sugar levels: weakness cold clammy nervous .Resident at risk for alteration in weight due to .cancer . Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #4's care plan with a goal date of 9/28/17 revealed .Observe and record s/sx (signs and symptoms) of elevated blood sugar levels .Administer medication as ordered for elevated blood sugars .Observe for s/sx of decreased blood sugar levels: weakness cold clammy nervous . Medical record review of the eMAR dated 7/18/17 revealed .Humalog (fast acting)(sliding scale .Blood Sugar is 301-350 .8-units . Continued review revealed on 7/18/17 at 5:30 PM the resident's blood sugar was 310 and 6 units was given when 8 units should have been administered to the resident per Physician's Orders. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #6's care plan with a goal date of 9/28/17 revealed .Insulin as ordered .Labs for blood sugars as ordered: accuchecks (blood sugar test) as ordered . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R (short acting .(give) Three Times (daily) .Blood Sugar is 151-200 .(give) 4 units .Blood Sugar is 251- 300 .(give) 6 units . Continued review revealed there was no sliding scale for blood sugar results of 201-250 on the MAR. Further review revealed on 6/30/17 the blood sugar was 214 and 6 units of insulin which was an incorrect dose of insulin, according to the MAR. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] (insulin) .Blood Sugar is 151-200 . (give) 4 units .Blood Sugar is 251- 300 .(give) 6 units . Continued review revealed there was no sliding scale for blood sugar results of 201-250 on the eMAR. Further review revealed the following: 7/2/17 at 9:00 PM-blood sugar 215-4 units of insulin given, which was the amount for a result of 151-200 on the eMAR. 7/4/17 at 9:00 AM-blood sugar 152-2 units of insulin given (should have received 4 units) 7/5/17 at 9:00 PM-blood sugar 215-4 units of insulin given, which was the amount for a result of 151-200 on the eMAR. Telephone Interview with LPN #10 on 7/20/17 at 4:05 PM, confirmed the insulin administration could have been an error. Further interview confirmed she was not aware there was a missing range for insulin administration (201-250) on Resident #6 on 6/30/17 when she administered the insulin. Interview with LPN #11 on 7/20/17 at 1:45 PM, in the 300 nurse's station, confirmed she failed to follow the care plan for diabetic management. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #7's care plan with a goal date of 9/8/17 revealed .Insulin as ordered .Labs for blood sugars as ordered: accuchecks (blood sugar test) as ordered .medicate with .insulin as ordered . Review of the Consultant Pharmacist's Medication Regimen Review dated 1/1/17-1/17/17 revealed, .Documentation/charting issues .Humalog 6 units bid (twice daily) with hold parameter for BS Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog (short acting insulin) .Sliding Scale Insulin .Blood Sugar is 151-200 (give) 2 Units . Continued review revealed on 3/19/17 at 5:00 PM the Blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 251-300 .(give) 6 units . Continued review revealed on 4/19/17 at 8:00 AM the resident's Blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 0-150 .(give) 0 Units .Blood Sugar is 201-250 (give) 4 units . Continued review revealed on 5/7/17 at 9:00 PM the Blood Sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on 5/9/17 at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 201-250 (give) 4 units .Blood Sugar is 251-300 (give) 6 Units . Continued review revealed the following: 6/8/17 at 9:00 PM the resident's Blood Sugar was 256 and 4 units given when the resident should have received 6 units. 6/10/17 at 12:00 PM the resident's Blood Sugar was 236 and 6 units was given when the resident should have received 4 units. 6/30/17 at 5:00 PM the resident's Blood Sugar was 217 and 2 units was given when the resident should have received 4 units. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 201-250 (give) 4 units .Continued review revealed the following: 7/4/17 at 5:00 PM the Blood Sugar was 212 and 2 units given when the resident should have received 4 units. 7/13/17 at 5:00 PM the Blood Sugar was 243 and 2 units given when the resident should have received 4 units. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #13's care plan with a goal date of 8/23/17 revealed .Insulin as ordered .Labs for blood sugars as ordered: accuchecks (blood sugar test) as ordered . Medical record review of the MAR indicated [REDACTED].Humalog .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on 4/26/17 at 12:00 PM, the blood glucose was 194 and 4 units were given to the resident when the resident should not have received any insulin. Medical record review of the MAR indicated [REDACTED]. Further review revealed on 5/3/17 at 12:00 PM, the blood glucose was 294 and 10 units were given to the resident when the resident should have received only 4 units. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Care Plan dated 8/11/14 revealed, .Potential for increased or decreased blood sugar levels .status .active .blood sugar (less than) 70 or (greater than) 110 .accuchecks as ordered .medicate .insulin as ordered . Medical record review of a Physician's Order dated 2/15/17 revealed, .Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated 2/16/17 at 5 PM revealed a blood sugar of 100 with documentation indicating 4 units of insulin had been given, when no insulin should have been given. Medical record review of Resident #5's eMAR dated 2/25/17 at 8 AM revealed a blood sugar of 102 with documentation indicating 4 units of insulin had been given, when no insulin should have been given when no insulin should have been given. Medical record review of Resident #5's eMAR dated 2/26/17 at 8 AM revealed a blood sugar of 130 with documentation indicating 4 units of insulin had been given, when no insulin should have been given. Medical record review of Resident #5's eMAR dated 3/6/17 at 8 AM revealed a blood sugar of 137 with documentation indicating 4 units of insulin had been given, when no insulin should have been given. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's MAR means medication was given. Further interview confirmed the care plan was not followed. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the Physicians Orders. Further interview confirmed when a nurse failed to follow the insulin order it put the residents at risk for harm. Interview with LPN #2 on 7/26/17 at 5:52 PM, via telephone confirmed she did not follow physician's orders and the care plan when giving Resident #5 insulin outside of parameters. Medical Record Review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #16's Care Plan with a goal date of 10/24/17 revealed, .Potential for increased or decreased blood sugar levels .accuchecks (test to check blood sugar) as ordered .Administer medication as ordered for elevated blood sugar levels .Insulin as ordered or sliding scale . Medical record review of Physician's Orders on the (MONTH) (YEAR) eMAR revealed, .[MEDICATION NAME] (short acting insulin) .(4 units) .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's eMAR dated 1/2/17 at 9:00 AM revealed a blood sugar of 88 with documentation indicating 4 units of insulin had been given when no insulin should have been given. Medical record review of Resident #16's eMAR dated 1/3/17 at 9:00 AM revealed a blood sugar of 77 with documentation indicating 4 units of insulin had been given when no insulin should have been given. Medical record review of Resident #16's eMAR dated 1/6/17 at 9 AM revealed a blood sugar of 76 with documentation indicating 4 units of insulin had been given when no insulin should have been given. Medical record review of Resident #16's eMAR dated 1/10/17 at 9:00 AM revealed a blood sugar of 115 indicating 4 units of insulin had been given. Medical record review of Physicians Orders dated 5/15/17 revealed, .[MEDICATION NAME] 6 units .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's eMAR dated 6/26/17 at 12 PM revealed a blood sugar of 176. Further review revealed .(insulin) Not Administered (Outside Parameters) . Interview with LPN #8 Nurse Manager, on 7/25/17 at 3:58 PM, in the DON office, confirmed LPN #5 and #6 administered insulin when it was not needed and LPN #7 held insulin when it should have been administered. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #18's Care Plan with a goal date of 10/27/17 revealed, .Diabetes .potential for complications .administer medications as ordered for elevated blood sugar levels .will have (blood sugar levels) between 70-110 (every day) this 90 days .accuchecks as ordered . Medical record review of the Consultant Pharmacist's Medication Regimen Review for Resident #18 dated 4/1/17-4/11/17 revealed, .there is no space for recording (blood sugar) on EMAR with the order so unclear if this has been done consistently . Medical record review of Physician's Orders dated 4/20/17 revealed, .Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 110 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of Resident #18's eMAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's eMAR dated (MONTH) (YEAR) revealed blood sugars over 400 on 5/2 at 4:46 PM, 5/6 at 1:10 PM, 5/6 at 5:06 PM, 5/7 at 7:39 AM, 5/7 at 4:34 PM, 5/8 at 4:40 PM, 5/23 at 9:48 AM, 5/30 at 7:52 AM, and at 5/30 at 11:30 AM. Further review revealed no documentation if additional 4 units of insulin were administered. Interview with LPN #8, Nurse Manager, on 7/26/17 at 11:10 AM, confirmed there was no way to determine if additional units of insulin were given or held. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the Physicians Orders. Further interview confirmed when a nurse failed to follow the insulin order it put the residents at risk for harm. Interview with the Administrator on 7/26/17 at 6:42 PM, in the DON office confirmed not following physician orders per care plans was a .problem . Interview with the Medical Director on 7/27/17 at 8:00 AM, confirmed, .anytime there is a parameter (ordered) you check the parameter . Refer to F 333",2020-09-01
22,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,309,E,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility documents, review of Emergency Medical Service documents, review of hospital records and interview, the facility failed to provide insulin management and monitoring for 1 diabetic resident of 17 residents reviewed for insulin medication administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of insulin, aspirating, and being sent to the hospital and placed on a ventilator (machine to assist with breathing). The facility failed to ensure insulin was administered according to correct blood sugar parameters per physician's orders [REDACTED].#6, #7, #12, #13, #14, #20, #22) of 17 residents reviewed for insulin medication administration, of 24 residents reviewed. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was transferred to the hospital on [DATE] after receiving an overdose of insulin. The resident died on [DATE]. Medical record review of a physician's orders [REDACTED].pureed diet and nectar thick liquids. Pt (patient) allowed to have mech (mechanical) soft/canned peaches, pears and jello. No straws . Medical record review of a Nurses note dated [DATE] revealed .resident having xtrem e (extreme) difficulties swallowing anything/liquids are tolerated better than food . Medical record review of a Speech Therapy note dated [DATE] revealed .Pt seen for 1:1 (one to one) skilled dysphagia (difficulty swallowing) therapy .pt recommended pureed diet and nectar thick liquids to decrease risk of aspiration . Medical record review of a Physicians Order dated [DATE] revealed Patient to be on nectar thick liquids Medical record review of the Medication Administration Record [REDACTED].Humalog (insulin) 100 unit/ml (milliliter) .Four Times Daily XXX[DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed on [DATE] at 9:00 PM the resident's blood sugar was 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. Review of a facility document Medication Error Report dated [DATE] revealed .based on CS ([MEDICATION NAME] blood sugar)- 247 at 9:00 PM, Agency nurse (temporary nurse from outside source) Administered 100 units of Humalog vs (versus) the ordered 6 units (should have been 4 units) .Sent to ER (emergency room ), admitted to CCU (critical care unit) on vent (ventilator to aid in breathing) . Review of a clinical note dated [DATE] at 6:39 AM, revealed Instant Glucose (sugar) given. Chocolate pudding and orange (juice) given. Review of an Emergency Medical Service (EMS) record dated [DATE] revealed at 6:00AM, .Unresponsive .Blood glucose reading/level: low comments: 30 (below 70 is considered low) .Upper Right Lung Rhonchi (abnormal breath sounds): Upper Left Lung Rhonchi; Lower Right Lung; Rhonchi: Lower Left Lung; Rhonchi .Glasco Coma Scale (scale to assess consciousness) GCS .6 (less than 8 is considered comatose) .Respiratory Effort: Labored .Narrative .Altered Mental Status and [DIAGNOSES REDACTED] .Pt (patient) was found unresponsive with low blood sugar. Nursing staff tried to feed the PT (patient) pudding and orange juice. Then activated 911. Pt found unconscious and unresponsive .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a procedure note from the hospital dated [DATE] revealed .Probable aspiration, possible foreign body .No food particles were seen, but the secretions were very thick and could be consistent with the pudding that the patient had eaten earlier in the day . Review of a hospital critical care progress note, dated [DATE] revealed .Acute [MEDICAL CONDITION]: Requiring mechanical ventilation day 15. Unable to wean due to severe [MEDICAL CONDITION] (disease, damage, or malfunction of the brain) apnea .Aspiration pneumonia: Required FOB (fiber optic [MEDICATION NAME]) with mucous plug removal from R (right) main stem (an airway passage within the lung) at admission . Interview with the Administrator and Director of Nursing (DON) on [DATE] at 4:30 PM, in the DON's office, confirmed LPN #1 was an agency nurse working at the facility on [DATE] on a night shift. Further interview confirmed the LPN administered 100 units of insulin to Resident #1 in error. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 6:55 PM, by phone, confirmed she did work at this facility for approximately 1 month through an agency. Continued interview confirmed she administered 100 units of insulin to Resident #1 in error. Continued interview confirmed .I read the dosage wrong . Continued interview confirmed the LPN gave the 100 units of insulin at around 9:00 PM. Further interview confirmed she knew something was not right because the resident was sleeping hard .couldn't waken him up .trying to give him pudding and orange juice . Continued interview confirmed the LPN noticed the resident to be breathing very deeply and he was hard to wake up. She attempted to give him [MEDICATION NAME] (medication to increase blood sugar), and also gave him thickened juice and fed him pudding to bring his sugar up. Further interview confirmed she called EMS and he was sent to the hospital. Interview with the Medical Director (MD), also Resident #1's physician, on [DATE] at 10:35 AM, in the conference room confirmed LPN #1 called the MD in the early morning of [DATE] after she had administered the 100 units of insulin. Continued interview confirmed the MD instructed the LPN to follow the [DIAGNOSES REDACTED] protocol, start an IV, and if unable to start an IV send the resident to the hospital. Continued interview confirmed the resident should not have received pudding or juice if the resident was lethargic or unconscious. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .[MEDICATION NAME] R .TID (three times daily) .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed a missing sliding scale for blood sugar results of ,[DATE] on the MAR. Further review revealed on [DATE] the blood sugar was 214 and 6 units of insulin was given. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . with no sliding scale for results between 201 - 250. Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 4 units .Blood Sugar is 251.00- 300.00 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the MAR. Further review revealed the following: [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin given [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin given [DATE] at 9:00 AM-blood sugar ,[DATE] units of insulin given Interview with LPN #11 on [DATE] at 1:45 PM, in the 300 nurse's station confirmed she failed to follow the physician's orders [REDACTED]. Interview with LPN #10 on [DATE] at 4:05 PM, by phone confirmed she was not instructed how to enter orders by order set and put the insulin order in manually. Continued interview confirmed she was not aware she made an error while entering the insulin order on Resident #6 on [DATE] when she administered the insulin. Medical record review revealed Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog XXX,[DATE] give 0 units XXX,[DATE] give 2 units . Medical record review of the (MONTH) (YEAR) MAR from a Physicians order dated [DATE] revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 151XXX,[DATE].00 2 Units . Continued review revealed on [DATE] at 5:00 PM the blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 251XXX,[DATE].00 6 units . Continued review revealed on [DATE] at 8:00 AM the blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 0XXX,[DATE].00 0 Units .Blood Sugar is 201XXX,[DATE].00 4 units . Continued review revealed on [DATE] at 9:00 PM the blood sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on [DATE] at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 4 units .Blood Sugar is 251XXX,[DATE].00 6 Units . Continued review revealed on [DATE] at 9:00 PM the Blood Sugar was 256 and 4 units was given when the resident should have received 6 units; on [DATE] at 12:00 PM the Blood Sugar was 236 and 6 units was given when the resident should have received 4 units; and on [DATE] at 5:00 PM the Blood Sugar was 217 and 2 units was given when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 4 units . Continued review revealed on [DATE] at 5:00 PM the Blood Sugar was 212 and 2 units was given when the resident should have received 4 units, and on [DATE] at 5:00 PM the Blood Sugar was 243 and 2 units was given when the resident should have received 4 units. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the MAR indicated [REDACTED]. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED].Humalog .(4 units) .before meals Starting [DATE] .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on [DATE] at 12:00 PM, the blood sugar was 194 and 4 units of insulin was administered to the resident when the resident should not have received any insulin. Continued review of the (MONTH) MAR indicated [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED].[MEDICATION NAME] (insulin) .12 units with meals give extra 4 units if BG > (greater than) 300 . Continued review revealed the following: [DATE] 1:00 PM blood sugar 345- 12 units given (should have received 16 units) [DATE] 1:00 PM blood sugar 325- 12units given (should have received 16 units) [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 320- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) [DATE] 8:00 AM blood sugar 394- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 325- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 324- 12 units given (should have received 16) [DATE] 8:00 AM blood sugar 322- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 358- 12 units given (should have received 16) [DATE] 5:30 PM blood sugar 333- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 346- 12 units given (should have received 16) [DATE] 5:30 PM blood sugar 323- 12 units given (should have received 16) [DATE] 5:30 PM blood sugar 399- 12 units given (should have received 16) [DATE] 8:00 AM blood sugar 284- 16 units of insulin (should have received only 12) [DATE] 5:30 PM blood sugar 387- 16 units of insulin (should have received only 16) [DATE] 1:00 PM blood sugar 274- 10 units of insulin (should have received only 12) Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the nurses failed to follow the Physicians Orders. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] .sliding scale .Blood Sugar is 150XXX,[DATE].00 1 Units .Blood Sugar is 200XXX,[DATE].00 2 Units .Blood Sugar is 300XXX,[DATE].00 4 units .Blood Sugar is > 349.00 5 units . Continued review revealed on [DATE] at 5:00 PM the blood sugar was 353 and 6 units insulin was given (should have received 5 units); on [DATE] at 5:00 PM blood sugar was 216 and 1 unit insulin given (should have received 2 units); and on [DATE] at 5:00 PM blood sugar was 343 and 5 units insulin was given (should have received 4 units). Medical record review of the MAR indicated [REDACTED].Humalog .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed on [DATE] at 5:00 PM blood sugar was 192 and 4 units was given (should not have received any insulin) and on [DATE] at 8:00 AM blood sugar was 204 and no insulin was given (should have received 4 units). Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED].Humalog .(4units) .Administer 4 units .with meals if BS > 200 . Continued review revealed: [DATE] at 12:00 PM blood sugar 156- 4 units insulin given [DATE] at 8:00 AM blood sugar 88- 4 units insulin given [DATE] at 8:00 AM blood sugar 85- 4 units insulin given [DATE] at 9:00 AM blood sugar 96- 4 units insulin given [DATE] at 9:00 AM blood sugar 155- 4 units insulin given [DATE] at 9:00 AM blood sugar 170- 4 units insulin given [DATE] at 9:00 AM blood sugar 98- 4 units insulin given [DATE] at 5:00 PM blood sugar 156- 4 units insulin given [DATE] at 9:00 AM blood sugar 154- 4 units insulin given [DATE] at 5:00 PM blood sugar 145- 4 units insulin given [DATE] at 9:00 AM blood sugar 108- 4 units insulin given [DATE] at 9:00 AM blood sugar 143- 4 units insulin given [DATE] at 8:00 AM blood sugar 134- 4 units of insulin given [DATE] at 8:00 AM blood sugar 182- 4 units of insulin given Interview with the Administrator on [DATE] at 8:00 AM, in the conference room confirmed the nurses failed to follow the physician's orders [REDACTED]. Further interview confirmed this put the residents at risk for potential harm. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the facility had a critical insulin administration error on [DATE] and since that time have failed to recognize and assess factors placing the diabetic residents at risk.",2020-09-01
23,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,329,E,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of Physicians' Desk Reference (PDR), Brunner & Suddarth's Textbook of Medical Surgical Nursing, medical record review, review of facility investigations, interview, and review of the Consultant Pharmacists reports, the facility administered medications unnecessarily for 9 residents (#1,#5, #7, #13, #14,#16,#18, #20, #22,) of 17 residents reviewed. The facility's failure resulted in Resident #1 receiving 100 units of insulin, instead of 4 units, and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on 7/27/17 at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of Physicians' Desk Reference (PDR) 69 Edition, (YEAR), pg 2044 - 2045, revealed, .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .In emergency situations, for adults who are unconscious and cannot swallow, an injection of glucogon (medication used to increase blood sugar) can be administered .[MEDICAL CONDITION] . (defined as) elevated blood glucose level .greater than 110 . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order dated 8/25/16 revealed .Humalog (fast-acting insulin) .Sliding Scale Insulin .Four Times Daily .Blood Sugar is 201.00-250.00 .(give) 4 units . Medical record review of the Electronic Medication Administration Record [REDACTED].Humalog 100 unit/ml (milliliter) .Four Times Daily .8/26/16 Sliding Scale Insulin .Blood Sugar is 201.00-250.00 - 4 units . Indicating the resident was to receive 4 units of Humalog insulin for a blood sugar reading of 201-250. Continued review revealed on 9/11/16 at 9:00 PM, the resident's blood sugar was 247 and 100 units of insulin was administered instead of 4 units. Medical record review of the Medication Error Report dated 9/12/16 revealed .based on CS (fingerstick lab to determine blood sugar) (blood sugar)- 247 at 9 PM, Agency nurse Administered 100 units of Humalog vs (versus) the ordered 6 units (order indicated 4 units was to be given) .Sent to ER (emergency room ), admitted to CCU (critical care unit) on vent (ventilator to assist breathing) . Review of the Emergency Medical Service or Ambulance Service (EMS) record dated 9/12/16 revealed at 6:00AM, .Unresponsive .Blood glucose reading/level; low comments: 30 (blood glucose reading was 30 with any level under 70 considered low) .Upper Right Lung Rhonci (continuous rattling lung sounds caused by obstruction or secretions): Upper Left Lung Rhonci; Lower Right Lung; Rhonci: Lower Left Lung; Rhonci . At 6:15 AM, .Blood Glucose Reading/Level: 216 . and at 6:16 AM, .Medication Administration [MEDICATION NAME] 50% Syringe (intravenous solution to raise blood sugar levels) .Result after improved .Blood Glucose Reading/Level: 130 .Glasco Coma Scale GCS (neurological scale used to assess conscious state) .6 (less than 8 is considered comatose) .Respiratory Effort: Labored . Further review of the EMS record revealed, .Altered Mental Status and [DIAGNOSES REDACTED] .Pt (patient) was found unresponsive with low blood sugar .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a signed statement by Licensed Practical Nurse (LPN) #1 on 9/12/16, revealed the LPN was scheduled to work at the facility on 9/11/16 from 7 PM to 7 AM. Further review revealed she checked the resident's blood sugar at approximately 8:30 PM and it was 247. Continued review revealed .I read the (insulin order) to say 100 units of Humilin R Insulin, I gave the 100 units and continued with med pass .walked the halls and noticed my male patient/resident breathing heavily around 11:30 PM, I checked his blood sugar at this time and it was 197 .went back to check on sliding scale around 5am .checked blood sugar and (blood sugar) 30. MD (Physician) was called and ordered instant glucose .start an IV (intravenous catheter in a vein to administer fluids and medications) .and if IV can't be started to send to ER .(emergency room ) . Interview with LPN #1 on 7/17/17 at 6:55 PM, via telephone, confirmed 100 units of insulin was administered to Resident #1 in error. Further interview confirmed she .read the dosage wrong .realized 1 or 2 hours later when he was sleeping .I went back and looked at the order . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an eMAR dated (MONTH) (YEAR) with a physician's orders [REDACTED].Humalog 100 units/ml .Four Times Daily Starting 3/18/2017 Sliding Scale Insulin .Blood Sugar is 201.00-250.00 (give) 4 units . Continued review revealed on 7/10/17 at 12:00 PM, Resident #7's blood sugar was 236 and 6 units of insulin was given, 2 more units of insulin than was necessary. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an eMAR with a physician's orders [REDACTED].Humalog 100 unit/ml .before meals Starting 04/18/2017 .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on 4/26/17 at 12:00 PM, Resident #13's blood glucose was 194 and 4 units were given to the resident, which was not necessary according to the physician's orders [REDACTED]. Medical record review of the eMAR with a physician's orders [REDACTED].#13's blood glucose was 181 and 4 units were given to the resident, which was not necessary according to the physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the physician's orders [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen for Resident #14 dated 3/1/17-3/14/17 revealed .Med Occurrence-transcription discrepancy resulting in error .1/30/17 order to increase [MEDICATION NAME] (fast-acting insulin) to 10 u (units)w (with) / each meal if 'BG (blood glucose or blood sugar) > 300 give 4 additional units'. The order on the eMAR states to give 4 additional units if BG 300 on several occasions in (MONTH) and the additional doses should have been given)(notified nurse (name) to correct this date 3/13/17; she stated the dose was given for BS (blood surgar) > 300) . Medical record review of the MARs for the time period revealed documentation did not clearly indicate when the additional insulin was administered or not administered. Medical record review of a physician's orders [REDACTED].Increase [MEDICATION NAME] to 12 (u) units w (with) meals TID (3 times a day) + (plus) extra 4 u if BG > 300 . Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] 100 unit/ml .Three Times Daily Starting 5/3/17 .give 12 units with meals (give extra 4 units if BG > 300) . Continued review revealed on 6/2/17 the blood sugar was 284 and 16 units of insulin was given, 4 more units of insulin than was necessary. Interview with the DON on 7/26/17 at 2:35 PM, in the conference room, confirmed when a nurse failed to follow the insulin order, residents were at risk for potential harm. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen report dated 4/1/17-4/11/17 revealed .Documentation/charting issues .Humalog is only to be given when blood sugar is above 200. It was documented as given 5 times so far this month when it should have been held . Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].[MEDICATION NAME] 100 unit/ml .Four Times Daily Starting 2/20/217 .sliding scale .Blood Sugar is 150.00-199.00 (give) 1 Units .Blood Sugar is 200.00-249.00 (give) 2 Units .Blood Sugar is 300.00-349.00 (give) 4 units .Blood Sugar is > 349.00 (give) 5 units . Continued review revealed on 3/1/17 at 5:00 PM Resident #20's blood sugar was 353 and 6 units of insulin was given, 1 unit of insulin more than necessary, and on 3/12/17 at 5:00 PM, the resident's blood sugar was 343 and 5 units of insulin was given, 1 unit of insulin more than was necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].Humalog 100 units/ml .Two Times Daily .Starting 4/18/17 .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed on 5/6/17 at 5:00 PM, Resident #20's blood sugar was 192 and 4 units of insulin was unnecessarily given (should not have received any insulin). Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].Humalog 100 unit/ml .Administer 4 units .with meals if BS > 200 . Continued review revealed the blood sugar on 2/18/17 at 12:00 PM, was 156 and 4 units of insulin was given to the resident, which was unnecessary according to the physician's orders [REDACTED]. Further review revealed at 5:00 PM the blood sugar level was 94. Medical record review of the (MONTH) (YEAR) eMAR revealed the blood sugar on 3/5/17 at 8:00 AM, was 85 and 4 units of insulin was administered, which was not necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED]. Further review revealed the insulin was administered when and not necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED]. Humalog 100 unit/ml .(4units) .Two Times Daily Starting 4/10/2017 .Administer 4 units .for BG > 200 . Continued review revealed the following unnecessary insulin administration: 4/14/17 at 9:00 AM blood sugar 96-4 units of insulin given 4/15/17 at 9:00 AM blood sugar 155- 4 units insulin given 4/16/17 at 9:00 AM blood sugar 170- 4 units insulin given 4/20/17 at 9:00 AM blood sugar 98-4 units insulin given 4/21/17 at 5:00 PM blood sugar 156-4 units insulin given 4/23/17 at 9:00 AM blood sugar 154-4 units insulin given 4/27/17 at 5:00 PM blood sugar 145- 4 units insulin given 4/29/17 at 9:00 AM blood sugar 108-4 units insulin given 4/30/17 at 9:00 AM blood sugar 143- 4 units insulin given Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].#22's blood sugar was 134 and 4 units of insulin was given unnecessarily, and on 5/17/17 at 8:00 AM, the resident's blood sugar was 182 and 4 units of insulin was given unnecessarily. Interview with the Administrator on 7/26/17 at 8:00 AM, in the conference room, confirmed the nurse failed to follow the physician's orders [REDACTED]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated 2/16/17 at 5:00 PM revealed a blood sugar of 100 with documentation LPN #2 gave 4 units of insulin when it was not needed. Review of Resident #5's eMAR dated 2/25/17 at 8:00 AM revealed a blood sugar of 102 with documentation LPN #3 gave 4 units of insulin when it was not needed. Medical record review of Resident #5's eMAR dated 2/26/17 at 8:00 AM revealed a blood sugar of 130 with documentation LPN #4 gave 4 units of insulin when it was not needed. Medical record review of Resident #5's eMAR dated 3/6/17 at 8:00 AM revealed a blood sugar of 137 with documentation LPN #2 gave 4 units of insulin when it was not needed. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's MAR meant medication was given. Further interview confirmed LPNs #2, #3, and #4 administered insulin when it was not needed per the physician's orders [REDACTED]. Interview with LPN #2 on 7/26/17 at 5:52 PM, via telephone, confirmed she administered insulin outside of parameters for Resident #5. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].(4 units) .two times daily .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's eMAR dated 1/2/17 at 9:00 AM revealed a blood sugar of 88 with documentation LPN #5 gave 4 units of insulin when it was not needed. Medical record review of Resident #16's eMAR dated 1/3/17 at 9:00 AM revealed a blood sugar of 77 with documentation LPN #5 gave 4 units of insulin that was not needed. Medical record review of Resident #16's eMAR dated 1/6/17 at 9:00 AM revealed a blood sugar of 76 with documentation LPN #5 gave 4 units of insulin that was not needed. Medical record review of Resident #16's eMAR dated 1/10/17 at 9:00 AM revealed a blood sugar of 115 with documentation LPN #6 gave 4 units of insulin that was not needed. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office confirmed LPN #5 and LPN #6 administered insulin when it was not necessary per physician's orders [REDACTED]. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 110 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of Resident #18's eMAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's eMAR dated 6/30/17 at 12:00 PM revealed a blood sugar of 104 with documentation RN #1 gave 4 units of insulin when it was not needed. Medical record review of Resident #18's eMAR dated 7/2/17 at 12:00 PM, revealed a blood sugar of 100 with documentation RN #1 gave 4 units of insulin when it was not needed. Interview with LPN #8, Nurse Manager, on 7/25/17 at 3:58 PM, in the DON's office, confirmed RN #1 administered insulin when it was not indicated by the physician's orders [REDACTED]. Interview with the DON on 7/26/17 at 2:35 PM, in the DON's office, confirmed if a nurse administered insulin to a resident with a blood sugar of 100, and the physician's orders [REDACTED].",2020-09-01
24,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,333,E,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of Physicians' Desk Reference (PDR), Brunner & Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, facility policy review, medical record review, review of Consultant Pharmacy Reports, and interview, the facility failed to prevent significant medication errors for 12 (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20 and #22) of 17 residents reviewed for insulin administration. The facility's failure resulted in Resident #1 receiving 96 more units of insulin than ordered. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of Physicians' Desk Reference (PDR) 69th Edition, (YEAR), pg 2044 - 2045, revealed, .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .In emergency situations, for adults who are unconscious and cannot swallow, an injection of glucogon (medication used to increase blood sugar) can be administered .[MEDICAL CONDITION] . (defined as) elevated blood glucose level .greater than 110 . Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .medications shall be administered as prescribed by the physician .If a dose seems excessive .the nurse should contact the physician .the nurse should compare the drug and dosage schedule to the resident's MAR (Medication Administration Record) and with the drug label . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident died on [DATE]. Medical record review of the Physicians Order dated [DATE] revealed .Humalog (fast acting) .Sliding Scale Insulin .Four Times Daily .Blood Sugar is 201XXX,[DATE].00 .(give) 4 units . Medical record review of the electronic Medication Administration Record [REDACTED].Humalog (insulin) 100 unit/ml (milliliter) .Four Times Daily XXX[DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE]XXX,[DATE] units . Continued review revealed on [DATE] at 9:00 PM the resident's blood sugar was 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. Review of a signed statement by LPN #1 dated [DATE], revealed the LPN was scheduled to work at the facility on [DATE] from 7:00 PM to 7:00 AM. Further review revealed she checked the resident's blood sugar at approximately 8:30 PM and it was 247. Continued review revealed .I read the (insulin order) to say 100 units of Humilin R Insulin, I gave the 100 units and continued with med pass .walked the halls and noticed my male patient/resident breathing heavily around 11:30 PM, I checked his blood sugar at this time and it was 197 .went back to check on sliding scale around 5am .checked blood sugar and 30 (below 70 considered low). MD (physician) was called and ordered instant glucose .start an IV (intravenous catheter in a vein to administer fluids and medications) .and if IV can't be started to send to ER (emergency room ) Further review revealed the resident was sent to the ER. Continued review revealed the EMS (Emergency Medical Service or Ambulance) started an IV on the resident and the resident was taken to the hospital. Review of an EMS record for Resident #1 dated [DATE], revealed at 6:00 AM, .Unresponsive .Blood glucose reading/level; low comments: 30 .Upper Right Lung Rhonchi (abnormal breath sound): Upper Left Lung Rhonchi; Lower Right Lung; Rhonchi: Lower Left Lung; Rhonchi . Further review revealed at 6:15 AM, .Blood Glucose Reading/Level: 216 . and at 6:16 AM .Medication Administration [MEDICATION NAME] 50% Syringe 25 (25 ml of IV solution with [MEDICATION NAME] to increase blood sugar) .Intravenous; Result after improved .Blood Glucose Reading/Level: 130 .Glascow Coma Scale (scale to detect level of consciousness) .6 (below 8 indicates comatose) .Respiratory Effort: Labored . Further review revealed, .Altered Mental Status and [DIAGNOSES REDACTED] (low blood sugar) .Pt (patient) was found unresponsive with low blood sugar .Then activated 911. Pt found unconscious and unresponsive .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a Clinical Note dated [DATE] at 6:25 AM revealed Insulin dose is listed incorrectly, 100 units were given. On call Dr (physician) was called; orders were to start IV, if IV can't be started, then send to ER .Sent to ER. Last blood sugar 215 at 5:45 am . Phone interview with LPN #1 on [DATE] at 6:55 PM, confirmed, LPN #1 did not start an IV because she was not IV certified. Further interview confirmed she did not ask for help. Review of a Clinical Note dated [DATE] at 6:39 AM, reveaIed Instant Glucose given. Chocolate pudding and orange (juice) given. Review of a Medication Error Report dated [DATE] revealed CS (blood sugar) - 247 at 9 PM, Agency nurse Administered 100 units of Humalog vs (versus) the ordered 6 units (4 units per the MAR) .Sent to ER, admitted to CCU (Critical Care Unit) on vent (ventilator to aid in breathing) . Medical record review of a critical care progress note dated [DATE], from the hospital, revealed, .Acute [MEDICAL CONDITION]: Requiring mechanical ventilation day 15. Unable to wean due to severe [MEDICAL CONDITION] (abnormal brain function), apnea (temporarily stop breathing) .Aspiration pneumonia (lung infection after inhaling food) . Medical record review of a Medicine Progress Report dated [DATE], from the hospital, revealed .Patient remains intermittently alert but totally unresponsive to voice. He opens his eyes, though he does not track movement . Interview with the Administrator and Director of Nursing (DON) on [DATE] at 4:30 PM, in the DON's office, confirmed LPN #1 was an agency nurse that was working at the facility on [DATE] night shift. Further interview confirmed the LPN administered 100 units of insulin to Resident #1 in error. Interview with the Medical Director on [DATE] at 10:35 AM, in the conference room, confirmed LPN #1 made a significant medication error. Continued interview confirmed she directed the LPN to monitor the resident closely after the insulin overdose, but at the time the blood sugar was maintained. Further interview confirmed the next call she received from LPN #1 was early morning and the blood sugar was low. The Physician instructed the LPN to follow the hypoglycemic protocol, if the resident was cooperative to administer the [MEDICATION NAME], start an IV, and if unable to start the IV, to send the resident to the ER. Continued interview confirmed the hypoglycemic episode of Resident #1 could have led to the resident becoming unstable. Interview with LPN #1 on [DATE] at 6:55 PM, by phone, revealed she worked night shift on [DATE]. Continued interview confirmed she did administer 100 units of insulin to Resident #1 by error. Continued interview confirmed .I read the dosage wrong . Continued interview confirmed the LPN gave the 100 units of insulin at around 9 (9:00) PM; the resident's blood sugar was 237 at that time. Further interview confirmed she knew something was not right because the resident was sleeping hard .couldn't wake him up .trying to give him pudding and orange juice . Continued interview confirmed she went back to check the insulin order and realized the error (unsure of what that time was). Further interview confirmed LPN #1 did not start an IV because she was not IV certified and she did not ask for help. Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated [DATE] revealed .Humalog .sliding scale .Four Times Daily Starting [DATE] .Blood Sugar is 301XXX,[DATE].00 (give) 8-units . Continued review revealed on [DATE] at 5:30 PM the blood sugar was 310 and 6 units was given when 8 units should have been administered to the resident. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the Physician's Orders were not followed. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .[MEDICATION NAME] R .TID (three times daily) .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the eMAR. Further review revealed on [DATE] the blood sugar was 214 and 6 units of insulin was given, the dosage for the ,[DATE] range on the eMAR. Medical record review of the facility's Sliding Scale A parameters dated [DATE] revealed, XXX,[DATE] give 6 units . Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .TID .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the EMAR. Further review revealed the following: [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin (range not indicated on eMAR) [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin (range not indicated on eMAR) [DATE] at 9:00 AM-blood sugar ,[DATE] units of insulin (4 units ordered) Interview with LPN #11 on [DATE] at 1:45 PM, in the 300 nurse's station, confirmed she failed to follow the Physician's Order for the sliding scale insulin. Interview with LPN #10 on [DATE] at 4:05 PM, by phone confirmed the insulin administration could have been an error. Further interview confirmed she was not instructed how to enter orders in the electronic record by order set and she put the insulin order in manually. Continued interview confirmed she was not aware she made an error while entering the insulin order on Resident #6 on [DATE] when she administered the insulin. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed .Documentation/charting issues .Humalog 6 units bid (twice a day) with hold parameter for BS Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .TID (three times a day) XXX,[DATE] give 0 units XXX,[DATE] give 2 units . Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 151XXX,[DATE].00 (give) 2 Units . Continued review revealed on [DATE] at 5:00 PM the blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the (MONTH) (YEAR) eMAR with a Physicians order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 251XXX,[DATE].00 (give) 6 units . Continued review revealed on [DATE] at 8:00 AM the blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 0XXX,[DATE].00 0 Units .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed on [DATE] at 9:00 PM the blood Sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on [DATE] at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units .Blood Sugar is 251XXX,[DATE].00 (give) 6 Units . Continued review revealed the following: [DATE] at 9:00 PM the Blood Sugar was 256 and 4 units given when the resident should have received 6 units. [DATE] at 12:00 PM the Blood Sugar was 236 and 6 units given when the resident should have received 4 units. [DATE] at 5:00 PM the Blood Sugar was 217 and 2 units given when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed the following: [DATE] at 5:00 PM the Blood Sugar was 212 and 2 units given when the resident should have received 4 units. [DATE] at 5:00 PM the Blood Sugar was 243 and 2 units given when the resident should have received 4 units. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed on [DATE] at 6:00 PM the resident's blood sugar was 286 and received 4 units of insulin when the resident should have received 6 units. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed .Documentation/charting issues .This patient has an order to get Humalog insulin when blood sugar is above 200 before meals. It has been documented as given 8 times this month when blood sugar was below 200 . Medical record review of the eMAR with a Physicians Order dated [DATE] revealed .Humalog 100 unit/ml .(4 units) .before meals Starting [DATE] .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on [DATE] at 12:00 PM, the blood glucose was 194 and 4 units were given to the resident when the resident should not have received any insulin. Medical record review of the (MONTH) (YEAR) eMAR revealed on [DATE] at 8:00 AM the blood sugar was 181 and 4 units were given to the resident when the resident should not have received any insulin. Further review revealed [DATE] at 12:00 PM, the blood glucose was 294 and 10 units were given to the resident when the resident should have received only 4 units. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed XXX[DATE] order to increase [MEDICATION NAME] to 10 u/w/each meal (units with each) and if BG > 300 give additional 4 units .(numerous med errors may have occurred; I can't determine from eMAR when additional doses were given but BG has been > 300 on several occasions in (MONTH) and the additional dose should have been given) (notified nurse (name) to correct this date [DATE]; she stated the dose was given for BS > 300) . Medical record review of the (MONTH) (YEAR) eMAR revealed a Physcians order dated [DATE] .[MEDICATION NAME] .12 units with meals (give extra 4 units if BG > 300) . Continued review revealed the following: [DATE] 1:00 PM blood sugar 345- 12 units given (should have received 16 units) and at 5:30 PM the blood sugar was 397, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 325- 12 units given (should have received 16 units) and at 5:30 PM the blood sugar was 441, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 347, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 320- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 238, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 304- 12 units given (should have received 16). Continued review revealed no documentation for a blood sugar at 5:30 PM. [DATE] 12:00 PM the blood sugar was 325, indicating Resident #14 continued to have high blood sugar and again only received 12 units (should have received 16) and at 5:30 PM the blood sugar was 397, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 324- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 429, indicating Resident #14 continued to have high blood sugar. [DATE] 8:00 AM blood sugar 322- 12 units given (should have received 16) and at 1:00 PM the blood sugar was 358, indicating Resident #14 continued to have high blood sugar and again only received 12 units (should have received 16). Continues review revealed no documentation for the 5:30 blood sugar. [DATE] 5:30 PM blood sugar 333- 12 units given (should have received 16) and at on [DATE] at 8:00 AM the blood sugar was 216, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 346- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 429, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar 323- 12 units given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 232, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar 399- 12 units given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 328, indicating Resident #14 continued to have high blood sugar. Medical record review of the (MONTH) (YEAR) eMAR revealed the following: [DATE] 8:00 AM blood sugar-284 - 16 units of insulin given (should have received only 12) [DATE] 5:30 PM blood sugar-,[DATE] units of insulin given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 173, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-274 - 10 units of insulin given (should have received 12) and on [DATE] at 8:00 AM the blood sugar was 191, indicating Resident #14 continued to have high blood sugar. Medical record review of the (MONTH) (YEAR) eMAR revealed the following: [DATE] 1:00 PM blood sugar-330 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 169, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-307 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 205, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-327 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 187, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar-316 - 12 units of insulin given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 150, indicating Resident #14 continued to have high blood sugar. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the nurses failed to follow the Physicians Orders. Continued interview confirmed when a nurse failed to follow the insulin order it put the resident at risk for harm. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] 100 unit/ml .Four Times Daily Starting [DATE] .sliding scale .Blood Sugar is 150XXX,[DATE].00 1 Units .Blood Sugar is 200XXX,[DATE].00 2 Units .Blood Sugar is 300XXX,[DATE].00 4 units .Blood Sugar is > 349.00 5 units . Continued review revealed the following: [DATE] 5:00 PM blood sugar 353- 6 units insulin given (should have received 5 units) [DATE] 5:00 PM blood sugar ,[DATE] unit insulin given (should have received 2 units) [DATE] 5:00 PM blood sugar 343- 5 units insulin given (should have received 4 units) Review of the Consultant Pharmacist's Medication Regimen report dated [DATE]-[DATE] revealed .Documentation/charting issues .Humalog is only to be given when blood sugar is above 200. It was documented as given 5 times so far this month when it should have been held . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog 100 units/ml .Two Times Daily .Starting [DATE] .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed the following: [DATE] 5:00 PM blood sugar 192- 4 units given (should not have received any insulin) [DATE] 8 AM blood sugar 204- 0 units (should have received 4 units) and at 5:00 PM the blood sugar was 293 indicating resident #20 continued to have high blood sugar. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog 100 unit/ml .(4units) .Before meals Starting [DATE] .Administer 4 units .with meals if BS > 200 . Continued review revealed the blood sugar on [DATE] at 12:00 PM was 156 and 4 units of insulin was given to the resident when no insulin should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed the blood sugar on [DATE] at 8:00 AM was 85 and 4 units was given to the resident when no insulin should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed the blood sugar on [DATE] was 149 and 4 units of insulin was given to the resident when no insulin should have been administered. Medical record review of the MAR indicated [REDACTED]. Humalog 100 unit/ml .(4units) .Two Times Daily Starting [DATE] .Administer 4 units .for BG > 200 . Continued review revealed the resident received insulin when it should not have been administered on: [DATE] at 9:00 AM blood sugar ,[DATE] units of insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 5:00 PM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 5:00 PM blood sugar 145- 4 units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar 143- 4 units insulin given Medical record review of the MAR indicated [REDACTED]. Continued review revealed on [DATE] at 8:00 AM, the blood sugar was 182 and 4 units of insulin was given when no insulin should have been administered. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated [DATE] revealed, .Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated [DATE] at 5:00 PM revealed a blood sugar of 100 with documentation LPN #2 gave 4 units of insulin when it was not ordered. Review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 102 with documentation LPN #3 gave 4 units of insulin when it was not ordered. Medical record review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 130 with documentation of LPN #4 gave 4 units of insulin when it was not ordered. Medical record review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 137 with documentation of LPN #2 gave 4 units of insulin when it was not ordered. Interview with LPN #8 Nurse Manager on [DATE] at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's eMAR mean medication was given. Further interview confirmed LPNs #2, # 3, and #4 administered insulin when it was not needed per the physician's orders. Continued interview confirmed Resident #5's initial order had been transcribed incorrectly. Further interview confirmed RN #1 should have administered the insulin, resulting in a significant medication error. Interview with LPN #2 on [DATE] at 5:52 PM, via telephone, confirmed she administered insulin outside of parameters for Resident #5. Medical Record Review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders documented on the (MONTH) (YEAR) MAR, revealed, .[MEDICATION NAME] (short acting insulin) .(4 units) .two times daily .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Physicians Orders dated [DATE] revealed, .[MEDICATION NAME] 6 units .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's MAR indicated [REDACTED]. Further review revealed LPN #7 did not administer 6 units of insulin. Interview with LPN #8, Nurse Manager, on [DATE] at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's eMAR mean medication was given. Further interview confirmed not documenting a reason why a medication was held when it should have been given is considered a medication error. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders dated [DATE] revealed, .Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 100 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of a Consultant Pharmacist's Medication Regimen Review for Resident #18 dated [DATE]-[DATE] revealed, .The hold parameter and order for additional units if (blood sugar) (greater than) 400 were not transcribed in the MAR . Medical record review of Resident #18's MAR indicated [REDACTED]. Medical record review of Resident #18's Vital Sign documentation on ,[DATE] /17 at 8:05 AM revealed a blood sugar of 405. Medical record review of Resident #18's MAR indicated [REDACTED]. Medical record review of Resident #18's MAR indicated [REDACTED]. Interview with the Pharmacy Consultant on [DATE] at 1:00 PM, by phone, confirmed pharmacy reviews were conducted on every resident monthly. Further interview confirmed an electronic monthly audit was completed at that time. The pharmacist reviews the MAR indicated [REDACTED]. Continued interview confirmed it was not her responsibility to check for administration errors but if she notes errors or discrepancies she includes them in the monthly report. Interview with the Administrator on [DATE] at 8:00 AM, in the conference room, confirmed the nurses failed to follow the Physician's orders for sliding scale insulin. Further interview confirmed this put the residents at risk for potential harm. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the facility had a critical insulin administration error on [DATE] and since that time had failed to recognize and assess factors placing the diabetic residents at risk for [DIAGNOSES REDACTED] or [MEDICAL CONDITION] continued interview confirmed, if a nurse administered insulin to a resident with a blood sugar of 100, and the physician's order stated hold for less than 120, it would be considered a medication error.",2020-09-01
25,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,490,E,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigations, review of the Pharmacist Consult Reports, and interview, the facility failed to be administered in a manner to ensure there were not significant medication errors, errors in insulin administration, errors in transcribing insulin orders, and to ensure staff monitored and documented blood sugars, and followed Physicians Orders for insulin administration for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Review of the Consultant Pharmacist's Medication Regimen for January, (MONTH) and (MONTH) (YEAR) revealed documentation from the Consultant Pharmacist indicating ongoing reported insulin errors, transcription errors, and problems with documentation of blood sugar levels. Medical record review for Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, and #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Interview with the Nursing Home Administrator on [DATE] at 7:45 AM, in the DON's office confirmed a serious insulin error involving Resident #1 occurred on [DATE] in the facility. Continued interview confirmed monthly Consultant Pharmacist Reports were sent to the Director of Nursing (DON) and the Administrator received a report through email. Further interview confirmed she did not review the reports and was not aware of the ongoing errors in transcription, documentation of blood glucose levels, or administration of insulin. Continued interview confirmed it was the Administrator's responsibility to over-see the actions of the facility staff. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F501 (E), F514 (E), F520 (E)",2020-09-01
26,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,501,E,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Medical Director Contract, facility policy review, review of facility investigations, review of Consultant Pharmacists Reports, medical record review, and interview, the facility failed to ensure the Medical Director participated in the development and implementation of facility policies to ensure Physicians orders were followed, insulin was administered as ordered, and blood glucose levels were monitored and documented for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of the Medical Director Contract dated [DATE] revealed .SERVICES TO BE PERFORMED BY PROVIDER .Provide medical services in accordance with accepted professional standards of practice and use only qualified duly licensed, certified or registered health care professionals in the performance of these services .Responsible for the overall coordination of medical care at the Facility .shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident policies and providing oversight and supervision of medical services and medical care of residents .Evaluate and take appropriate steps to correct any problems associated with any possible inadequate care Provider identifies or about which Provider receives a report . Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Medical record review for Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Interview with the Medical Director (MD) on [DATE] at 8:00 AM, by phone, and on [DATE] at 8:00 PM, in the Director of Nursing (DON)'s office, confirmed the facility had a critical insulin error for Resident #1 on [DATE]. Continued interview confirmed she took this error to Quality Assurance (QA). The MD stated the goal of Quality Assurance (QA) was to look for the .etiology in errors . Continued interview confirmed there were not any pharmacy reports or major trends in insulin errors discussed in the QA meetings; .I felt we were doing pretty good . Further interview confirmed the MD did not receive copies of the monthly Pharmacy Reports. Further interview revealed the MD was involved in generating protocols and procedures regarding medication administration, but did not do inservices and was not involved in hitting the floor to monitor or audit for errors. Her expectations were education occurred. Further interview confirmed the Consult Pharmacist Reports indicated ongoing transcription errors of insulin orders, errors in administration of insulin, and missing documentation of blood glucose levels occurring in the facility in January, March, April, (MONTH) and (MONTH) (YEAR). Continued interview confirmed she was not aware of the Consultant Pharmacist Reports. Further interview confirmed the Medical Director was responsible for ensuring implementation of resident policies and providing oversight and supervision of medical services and medical care of residents. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F490 (E), F 514 (E), F520 (E)",2020-09-01
27,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,514,E,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, review of Brunner and Suddarth's Textbook of Medical Surgical Nursing, medical record review, and interview, the facility failed to provide sufficient documentation to determine the status or progress after the implementation of care for 4 diabetic residents (#5, #6, #16, and #18) of 17 residents reviewed for insulin, of 24 residents reviewed. The findings included: Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .when PRN (as needed) medications are administered, the nurse must record .date and time administered .dosage . Review of the facility's Insulin Administration Policy revised (MONTH) 2010 revealed, .Procedure .check blood glucose per physician order .Documentation .resident's blood glucose results, as ordered . Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Care Plan Dated 8/11/17 revealed, .Potential for increased or decreased blood sugar levels .[DIAGNOSES REDACTED] (low blood sugar) .Goals .blood sugar (greater than) 70 or (less than) 110 (every) day .accuchecks (lab to monitor blood sugar levels) as ordered .insulin as ordered .see MAR (Medication Administration Record) . Medical record review of Physician Orders dated 3/21/17 revealed, .(increase) chemsticks (blood sugar testing) to AC/HS (before meals and bedtime) . Medical record review of Physician Orders dated 3/27/17 revealed, .Humalog (insulin) 6 (units) with lunch and supper .hold if (blood glucose) (less than) 150 . Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed 27 administrations of insulin, without documentation of the resident's blood sugar, out of 60 opportunities. Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed 26 administrations of insulin, without documentation of the resident's blood sugar, out of 62 opportunities. Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed 28 administrations of insulin, without documentation of the resident's blood sugar, out of 54 opportunities. Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed, 24 administrations of insulin without documentation of the resident's blood sugar, out of 41 opportunities. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Order on Resident #16's MAR dated 5/15/17 revealed, .[MEDICATION NAME] (insulin) .(6 units) .two times daily .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's MAR dated (MONTH) (YEAR) revealed 25 administrations of insulin, without documentation of the resident's blood sugar, out of 27 opportunities. Medical record review of Resident #16's MAR dated (MONTH) (YEAR) revealed 34 administrations of insulin, without documentation of the resident's blood sugar, out of 37 opportunities. Interview with Licensed Practical Nurse (LPN) #8, Nurse Manager, on 7/25/17 at 3:58 PM, in the Director of Nursing (DON) office, confirmed there was incomplete documentation in the medical record. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Consultant Pharmacist's Medication Regimen Review for Resident #18 dated 4/1/17-4/11/17 revealed, .there is no space for recording (blood sugar) on EMAR (Electronic Medication Administration Record) with the order so unclear if this has been done consistently . Medical record review of Resident #18's MAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's MAR dated (MONTH) (YEAR) revealed blood sugars over 400 on 5/2 at 4:46 PM, 5/6 at 1:10 PM, 5/6 at 5:06 PM, 5/7 at 7:39 AM, 5/7 at 4:34 PM, 5/8 at 4:40 PM, 5/23 at 9:48 AM, 5/30 at 7:52 AM, and at 5/30 at 11:30 AM. Further review revealed no documentation if the additional 4 units of insulin were administered per physician order. Interview with LPN #8, Nurse Manager, on 7/26/17 at 11:10 AM, in the DON's office, confirmed if there was not a physical monitor (a space on the MAR for nurse to document the number of insulin units) placed on the MAR with the insulin order, then there was no place to document the amount of insulin given. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R (insulin) .Three Times Daily Starting 6/28/2017 .Blood Sugar is 151.00-200.00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of 201-250 on the MAR. Further review revealed on 6/30/17 the blood sugar was 214 and 6 units of insulin was given. Medical record review of the MAR dated (MONTH) (YEAR) revealed the following: 7/2/17 at 9:00 PM-blood sugar 215-4 units of insulin given 7/5/17 at 9:00 PM-blood sugar 215-4 units of insulin given 7/4/17 at 9:00 AM-blood sugar 152-2 units of insulin given Interview with LPN #10 on 7/20/17 at 4:05 PM, by phone, confirmed she was not aware there was an incomplete scale order on Resident #6's MAR. Interview with LPN #7 on 7/20/17 at 5:20 PM, by phone, confirmed she entered the insulin order in the computer for Resident #6 on 6/28/17. Further interview confirmed she entered the order manually instead of picking an order set from the library and made an error during the order entry. Interview with the Administrator on 7/19/17 at 11:00 AM, in the DON's office, confirmed a 24 hour chart check was completed nightly by the night shift nurse to ensure orders and documentation was correct. Interview with the DON on 7/26/17 at 2:35 PM, in the DON's office, confirmed nurses were not entering insulin orders correctly. Further interview confirmed insulin orders were not to be put in manually unless it was a scale other than scale A or B. Continued interview confirmed transcription errors should be identified during the 24 hour chart checks. Interview with the Administrator on 7/26/17 at 6:42 PM, in the DON office, confirmed documentation was .not as good as it should be . Interview with the Administrator on 7/27/17 at 7:45 AM, in the DON office, confirmed blood sugars should be documented on the MAR. Continued interview confirmed if no blood sugars were documented, .how are we supposed to know . if the correct dose had been given. Refer to F333",2020-09-01
28,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,520,E,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Monthly Pharmacist's Medication Regimen Review, review of facility investigations, medical record review, and interview, the facility failed to identify and address problems with errors in insulin administration, transcribing insulin orders, monitoring and documenting blood sugars, and following Physicians Orders for insulin administration for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Medical record review for Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Review of the Consultant Pharmacist's Medication Regimen for January, (MONTH) and (MONTH) (YEAR) revealed documentation from the Consultant Pharmacist indicating problems with insulin errors, transcription errors, and problems with documentation of blood sugar levels. Interview with the Director of Nursing (DON) on [DATE] at 2:35 PM, in the DON's office, confirmed she received the monthly Consultant Pharmacist's Medication Regimen reports, as well as the Administrator. Continued interview confirmed the Quality Assurance (QA) members met monthly and after the critical insulin error on [DATE], it was brought to QA meeting. The DON initiated insulin education for nurses and initiated medication observation audits monthly after [DATE].We probably should have done better . The Medical Director, Administrator and Director of Nursing met monthly to discuss any pertinent problems. Interview with the Medical Director (MD) on [DATE] at 8:00 AM, by phone, confirmed the goal of QA was to look for the .etiology in errors . Continued interview confirmed there were not any pharmacy reports or major trends in insulin errors discussed in the QA meetings.I felt we were doing pretty good . Further interview confirmed the MD did not receive copies of the monthly Pharmacy Reports and the QA Team failed to identify ongoing insulin administration errors, errors in transcription of insulin orders, and lack of blood sugar monitoring. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F490 (E), F501 (E), F514 (E)",2020-09-01
63,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-03-28,607,D,1,0,8HII11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and staff interview, the facility failed to timely report an injury of unknown origin per policy to facility administration per facility policy; failed to implement facility policy related to training after an allegation of injury of unknown origin; and the facility administration failed to report the allegation of injury of unknown origin within 2 hours to the State Agency (SA) per facility policy. Failing to implement abuse policies had the potential for abuse events to reoccur and put all 176 residents residing in the facility at risk. Findings include: Review of the facility Abuse, Neglect and Misappropriation or Property, policy, revised 8/24/17, revealed the definition of an injury of unknown origin as: .means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown source, or suspicion of crime. Directly after assuring that the resident(s) involved in the allegation or abuse event is safe and secure, the alleged perpetrator has been removed from the resident care area, and any needed medical interventions for the resident have been requested/obtained, the charge nurse will inform the Facility Administrator (the abuse coordinator), Director of Nursing (DON), physician and family or resident's representative of the allegation of abuse or suspicion of crime. The facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of crime as defined in this policy, and, if so, he or she, or the DON, will notify State agencies according to State reporting procedures within two hours. The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegation of abuse, injuries of unknown source, exploitation, or suspicions of crime as defined in this account. The facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed Resident #10 with severe cognitive impairment and no behaviors. Resident #10 required extensive assist of 1 person for bed mobility, dressing, and eating, and was dependent with 1 person assist for transfers, toilet needs, and bathing. Medical record review of a nursing assessment, completed by Licensed Practical Nurse (LPN) #7, dated 12/29/17 at 1:00 AM, revealed Resident #10 complained of pain and the LPN assessed the resident with swelling and pain in the right arm. The assessment did not indicate if the Administrator, or the DON were notified. Medical record review of a radiology report for Resident #10, dated 12/30/17 and faxed at 7:14 AM, revealed an acute mildly displaced distal humerus fracture. Medical record review of a Nursing Progress Note, dated 12/30/17, written by LPN #7 revealed the night shift nurse reported an x-ray indicating a right arm fracture. The resident was transported to the emergency room at 10:15 AM. The DON and Administrator were contacted as well (first observation of pain and swelling was on 12/29/17 at 1:00 AM). Medical record review of the emergency room Progress Note, dated 12/30/17, revealed a right arm fracture that the physician documented .was not a result of abuse/neglect . Medical record review of a Nursing Progress Note, dated 12/31/17 at 12:08 AM, revealed the .resident returned from the hospital in no acute distress with a right arm splint and arm sling, family at bedside, and pain medication administered with good results . Review of the facility interventions related to the investigation included Abuse Education (MONTH) (YEAR), which included 5 questions related to when to report abuse, signs of abuse, factors increasing the risk of abuse, and common reasons for abuse. Nurses were required to sign they received a copy of the Signature Healthcare's Triage Process. Review of the sign-in sheets for the Abuse Education (YEAR), revealed 137 of 285 listed staff had signed to indicate the training was completed. Review of the facility Positioning Competency, revealed guidelines for assistance for a resident positioning in a bed and chair, and included areas to indicate completion, comments, employee signature, supervisor signature, and yes or no for successful completion. Review of the facility sign-off sheet included completed sign-off for all staff. Upon review of the individual competency sheets revealed multiple sheets were missing dates, evidence the competency was completed, and supervisor signatures. Interview with the DON on 3/28/18 at 1:00 PM in the Conference Room revealed when Certified Nurse Assistant (CNA) #9 came on shift at 11:00 PM the CNA discovered Resident #10 complaining of pain when being turned. CNA #9 reported the issue to LPN #7 and the resident was assessed with [REDACTED]. The Night Shift Supervisor/Registered Nurse (RN) #2 was notified and came to assess the resident. An x-ray was obtained with the results of a right arm fracture. Further interview confirmed the RN did not notify the DON or the Administrator per policy of the injury of unknown origin. Further interview confirmed the facility failed to report the injury of unknown origin to the SA within 2 hours as required and per policy. Interview with the Administrator on 3/28/18 at 1:35 PM in the Conference Room revealed he did not recall the time of notification of the incident. Further interview confirmed he called the DON on 12/30/17 after the x-ray results were received. Further interview revealed the facility began abuse training immediately on the day of discovery. When CNA #8 stated on 1/03/18 the injury might have occurred during positioning the facility felt the injury was caused by faulty positioning, and the facility began staff competencies for positioning. Since the emergency room physician did not think the injury was related to abuse/neglect the facility moved from an allegation of abuse to care competency. Further interview confirmed a delay in notification resulted in the facility not reporting the injury of unknown origin within 2 hours to the SA per facility policy. The Administrator confirmed the abuse training and positioning competencies for nursing were not completed by the facility after the incident. Interview with the DON on 3/28/18 at 2:00 PM in the Conference Room confirmed the abuse training of when to report abuse was not completed for all staff and the positioning competencies were not completed for all nursing staff at the time of the investigation.",2020-09-01
64,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-03-28,609,D,1,0,8HII11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review,and staff interview, the facility failed to timely report an injury of unknown origin to the facility administration; and failed to notify the State Agency (SA) within 2 hours for 1 of 8 residents (Resident #10) reviewed for injury of unknown origin. Failing to report allegations of injury of unknown origin could increase the risk to all 176 residents residing in the facility. Findings include: Review of the undated facility Abuse, Neglect and Misappropriation or Property policy, revealed the definition of an injury of unknown origin as: .means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown source, or suspicion of crime .the charge nurse will inform the Facility Administrator (the abuse coordinator), Director of Nursing (DON) .of the allegation of abuse .The facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of crime as defined in this policy, and, if so, he or she, or the DON, will notify State agencies according to State reporting procedures within two hours . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #10 with severe cognitive impairment, no behaviors, and requiring extensive assist of 1 person for bed mobility, dressing, and eating. Resident #10 was dependent with 1 person assist for transfers, toilet needs, and bathing. Medical record review of a nursing assessment, completed by Licensed Practical Nurse (LPN) #7, dated 12/29/17 at 1:00 AM, revealed Resident #10 complained of pain and the LPN assessed the resident with swelling and pain in the right arm. The assessment did not indicate if the Administrator, or the DON were notified. Medical record review of a radiology report for Resident #10, dated 12/30/17 and faxed at 7:14 AM, revealed an acute mildly displaced distal humerus fracture. Medical record review of a Nursing Progress Note, dated 12/30/17, written by LPN #7 revealed the night shift nurse reported an x-ray indicating a right arm fracture. The resident was transported to the emergency room at 10:15 AM. The DON and Administrator were contacted as well (first observation of pain and swelling was on 12/29/17 at 1:00 AM). Review of the facility documentation report revealed the SA was notified on 12/30/17 at 1:35 PM, 36 1/2 hours after the event. Interview with the DON on 3/28/18 at 1:00 PM in the Conference Room revealed when CNA #9 came on duty at 11:00 PM Resident #10 complained of pain when being turned. CNA #9 reported the issue to LPN #7 and the resident was assessed with [REDACTED]. The Night Shift Supervisor/Registered Nurse (RN) #2 was notified and came to assess the resident. An x-ray was obtained with the results of a right arm fracture. Further interview confirmed the RN did not notify the DON or the Administrator per policy of the injury of unknown origin. Further interview confirmed the facility failed to report the injury of unknown origin to the SA within 2 hours as required and per policy. Interview with the Administrator on 3/28/18 at 1:35 PM in the Conference Room confirmed there was a delay in notification of the injury of unknown origin to administrative staff resulting in the facility's failure of not reporting the injury within two hours to the State Agency as required and per policy.",2020-09-01
65,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-03-28,880,D,1,0,8HII11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record review, staff interview, and observation, the facility failed to ensure infection control measures related to the dressing change of a peripherally inserted intravenous catheter (PICC) for 1 of 3 residents (Resident #7) reviewed with PICC lines; and failed to properly utilize hand hygiene during medication administration for 1 of 4 residents (Resident #15) observed for medication administration. Failing to change PICC line dressings had the potential to affect eight residents identified with PICC lines; failing to use hand hygiene could increase the risk of infection, and had the potential to affect all 176 residents in the facility. Findings include: Review of facility Infusion Therapy Procedures dated 2011, was reviewed and revealed .PICC and Midline Catheter dressing changes must be completed at minimum every seven days. Change immediately if: loose, not occlusive, moisture accumulation, drainage, redness, or irritation. Initial dressings will be changed PRN (as needed) if saturated, and 24-48 hours post insertion of Midlines, PICC's . if there is gauze present under the dressing or drainage is noted . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was alert, oriented, and independent with all activities of daily living except assistance of 1 to be off the unit. Medical record review of the nursing admission assessment dated [DATE] revealed the resident was admitted with a right upper extremity PICC line. Medical record review of physician progress notes [REDACTED]. Medical record review of physician orders [REDACTED]. Medical record review of a Daily Skilled Nursing Note dated 12/08/17 revealed .central line dressing scheduled as per staff to be changed . Medical record review of Medication Administration Records, (MAR), dated 11/30/17 through 12/10/17 (11 days) revealed no evidence of a dressing change to the PICC line. Medical record review of Physician order [REDACTED].#7 revealed .discontinue PICC line and reinsert new Midline catheter . Review of a procedure form for Resident #7 dated 12/10/17 revealed .the patient PICC line was out 7 centimeters and the dressing was loose on three sides. A Midline catheter was inserted into the left upper arm with a dressing applied . Medical record review of Physician order [REDACTED]. Medical record review of the MAR for Resident #7 dated from 12/11/17 through 12/26/17 (17 days) revealed no evidence of a dressing change to the Midline catheter. Medical record review of the Comprehensive Care Plan dated 12/11/17, revealed the .resident as at risk for complications related to the use of IV (intravenous) fluids and /or medications with a right upper arm PICC line . Interventions included .apply and check IV site treatment/dressings as ordered . Interview with the Director of Nursing (DON) on 3/28/18 at 2:30 PM confirmed the resident was admitted with a PICC line. Further interview revealed the PICC line became misplaced and a new Midline catheter was placed to continue the antibiotic administration. The DON confirmed the facility failed to have documentation of a dressing change to the PICC line and Midline catheter every seven days as per the facility policy. Review of the facility Medication Administration General Guidelines dated 2007 revealed, .hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, [MEDICATION NAME], enteral, rectal, and vaginal medications. Hand are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of medication administration on 3/27/18 at 8:50 AM revealed Licensed Practical Nurse (LPN) #6 entering the isolation room for Resident #15. LPN #6 donned personal protective equipment (PPE) to include a mask, gown, and gloves. With the help of Rehab #2 the resident was repositioned to allow better access to the resident gastronomy tub ([DEVICE]). LPN #6 removed gloves, donned new gloves, and assessed the [DEVICE] for placement and residual tube feed, changed gloves and administered several medications per the [DEVICE]. LPN #6 then changed gloves and administered prescription eye drops in each eye. LPN #6 took off gloves and reached under the PPE gown and took a large bore needle from a uniform pocket, donned gloves and used the needle to puncture two fish oil capsules, and place the liquid from the capsules in a medication cup. After changing gloves, LPN #6 administered the fish oil through the [DEVICE], changed gloves and administered a subcutaneous injection into the resident's abdomen. After changing gloves, LPN #6 administered a second drop of the prescription eye drop to each of the resident's eyes. LPN #6 then removed the PPE and gloves, washed hands with soap and water before exiting the room. The hand washing prior to exit was the only time LPN #6 completed hand washing or hand hygiene for the entire medication administration. Interview with LPN #6 on 3/27/18 at 9:30 AM on the second-floor hallway confirmed hand hygiene, to include hand washing or alcohol rub, was not used during the medication administration with Resident #15. Further interview revealed LPN#6 was unsure of the facility policy for hand hygiene. Interview with the DON on 3/28/18 at 5:10 PM in the facility Conference Room revealed staff were expected to wash hands or use alcohol rub any time gloves were worn and removed, before and after injections, and before eye drops and [DEVICE] medications. Further interview confirmed nursing staff should not remove items from pockets while in an isolation room.",2020-09-01
82,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-05,580,D,1,0,FKIB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the Physician of a change in condition for 1 of 5 residents (Resident #1) reviewed. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician ordered ventilator settings for Resident #1 revealed: Mode- SIMV (synchronized intermittent mechanical vent), and Rate- 12 (minimum number of respirations per minute). Continued medical record review of a Respiratory care flow sheet revealed on 6/6/18 at 3:35 AM, 7:34 AM, 10:53 AM, 3:13 PM, and 7:00 PM the ventilator mode for Resident #1 was documented as being SIMV and the Set rate was 12. Continued review revealed at 3:13 PM the total respiratory rate had elevated to 21, and then to 28 at 7:00 PM which indicated Resident #1 was tachypnic (increased respirations). Continued review revealed at 11:05 PM on 6/6/18 Registered Respiratory Therapist (RRT) #1 changed Resident #1's ventilator mode to Assist Control which was an increase in ventilator support and also changed the respiratory set rate to 18. Continued review of the medical record revealed no documented notification to the Physician of Resident #1's change in condition. Interview with Director of Respiratory Services on 7/3/18 at 9:10 AM in the conference room confirmed Resident #1 had a change in condition on 6/6/18 which required an increase in ventilator support and RRT #1 failed to notify the Physician of the change in the resident's condition. Telephone interview with RRT #1 on 7/3/18 at 1:50 PM revealed on 6/6/18 Resident #1 trended tachypnic and he followed the respiratory algorithm to adjust the ventilator settings without first notifying the Physician of the change in the resident's condition.",2020-09-01
83,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-05,684,D,1,0,FKIB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to administer antibiotic medication per physician order and per facility policy for 1 of 3 residents (Resident #3) reviewed receiving antibiotic medication. Findings include: Review of the facility policy, Medication Administration, dated 5/16, revealed .Procedures .Medication Administrations .Medications are administered with written orders of the prescriber . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders for antibiotic medication revealed the following: 1. On 6/6/18 [MEDICATION NAME] 500 milligrams (mg) every 12 hours for 7 days for [DIAGNOSES REDACTED]. 2. On 6/12/18 [MEDICATION NAME] ([MEDICATION NAME]/Clavulanic Acid) 875 mg by mouth three times daily for 7 days for [DIAGNOSES REDACTED]. 3. On 6/19/18 [MEDICATION NAME] 3.375 gram infuse intravenously every 6 hours for 10 days for [DIAGNOSES REDACTED]. Medical record review of the 6/2018 Medication Administration Record [REDACTED] 1. [MEDICATION NAME] was administered for 12 of 14 doses ordered from 6/7/18 at 12:01 AM through 6/12/18 at Noon. The facility failed to administer 2 of the 14 ordered doses. 2. [MEDICATION NAME] was administered for 19 of the 21 doses ordered from 6/12/18 at 8:00 PM through 6/18/18 at 8:00 PM. The facility failed to administer 2 of the 21 ordered doses. 3. [MEDICATION NAME] was administered for 36 of 40 doses ordered from 6/20/18 at 12:01 AM through 6/28/18 at 6:00 PM. The facility failed to administer 4 of the 40 ordered doses. Interview with the Unit B2 Manager on 7/3/18 at 10:50 AM in his office, after reviewing the 6/2018 antibiotic orders and the MAR for Resident #3, confirmed the facility failed to administer the antibiotics as ordered for [MEDICATION NAME], and [MEDICATION NAME]. Interview with the Director of Nursing on 7/3/18 at 11:18 AM in her office, after reviewing the 6/2018 antibiotic orders and the MAR for Resident #3, confirmed the facility failed to administer the antibiotics as ordered for [MEDICATION NAME], and [MEDICATION NAME]. Further interview confirmed the facility failed to follow the facility Medication Administration policy and failed to administer antibiotics per the physician orders.",2020-09-01
96,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-09-28,224,J,1,0,ONHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, and interview, the facility failed 2 of 8 residents reviewed for neglect (#1, #2). The facility staff failed to provide services in a manner to prevent neglect resulting in physical harm to two residents who were aggressive and resistive during care being provided. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #1 and #2. F-224 is Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .6. In cases of alleged resident abuse, the Director of Nursing or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are incapable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 required extensive assistance of 1 staff for hygiene, and Activities of Daily Living (ADL). Continued review of the MDS revealed Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Further review of the MDS revealed Resident #1 had not exhibited any behaviors. Medical record review of General Emergency Department Discharge Instructions dated 6/24/17 revealed Resident #1 had a [MEDICAL CONDITION] (long bone of the upper arm) and was given a splint to use. Resident #1 was also written a prescription for [MEDICATION NAME] 5/325 milligrams (mg) (pain medication). Review of a Witness Statement taken by the Administrator on 6/24/17 at 1:15 PM, from NA (Nurse Assistant #1) revealed 2 NAs were assisting Resident #1 with perineal care. Continued review revealed, .NA (#1) said NA (#2) got a towel trying to clean her and (Resident #1) started swinging (and) flailing arms not making contact .NA (#2) stepped back and stated don't be hitting me .Then grabbed patient's arms (and) held (them) down on (the) bed with the towel in the other hand trying to clean her .Grabbed (her) arm too hard (and the) arm snapped .Looked like bone was going to come through (resident's) arm. Force held arm down and bone popped .Patient screamed said you broke my arm. I commented (NA #2) you broke her arm . Review of a Witness Statement dated 6/24/17 written by NA #2 revealed, .I attempted to provide morning perineal care for (Resident #1) but she wouldn't let me clean her because she was swinging her arms .I went to get the assistance of (NA #1) but the resident was still swinging her arms so hard, she almost hit my face because I was standing at the head of the bed so she can't (could not) hit me but she was swinging so hard that I proceed (ed) to hold her hand when I heard a crack . Review of a Witness Statement dated 6/24/17 written by NA #1 revealed, .(NA #2) came to get her for assistance with the Resident (#1) morning perineal care .(Resident) started swinging her arm and trying to hit staff .don't hit me, then grabbed (the) resident's arm and held it down, I heard her bone crack . Review of a Witness Statement dated 6/24/17 written by Licensed Practical Nurse #3 (LPN) revealed, .(NA #2) came and asked her to come to Resident (#1's) room quickly .She said NA (#2) had broken Resident (#1's) arm .(LPN #3) asked (NA #2) how she know (knew) she had broken her arm and (NA #2) stated the resident was swinging her arms and she put her arm up to block it and she heard it crack .(LPN #3) looked at Resident (#1's) arm and could tell it was broken . Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property dated 6/28/17 revealed Resident #1 suffered a distal humerus fracture due to physical contact with a Nurse Aide #2 (NA) #2. Continued review revealed the .resident was displaying agitation while staff were attempting to provide personal care .Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. Further review of the Resident Investigative Tool revealed .resident was displaying agitation while providing care .She became restless and began swinging her arm at the Nursing Assistant (NA #2) .(NA #2) redirected the resident by placing residents hand down by her side .Due to her [DIAGNOSES REDACTED].This allegation was not substantiated because there was no willful intent to harm the resident. The Assistant Administrator went on to write the facility .educated all clinical staff to step away from residents when they become agitated during care. Interview with NA #1 on 9/26/17 at 9:30 AM in the conference room revealed Resident (#1) could be very feisty and did not like to be changed during perineal care. NA #1 stated Resident #1 would become aggressive at times, trying to hit or kick staff .when the resident became agitated she would reapproach, go get help from another NA or let the nurse know she could not complete personal care for the resident. Continued interview with NA (#1) revealed .on 6/24/17 (NA #2) came to get her to help provide perineal care for (Resident #1) because she was agitated and had bowel movement (BM) all over her .the resident had BM on her hands and was swinging her arms around in agitation, but she was not involved in the actual perineal care but was trying to talk to the resident and calm her down .she suggested to (NA #2) they take a break and reapproach the resident but (NA #2) continued doing care .(NA #2) blocked the resident from touching her face and held her arm down on the bed when she heard a loud popping sound .told the other (NA #2) that she broke the resident's arm and to go get the nurse .she worked with (NA #2) for a long time and did not think she intentionally hurt the resident . Further interview with NA #1 revealed NA #2 had a we're going to do it now, want to get your work done type of attitude. Interview with NA #2 on 9/26/17 at 10:00 AM, in the conference room revealed she had worked with Resident #1 for many years and Resident #1 had dementia but would be more agreeable to care if you gave her coffee. NA #2 stated on 6/24/17 .she attempted to provide perineal care for Resident #1 but she became agitated and she went to get help from (NA #1) who came into the resident's room to assist her .the resident was swinging her arms and had BM on her hands when she swung her arm towards her (NA #2's) face .reacted and it all happened so quickly but she blocked her arm and put the resident's arm down by her side when they heard a crack. Interview with Licensed Practical Nurse #1 (LPN) on 9/26/17 at 11:20 AM in the 300 Hall manager's office revealed LPN #1 served as the Unit Manager for the 300 Hall and stated Resident (#1) .was a confused, pleasant lady who, at times, was resistive to perineal care and showers. Continued interview with LPN #1 revealed Resident #1 did not have any specific triggers and that it varied from day to day whether the resident would become agitated or aggressive during personal care. Regarding the incident on 6/24/17 LPN #1 indicated he would expect staff to always back away and reapproach a resident who was resisting care and having combative behaviors. He indicated he would expect staff to back away from residents before it came to the point where they had to put their hands on them. He stated, we have a lot of psych (mental disorder) and dementia training. Interview with the Behavior Health Manager (BHM) on 9/26/17 at 2:30 PM in the conference room revealed she would expect staff to respect residents' rights without neglecting them. Continued interview revealed if a resident exhibited aggressive behaviors during care she would expect them to step away and not expect staff to physically touch the resident to intervene unless a resident was falling or about to hurt themselves. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room, revealed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17. Continued interview confirmed she was suspended and an investigation was completed. He confirmed the NAs knew they should have handled the situation differently by stepping back, letting the resident calm down and reapproaching. Interview with LPN #3 by phone on 9/26/17 at 4:10 PM revealed on .6/24/17 she was notified by (NA #2) she had broken (Resident #1's) arm during personal care. LPN #3 said she assessed the resident and called the Unit Manager. Continued interview revealed Resident #1 could be resistive to care, very fragile and if the resident was swinging her arms around she would expect the NA to step back, let her calm down, reapproach and get a nurse if needed. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and stated if a resident had combative behaviors during care she expected the staff to call the charge nurse and not force the resident to do anything. She further confirmed in Resident #1's case a fracture can happen very easily and if (NA #2) had not touched her, her arm would not have (been) broken. Continued interview confirmed if the resident was resisting that much (NA #2) could have stopped care completely. The Medical Director confirmed NA #2 did not use common sense while providing care with Resident #1 and her actions could cause [MEDICAL CONDITIONS] type symptoms. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed Resident #2 scored a 4 out of 15 on the BIMS which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed the resident had not exhibited any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17 indicated Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use included .provide non-confrontational environment for care . and .reapproach resident later, when she becomes agitated . Medical record review of a Weekly Skin assessment dated [DATE], revealed Resident #2 had reddened intact skin on her sacrum. Continued review revealed no other skin issues were noted on the assessment. Medical record review of a Daily Skilled Nurses Note dated 6/29/17 at 11:50 PM revealed Resident #2 refused all her nighttime medications. Continued review revealed the note did not indicate Resident #2 had any aggressive behaviors or that LPN #4 had any contact with the resident during her shift. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/, revealed Resident #2 made an allegation of abuse against LPN #4 on 6/30/17 stating .LPN (#4) came into her room to get her to take 7 pills and she refused because she had her own Dr.(doctor) and reported the nurse cut her arms to pieces with her claws . Continued review of the tool revealed Resident #2 had a history of [REDACTED]. Further review revealed Resident #2 had episode slapping meds (medications) out of (the) nurse hands .Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and the resident bruises easily. Review of a Witness Statement dated 6/30/17, written by NA #3 indicated Resident #2 called the NA between 9:00 AM and 10:00 AM and stated, look what she did to me while showing her both of her arms. Review of a Witness Statement dated 6/30/17, written by LPN #2 who served as the Unit Manager for the 200 Hall revealed a NA came to her and reported, someone was rough. LPN #3 took Resident #2 to her room to complete a skin assessment and interview. Resident #2 stated to LPN #3 on 6/29/17, a nurse came into her room and try (tried) to get her to take 7 pills and that she refused because she had her own Dr. (doctor) and then stated the nurse cut her arms to pieces with her claws trying to get her to take meds. Review of a Witness Statement dated 6/30/17, written by LPN #4 revealed went in to give her the meds and she slapped the meds off my hand stating she didn't want it. I then held her hands and scooped up the crushed meds off her bed. Review of the C.N.[NAME] (Certified Nursing Assistant) Skin Care Alert form dated 6/30/17, completed by LPN #2 revealed Resident #2 had 4 areas on her left arm and hand and 3 areas on her right arm and hand with the following written in multiple discolorations. Medical record review of Resident #2's Care Plan dated 6/30/17, revealed Resident #2 had bruises on her bilateral forearms and top of hands Review of one of the staff interviews dated 6/30/17, written by LPN #4 with the questions Did you notice any bruising on her legs? revealed the response, her arms was what I noticed (bruises/dark spots). Review of the facility handwritten notes provided by the Assistant Administrator revealed on 6/30/17 at 2:00 PM an allegation of abuse was reported regarding Resident #2. Continued review revealed Resident #2 stated that .nurse came in last night to give medication, but she refused it. The nurse allegedly cut her arms with her claws. She didn't take her medication but then stated that she did take her medicine because it was the only way that she could stop what the nurse was doing. States she tried to call for help .does have bruising to bilateral forearms/discolorations/dark spots? The Assistant Administrator took a statement from Resident #2 that stated .she grabbed her arms when she refused her meds .Felt like she was cutting her arms with a knife .she was in bed and trying to fight her off and she finally left the room .she tried to call for help .Described the nurse as having black frizzy hair with some red .she (nurse) tried to give her 9 pills but she wasn't going to take them .she didn't tell anyone during the night because they cut her communication off. Continued review revealed the notes also describe information taken from the Psych Services provider revealed APN (#1) (Advanced Practice Nurse) reported the resident told her nurse came in and gave her 7 pills and told her that the Dr. had ordered them .the resident slapped them away and grabbed her with her claws and she tried to call for help .she grabbed and twisted her arms. Medical record review of a Social Service Note dated 6/30/17 at 5:41 PM revealed the Social Service Worker #1 (SSW) spoke with the resident as she was eating in the unit dayroom and noticed bruises on the resident's arm and asked the resident what happened. (Resident #2) began the story of how she refused medications but the nurse made her take them anyway. SSW #1 asked the resident why she did not want to take her medications and the resident responded she only takes medications from her doctor whom she trusts. Medical record review of a Behavioral Medicine/Progress Note dated 6/30/17, written by APN #1 revealed during an interview Resident #2 appeared to acknowledge her confusion as she struggled to find words and organize her thoughts. APN #1 wrote Resident #2 said last PM she had gone to her room for the evening .The black lady that checks on me came in to give me 7 pills and I refused to take them swatting her hand away .She grabbed my arm and twisted it .She pointed to open areas and said those were her claws .she struggled staying awake to watch the black lady that kept checking on her .As above, pt (patient) struggled very hard to express her words, was confused At times, appeared to want to become tearful .The last thing she told this provider was if it can happen to me then it can happen to someone else . Review of a facility Coaching & (and) Counseling session form dated 6/30/17, revealed LPN #4 was counseled regarding failure to complete proper paperwork regarding medication administration. Review of the Working Schedule for LPN #4 revealed she worked on 6/30/17 clocking in at 6:35 PM and out at 7:22 AM. LPN #4 worked on B2 which was the 200 Hall with Resident #2. Interview with LPN #2 on 9/27/17 at 8:40 AM in the Manager's office who served as the Unit Manager for the 200 Hall revealed on 6/30/17, Resident #2 had discolorations on her arms but not bruises. She stated they were purple in color but they were not bruises and she did not discuss the incident with LPN #4 who was accused of abuse by the resident. She further stated NA #4 came to her and told her Resident #2 said someone grabbed her arms. LPN #2 said she did the skin assessment and interviewed the resident and passed the information on to the administrative staff. Interview with the Assistant Administrator on 9/27/17 at 8:50 AM in the conference room, revealed she interviewed LPN #4 and she stated Resident #2 smacked the medications out of her hand. Continued interview revealed the Assistant Administrator questioned LPN #4 about her statement and she stated LPN #4 told her she put the resident's hand down in her lap and reassured her. Further interview confirmed the Assistant Administrator did not interview NA #4 who Resident #2 told first about the incident. Further interview with the Assistant Administrator revealed the resident always had discolorations and age spots on her skin. Interview with the Assistant Director of Nursing #1 (ADON) on 9/27/17 at 9:05 AM in the Manager's office, revealed she sat in on the interview between the Assistant Administrator and LPN #4. Interview revealed ADON #1 confirmed LPN #4 stated in the interview she held Resident #2's hands in her hand while she picked up the medication. Continued interview revealed ADON #1 stated when she reviewed the skin assessment and it said multiple discolorations on her arms she would think bruising, a purplish color, maybe age spots, may be old but I would need more detail. She further stated since the skin assessment from 6/29/17 and 6/30/17 do not match, it would make her want to investigate further. Further interview with ADON #1 confirmed LPN #4 could have done something differently so she would not have had physical contact with the resident. She confirmed LPN #4 could have stayed in the room but backed away from the resident so she would calm down or pulled the call light so someone would come and help her. Continued interview confirmed LPN #4 did not have to physically intervene with the resident and if Resident #2 had discoloration on her arms all the time, she would expect to see it reflected in the skin assessments. Interview by telephone with LPN #4 on 9/27/17 at 1:30 PM, revealed on 6/30/17 she went into Resident #2's room to give her medication. Continued interview revealed the resident slapped the medications out of her hand and was swinging her arms trying to hit her. Further interview revealed LPN #4 stated she held the resident's hands with one hand and picked up the medication with her other hand. Interview with LPN #4 revealed the resident always had discolorations on her hands and arms and she did not use any physical force on Resident #2. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview revealed the Medical Director confirmed the bruises on Resident #2's arms were not documented beforehand so they were not old bruises, they were new ones. Interview with APN #1 on 9/28/17 at 1:10 PM in the conference room, confirmed after reading her documentation from 6/30/17 on Resident #2, she (resident) was clearly distraught about something that had happened. APN #1 stated she communicated this information to the Assistant Administrator and the DON (Director of Nursing) that day. Interview with the DON on 9/28/17 at 2:10 PM in the conference room revealed the DON was not employed with the facility in (MONTH) (YEAR) and stated if residents have combative behaviors she expects staff to always stop what they are doing, ensure the residents are safe and call for help, reapproach and let the nurse know. Continued interview confirmed if the staff are unable to complete care or give medication then they should document it. Further interview confirmed staff should not have unnecessary physical contact with residents.",2020-09-01
97,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-09-28,225,J,1,0,ONHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to conduct a thorough investigation for 1 of 4 residents reviewed for abuse. After receiving an allegation of abuse from Resident #2 the facility failed to suspend the accused employee who then worked with the resident on the same night. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #2. F-225 is Substandard Quality of Care The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .allegation of abuse as a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred or plausibly might have occurred .neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .if the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated Investigation Guidelines .The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegations of abuse .injuries of unknown origin source .exploitation .or suspicious crime .6. In cases of alleged resident abuse, the Director of Nursing (DON) or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are incapable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. The MDS revealed no documentation of Resident #2 exhibiting any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17, revealed Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use provide non-confrontational environment for care and reapproach resident later, when she becomes agitated. Medical record review of Resident #2's Care Plan dated 6/30/17, revealed Resident #2 had bruises on her bilateral forearms and tops of hands and was initiated after the allegation of abuse was made on 6/30/17. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/ revealed Resident #2 made an allegation of abuse against Licensed Pratical Nurse #4 (LPN) on 6/30/17. Resident #2 reported LPN #4 came into her room to get her to take 7 pills and she refused because she had her own Dr. (Doctor) She reported the nurse cut her arms to pieces with her claws. Continued review of the Investigative Tool revealed Resident #2 had a history of [REDACTED]. The report indicated Resident #2 had episode slapping meds out of nurse('s) hands. Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and that the resident bruises easily. Review of a Witness Statement dated 6/30/17 written by LPN #4 revealed she went in to give her the meds and she slapped the meds off my hand stating she didn't want it. So, I held her hands and scooped up the crushed med off her bed. Review of the investigative documentation provided by the facility for their self-reported abuse allegation against LPN #4 on 6/30/17 revealed the administrative staff interviewed 2 residents regarding their care. Five staff members were interviewed regarding Resident #2 and her behavior on the day of the incident. LPN #4 who was the staff member named in the allegation was not suspended during the investigation per facility protocol and returned to work the same day, working the same assignment area where the resident (who had verbalized fear of the same incident happening again) resides. Review of a Coaching & (and) Counseling Session form dated 6/30/17 revealed LPN #4 was counseled regarding failure to complete proper paperwork regarding medication administration. Review of the Working Schedule for LPN #4 revealed she worked on 6/30/17 clocking in at 6:35 PM and out at 7:22 AM. LPN #4 worked the night shift on B2 which was the 200 Hall with Resident #2 the same day she made an allegation of abuse. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation and interviewed other staff regarding LPN #4. Continued interview with the Administrator confirmed he believed the investigation was complete and did not suspend LPN #4. Interview with the Administrator revealed it was more likely the skin assessment prior to the incident was inaccurate because the night shift nurse who completed it may not have seen the resident. Further interview confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. Interview on 9/27/17 at 1:30 PM by telephone with LPN #4 confirmed she was not suspended after the allegation of abuse by Resident #2 and did not receive any education regarding residents with dementia or combative behaviors. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview with the Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new bruises and if a resident described an incident or person as abusive, it needed to be investigated. Further interview with the Medical Director confirmed the facility failed to follow all the steps of the investigative process including suspending the accused nurse. Interview with the Assistant Administrator on 9/28/17 at 1:30 PM in the conference room, confirmed the investigation was completed on 6/30/17 and she cleared LPN #4 to come back to work that night. Continued interview confirmed she did not know if the Investigative Tool needed to be filled out and dated with the date the investigation was completed so she did not document any interview with LPN #4 during the investigation and she did not document findings from the investigation where she cleared her to work that night. Interview with the DON on 9/28/17 at 2:10 PM, in the conference room confirmed staff should not have unnecessary physical contact with residents and if staff were described in the allegation they should be suspended for the course of the investigation. Continued interview confirmed the DON stated if staff were accused of abuse and the allegation was unsubstantiated, then staff should still receive education and training regarding the issue. Refer to F-224 J",2020-09-01
98,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-09-28,226,J,1,0,ONHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation and interview, the facility failed to implement their abuse policy related to the proper identification, training and investigation of abuse/neglect. The facility failed to operationalize its abuse policy after an allegation of abuse against a resident (#2) by a Licensed Practical Nurse (LPN) #4 was reported. This failure resulted in the potential for continued abuse against residents with whom LPN #4 continued caring for as part of her work assignment. This failure resulted in an Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #1 and #2. The facility further failed to properly identify neglect regarding Resident #1 as related to not substantiating abuse after Nurse Aide #2 (NA) intervened during resistive care of a resident by using physical force. The facility failed to ensure residents were free from abuse/neglect as per their abuse policy for 2 of 8 residents reviewed (#1, #2). F-226 is Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .non-accidental or not reasonably related to the appropriate provision of ordered care and services .allegation of abuse as a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred or plausibly might have occurred .neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .if the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated .Investigation Guidelines .6. In cases of alleged resident abuse, the Director of Nursing (DON) or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are incapable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents. Medical record review for Resident #1 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 required extensive assistance of 1 staff for hygiene and scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident as severely cognitively impaired. Review of the Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property form dated 6/28/17 indicated Resident #1 suffered a distal humerus (upper arm bone) fracture on 6/24/17 because of physical contact with a Nurse Aide #2 (NA). The tool indicated the resident was displaying agitation while staff were attempting to provide care. Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. The Investigative Tool indicated the resident was displaying agitation while providing care. She became restless and began swinging her arm at the (NA #2). The NA (#2) redirected the resident by placing the resident's hand down by her side. Due to her [DIAGNOSES REDACTED]. Continued review revealed the incident was not deemed as neglect by the facility. Further review of the Investigative Tool revealed the facility determined Resident #1's combative behavior, her [DIAGNOSES REDACTED]. Continued review of the Investigative Tool revealed the Assistant Administrator documented educated all clinical staff to step away from residents when they become agitated during care. Review of the facility investigation provided by the facility for their self-reported abuse allegation against NA #2 on 6/24/17 revealed the administrative staff did not substantiate the allegation of abuse/neglect. Continued review revealed the facility did not substantiate neglect, even though NA #2 intervened with physical force acting against the facility's policy and procedure for abuse/neglect while providing personal care for Resident #1 where she exhibited aggressive and resistive behaviors toward personal care offered which caused an acute physical injury to occur. Interviews by the surveyor with the two NAs involved in the incident, the Nurse on duty, the Unit Manager and Administrator indicated the events happened in accordance with the Investigative Report filled out by the Assistant Administrator. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room revealed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17. He stated she (NA #2) was suspended and an investigation was completed. Continued interview with the Administrator revealed the facility did not determine neglect had occurred during the incident. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed the Medical Director reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and stated if a resident had combative behaviors during care she expected the staff to call the Charge Nurse and not force the resident to do anything. Continued interview with the Medical Director confirmed in Resident #1's case a fracture can happen very easily and if NA #2 had not touched her, her arm would not have been fractured. Further interview confirmed if the resident was resisting that much she could have stopped care completely and NA #2 did not use common sense while providing care for Resident #1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] indicated Resident #2 scored a 4 out of 15 on the BIMS which indicated the resident was severely cognitively impaired. The MDS did not indicate Resident #2 exhibited any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17 indicated Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use included provide non-confrontational environment for care and reapproach resident later, when she becomes agitated. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/ indicated Resident #2 made an allegation of abuse against LPN #4 on 6/30/17. Resident #2 reported LPN #4 came into her room to get her to take 7 pills and she refused because she had her own Dr. (doctor). She reported the nurse cut her arms to pieces with her claws. Review of the Resident Investigative Tool revealed Resident #2 had a history of [REDACTED]. Continued review revealed the report indicated Resident #2 had episode (of) slapping meds out of nurse('s) hands. Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and that the resident bruises easily. Review of the investigative documentation provided by the facility for their self-reported abuse allegation against LPN #4 on 6/30/17 revealed the administrative staff interviewed 2 residents regarding their care. Five staff members were interviewed regarding Resident #2 and her behavior on the day of the incident. LPN #4 who was the staff member named in the allegation was not suspended during the investigation per facility protocol and returned to work the same day, working the same assignment area where the resident (who had verbalized fear of the same incident happening again) resides. There was no documentation LPN #4 and other staff were provided education or training after the incident. Medical record review of Resident #2's Care Plan dated 6/30/17 indicated Resident #2 had bruises on her bilateral forearms and tops of hands. This Care Plan was initiated after the allegation of abuse was made on 6/30/17. Interview with Nurse Aide (#3) on 9/28/17 at 8:05 AM in an empty resident room on the 200 Hall, confirmed NA #3 did not receive any training or education that she could recall after she reported the incident on 6/30/17 regarding alleged abuse towards Resident #2. Interviews with 6 staff members by the facility revealed Resident #2 described her interaction with LPN #4 similarly. Interviews revealed the resident reported she refused to take medications from LPN #4 and slapped the medications from her hand and reported the Nurse touched her hands and arms. Resident #2 referred to LPN #4 as cutting her arms to pieces with her claws in multiple accounts to different staff members. According to LPN #4's statement and the investigation by the Administrative staff, LPN #4 did have unnecessary physical contact with Resident #2. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation, however he could not confirm the staff received any further education or training regarding this issue. Continued interview with the Administrator confirmed they should have also interviewed other staff and additional residents regarding LPN #4 according to the facility policy. He confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview with the Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new and if a resident described an incident or person as abusive, it needed to be investigated. Further interview confirmed the facility should have followed all the steps of the investigative process including suspending the accused nurse. Interview with the DON on 9/28/17 at 2:10 PM in the conference room revealed the DON was not employed with the facility in (MONTH) (YEAR) and stated if residents have combative behaviors she expects staff to always stop what they are doing, ensure the residents are safe and call for help, reapproach and let the nurse know. Continued interview confirmed if the staff are unable to complete care or give medication then they should document it. Further interview confirmed staff should not have unnecessary physical contact with residents. Refer to F-224 J, F-225 J",2020-09-01
99,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-09-28,279,J,1,0,ONHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to develop a comprehensive care plan for 2 residents (#1, #8) of 8 residents reviewed. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #1. The findings included: Review of facility policy, Care Plans-Comprehensive, dated 9/21/16 revealed .The nurse/Interdisciplinary Team develops and maintains a comprehensive Care Plan for each resident that identifies the highest level of functioning the resident may be expected to attain .Each resident's comprehensive Care Plan is designed to .Incorporate identified problem areas .Incorporate risk factors associated with identified problems .Aid in preventing or reducing declines in the resident's functional status and/or functional levels .Care Plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers .Care Plans are revised as information about the resident and the resident's condition change .The nurse/Interdisciplinary Team is responsible for the review and updating of Care Plans. The Care Plan should reflect the current status of the resident and be updated with changes in the residents status .When the resident has been readmitted to the facility from a hospital stay . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 required extensive assistance of 1 staff for hygiene, and scored a 3 of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Further review of the MDS revealed Resident #1 had not exhibited any behaviors. Medical record review of Resident #1's Care Plan dated 6/6/17 revealed no individualized interventions for agitation, aggressiveness or combative behaviors during perineal care. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property dated 6/28/17 revealed Resident #1 suffered a distal humerus (long bone of the upper arm) fracture on 6/24/17 due to physical contact with a Nurse Aide (NA) #2. Continued review revealed the .resident was displaying agitation while staff were attempting to provide personal care and .Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. Further review of the Resident Investigative Tool revealed .resident was displaying agitation while providing care .She became restless and began swinging her arm at Nurse Aide (NA #2) .The NA redirected the resident by placing residents hand down by her side .Due to her [DIAGNOSES REDACTED]. Interview with NA #1 on 9/26/17 at 9:30 AM in the conference room revealed Resident #1 could be very feisty, did not like to be changed during perineal care, and would become aggressive at times, trying to hit or kick staff. Continued interview with NA #1 revealed Resident #1 has had these behaviors for a long time and usually if the staff offered her black coffee she would calm down and comply with care. Further interview revealed when the resident became agitated the NA would reapproach, go get help from another NA or let the nurse know she could not complete care on the resident. Interview with NA #2 on 9/26/17 at 10:00 AM in the conference room revealed she had worked with Resident #1 for many years. Further interview revealed Resident #1 had Dementia and could be combative with care at times but would be more agreeable to care if you gave her coffee. Interview with License Practical Nurse #1 (LPN) on 9/26/17 at 11:20 AM in the 300-hall manager's office, revealed the LPN served as the Unit Manager for the 300 hall. Further interview revealed Resident #1 was a confused, pleasant lady who, at times, was resistive to perineal care and showers. Further interview revealed Resident #1 did not have any specific triggers and that it varied from day to day whether the resident would become agitated or aggressive during care. Further interview with LPN #1 revealed he was unsure if there was a Care Plan in place for Resident #1's behaviors and staff knew to offer the resident black coffee as a way of calming her down when she became agitated. Interview with the Behavior Health Manager (BHM) on 9/26/17 at 2:30 PM in the conference room revealed she did not have a Behavior Health Plan in place for Resident #1 and did not recall a time when staff approached her for suggestions or education for that particular resident. Further interview revealed the BHM was unsure if there was a Care Plan in place for Resident #1's behaviors. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room revealed there should have been a Care Plan in place to address Resident #1's combative behaviors during care and the individualized interventions the staff used when the resident displayed combative behaviors. Telephone interview with LPN #3 on 9/26/17 at 4:10 PM revealed Resident #1 could be resistive to care and was very fragile. Further interview revealed the NAs knew how to get the resident to calm down and would offer her coffee at times. Further interview revealed the LPN was unsure if there was a Care Plan in place for Resident #1's behaviors. Interview with the Medical Director on 9/28/17 at 11:05 PM in the conference room, revealed the nursing staff should ensure Care Plans were in place for the resident's problems. Further interview revealed Resident #1's combative behaviors should be care planned and interventions documented. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/14/17 with [DIAGNOSES REDACTED]. Medical record review of Progress Notes revealed Resident #8 was sent for a Psychiatric Evaluation on 6/26/17 after an incident with Resident #4 and returned to the facility on [DATE]. Review of a Discharge Summary dated 7/12/17 revealed .The medication mgmt. (management) for this patient was aimed towards minimizing disruptive behavior both verbal and physical at her facility, however, given her chronic and persistent mental illness, periods of agitation or bizarre behavior are likely to continue to occur, and will require consistent behavioral supervision . Continued review of the Progress Notes revealed Resident #8 received another Psychiatric Evaluation from 7/17/17 until 8/14/17. Review of a Discharge Summary Psychiatry dated 8/14/17 revealed the admission was due to .behavioral issues continued to manifest themselves because of her problematic behavior after her last discharge . Continued review of Progress Notes revealed Resident #8 continued to exhibit behaviors after the second Psychiatric Evaluation. Medical record review of the Care Plan dated 8/14/17 failed to reflect the incident between Resident #8 and Resident #4. Continued review revealed the Care Plan also failed to contain information about Resident #8's behaviors. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) of 3, indicating she was severely cognitively impaired. Further review revealed the resident exhibited wandering behaviors 4-6 days of the review period. Medical record review of the Care Plan dated 8/14/17 revealed the Care Plan was not updated after the MDS dated [DATE] addressed wandering behaviors. Interview with the Behavioral Health Manger (BHM) on 9/26/17 at 2:35 PM in the conference room revealed Resident #8 does have behaviors that include wandering, going into other residents' rooms, spitting, and the resident required constant redirection. Further interview confirmed Resident #8 was sent for a Psychiatric Evaluation on 6/26/17 after the incident with Resident #4 and sent for a Psychiatric Evaluation again after continued behaviors following the readmission on 7/12/17. Interview with Social Services Worker #2 (SSW) on 9/26/17 at 4:05 PM in the conference room revealed SSW #2 was the assigned SSW for the unit where Resident #8 resides. Further interview confirmed Resident #8 had behaviors that included agitation, invasion of personal space of others and aggressive behaviors at times. Further interview revealed Resident #8 went for the second Psychiatric Evaluation and received electroconvulsive therapy and medication changes. Interview with the Administrator on 9/26/17 at 2:30 PM in the conference room revealed Resident #8 received a second Psychiatric Evaluation due to the facility's concern of the resident being a threat to herself and others. Further interview confirmed the facility failed to update Resident #8's Care Plan after the resident-to-resident incident with Resident #4 and after both psychiatric evaluations. Refer to F-224 J, F-225 J, F-226 J",2020-09-01
100,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-09-28,490,J,1,0,ONHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy and procedure, medical record review, observation, and interview, the Administrator failed to administer the facility in an effective manner, utilizing all its resources including the proper investigation process per the abuse/neglect policy and procedure and training and education on how to handle aggressive resident interactions during care provided, resulting in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for resident (#1, #2) of 8 residents reviewed. The findings of the abbreviated and partial extended survey found Immediate Jeopardy with Substandard Quality of Care at 483.13 (Resident Behaviors and Facility Practice). Resident #1 and Resident #2 were free from neglect. A Nurse Aide #2 (NA) and Licensed Practical Nurse #4 (LPN) physically intervened when the residents resisted care and had aggressive behaviors resulting in bodily injury and psychological trauma to the residents. Components of the facility's abuse/neglect prevention programs were not immediately implemented, including identification of the neglect, thorough investigation as well as prevention of further potential neglect by LPN #4 (Refer to F224, F225, and F226). The Administrator's failure to protect Resident #1 and Resident #2 from abuse/neglect, as well as ensure the staff were competent and trained in working with residents with combative behaviors has caused or is likely to cause acute injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 9/27/17, and determined to exist on 6/24/17. The facility's Administrator was informed of the Immediate Jeopardy on 9/27/17 at 2:30 PM in the Administrator's office. The findings included: 1. F224 - The Administrator failed to provide services necessary to avoid physical harm or mental anguish for Resident #1 and Resident #2. Resident #1 suffered a fractured arm after NA #2 intervened with physical force during perineal care being provided. Resident #2 potentially suffered from mental anguish and bruising due to LPN #4 intervening using physical force by holding her hands or arms while the resident was being aggressive and resistive to medication administration. 2. F225 - The Administrator failed to conduct a thorough investigation for the incident regarding Resident #2. Allegedly, LPN #4 held the resident's hands or arms while the resident was exhibiting aggressive and resistive behaviors during medication administration. The facility did not suspend the LPN during the investigation, and did not interview residents or staff about their interactions with the LPN. 3. F226 - The Administrator of the facility failed to ensure their abuse/neglect policy was implemented related to identification of abuse/neglect, investigation of abuse/neglect and training and education offered. The Administrator failed to ensure a thorough investigation was conducted for an allegation of physical abuse by Resident #2. The Administrator, who served as the Abuse Coordinator, did not recognize the staff members who had used physically forced interventions with Resident #1 and Resident #2 failed to provide the necessary services to prevent physical harm or mental anguish, and did not provide education or training to staff after the incident on how to handle residents with aggressive and resistive resident behaviors. 4. F279 - The Administrator failed to ensure a comprehensive Care Plan for Resident #1 was incorporated and identified problem areas, for Resident #1 and #2, and ensured Care Plans are revised to reflect the current status and/or functional level of the resident to include resident behaviors with appropriate interventions for staff to act appropriately. Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 defined neglect as .failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute .allegations of abuse .injuries of unknown source .exploitation .or .suspicious crime .The Facility Administrator may delegate some or all of the investigation to the Director of Nursing, Medical Director, or other subject matter experts as appropriate but the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation and to draw conclusions regarding the nature of the incident .Under the heading .Investigation Guidelines .6. In cases of alleged resident abuse, the Director of Nursing or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are capable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room, confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation; however, the Administrator did not state if the staff received education or training on this issue. Continued interview confirmed they should have also interviewed other residents and staff regarding LPN #4 according to their policy. Further interview confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. The Administrator confirmed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17 and she was suspended and an investigation was completed. The Administrator confirmed the NAs knew they should have handled the situation differently by stepping back, letting the resident calm down and reapproaching. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. The Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new bruises and if a resident described an incident or person as abusive, it needed to be investigated. Continued interview with the Medical Director confirmed the facility should have followed all the steps of the investigative process including suspending the accused nurse. The Medical Director confirmed she reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and if a resident had aggressive/combative behaviors during care she expected the staff to call the Charge Nurse and not force the resident to do anything. She confirmed in Resident #1's case a fracture can happen very easily and if NA #2 had not touched her, her arm would not have been broken and if the resident was resisting that much she should have stopped care completely. The Medical Director confirmed NA #2 did not use common sense while providing care with Resident #1 and her actions could cause [MEDICAL CONDITION] (Post Traumatice Stress Disorder) type symptoms.",2020-09-01
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
118,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-02-22,725,E,1,0,BOIT11,"> Based on review of the facility nurse staffing schedules and interviews the facility failed to have sufficient nursing staff to provide nursing and related services and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the staffing schedule for 2/10/18. The findings included: Review of the facility nurse staffing for 2/10/18 revealed 3 CNAs were scheduled for the 3:00 PM to 11:00 PM shift. 1 of 3 scheduled CNAs was present to work the evening shift. CNA #3 worked the 7:00 AM to 3:00 PM shift and stayed over to help cover the evening shift. Interview with Resident #2 on 2/20/18 at 12:15 PM in the resident's room revealed he was cognitively intact and stated the facility was understaffed for the evening shift on 2/10/18 with only 1 of the scheduled CNAs showing up to work. Further interview with Resident #2 revealed CNA #3 worked a double to help cover the evening shift on 2/10/18. Continued interview with Resident #2 revealed the medications were administered .about an hour late . on evening shift for 2/10/18. Interview with Resident #4 on 2/22/18 at 1:40 PM in the resident's room revealed he was cognitively intact. He stated the facility staffing is frequently short. He also stated he required assistance to get in and out of the bed. He further stated he prefers to be in bed by 8:30 PM and on the evening shift of 2/10/18 he was not assisted into bed until between 10:00 PM and 11:00 PM. Interview with CNA #1 on 2/21/18 at 8:40 AM in the north hall revealed she worked the day shift on 12/31/17. Continued interview revealed CNA #1 stated only 1 CNA was in attendance to work the 3:00 PM to 11:00 PM shift. Interview with RN #4 on 2/21/18 at 8:45 AM in the north hall revealed she worked the evening shift for 2/10/18. Continued interview revealed she stated the medications were given approximately 1 hour late. Further interview revealed some residents were not assisted into bed at their usual preferred times. Interview with CNA #5 on 2/21/18 at 10:50 AM in the east hall revealed she worked the day shift on 2/10/18. Continued interview revealed she noticed only 1 CNA had arrived to work the evening shift for 2/10/18. Interview with the Director of Nursing (DON) on 2/21/18 at 1:03 PM in the conference room confirmed staffing was short on 2/10/18. Continued interview revealed the DON offered incentive pay to the nursing staff to attempt coverage of the evening shifts. Interview with CNA #3 on 2/22/18 at 2:45 PM in the conference room confirmed she was scheduled and worked the 7:00 AM to 3:00 PM shift on 2/10/18. Continued interview confirmed CNA #3 also worked the 3:00 PM to 11:00 PM shift on 2/10/18. Further interview revealed CNA #3 was assigned resident rooms 1 to 24 and CNA #4 was assigned resident rooms 25 to 48. CNA #3 stated all the work got done .the meds were about an hour late and the residents got checked and turned about twice that shift but some did not get to bed at their usual times.",2020-09-01
119,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-05-15,921,E,1,0,2DLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, observation, and interview the facility failed to maintain the physical environment in a safe and sanitary manner for 22 bathrooms out of 31 bathrooms observed. The findings included: Review of facility policy, Infection Control, revised 10/2018, revealed .The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infection .The QAPI Committee through the Infection Control; Committee, shall establish, review, and revise infections control policies and practices, and help department heads and managers ensure they are implemented and followed . Observation of the facility during tours on 5/14/19 and 5/15/19 revealed the following: room [ROOM NUMBER] - loose faucet; missing toilet seat room [ROOM NUMBER] - room trash can overflowing; urine odor room [ROOM NUMBER] - diaper on bathroom floor; dirty water in commode room [ROOM NUMBER] - brown debris in toilet bowl; basin on floor with used gloves and cleansers in it Rooms 8 & 10 share bathroom - unflushed toilet room [ROOM NUMBER] - clothes on bedside table and floor room [ROOM NUMBER] - strong urine odor; dirty linen in sink Rooms 12 & 14 - strong smell of urine in bathroom Rooms 15 & 17 - bathroom trash can overflowing Rooms 16 & 18 - dirty water in commode with brown particles in bowl Shower room - drain without cover room [ROOM NUMBER] - powder on toilet seat and floor; strong urine odor; colored water in toilet room [ROOM NUMBER] - urine in toilet room [ROOM NUMBER] - diaper and pitcher on overbed table; lift sling on bedside table; brown material on toilet bowl; soiled linen on floor, in sink, and on toilet tank room [ROOM NUMBER] - dirty streaks in toilet; trash can full room [ROOM NUMBER] - 1 unlabeled bedpan on floor and 1 unlabeled bedpan on bathroom rail room [ROOM NUMBER] - diaper in chair and clothes as well room [ROOM NUMBER] - trash can overflowing; urine in commode; commode dirty room [ROOM NUMBER] - stains on toilet seat; hair, urine in commode Rooms 40 & 42 - brown debris in toilet bowl and on commode; soiled linens on floor and toilet tank room [ROOM NUMBER] - commode not flushed room [ROOM NUMBER] - dirty water in commode; sink dirty with tan ring around bowl room [ROOM NUMBER] - toilet bowl with brown residue room [ROOM NUMBER] - O2 mask and tubing on empty bed room [ROOM NUMBER] - unlabeled bedpan and urinal on floor; unlabeled basin with wet towels in it on floor Interview with the DON on 5/15/19 at 12:30 PM while touring the facility confirmed the 22 bathrooms were not clean with dirty water in the commodes; soiled linen on the floors; and trash cans overflowing. The DON also confirmed it was the responsibility of Housekeeping to keep the bathrooms clean.",2020-09-01
120,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2017-06-23,282,G,1,0,Q80711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, manufacturer's instructions review, observation, medical record review and interview the facility failed to follow the resident's care plan to ensure safe transfer techniques were implemented for 1 resident (#1) of 9 residents reviewed for abuse of 11 residents sampled. The facility's failure resulted in harm to Resident #1. The findings included: Review of the facility's policy, Resident Lift, undated, revealed, .Residents who are unable to transfer themselves independently or with minimal assistance shall be transferred safely with a lift .Guideline .2. At least two (2) trained staff are needed to transfer a resident when using a lift .7. In order to lift safely, follow manufactures operational guidelines for lifting, positioning, and transfer .Note: Make sure to pull appropriate make and model manufacturer guidelines for the lift used and follow manufacturer's instructions. Review of the manufacturer's Safety Instructions for Intended use revealed, (Product name) is a mobile raising aid .intended to be used on a horizontal surface for raising to a standing position and short transfer of residents .where the resident has been clinically assessed to correspond to the following categories .Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on carer in most situations - Physically demanding for carer . Review of facility's assessment, Mechanical Lifts - Function Flow Chart dated [DATE], revealed .Can the resident bear weight on at least one leg? No .Total lift required for transfer . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating the resident's cognition was severely impaired. Continued review revealed the resident required extensive assistance of 2 persons for bed mobility, transfers, and used a wheelchair for mobility. Medical record review of Resident #1's Care Plan dated [DATE] revealed problem of .[MEDICAL CONDITION] with Cognitive Deficits and Impaired Mobility .Two person assist and hoyer (total lift transfer device) lift required during transfers . Medical record review of Progress Note dated [DATE] revealed .Musculoskeletal: No joint deformity .Nonambulatory . Medical record review of the CNA (certified nurse assistant) Care Kardex, undated, revealed .Transfers .Assist 2 .hoyer (total lift) . Medical record review of Physical Therapy (PT) PT Evaluation & Plan of Treatment dated [DATE] revealed .Standing Balance .Unable (total dependence) . Medical Record review of Physician order [REDACTED].X-ray (L) hip 4 views STAT hip pain .May give [MEDICATION NAME] ,[DATE] mg (pain medication) by mouth every 8 hours as needed for hip pain . Medical Record review of Clinical page dated [DATE] 8:38 PM revealed .assisted to bed .had intense pain in left leg during the transfer .noted the inward rotation of her left leg and swelling in left upper thigh at hip area. NP was notified and order received. Family is aware . Medical record of Physician order [REDACTED].please transfer to ED (emergency department) for eval (evaluation) + Hx (history) L (left) hip pain, (decrease) ROM (range of motion) and acute swelling . Medical Record review of the hospital Ortho-Trauma Consult Note dated [DATE] revealed Angulated spiral [MEDICAL CONDITION] left femoral shaft . Medical Record review of the hospital discharge summary dated [DATE] revealed Resident #1 had an ORIF (open reduction internal fixation) to left femur on [DATE] and returned to the facility on [DATE]. Observation of Resident #1 on [DATE] at 1:40 PM revealed the head of the bed elevated 35 degrees, over-bed table in front of her, and currently eating lunch. Continued observation revealed the quarter upper rails were in the raised position on the bed. The daughter is sitting in a chair beside Resident #1's bed. Interview with the Therapy Director in the physical therapy department on [DATE] at 2:40 PM revealed they (Therapy Department) provide recommendations on transfer methods. (Resident #1) would not be appropriate for a sit to stand lift because she is unable to stand; a total lift transfer would be appropriate because she cannot stand. Interview with CNA #2 (7 AM-3 PM shift) on [DATE] at 1:55 PM revealed CNA #2 had provided care for Resident #1 on Wednesday, (MONTH) 7th. Continued interview revealed .we're supposed to use the Hoyer lift for (Resident #1) because that's what's on the card (referring to the CNA Care Kardex) .I used the Hoyer lift on that Wednesday, but sometimes when her daughter was here, we would use the sit to stand for transfers. The daughter liked the sit to stand better; she (the daughter) would help and I'd use the sit to stand. Telephone interview with CNA #4 on [DATE] at 7:57 PM revealed she had cared for Resident #1 three times on the evening shift. Continue interview confirmed, I buddied up with CNA #3 to get the residents ready for bed .When they went to assist (Resident #1) the daughter had already put the resident in bed, and the sit to stand lift was in the room. I went and told .(RN #1) and then we finished getting our residents in bed. Interview with CNA #3 on [DATE] at 2:00 PM revealed CNA #3 routinely worked 7AM - 3 PM and sometimes worked over, up until 7 PM. Continued interviewed confirmed I used the Hoyer lift because that's what's on the card (referring to Kardex) to use .I worked 3 days over that week. I would ask the daughter when the resident wanted to go to bed and then I would go and get other residents ready. When I returned, the daughter had already put her to bed and the sit to stand was in the room. I asked the daughter, 'Who helped you put her in bed?' She said, 'I did .I can do it.' I notified the charge nurse (RN #1) that (Resident #1) daughter had used the sit to stand and put the resident to bed. CNA#3 stated she had not seen Resident #1 in any kind of pain while working. Interview with the resident's Power of Attorney (POA) in Resident #1's room on [DATE] at 3:39 PM, revealed she would transfer the resident with the sit to stand lift, but only with assistance of a CN[NAME] I never transferred mother without help stated PO[NAME] I had gone home for church on Wednesday (MONTH) 7th. I did not help put her back to bed that night. Telephone interview with CNA #6 on [DATE] at 6:21 PM, who provided care for Resident #1 on [DATE] evening shift, 7 PM-7 AM, revealed the resident went to church that night, and she put her to bed after church around 8 PM. (CNA) assisted me with the Hoyer lift and we put her in the bed. She didn't have any complaints of pain and we teamed up during the night and turned our residents. After we got her (Resident #1) in bed, around 10 PM, when we went back and checked to make sure she wasn't wet, and turned her. We checked on her every two hours throughout the night. There was nothing out of the ordinary with turning her. She didn't catch her foot in the covers or anything else. Again, she didn't have any complaints throughout the night. Telephone interview with CNA #10 on [DATE] at 6:38 PM, revealed she provided care to Resident #1 on (MONTH) 8, 7 AM-3 PM shift. Continued interview revealed, .that morning (Resident #1) said her leg was hurting when we were cleaning her up. I asked her which leg and one time she said her right, then she said her left. I told the charge nurse (LPN #2), and then I provided her AM care. After that, I had another aide come and we used the Hoyer lift, got her up and sat her in her wheelchair. She ate lunch while she was up in her wheelchair and later went to activities .every two hours we took her back to her room, used the Hoyer lift, placed her in bed, and provided incontinence care . then we used the Hoyer lift to put her back into her wheelchair .after the complaints of leg pain in the morning, there were no further complaints of pain . Telephone interview with CNA #9 on [DATE] at 6:40 PM, who provided care for Resident #1 on [DATE] evening shift, 3 PM-11 PM, revealed he had assisted the resident to bed sometime after 5:00 PM. I was told by staff, don't remember who it was .that you use the sit to stand lift with (Resident #1). Continued interview revealed another CNA helped him with the sit to stand and (POA) was in the room too, but did not help. I sat her (Resident #1) on the bed and swung her legs onto the bed. I asked her if her leg was hurting and she said it was. Continued interview confirmed the POA provided assistance with and removal of (Resident #1's) pants. That is when I noticed the swelling to her left hip. I went and told the nurse that her leg was swollen and looked like it needed an x-ray. The nurse came and looked at (Resident #1) and later the mobile x-ray came. We had to turn her quite a few times to try and get a good x-ray. (Resident #1) would grimace when we turned and repositioned her. There was no catching of her feet in covers or legs falling off the bed as we turned and repositioned her. Interview on [DATE] at 10:05 AM, with the Director of Nursing in the conference room confirmed the resident (#1) was to be transferred with the total lift (Hoyer lift) with 2 person assist only, and that is what's on her care plan. She was not aware of use of the sit to stand on the resident until after the resident was sent to the hospital. I was never informed of the use of a sit and stand for the resident or that the family member was transferring or assisting with transfers until after the injury, stated DON. Interview confirmed the sit and stand was not to be used for the transfer of Resident #1 because she could not stand and only the total lift (Hoyer lift) was to be used; use of improper lift equipment for Resident #1 placed her at harm.",2020-09-01
121,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2017-06-23,323,G,1,0,Q80711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, manufacturer's instructions review, observation, medical record review, and interview the facility failed to ensure safe transfer techniques were implemented for 1 resident (#1) of 1 resident reviewed for injury of unknown origin of 11 residents reviewed. The facility's failure resulted in harm to Resident #1. The findings included: Review of the facility's policy, Resident Lift, undated, revealed, .Residents who are unable to transfer themselves independently or with minimal assistance shall be transferred safely with a lift .Guideline .2. At least two (2) trained staff are needed to transfer a resident when using a lift .7. In order to lift safely, follow manufactures operational guidelines for lifting, positioning, and transfer .Note: Make sure to pull appropriate make and model manufacturer guidelines for the lift used and follow manufacturer's instructions. Review of the manufacturer's Safety Instructions for Intended use revealed, (Product name (sit to stand lift)) is a mobile raising aid .intended to be used on a horizontal surface for raising to a standing position and short transfer of residents .where the resident has been clinically assessed to correspond to the following categories .Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on carer (care giver) in most situations - Physically demanding for carer . Review of facility's assessment, Mechanical Lifts - Function Flow Chart dated [DATE], revealed .Can the resident bear weight on at least one leg? No .Total lift required for transfer . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating the resident's cognition was severely impaired. Continued review revealed the resident required extensive assistance of 2 persons for bed mobility, transfers, and used a wheelchair for mobility. Medical record review of Resident #1's Care Plan dated [DATE] revealed problem of .Alzheimer's Disease with Cognitive Deficits and Impaired Mobility .Two person assist and hoyer (total lift transfer device) lift required during transfers . Medical record review of Progress Note dated [DATE] revealed .Musculoskeletal: No joint deformity .Nonambulatory . Medical record review of the CNA (certified nurse assistant) Care Kardex, undated, revealed .Transfers .Assist 2 .hoyer (total lift) . Medical record review of Physical Therapy (PT) PT Evaluation & Plan of Treatment dated [DATE] revealed .Standing Balance .Unable (total dependence) . Medical Record review of the Physician order [REDACTED].X-ray (L) hip 4 views STAT hip pain .May give Norco ,[DATE] mg (pain medication) by mouth every 8 hours as needed for hip pain . Medical Record review of Clinical page dated [DATE] 8:38 PM revealed .assisted to bed .had intense pain in left leg during the transfer .noted the inward rotation of her left leg and swelling in left upper thigh at hip area. NP (Nurse Practitioner) was notified and order received. Family is aware . Medical record of Physician order [REDACTED].please transfer to ED (emergency department) for eval (evaluation) + Hx (history) L (left) hip pain, (decrease) ROM (range of motion) and acute swelling . Medical Record review of the hospital Ortho-Trauma Consult Note dated [DATE] revealed Angulated spiral fracture of the proximal left femoral shaft . Medical Record review of the hospital discharge summary dated [DATE] revealed Resident #1 had an ORIF (open reduction internal fixation) to left femur on [DATE] and returned to the facility on [DATE]. Observation of Resident #1 on [DATE] at 1:40 PM revealed the head of the bed elevated 35 degrees, over-bed table in front of her, and currently eating lunch. Continued observation revealed the quarter upper rails were in the raised position on the bed with the resident's daughter was sitting in a chair beside Resident #1's bed. Interview with the Therapy Director in the physical therapy department on [DATE] at 2:40 PM revealed they (Therapy Department) provided recommendations on transfer methods. (Resident #1) would not be appropriate for a sit to stand lift because she was unable to stand; a total lift transfer would be appropriate because she cannot stand. Interview with CNA #2 (7 AM-3 PM shift) on [DATE] at 1:55 PM revealed CNA #2 had provided care for Resident #1 on Wednesday, (MONTH) 7th. Continued interview revealed .we're supposed to use the Hoyer lift for (Resident #1) because that's what's on the card (referring to the CNA Care Kardex) .I used the Hoyer lift on that Wednesday, but sometimes when her daughter was here, we would use the sit to stand for transfers. The daughter liked the sit to stand better; she (the daughter) would help and I'd use the sit to stand. Telephone interview with CNA #4 on [DATE] at 7:57 PM revealed she had cared for Resident #1 three times on the evening shift. Continue interview confirmed, I buddied up with CNA #3 to get the residents ready for bed .When they went to assist (Resident #1) the daughter had already put the resident in bed, and the sit to stand lift was in the room. I went and told .(RN #1) and then we finished getting our residents in bed. Interview with CNA #3 on [DATE] at 2:00 PM revealed CNA #3 routinely worked 7AM - 3 PM and sometimes worked over, up until 7 PM. Continued interviewed confirmed I used the Hoyer lift because that's what's on the card (referring to Kardex) to use .I worked 3 days over that week. I would ask the daughter when the resident wanted to go to bed and then I would go and get other residents ready. When I returned, the daughter had already put her to bed and the sit to stand was in the room. I asked the daughter, 'Who helped you put her in bed?' She said, 'I did .I can do it.' I notified the charge nurse (RN #1) that (Resident #1) daughter had used the sit to stand and put the resident to bed. CNA#3 stated she had not seen Resident #1 in any kind of pain while working. Interview with the resident's Power of Attorney (POA) in Resident #1's room on [DATE] at 3:39 PM, revealed she would transfer the resident with the sit to stand lift, but only with assistance of a CN[NAME] I never transferred mother without help stated PO[NAME] I had gone home for church on Wednesday (MONTH) 7th. I did not help put her back to bed that night. Telephone interview with CNA #6 on [DATE] at 6:21 PM, who provided care for Resident #1 on [DATE] evening shift, 7 PM-7 AM, revealed the resident went to church that night, and she put her to bed after church around 8 PM. (CNA) assisted me with the Hoyer lift and we put her in the bed. She didn't have any complaints of pain and we teamed up during the night and turned our residents. After we got her (Resident #1) in bed, around 10 PM, when we went back and checked to make sure she wasn't wet, and turned her. We checked on her every two hours throughout the night. There was nothing out of the ordinary with turning her. She didn't catch her foot in the covers or anything else. Again, she didn't have any complaints throughout the night. Telephone interview with CNA #10 on [DATE] at 6:38 PM, revealed she provided care to Resident #1 on (MONTH) 8, 7 AM-3 PM shift. Continued interview revealed, .that morning (Resident #1) said her leg was hurting when we were cleaning her up. I asked her which leg and one time she said her right, then she said her left. I told the charge nurse (LPN #2), and then I provided her AM care. After that, I had another aide come and we used the Hoyer lift, got her up and sat her in her wheelchair. She ate lunch while she was up in her wheelchair and later went to activities .every two hours we took her back to her room, used the Hoyer lift, placed her in bed, and provided incontinence care . then we used the Hoyer lift to put her back into her wheelchair .after the complaints of leg pain in the morning, there were no further complaints of pain . Telephone interview with CNA #9 on [DATE] at 6:40 PM, who provided care for Resident #1 on [DATE] evening shift, 3 PM-11 PM, revealed he had assisted the resident to bed sometime after 5:00 PM. I was told by staff, don't remember who it was .that you use the sit to stand lift with (Resident #1). Continued interview revealed another CNA helped him with the sit to stand and (POA) was in the room too, but did not help. I sat her (Resident #1) on the bed and swung her legs onto the bed. I asked her if her leg was hurting and she said it was. Continued interview confirmed the POA provided assistance with and removal of (Resident #1's) pants. That is when I noticed the swelling to her left hip. I went and told the nurse that her leg was swollen and looked like it needed an x-ray. The nurse came and looked at (Resident #1) and later the mobile x-ray came. We had to turn her quite a few times to try and get a good x-ray. (Resident #1) would grimace when we turned and repositioned her. There was no catching of her feet in covers or legs falling off the bed as we turned and repositioned her. Interview on [DATE] at 10:05 AM, with the Director of Nursing (DON) in the conference room confirmed the resident (#1) was to be transferred with the total lift (Hoyer lift) and 2 persons assist only. Continued interview confirmed she was not aware of anyone using the sit to stand lift with the resident until after the resident was sent to the hospital. I was never informed of the use of a sit to stand for the resident or that the family member was transferring or assisting with transfers until after the injury. Interview confirmed the sit to stand was not to be used for the transfer of Resident #1 because she could not stand and only the total lift (Hoyer lift) was to be used. Interview with Medical Director (MD) on [DATE] at 10:08 AM in the conference room revealed the fracture may have occurred up to a week prior to the complaint of pain on (MONTH) 8th. Continued interview revealed . the mobile x-rays obtained on (MONTH) 8th revealed no fracture or dislocation; don't know if the x-ray was misinterpreted or if it wasn't displaced. Continued interview confirmed she probably fractured upon the transfer but did not displace .whoever was there when the fracture occurred may not have been aware because it was not dislocated .the initial x-ray did not show the fracture .and she would not have been able to communicate that. Continued interview confirmed the give away was the thigh swelling. When the bones separate with a fracture is when you have pain that can become unbearable. Continued interview revealed the MD was unaware of Resident #1's family member transferring the resident until after the injury occurred. Continued interview revealed Resident #1 was unable to stand; she would require two people beside her to hold her weight; she is a large lady (280 pounds per MDS), and her frame is only capable of carrying maybe 100 pounds. Continued interview revealed if Resident #1 stood up (with a sit to stand lift) and her foot was planted when they tried to rotate her it could have created a torque (a rotating force) on the bone and fractured the femur resulting in a spiral fracture (a bone fracture occurring when torque is applied along the axis of a bone).",2020-09-01
122,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,558,G,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility record review and interview, the facility failed to ensure reasonable accommodation of needs to prevent decline for 1 (#22) of 38 residents reviewed resulting in psychosocial and physical Harm for Resident #22. The findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #22 required extensive assistance of 1 staff member for bed mobility and 2 staff members for transfers. Medical record review of the Progress Notes Report dated 4/8/19 revealed .Maintenance man reported to this nurse, f/u (follow up) with resident regarding having his bed replaced. (named medical equipment provider) delivered bed for resident in the interim, so maintenance can work/replace the parts to the existing bed . Resident #22 was transferred to the rental bed at this time. Medical record review of the service document from the rental company dated 4/9/19 revealed the order requisition sheet for a rental bariatric bed. Continued review revealed .5/8/19 fixed . Medical record review of the Former Nurse Practitioner (NP) notes dated 4/25/19 revealed .Patient appears hemodynamically stable, afebrile, nontoxic, but presents with left lower extremity [MEDICAL CONDITION] (bacterial infection of the skin) in the setting of chronic [MEDICAL CONDITION] .Elevate extremities . Medical record review of the Former NP notes dated 5/19/19 revealed .As such, it is medically necessary that the bed be changed to one that will allow extremity elevation, as this patient is rather immobile and morbidly obese and does suffer from marginally compensated heart failure and chronic [MEDICAL CONDITION] now presenting with [MEDICAL CONDITION]. (named resident) will require extremity elevation throughout the day. See (named resident) back as directed, follow-up and treat as clinically indicated . Medical record review of the physician's orders [REDACTED].Treatment/Procedure .Elevate Legs At All times . Medical record review of the Former NP notes dated 5/31/19 revealed .(named resident) current (rental) bariatric hospital bed has a non functioning motor so that legs are unable to be elevated, chronically dependent (leg constantly in a downward position) now. He does remain on [MEDICATION NAME] (diuretic) and [MEDICATION NAME] (diuretic) for diuretic management .It is medically imperative that the patient be provided a functioning bariatric bed to assist with extremity elevation for fluid management, as he does contend with profound chronic [MEDICAL CONDITION] and [MEDICAL CONDITION] now resulting in [MEDICAL CONDITION] . Medical record review of the Progress Notes Report dated 6/3/19 revealed .Resident called nurse to room, very upset regarding legs continuing to swell and not going down, resident requested the nurse to call the NP d/t (due to) his wanting to go to hospital for evaluation. NP contacted with new orders received and noted to transport resident to ER (emergency room ) of choice for eval (evaluation) and tx (treatment). Resident was tearful when moved to stretcher due to pain in heels when they touched the stretcher. Blankets placed under resident's heels. A blanket was placed across resident abdomen for straps from stretcher. Resident medicated with routine [MEDICATION NAME] 10/325 mg (milligram) for pain prior to transfer . Medical record review of the Hospital History of Present Illness dated 6/3/19 revealed .Patient .with a Hx (history) of chronic leg pain who presents to the ED (emergency department) via EMS (emergency medical services) with complaint of bilateral lower extremity pain and swelling that began 3 weeks ago. Patient reports that he has received 3 rounds of antibiotics at (named facility) .rehab facility for [MEDICAL CONDITION] but denies improvement .reports of chills, leg swelling, and wounds on hips .Differential Diagnosis: [REDACTED]. Medical record review of the Progress Notes Report dated 6/4/19 revealed .Patient (pt) arrived back at facility on 6/4/19. Pt was very upset because bed had not been changed out while he was gone to ER. Legs very swollen and this writer can only feel faint pedal pulses. Report from (named nurse) was given at 8 PM (8:00 PM) last night but return was delayed until early morning because of transportation issues . Medical record review of the Progress Notes Report dated 6/4/19 revealed .Patient remains in bed, bilateral lower extremities remain very [MEDICAL CONDITION], remains on abt (antibiotic) for [MEDICAL CONDITION], afebrile, resident continues to c/o (complain of) bed not being changed out, will continue to monitor and report any changes . Medical record review of the care plan dated 6/4/19, revised on 7/3/19 revealed the care plan failed to address the need for elevation of legs and feet. Medical record review of the service document revealed Resident #22 was in a rental bariatric bed for 58 days. Interview with Resident #22 on 8/12/19 at 11:11 AM in Resident #22's room revealed the resident has had [MEDICAL CONDITION] for [AGE] years. Further interview revealed Resident #22 stated .this (bed) needed to be fixed . It would not elevate the legs. Continued interview with Resident #22 revealed the facility rented a bariatric hospital bed to use while his bed was being repaired. The rented hospital bed raised the resident's knees. Further interview with Resident #22 revealed he was transferred to theER on [DATE] for pain and swelling in the legs and [MEDICAL CONDITION] in the ankle. Continued interview with Resident #22 revealed when he was transferred back to the facility from the hospital, the rented hospital bed which did not elevate his legs and feet was still in the room. He had asked the Administrator about changing to his original bed which was repaired on 5/8/19 and was in the hallway beside his room for almost 1 month. Telephone interview with the Former Nurse Practitioner (NP) on 8/12/19 at 9:47 AM revealed she had cared for the resident for many years and was familiar with the resident's comorbidities. Continued interview with the Former NP revealed Resident #22 was being treated with diuretics and elevation of the legs. Further interview with the Former NP revealed the resident had not had [MEDICAL CONDITION] until recently. Continued interview with the Former NP revealed Resident #22's bed was not working to elevate the legs. His original bed had been repaired and was sitting in the hallway but the resident had not been moved to it. This continued for some time but she could not remember how long. Continued interview with the Former NP revealed when she came to see Resident #22 on 5/15/19 his legs were severely swollen. Interview with the Administrator on 8/13/19 at 3:51 PM in the West dining room confirmed he wrote on the service document 5/8/19 fixed showing the bed was fixed. Interview with the Administrator on 8/20/19 at 2:10 PM in the West dining room revealed the Former Maintenance Director ordered the parts for the bed. Continued interview with the Administrator when asked and shown the Progress Notes Reports when the Former Maintenance Director was made aware of the broken bed and when Resident #22 was transferred back into the fixed bed confirmed give or take 60 days. Telephone interview with the Former NP on 8/23/19 at 12:26 PM confirmed she agreed with the statement made in the NP notes dated 5/31/19 which revealed she had observed several times when the resident's lower legs were in a dependent position (hanging down) due to the motor not functioning. Continued interview with the Former NP confirmed she had spoken to staff nurses and the Corporate Nurse regarding her concerns. Resident #22 remained in the rental bed, unable to have his lower extremities elevated per physician's orders [REDACTED].",2020-09-01
123,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,580,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to notify the physician when there was a significant change in condition for 1 (#22) of 38 residents reviewed. The findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident #22's Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #1 revealed, .called to Resident's room to evaluate [MEDICAL CONDITION] area to right thigh area .area cleansed and maggots removed . Medical record review of Resident Progress Notes dated 6/18/19 written by LPN #2 revealed, .called to Resident's (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) per request. Telephone interview with LPN #2 on 8/14/19 at 2:02 PM revealed she had not called the Nurse Practitioner (NP) or Medical Director (MD) #2. Interview with LPN #1 on 8/14/19 at 3:38 PM in the West Dining Room confirmed she did not notify the NP or MD #2 on 6/18/19 when the maggots were discovered and Resident #22 was transferred to the hospital. Telephone interview with the Former MD #2 on 8/14/19 at 10:29 AM confirmed he was not notified of the maggots, increased [MEDICAL CONDITION], or transfer to the hospital on [DATE]. Telephone interview with the NP on 8/12/19 at 9:47 AM confirmed she was not notified by staff when (named Resident #22) presented with maggots in the plaques and fissures on his right thigh until a week after the finding. Refer to F600.",2020-09-01
124,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,600,J,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, service reports, observation, and interview, the facility failed to prevent neglect for 3 (#1, #16, and #22) of 38 residents reviewed. The facility failed to provide needed care and services to prevent the infestation of fly larvae (maggots) in subcutaneous tissue (underneath the skin) and under skin folds for 1 (#22) of 5 residents reviewed. The facility failed to monitor and document bowel movements and failed to administer appropriate bowel medications for 12 (#1, #5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements. The facility failed to prevent actual abuse to 1 (#23) of 38 residents reviewed. Actual Harm occurred when Residents #1 and #16 complained of severe abdominal pain and constipation necessitating a visit to the hospital. The facility's non-compliance resulted in Residents #1 and #16 psychological and physical harm. This failure placed Resident #22 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Interim Director of Nursing, Corporate Nurse and Corporate Vice President of Operations were notified of the Immediate Jeopardy on [DATE] at 4:00 PM in the Social Worker's office. An acceptable Allegation of Compliance was received on [DATE] at 8:45 PM which removed the immediacy of the jeopardy. Corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on [DATE]. The Immediate Jeopardy was effective from [DATE] - [DATE]. F689 is Substandard Quality of Care. Noncompliance continues at a scope and severity of D to monitor the effectiveness of the corrective actions. The findings include: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revised ,[DATE], revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, and misappropriation of resident property .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .Criminal background checks will be conducted prior to permanent employment as well as a search of the State Aide Registry .During orientation all new Stakeholders will be trained on abuse .Each Stakeholder will receive annual training on abuse and neglect policies .The Facility Administrator will investigate all allegations of abuse .Every Stakeholder shall immediately report any allegation of abuse, injury of unknown source, of suspicion of crime .If the suspected perpetrator is a Stakeholder the charge nurse shall immediately remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated .The Administrator/Director Of Nursing (DON) will take measures to secure the safety and well-being of the affected resident . Review of facility policy, BM (Bowel Movement) Regimen, reviewed [DATE], revealed .The facility will monitor and track residents to determine the need for dietary and or chemical intervention to treat chronic and/or acute episodes of constipation .If a resident has had no bowel movement for 3 days the resident will receive additional high fiber drink and/or food supplements .If the resident has had no BM for 3 days the resident will receive on the evening shift a designated laxative and if no BM by the following morning the resident will receive a suppository after breakfast and if no BM by the evening of the fourth day the resident will be given a Fleets enema . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident #22's Progress Notes dated [DATE] written by Licensed Practical Nurse (LPN) #1 revealed, .called to Residents room to evaluate [MEDICAL CONDITION] area to right thigh area .area cleansed and maggots removed . There is no documentation she notified the physician. Medical record review of Resident Progress Notes dated [DATE] written by LPN #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Observation on [DATE] at 10:34 AM in Resident #22's room revealed Resident #22 was in the bed in a supine (lying on back) position. Continued observation of Resident #22 revealed the right hip area appeared discolored, leather like, and appeared to have raised rounded plaques (small distinct raised patch or region) and fissures (long narrow opening or line of breakage). Continued observation revealed the same rounded plaques and fissures were observed on the left hip. Telephone interview with CNA (Certified Nurse Aid) #3 on [DATE] at 12:14 PM revealed on [DATE] CNA #3 went to Resident #22's room to give the resident a bed bath. The CNA was asked by Resident #22 to perform a light wash (not too vigorous cleansing) due to increased pain in his hip. As CNA #3 began to wash the right hip with a wash cloth and soapy water, maggots were noted coming from the right thigh area crawling on the resident's abdominal folds. Continued interview with CNA #3 revealed he stopped cleaning the area and notified Licensed Practical Nurse (LPN) (Wound Care Nurse) #1 and the Administrator. He asked CNA #2 to help him. Both CNA #2 and CNA #3 returned to the room and he removed the covers to show CNA #2 the maggots. LPN #1 left the room and returned with a brown bottle of Dakin's (A dilute hypochlorite (bleach) antibiotic solution that kills the micro-organisms, but also harms healthy cells in all concentrations) and a toothbrush to cleanse the wound and skin folds and to remove the maggots. Further interview with CNA #3 revealed LPN #1 told both CNA #2 and CNA #3 to pour the Dakin's solution on the plaques and fissures to clean the area with the solution and the toothbrush. Further interview with CNA #3 revealed the maggots looked medium to large. Continued interview with CNA #3 revealed Resident #22 could feel the maggots crawling once they came out of the wound. CNA #3 stated Resident #22 said, .I feel them, I feel them . Interview with CNA #2 on [DATE] at 2:42 PM in the conference room revealed the maggots were observed between 10:30 AM and 11:00 AM on [DATE]. CNA #3 had been giving Resident #22 a bed bath. Continued interview with CNA #2 revealed when she went into the room to assist CNA #3, Resident #22 was in a supine position on the bed. Continued interview with CNA #2 revealed the Wound Care Nurse LPN #1 was already in the room. CNA #3 removed the sheet covering Resident #22's body and CNA #2 observed maggots crawling on the stomach and in the skin folds. LPN #1 started pouring the Dakin's solution on Resident #22's thigh area, then CNA #2 stated, .I poured some . Continued interview with CNA #2 revealed, .The maggots would come out and I would scoop them in a cup . Continued interview with CNA #2 revealed the maggots looked yellow and white. Interview with LPN #1 on [DATE] at 3:21 PM in the West dining room revealed LPN #1 was requested in the room because Resident #22 thought he had maggots .and the resident requested to go to the hospital . Continued interview with LPN #1 revealed Resident #22 had [MEDICAL CONDITION] in the area where the maggots were located. The area had been raised and bumpy. Continued interview with LPN #1, the wound care nurse, revealed when asked how often she checked the site of the [MEDICAL CONDITION] LPN #1 stated .I don't look at it every day. I just go and check on Resident #22 once a week . Telephone interview with CNA #3 on [DATE] at 2:01 PM revealed Resident #22 complained of pain for about 3 weeks prior to the maggots coming out of the plaques and fissures and there were times when staff had to alter how they cleaned the area because it was so painful for the resident. Telephone interview with the Former Nurse Practitioner (NP) on [DATE] at 9:47 AM revealed she was not notified by staff when Resident #22 presented with maggots in the plaques and fissures; did not give any orders for Dakin's solution to be used; and was not notified until a week after the findings. Interview with Resident #22 on [DATE] at 3:13 PM in his room revealed Resident #22 felt the maggots when they were crawling on his skin. Continued interview revealed when staff told the resident it was maggots the resident started crying and stated Why me? It's one thing to have this fluid but now maggots. Continued interview with Resident #22 confirmed the resident was scared and insisted on going to the hospital. Telephone interview with the Former Medical Director (MD) #2 on [DATE] at 10:29 AM confirmed he was not notified of the maggots, increased lower extremity [MEDICAL CONDITION] or transfer to the hospital on [DATE]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing; required extensive assistance of 1 person with grooming; required limited assistance with transfers, dressing, and toileting; and was frequently incontinent of bowel and bladder. Medical record review of the Elimination Record for ,[DATE] and ,[DATE] revealed: [DATE] had a small BM (bowel movement) [DATE] - [DATE] no documentation [DATE] no BM [DATE] - [DATE] no documentation [DATE] no BM [DATE] - [DATE] no documentation [DATE] no BM. Medical record review of the Medication Administration Record [REDACTED]. Further review revealed no documentation [DATE] or [DATE]. Medical record review of the MAR indicated [REDACTED]. There is no documentation this was administered in ,[DATE] or ,[DATE]. Medical record review of the MAR indicated [REDACTED]. Further review revealed no documentation these medications were ever administered. All the above medications were ordered on admission ([DATE]). Medical record review of a note by the Former Medical Director #1 dated [DATE] revealed .Pt reports she has significant abdominal pain and distention. She reports she has not had a bowel movement in 7 days. She has already tried Milk of Magnesia, [MEDICATION NAME], Senna, and [MEDICATION NAME]. She denies pain, dyspnea, dysuria, nausea, and depression. She requests a trip to (named hospital) for management of her constipation. She reports feeling awful from constipation. Patient encouraged to attempt a suppository before requesting to go to hospital again. Senekot (laxative) 2 tabs BID (twice daily) scheduled and 2 tabs BID PRN constipation. Encouraged patient to call after 3 days if no BM from now on to prevent her current discomfort in the future . Medical record review of the emergency room (ER) notes dated [DATE] revealed . Patient c/o (complained of) lower abdominal pain x 1 week. Said she was at a picnic [DATE] and since then has had intermittent daily abdominal and pelvic pain which has worsened over the past week. Last bowel movement 7 days ago. Family member had found patient in dirty diaper this morning . A further ER note revealed a statement .Noted the patient's diaper was full of dried stool that had adhered to the patient's skin . Continued review of the ER (Emergency Department) record dated [DATE] revealed the resident's abdomen was soft with mild tenderness to deep palpation in the suprapubic (central front wall of the abdomen immediately above pubic bone) and epigastric (upper central region of abdomen) regions. There was also a palpable pulsatile mass on examination of the abdomen. Continued review of ER records revealed a CT (Computerized [NAME]ography) scan was performed on [DATE], which demonstrated .Infrarenal (below the kidneys) abdominal aortic aneurysm, enlarged in size, with retroperitoneal (toward the back of the body) stranding (thinning) concerning for threatened rupture. The neck of the aneurysm is poorly suitable for repair. She is not a candidate for repair of aneurysm now or in the future . Continued review of the hospital record dated [DATE] revealed Resident #1 began to have worsening kidney failure; refused [MEDICAL TREATMENT]; was placed on palliative care; and expired on [DATE] due to [MEDICAL CONDITION]. Telephone interview with the Former Medical Director #1 on [DATE] at 2:15 PM revealed during her rounds of the facility she did not document her findings in the resident records. Information, especially bowel movements, was not documented in the medical record because the staff was having problems with the new computer program. When she asked the Administrator about paper records she was told if they went back to paper the staff would never use the computer. Telephone interview with the complainant on [DATE] at 2:30 PM revealed the resident's family member found her in distress and drove her to the hospital. Interview with the Interim Director of Nursing (DON) on [DATE] at 1:15 PM in the Social Worker's office revealed Resident #1 was at an ophthalmology appointment and the resident's family member called to say Resident #1 was admitted to the hospital for abdominal pain. The Interim DON confirmed bowel movements were not documented because the facility was switching to a new documentation system and the staff was unfamiliar with how and where to document bowel movements. There were no Nursing Notes available from Resident #1's admission on [DATE] through her discharge on [DATE] including the incident which precipitated her discharge from the facility. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #16 scored 13 on the BIMS indicating she was slightly cognitively impaired. Continued review of the MDS revealed Resident #16 was dependent on 1 person for bathing; required extensive assistance of 2 people with transfers; required extensive assistance of 1 person with dressing, toileting, and grooming; was frequently incontinent of urine; and was always incontinent of bowel. Medical record review of Nursing Notes dated [DATE] revealed .Called to resident room. Sitting on the toilet vomiting chunks of her dinner. Stated she does not feel well. Is sick to her stomach. BS (blood sugar) 289 (normal 70 - 110). NP notified and new orders received to transfer resident to hospital. Will monitor . The resident was transferred to the ER for evaluation on [DATE]. Medical record review of a Nursing Note dated [DATE] revealed .Received back from the ER. No needs voiced. States she feels better. Abd (abdomen) soft, non tender. No reports of feeling constipated at this time . The above 2 entries are the only ones in the medical record. There was no documentation of the resident being transferred to the hospital or post hospitalization status. Medical record review of the Elimination Record for ,[DATE] and ,[DATE] revealed: [DATE] and [DATE] the resident had no BM [DATE] no documentation [DATE], [DATE], [DATE] resident had no BM [DATE] no documentation [DATE] and [DATE] resident had no BM [DATE] - [DATE] no documentation. Review of facility investigation dated [DATE] revealed .Medical staff alleges Resident #16 was not sent out for fecal emesis (vomiting stool-colored material) after being given an order to do so and was found the next day in distress and sent out . Review of facility investigation dated [DATE] of a written statement by Licensed Practical Nurse (LPN) #3 revealed .On [DATE] (named Resident #16) was c/o (complaining of) abd (abdominal) pain. Oral laxatives were administered per bowel regimen ,[DATE] ([DATE]) with no effect. Suppository was administered ,[DATE] ([DATE]) with no immediate effect. Resident vomited shortly after administration and NP was made aware. Order was given to send (named Resident #16) to ER. After phone call to NP resident had a LARGE BM. Resident then stated symptoms had improved. NP was contacted again and made aware of BM and statement of relief by (named Resident #16) NP told me then not to send resident to ER. NP made rounds in facility on ,[DATE] ([DATE]) and (named Resident #16) stated she had started having pains again and wanted to go to the ER. NP gave order to send (named Resident #16) to ER and she was sent to (named hospital) . Review of the ER notes dated [DATE] revealed .The patient had a small bowel movement prior to my examination. The patient had a moderate amount of soft stool in her rectal vault (area where stool collects before being eliminated) but she could not comply with disimpaction due to significant discomfort. There is a large amount of [MEDICAL CONDITION] along the rectum which is distended with stool. Dilated loops of colon with stool consistent with constipation. She had another bowel movement prior to receiving the enema I had ordered. The enema resulted in good stool production. CT showed markedly stool throughout the colon. On re-exam her abdomen is soft, nontender, and nondistended. We will discharge her with prescriptions for Peri-[MEDICATION NAME] and Mag [MEDICATION NAME] as ordered . Medical record review of the MAR for ,[DATE] revealed an order for [REDACTED]. Interview with the Interim DON on [DATE] at 1:30 PM in the Social Worker's office confirmed BMs were not documented consistently due to problems with staff having difficulty entering data in the new system. Medical record review revealed Resident #23 was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. Continued review revealed Resident #23 expressed little interest in doing things, feeling depressed and hopeless, trouble falling asleep and having little energy. Further review revealed the resident was able to make her needs known to the staff through gestures as well as nodding and shaking her head. Medical record review of a Comprehensive Care Plan revised [DATE] revealed assessment and intervention occurred for communication deficits, mobility, skin management and bowel elimination. Review of the facility investigation of an interview between the Administrator and LPN #5 dated [DATE] revealed LPN #5 stated to the Administrator that .she (LPN #5) filled a medicine cup (half) way and went in the room to shock (Resident #23) out of her yelling and screaming . Further review of the facility investigation dated [DATE] revealed it was documented LPN #5 stated she .poured it (water) on her (Resident #23) chest and belly area . Interview with Resident #5, (Resident #23's roommate) with a BIMS of 15, on [DATE] at 10:15 AM in the resident's room revealed on [DATE] early in the morning but still dark LPN #5 entered the room on Resident #23's side (door side). Continued interview revealed Resident #5 stated the privacy curtain was pulled so that she was unable to see LPN #5 but recognized her voice. Further interview revealed Resident #5 next heard Resident #23 state stop pouring water on me. The resident stated after LPN #5 left the room she heard CNA #7 enter the room and ask Resident #23 why her gown and bottom sheet were damp. Interview with CNA #7 on [DATE] at 7:05 AM in the West dining room revealed on [DATE] at approximately 3:00 AM she was in the hall outside Resident #23's room with CNA #8. Continued interview revealed CNA #7 heard LPN #5 tell Resident #23 to stop yelling and stated you're going to wake everyone up. Further interview revealed CNA #7 heard Resident #23 state stop pouring water on me. The CNA stated after LPN #5 left the room, she entered to checked on Resident #23 and Resident #5. Further interview revealed Resident #23's right side of her gown, right side of her pillowcase at the resident's jaw-line and the fitted sheet on the right side at the resident's shoulder area were damp. CNA #7 stated Resident #23 stated she poured water on me and was unable to identify the person. Continued interview revealed CNA #7 left Resident #23's room to find the weekend supervisor, Registered Nurse (RN) #4. Further interview revealed as CNA #7 passed the back nurse's station she heard LPN #5 talking about pouring a medicine cup of water on Resident #23 to cause her to stop yelling. CNA #7 informed RN #4 of LPN #5 pouring water on Resident #23 to get her to stop yelling. Validation of the Allegation of Compliance (A[NAME]) to remove the Immediate Jeopardy was completed [DATE] through review of facility documentation, observations, and interviews. Surveyor verified the A[NAME] by: 1. Observation of the skin audits completed [DATE] revealed no new skin issues with residents. 2. Observation revealed Housekeeping supervisor and certified Dietary Manager assessing all rooms for the presence of food and removing it. 3. Observation of Maintenance Director installing blue light pest filters in hallways which previously had none. 4. Interview with the Administrator on [DATE] at 4:00 PM revealed the environmental lab was scheduled to visit the facility during the evening of [DATE]. They were observed entering the facility at 7:20 PM. 5. Review of inservice records revealed the Administrator, Maintenance Director, Dietary Manager, and Regional Maintenance Director were educated on [DATE] on reviewing and following up on all environmental concerns. 6. Review of inservice records dated [DATE] revealed education on reporting pest presence; removal of resident food items; daily skin observations for changes; cleaning rooms and emptying trash. This inservice will be presented to new hires during orientation. 7. Daily Ambassador Rounds tool was revised [DATE] by the Interim DON to include observation of pests in kitchen, common areas, and residential rooms. Observations will be made daily. 8. Regional Vice President of Operations conducted a round of the facility kitchen to observe for pests. Administration will conduct kitchen rounds 5 days per week to assess for pest or sanitation issues. 9. On [DATE] ad hoc QAPI meeting to discuss survey results, citation, and allegation of compliance and all agreed with the plan. 10. All audit findings will be reviewed during monthly QAPI meeting for further suggestions.",2020-09-01
125,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,609,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, State Survey Agency Facility Reported Incidents database review, and interview, the facility failed to report neglect to the State Survey Agency for 1 (#22) of 38 residents reviewed. The findings include: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revised 5/2019, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, and misappropriation of resident property .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .During orientation all new Stakeholders will be trained on abuse .Each Stakeholder will receive annual training on abuse and neglect policies .The Facility Administrator, or designee, will investigate all such allegations .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Telephone interview with CNA (Certified Nurse Aid) #3 on 8/8/19 at 12:14 PM revealed on 6/18/19 CNA #3 went to Resident #22's room to give the resident a bed bath. The CNA was asked by Resident #22 to perform a light wash (not too vigorous cleansing) due to increased pain in his hip. As CNA #3 began to wash the right hip with a wash cloth and soapy water, maggots were noted coming from the right thigh area crawling on the resident's abdominal folds. Continued interview with CNA #3 revealed he stopped cleaning the area and notified Licensed Practical Nurse (LPN) (Wound Care Nurse) #1 and the Administrator. He asked CNA #2 to help him. Both CNA #2 and CNA #3 returned to the room and he removed the covers to show CNA #2 the maggots. LPN #1 left the room and returned with a brown bottle of Dakin's (A dilute hypochlorite (bleach) antibiotic solution that kills the micro-organisms, but also harms healthy cells in all concentrations) and a toothbrush to cleanse the wound and skin folds and to remove the maggots. Further interview with CNA #3 revealed LPN #1 told both CNA #2 and CNA #3 to pour the Dakin's solution on the plaques and fissures to clean the area with the solution and the toothbrush. Further interview with CNA #3 revealed the maggots looked medium to large. Continued interview with CNA #3 revealed Resident #22 could feel the maggots crawling once they came out of the wound. CNA #3 stated Resident #22 said, .I feel them, I feel them . Review of the facility self-reported incidents confirmed the facility did not report this incident of neglect to the State Survey Agency. Refer to F600.",2020-09-01
126,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,641,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to complete an accurate assessment of the resident status for 3 (#5, #14, and #21) of 38 residents reviewed. The findings include: Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored 14 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #5 was dependent on 2 people for transfers, toileting, and bathing; required extensive assistance of 2 people with dressing and grooming; frequently incontinent of bowel; and had a suprapubic urinary drainage catheter in place. Medical record review of the Annual MDS dated [DATE] for Resident #5 revealed in the section on Bowel and Bladder, under Appliances it was documented as none of the above but the space for suprapubic catheter should have been marked. Under urinary continence it was marked not rated, resident had a catheter. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #14 had a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #14 required total dependence with 2 staff members for bed mobility and transfers. Continued review revealed Resident #14 required extensive assistance with 1 staff member for toileting. Continued review revealed Resident #14 was frequently incontinent of bowel. Continued review revealed Resident #14's use of a condom catheter was not addressed in the Bowel and Bladder section. Interview with the Corporate Nurse on 8/21/19 at 2:33 PM in the Social Services office confirmed the facility failed to capture the condom catheter on the Admission MDS. Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident was placed on hospice on 6/17/19 and there was no Significant Change MDS completed for Resident #21. Interview with the Administrator on 8/6/19 at 3:25 PM in the West dining room revealed there was no Significant Change MDS when the resident was placed on hospice. Continued interview with the Administrator confirmed she (MDS Coordinator) failed to address it (significant change).",2020-09-01
127,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,656,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to have an updated care plan for 1 (#22) of 38 residents reviewed. The findings include: Review of the facility policy Comprehensive Care Plans revised 7/19/18 revealed .The Comprehensive Care Plan will be person-centered to include the discharge plans to meet the resident's preference and goals to address the resident's medical, physical, mental and psychosocial needs . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of the Physician's Order Sheet dated 5/19/19 revealed .TREATMENT/PR[NAME]EDURE .ELEVATE LEGS AT ALL TIMES . Medical record review of the care plan dated 6/18/19 and 7/4/19 revealed the care plan was not revised to reflect orders to elevate Resident #22's legs at all times. Interview with Resident #22 on 8/12/19 at 11:11 AM in his room revealed the he had [MEDICAL CONDITION] for [AGE] years. Further interview revealed Resident #22 stated .this (the bed) needed to be fixed . It would not elevate his legs. Interview with the Corporate Nurse on 8/21/19 at 12:53 PM in the Social Services office confirmed the facility failed to update Resident #22's care plan to include elevation of the legs.",2020-09-01
128,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,658,F,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to provide care according to professional standards of practice by failing to monitor bowel movements; failing to intervene according to facility policy and physician's orders [REDACTED].#1,#5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements. The facility failed to document nursing information for 3 (#1, #4, and #16) of 38 residents reviewed. The findings include: Review of facility policy, BM Regimen, reviewed 6/1/18, revealed .The facility will monitor and track residents to determine the need for dietary and or chemical intervention to treat chronic and/or acute episodes of constipation If a resident has had no bowel movement for 3 days the resident will receive additional high fiber drink and/or food supplements .If the resident has had no BM for 3 days the resident will receive on the evening shift a designated laxative and if no BM by the following morning the resident will receive a suppository after breakfast and if no BM by the evening of the fourth day the resident will be given a Fleets enema . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing; required extensive assistance of 1 person with grooming; required limited assistance with transfers, dressing, and toileting; and was frequently incontinent of bowel and bladder. Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/12/19 had a small BM (bowel movement) 6/13/19 - 6/18/19 no documentation 6/19/19 no BM 6/20/19 - 6/24/19 no documentation 6/25/19 no BM 6/26/19 - 7/8/19 no documentation 7/9/19 no BM. Medical record review of the MAR indicated [REDACTED]. Medical record review of the MAR indicated [REDACTED]. There is no documentation this was administered. Medical record review of the MAR indicated [REDACTED]. Telephone interview with the previous Medical Director on 8/13/19 at 2:15 PM revealed during her rounds of the facility she did not document her findings in the resident records. Information, especially bowel movements, was not documented in the medical record because the staff was having problems with the new computer program. When she asked the Administrator about paper records she was told if they went back to paper the staff would never use the computer. Medical record review revealed Resident #1 had no nursing notes in the computer either in their new program or the old program. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #16 scored 13 on the BIMS indicating she was slightly cognitively impaired. Continued review of the MDS revealed Resident #16 was dependent on 1 person for bathing; required extensive assistance of 2 people with transfers; required extensive assistance of 1 person with dressing, toileting, and grooming; was frequently incontinent of urine; and was always incontinent of bowel. Medical record review of Nursing Notes dated 6/23/19 revealed .Called to resident room. Sitting on the toilet vomiting chunks of her dinner. Stated she does not feel well. Is sick to her stomach. BS (blood sugar) 289. NP notified and new orders received. Will monitor . Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/18/19 and 6/19/19 the resident had no BM 6/20/19 no documentation 6/21/19, 6/22/19, 6/23/19 resident had no BM 6/24/19 no documentation 6/25/19 and 6/26/19 resident had no BM 6/27/19 - 7/15/19 no documentation. Medical record review of the MAR for 7/2019 revealed an order for [REDACTED]. Review of the ER notes dated 7/10/19 revealed .The patient had a small bowel movement prior to my examination. The patient had a moderate amount of soft stool in her rectal vault (area where stool collects before being eliminated) but she could not comply with disimpaction due to significant discomfort. There is a large amount of [MEDICAL CONDITION] along the rectum which is distended with stool. Dilated loops of colon with stool consistent with constipation. She had another bowel movement prior to receiving the enema I had ordered. The enema resulted in good stool production. CT showed markedly stool throughout the colon. On re-exam her abdomen is soft, nontender, and nondistended. We will discharge her with prescriptions for Peri-[MEDICATION NAME] and Mag [MEDICATION NAME] as ordered . Medical record review of a Nursing Notes dated 7/11/19 revealed .Received back from the ER. No needs voiced. States she feels better. Abd soft, non tender. No reports of feeling constipated at this time . The above 2 entries are the only ones in the medical record. There is no documentation of the resident being transferred to the hospital; post hospitalization status; or follow-up by Social Services after hospitalization . Interview with the Interim Director Of Nursing (DON) on 8/13/19 at 8:30 AM in the West dining room revealed the facility changed to a new documentation system at the end of (MONTH) 2019. Continued interview revealed she confirmed some data on residents was lost and could not be retrieved and the missing notes on Residents #1 and #16 were in that category. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day MDS dated [DATE] revealed Resident #4 scored 15 on the BIMS indicating he was alert, oriented, and able to make his needs known. Continued review of the MDS revealed Resident #4 required limited assistance with bathing, transfers, dressing, and grooming; extensive assistance of 1 person with toileting; and was always incontinent of bowel and bladder. Medical record review of physician's orders [REDACTED]. Review of physician's orders [REDACTED].#4 was ordered [MEDICATION NAME] 4.5 Grams 4 times daily and scheduled for 4:00 AM, 10:00 AM, 4:00 PM, and 10:00 PM. Medical record review of the Medication Administration Record [REDACTED]. There was also no documentation in the Nursing Notes if the medication was held for some reason. Medical record review of physician's orders [REDACTED].Cleanse wound to left heel with wound cleanser; pat dry; apply Dakins 0.125% wet to dry dressing; change daily and as needed . Medical record review of the MAR for 7/2019 revealed there was no documentation the dressing was changed on 7/6/19 and 7/7/19. Medical record review of the hospital discharge notes revealed an order for [REDACTED]. Medical record review of physician's orders [REDACTED].Follow-up with Infectious Diseases and make appointment. Follow-up with (named Wound Clinic) . Medical record review revealed no documentation the appointment was scheduled or the resident went to the appointment. Interview with the Interim Director of Nurses (DON) on 8/21/19 at 12:30 PM in the Social Services Office confirmed the physician's orders [REDACTED].#4 in a timely fashion according to the physician's orders [REDACTED]. Medical record review of the Bowel Elimination Records revealed: Resident #5 had no BM documented 7/11/19 - 7/22/19 and 7/22/19 - 7/31/19 with a laxative administered 7/23/19. Resident #7 had no BM 7/18/19 - 7/22/19 and 8/1/19 - 8/8/19 with no medication intervention documented. Resident #10 had no BM documented 7/5/19 - 7/9/19 and 7/8/19 - 7/15/19 with no medication intervention documented. Resident #19 had no BM documented 7/12/19 - 7/16/19, 7/20/10 - 7/24/19, and 7/24/19 - 7/29/19 with no medication intervention documented. Resident #21 had no BM documented 7/12/19 - 7/16/19 with no medication intervention documented. Resident #24 had no BM documented 7/18/19 - 7/22/19, 7/23/19 - 7/27/19, 8/2/19 - 8/8/19 with no medication intervention documented. Resident #25 had no BM documented 7/25/19 - 7/29/19 with no medication intervention documented. Resident #29 had no BM documented 7/10/19 - 7/18/19 and 7/25/19 - 7/31/19 with no medication intervention documented. Resident #36 had no BM documented 7/7/19 - 7/12/19 and 7/12/19 - 7/17/19 with no medication intervention documented. Resident #37 had no BM documented 7/12/19 - 7/15/19 and 7/17/19 - 7/22/19 with no medication intervention documented. Telephone interview with the Former Medical Director #1 on 8/13/19 at 2:15 PM confirmed during her rounds of the facility she did not document her findings in the resident records. Information, especially bowel movements, was not documented in the medical record because the staff was having problems with the new computer program. When she asked the Administrator about paper records she was told if they went back to paper the staff would never use the computer. Interview with the Interim Director of Nursing (DON) on 8/21/19 at 1:15 PM in the Social Worker's office confirmed . bowel movements were not documented because of the facility switching to a new documentation system and the staff's unfamiliarity with how and where to document bowel movements .",2020-09-01
129,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,695,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation and interview the facility failed to date and change oxygen tubing and humidifier canisters for 1 (#21) of 5 residents reviewed with oxygen. The findings include: Review of the facility policy Oxygen Administration dated 9/6/18 revealed .Check the mask, tank, humidifier canister, etc. (when in use), to be sure they are good working order and are securely fastened. Be sure there is water in the humidifier canister and that the water level is high enough that the water bubbles as oxygen flows through . Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Medical record review of the care plan revised on 3/29/19 revealed .increase oxygen to 4 liters per nasal cannula . Observation and interview with Resident #21 on 8/5/19 at 11:24 AM in his room revealed the resident was lying in bed with his head elevated at a 45 degree angle and wearing a hospital gown. Continued observation revealed the resident was receiving oxygen therapy by nasal cannula. Further observation revealed the humidifier canister was not dated. Observation and interview on 8/6/19 at 8:59 AM in Resident #21's room revealed he had nasal cannula in place but the prongs were not in his nostrils. Continued interview with Resident #21 revealed when asked if he was comfortable with the prongs not in his nostrils the resident stated his nose was hurting. Continued observation revealed the humidifier canister was empty and undated. Interview with Registered Nurse (RN) #1 on 8/6/19 at 9:11 AM in Resident #21's room revealed RN #1 confirmed the humidifier canister was out of water and not dated. Interview with the Interim Director of Nursing (DON) on 8/22/19 at 11:14 AM in the Administrator's office confirmed .we should have oxygen tubing and the humidifier canister dated. Continued interview with the Interim DON confirmed .they (humidifier canisters) should be changed out when no water is in them .",2020-09-01
130,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,755,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to obtain Physicians' Orders for a medicated solution and failed to ensure that only licensed personnel administered medications for 1 (#22) of 38 residents reviewed. The findings include: Record review of the facility policy Medication Administration General Guidelines revised 9/6/18 revealed .Medications are prepared and administered only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare and administer medications . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Medical record review of the Physicians' Order Sheets and Physician's Telephone Orders dated (MONTH) 2019 revealed no orders for Dakin's (a dilute hypochlorite (bleach) antibiotic solution. It kills the microorganisms but also harms healthy skin in all concentrations) solution for Resident #22. Interview with Resident #22 on 8/7/19 at 1:26 PM in his room revealed Certified Nurse Aide (CNA) #2 and CNA #3 began to cleanse the plaques and fissures by pouring a solution (Dakin's) on the area. Continued interview with Resident #22 revealed the Wound Care Nurse (LPN #1) gave the CNAs the solution to pour on the plaques and fissures Continued interview with Resident #22 revealed .maggots would come out and then they would clean them off . Interview with CNA #2 on 8/7/19 at 2:42 PM in the West dining room revealed, .Licensed Practical Nurse (LPN) #1 stepped out to get Dakin's (A dilute hypochlorite (bleach) solution that shows effectiveness against Gram-Positive bacteria such as strep and staph, as well as a broad spectrum of anaerobic organisms and fungi) solution. Upon return to the room LPN #1 started pouring the Dakin's solution on Resident #22's plaques and fissures on his right thigh, then CNA #2 stated, .I poured some . Telephone interview with CNA (Certified Nurse Aid) #3 on 8/8/19 at 12:14 PM revealed LPN #1 left the room, returned with a brown bottle of Dakin's and a toothbrush to start cleaning the plaques and fissures on his thigh and abdominal skin folds and to clear the maggots off. Further interview with CNA #3 revealed LPN #1 (Wound Care Nurse) told both CNA #2 and CNA #3 to pour the Dakin's on the plaques and fissures and to clean the area with the solution and the toothbrush. Telephone interview with the Former Nurse Practitioner (NP) on 8/12/19 at 9:47 AM confirmed she was not notified by staff when (named Resident #22) presented with maggots in the plaques and fissures on his right thigh, and did not give any orders for Dakin's solution to be used. Telephone interview with the Pharmacy Consultant on 8/21/19 at 8:28 AM revealed Dakins solution was diluted bleach used to cleanse wounds. Continued interview with the Pharmacy Consultant confirmed nurses can use it (Dakins solution) as long there is an order .",2020-09-01
131,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,835,J,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interviews Administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The inactions and decisions of Administration contributed to physical and psychosocial harm for 3 (#1, #16, #22) of 38 residents reviewed. This failure placed Resident #22 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Interim Director of Nursing, Corporate Nurse and Corporate Vice President of Operations were notified of the Immediate Jeopardy on 8/21/19 at 4:00 PM in the Social Worker's office. An acceptable Allegation of Compliance was received on 8/21/19 at 8:45 PM which removed the immediacy of the jeopardy. Corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 8/21/19. The Immediate Jeopardy was effective from 6/18/19 - 8/21/19. The findings include: Review of Pest control customer service reports (This report is provided to identify sanitation deficiencies, structural defects and improper storage practices contributing to pest infestation.) revealed: 2/20/19 Small flies noted during service in kitchen .Reviewed with management . 3/20/19 Small flies noted under dishwasher sink .Reviewed with management .excess water noted under dishwasher .Keep area dry . 4/17/19 .Excess water noted under dishwasher .Keep area dry .Reviewed with management . 5/9/19 .Small flies noted during service by dishwasher sink .Reviewed with management . 6/5/19 .Small flies noted during service under dishwasher .Reviewed with management . 7/24/19 revealed .Excess water under dishwasher .Keep area dry .Illuminated light trap found unplugged, interior kitchen .Large flies noted in hallways .Reviewed with management . During the survey from 8/6/19 - 8/21/19 the survey team noted multiple flies and gnats in the West dining room and discussed this with management during the exit conference. 1. Interview with the Maintenance Director on 8/5/19 at 3:18 PM in the West dining room revealed the facility had a note pad for work orders at the nursing station but the staff would often stop him in the hall to tell him about a problem. Otherwise there was no consistent process for notification of needed equipment repairs. 2. Observation on 8/13/19 at 12:30 PM and 8/15/19 at 1:34 PM in the Dietary Department revealed flies and gnats and a small yellow round dryer underneath the sink of the garbage disposal. Continued observation in the dietary department revealed a dehumidifier and vacuum cleaner under a table. 3. Interview with the Dietary Manager on 8/13/19 at 1:57 PM in the West dining room revealed a month ago the connection in the drain of the three compartment sink had separated and was fixed by maintenance through reattachment. Continued interview revealed the floor under the dishwasher and garbage disposal needed to be repaired. The floor was old and the water would pool and not go down the drain. 4. Interview with the Maintenance Director on 8/13/19 at 2:01 PM in the West dining room confirmed the water had cracked the floor in the kitchen where water was pooling on the floor. Continued interview revealed the Administrator had not approved repair of the floor. 5. Telephone interview with the Pest Service Specialist on 8/26/19 at 9:49 AM revealed the Service Specialist had been servicing the facility for a year and was the primary Specialist. Continued interview with the Service Specialist confirmed when he would see things he would report it to management and they were supposed to fix it and their relationship was supposed to be a partnership. Continued interview with the Service Specialist confirmed the issues with the flies and gnats were a sanitation and structural problem. Continued interview confirmed .when you see pests activities like this it is a sign that it (named facility) was not cleaned regularly . 6. Interview with Resident #22 on 8/12/19 at 11:11 AM in Resident #22's room revealed the resident has had [MEDICAL CONDITION] for [AGE] years. Further interview revealed Resident #22 stated .this (bed) needed to be fixed . It would not elevate the legs. Continued interview with Resident #22 revealed the facility rented a bariatric hospital bed to use while his bed was being repaired. The rented hospital bed raised the resident's knees but left the lower leg and feet hanging down in a dependent position. Further interview with Resident #22 revealed he was transferred to theER on [DATE] for pain and swelling in the legs and [MEDICAL CONDITION] in the ankle. Continued interview with Resident #22 revealed when he was transferred back to the facility from the hospital, the rented hospital bed which did not elevate his legs and feet was still in the room. He had asked the Administrator about changing to his original bed which was repaired on 5/8/19 and was in the hallway beside his room for almost 1 month. 7. Medical record review of Resident Progress Notes dated 6/18/19 written by LPN #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. 8. Telephone interview with CNA #3 on 8/8/19 at 12:14 PM revealed he noted the maggots coming out of the plaques and fissures on the right hip of Resident #22 and notified both the Wound Care Nurse and the Administrator. CNA #3 continued the Administrator did not come to the room to see the resident. He also stated Resident #22 could feel the maggots crawling as they came out of the plaques and fissures and said I feel them, I feel them. 9. Interview with Resident #22 on 8/12/19 at 3:13 PM in his room revealed Resident #22 felt the maggots when they were crawling on his skin. Continued interview revealed when staff told the resident it was maggots the resident started crying and stated Why me? It's one thing to have this fluid but now maggots. Continued interview with Resident #22 revealed the resident was scared and insisted on going to the hospital. 10. Resident #22 had a [DIAGNOSES REDACTED].#22 was placed on a rental bed which flexed his knees but left his lower legs and feet in a downward position. On 6/4/19 the resident returned to the facility having been hospitalized for [REDACTED]. The bed had been repaired for 54 days and was in the hallway. 11. Interview with Resident #22 on 8/12/19 at 11:11 AM in his room revealed when he transferred back to the facility the rented hospital bed was still in the room. Continued interview with Resident #22 revealed he spoke with the Administrator about getting the original bed back but he kept telling Resident #22 he did not know when it would be ready. Resident #22 asked the Corporate Nurse what was the hold up? and the Corporate Nurse got nurses and the Administrator to transfer him back to the original bed. 12. Interview with the Administrator on 8/20/19 at 2:10 PM in the West dining room confirmed Resident #22 was not provided a functioning bed to elevate his legs as ordered for give or take 60 days. 13. Interview with the Interim DON on 8/12/19 at 9:30 AM in the West dining room revealed on 6/30/19, the facility began to use a new documentation program. Continued interview revealed the first week (6/30/19 - 7/7/19), the staff did not know how to use the part of the program needed to enter resident bowel movements so they were not documented. 14. Telephone interview with the Former Medical Director (MD) #1 on 8/13/19 at 2:15 PM revealed she was concerned about residents having bowel movements. When she asked the Administrator about going back to paper records until the staff was more familiar with the program the Administrator told her they would not go back to paper records or the staff would never learn how to navigate the program. As a result bowel movement records were not documented for at least a week. Continued interview with the former MD #1 revealed she was aware there were serious problems in the facility. She had addressed these concerns with the Administrator, but he rebutted all her allegations. The Medical Director stated .When these issues are brought to the Administrator's attention he talks a good game and promises change but seldom follows through. Whenever I bring a complaint to (named Administrator) he blames the residents rather than taking their complaints seriously and addressing their complaints . 15. Telephone interview with former MD #2 on 8/21/19 at 3:15 PM revealed the Administrator refused to accept there were any problems in the facility and if there were, they were the fault of the residents. Continued interview revealed if the Physician complained the wound dressings were not changed the Administrator stated it was because the resident refused to allow a dressing change. Further interview revealed if the Physician complained medications were not administered when scheduled the Administrator stated the resident refused the medication at the scheduled time. Continued interview revealed the Administrator told the Physician he would act on an issue then did nothing. Further interview confirmed the Medical Director felt the concerns in the facility were caused by and contributed to by the Administrator. Validation of the Allegation of Compliance (A[NAME]) to remove the Immediate Jeopardy was completed 8/21/19 through review of facility documentation, observations, and interviews. Surveyor verified the A[NAME] by: 1. Observation of the skin audits completed 8/21/19 revealed no new skin issues with residents. 2. Observation revealed Housekeeping supervisor and certified Dietary Manager assessing all rooms for the presence of food and removing it. 3. Observation of Maintenance Director installing blue light pest filters in hallways which previously had none. 4. Interview with the Administrator on 8/21/19 at 4:00 PM revealed the environmental lab was scheduled to visit the facility during the evening of 8/21/19. They were observed entering the facility at 7:20 PM. 5. Review of inservice records revealed the Administrator, Maintenance Director, Dietary Manager, and Regional Maintenance Director were educated on 8/21/19 on reviewing and following up on all environmental concerns. 6. Review of inservice records dated 8/21/19 revealed education on reporting pest presence; removal of resident food items; daily skin observations for changes; cleaning rooms and emptying trash. This inservice will be presented to new hires during orientation. 7. Daily Ambassador Rounds tool was revised 8/21/19 by the Interim DON to include observation of pests in kitchen, common areas, and residential rooms. Observations will be made daily. 8. Regional Vice President of Operations conducted a round of the facility kitchen to observe for pests. Administration will conduct kitchen rounds 5 days per week to assess for pest or sanitation issues. 9. On 8/21/19 ad hoc QAPI meeting to discuss survey results, citation, and allegation of compliance and all agreed with the plan. 10. All audit findings will be reviewed during monthly QAPI meeting for further suggestions.",2020-09-01
132,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,842,F,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Medical record review and interview the facility failed to maintain complete medical records for 12 (#1, #5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements and /or treatments. The findings include: Review of facility policy, BM (Bowel Movement) Regimen, reviewed 6/1/18, revealed .The facility will monitor and track residents to determine the need for dietary and or chemical intervention to treat chronic and/or acute episodes of constipation .If a resident has had no bowel movement for 3 days the resident will receive additional high fiber drink and/or food supplements .If the resident has had no BM for 3 days the resident will receive on the evening shift a designated laxative and if no BM by the following morning the resident will receive a suppository after breakfast and if no BM by the evening of the fourth day the resident will be given a Fleets enema . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing; required extensive assistance of 1 person with grooming; required limited assistance with transfers, dressing, and toileting; and was frequently incontinent of bowel and bladder. Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/12/19 had a small BM (bowel movement) 6/13/19 - 6/18/19 no documentation 6/19/19 no BM 6/20/19 - 6/24/19 no documentation 6/25/19 no BM 6/26/19 - 7/8/19 no documentation 7/9/19 no BM. Medical record review of the Nurse's Notes confirmed there were no Nursing Notes available from admission on 2/23/18 to discharge on 7/9/19 including the incident which precipitated her discharge from the facility. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #16 scored 13 on the BIMS indicating she was slightly cognitively impaired. Continued review of the MDS revealed Resident #16 was dependent on 1 person for bathing; required extensive assistance of 2 people with transfers; required extensive assistance of 1 person with dressing, toileting, and grooming; was frequently incontinent of urine; and was always incontinent of bowel. Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/18/19 and 6/19/19 the resident had no BM 6/20/19 no documentation 6/21/19, 6/22/19, 6/23/19 resident had no BM 6/24/19 no documentation 6/25/19 and 6/26/19 resident had no BM 6/27/19 - 7/15/19 no documentation. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed there was no documentation that the medications were administered and no documentation in the Nursing Notes of the need for the medications. Medical record review of Nursing Notes dated 6/23/19 revealed .Called to resident room. Sitting on the toilet vomiting chunks of her dinner. Stated she does not feel well. Is sick to her stomach. BS (blood sugar) 289 (normal 70 - 110). NP notified and new orders received. Will monitor . The resident was transferred to the ER for evaluation. Medical record review of a Nursing Note dated 7/11/19 revealed .Received back from the ER. No needs voiced. States she feels better. Abd (abdomen) soft, non tender. No reports of feeling constipated at this time . The above 2 entries are the only ones in the medical record. There was no documentation of the resident being transferred to the hospital or post hospitalization status. Medical record review of the Bowel Elimination Records revealed: Resident #5 had no BM documented 7/11/19 - 7/22/19 and 7/22/19 - 7/31/19 with a laxative administered 7/23/19. Resident #7 had no BM 7/18/19 - 7/22/19 and 8/1/19 - 8/8/19 with no medication intervention documented. Resident #10 had no BM documented 7/5/19 - 7/9/19 and 7/8/19 - 7/15/19 with no medication intervention documented. Resident #19 had no BM documented 7/12/19 - 7/16/19, 7/20/10 - 7/24/19, and 7/24/19 - 7/29/19 with no medication intervention documented. Resident #21 had no BM documented 7/12/19 - 7/16/19 with no medication intervention documented. Resident #24 had no BM documented 7/18/19 - 7/22/19, 7/23/19 - 7/27/19, 8/2/19 - 8/8/19 with no medication intervention documented. Resident #25 had no BM documented 7/25/19 - 7/29/19 with no medication intervention documented. Resident #29 had no BM documented 7/10/19 - 7/18/19 and 7/25/19 - 7/31/19 with no medication intervention documented. Resident #36 had no BM documented 7/7/19 - 7/12/19 and 7/12/19 - 7/17/19 with no medication intervention documented. Resident #37 had no BM documented 7/12/19 - 7/15/19 and 7/17/19 - 7/22/19 with no medication intervention documented. Telephone interview with the Former Medical Director #1 on 8/13/19 at 2:15 PM confirmed during her rounds of the facility she did not document her findings in the resident records. Information, especially bowel movements, was not documented in the medical record because the staff was having problems with the new computer program. When she asked the Administrator about paper records she was told if they went back to paper the staff would never use the computer. Interview with the Interim Director of Nursing (DON) on 8/21/19 at 1:15 PM in the Social Worker's office confirmed . bowel movements were not documented because of the facility switching to a new documentation system and the staff's unfamiliarity with how and where to document bowel movements . Refer to F600.",2020-09-01
133,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,880,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, observation and interview the facility failed to change the dressing and have a legible date on a PICC (Peripherally Inserted Central Catheter) (a catheter inserted in a peripheral vein and threaded to a vein close to the heart used for prolonged IV (intravenous) medications) for 2 (#31 and #32) of 2 residents reviewed with PICC lines. The findings include: Review of the facility policy Dressing Change For Vascular Access Devices dated 8/1/16 revealed .Central venous access device and midline dressing changes will be done at the established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present or for further assessment if infection is suspected .Transparent semi-permeable membrane (TSM) dressing are changed every 7 days and PRN (as needed) .All catheters - Apply label on dressing with date and nurse's initials. Do not write on TSM dressing with pen or magic marker . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #31 required IV medications. Medical record for Resident #31 review of the Physician Order Report dated 8/1/19-8/7/19 revealed Resident #31 received .dressing change PRN (as needed) soiling or dislodgement Special Instruction: Date and time dressing for change and readjust standing Midline schedule change . Observations on 8/5/19 at 2:37 PM and on 8/7/19 at 9:50 AM in Resident #31's room revealed the PICC line to the right upper arm had gauze over the insertion site and a transparent dressing over the site with illegible writing on the dressing. Observation and interview on 8/7/19 at 2:06 PM in Resident #31's room with the Nurse Practitioner (NP) revealed the same dressing on the PICC line with illegible writing on it. Continued interview with the NP confirmed during every shift the nurse should check the location; make sure it (PICC dressing) is timed and dated; assess for signs and symptoms of infection; and document. Continued interview with the NP when asked to look at the dressing confirmed she had .no idea when it was placed or when the dressing was changed . Interview with the ADON (Assistant Director of Nursing) on 8/7/19 at 2:30 PM in the West dining room confirmed .I should have marked it with a marker. I just marked it (PICC line transparent dressing) with a pen . Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #32 had a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #32 required IV medications while a resident in the facility. Medical record review of the Physician Order Report dated 8/1/19 to 8/7/19 revealed an order to .Change PICC Line dressing PRN soiling or dislodgement. Special Instructions: Date and Time dressing for change and readjust standing PICC dressing schedule change . Observation on 8/5/19 at 10:51 AM in Resident #32's room revealed the PICC line dressing was dated 7/25/19. The dressing had been reinforced with tape. Observation and interview on 8/5/19 at 11:20 AM in Resident #32's room with the ADON confirmed the PICC dressing was noted with a date of 7/25/19. Continued interview with the ADON when asked what the facility policy was regarding PICC line dressing changes she confirmed .they are changed once a week .",2020-09-01
134,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,921,E,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure a sanitary environment for the residents in 10 (#9, #16, #20, #23, #25, #34, #36, #42, and #44) of 30 rooms observed. The findings include: The initial facility tour revealed the following findings: Observation on 8/5/19 at 10:30 AM in room [ROOM NUMBER] revealed brown debris in the toilet. Observation on 8/5/19 at 10:40 AM in room [ROOM NUMBER] revealed an unlabeled basin and bedpan sitting on the bathroom floor. Observation on 8/5/19 at 10:46 AM in room [ROOM NUMBER] revealed an odor resembling old urine in the room. Observation on 8/5/19 at 10:51 AM in room [ROOM NUMBER] revealed the toilet seat had brown debris on it and there was yellow liquid in the toilet. Observation on 8/5/19 at 10:55 AM in room [ROOM NUMBER] revealed an unlabeled basin and bedpan sitting on the bathroom floor. These findings were confirmed on 8/5/19 at 11:30 AM with the nurse on the unit, LPN #2. Observation on 8/5/19 at 10:51 AM in the bathroom of room [ROOM NUMBER] revealed the soap dispenser cover was missing and there was no soap in the bathroom for the residents to use. Observation on 8/5/19 at 11:20 AM in the bathroom of room [ROOM NUMBER] revealed the ADON attempted to wash her hands but there was no soap in the bathroom. Continued observation confirmed the ADON left the bathroom; came back with body wash soap to wash her hands; and placed the body wash soap on the bathroom sink. Observation on 8/5/19 at 11:24 AM, 2:02 PM and 3:45 PM in the bathroom of room [ROOM NUMBER] revealed 2 unlabeled bed pans and 2 unlabeled wash basins on the floor 1 on each side of the toilet. Interview with Resident #32 on 8/5/19 at 1:32 PM in his room revealed he asked for a bar of soap and a staff member told him a soap dispenser was needed. Continued interview with the resident revealed .they just put in a dispenser today . Interview with Maintenance Director on 8/5/19 at 3:18 PM in the West dining room revealed the facility had a note pad for work orders at the nursing station or staff would stop him in the hall way. Continued interview with the Maintenance Director revealed he was not sure who was responsible to replace hand sanitizer or soap dispensers. Further interview with the Maintenance Director revealed he had replaced the soap dispenser today for room [ROOM NUMBER], and the soap dispenser was on the shelf behind the toilet. Continued interview with the Maintenance Director revealed he did not know the dispenser was not working. Further interview with the Maintenance Director confirmed he .expected them (staff) to report it to make my job more efficient . Interview with Certified Nurse Aide (CNA) #1 on 8/6/19 at 9:07 AM in room [ROOM NUMBER] revealed when asked if the staff could tell which bed pans and wash basins belonged to the resident she stated neither one of these. Continued interview with CNA #1 confirmed I don't know why they are on the ground. Interview with the Housekeeping Supervisor on 8/6/19 at 1:37 PM in the West dining room revealed the housekeeping staff only ensures the dispensers are filled while the maintenance department ensures the dispensers are on the wall and functioning. Interview with Resident #33 on 8/7/19 at 9:33 AM revealed the resident did not have soap for 2 weeks. Continued interview with Resident #33 on 8/7/19 at 9:40 AM in his room revealed the soap dispenser was broken because someone knocked it off. Continued interview revealed the resident was aware and notified one of the CNAs. Continued interview with the resident when asked what he used to wash his hands he stated .using hand sanitizer to wash hands . Continued interview with Resident #33 revealed .I heard housekeeping in there at times. I felt they could have done a better job . Interview with Resident #31 on 8/7/19 at 9:42 AM in his room revealed .it was a little rough. Wasn't any soap at the time, the dispenser was hanging on the wall at the time over to left. I had to pump but there was nothing in there . Continued interview with Resident #31 revealed he was using his own soap in the bottle when using the bathroom and would take it out when he finished. Observation on 8/5/19 at 10:55 AM in room [ROOM NUMBER] revealed an unlabeled basin and bedpan sitting on the bathroom floor. Observation on 8/5/19 at 11:05 AM in room [ROOM NUMBER] revealed yellow liquid in the toilet as well as an unlabeled basin and bedpan on the bathroom floor. Observation on 8/5/19 at 11:29 AM in room [ROOM NUMBER] revealed there was dried brown debris on the toilet seat and dried brown debris on a pillow in the chair. Observation on 8/5/19 at 11:51 AM in room [ROOM NUMBER] revealed a strong odor in the room. The Maintenance Director came into the bathroom and flushed the toilet, then came back with a bottle of air freshner and sprayed the bathroom.",2020-09-01
135,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,925,F,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, pest control customer service report review, facility observation, and interview, the facility failed to maintain an effective pest control program to prevent infestation of insects (flies and gnats) in the kitchen, hallways, and resident rooms. The findings include: Review of the facility policy titled Pest Control dated (MONTH) 2005 revealed .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided by (named pest control service) .Maintenance services assist, when appropriate and necessary, in providing pest control services. Record Review of Pest control customer service reports revealed: 2/20/19 .Small flies noted during service in kitchen .Reviewed with management . 3/20/19 .Small flies noted under dishwasher sink .Reviewed with management .excess water noted under dishwasher .Keep area dry . 4/17/19 .Excess water noted under dishwasher .Keep area dry .Reviewed with management . 5/9/19 .Small flies noted during service by dishwasher sink .Reviewed with management . 6/5/19 .Small flies noted during service under dishwasher .Reviewed with management . 7/24/19 revealed .Excess water under dishwasher .Keep area dry .Illuminated light trap found unplugged, interior kitchen .Large flies in hallways .Reviewed with Management . Record Review of the Life Safety/Plant Ops Communication Report dated 7/8/19 revealed .drain lines, cleaning . Observation on 8/5/19 though 8/21/19 revealed the Illuminated Light Trap (to attract flies and gnats) was not working on the back hall on the right. Observation on 8/8/19 at 9:30 AM in rooms [ROOM NUMBERS] revealed gnats and flies. Continued observation on 8/8/19 at 9:45 AM revealed gnats and flies in the women's public restroom. Continued observation on 8/8/19 at 10:00 AM revealed flies and gnats in the West dining room. Observation on 8/8/19 at 2:00 PM in room [ROOM NUMBER] revealed 1 fly and gnats. Observation on 8/8/19 at 2:10 PM in room [ROOM NUMBER] revealed flies and gnats. Observation on 8/12/19 at 8:15 AM in room [ROOM NUMBER] revealed a fly and gnats. Observation on 8/12/19 at 8:30 AM in the back nurses station revealed flies and gnats. Observation on 8/12/19 at 11:11 AM in Resident #22's room revealed flies and gnats flying around the urinal with yellow liquid in it which was on top of the bedside table in front of the resident. Observation on 8/12/19 at 2:30 PM in the front nurses station revealed flies and gnats around 2 residents Observation on 8/13/19 at 7:30 AM in rooms 28, 29, 30, and 31 of the back hall revealed flies and gnats. Observation on 8/13/19 at 9:30 AM and 8/15/19 at 1:34 PM in the Dietary Department revealed flies and gnats and a small yellow round dryer underneath the sink of the garbage disposal. Continued observation in the dietary department revealed a dehumidifier and vacuum cleaner under a table. Observation on 8/14/19 at 11:00 AM in rooms [ROOM NUMBER] revealed flies and gnats. Observation on 8/14/19 at 11:15 AM at the back nursing station revealed flies and gnats. Observation on 8/15/19 at 7:25 AM at the front nursing station revealed flies. Observation on 8/15/19 at 7:35 AM in room [ROOM NUMBER] revealed flies and gnats. Observation on 8/15/19 at 1:12 PM at in the West dining room revealed a fly. Observation on 8/19/19 at 2:30 PM in the front nurses station revealed a fly crawling on the arm of Resident #9. Observation on 8/20/19 at 10:30 AM in rooms [ROOM NUMBERS] revealed flies and gnats. Observation on 8/20/19 at 1:44 PM revealed a fly flying around a resident and the resident swatting at the insect. Interview with Resident #33 on 8/7/19 at 9:33 AM in his room revealed he was concerned about flies and gnats in the room. During the entire survey from 8/7/19 - 8/21/19 the survey team experienced flies and gnats in the West dining room. Interview with Resident #22 on 8/7/19 at 1:26 PM in Resident #22's room revealed the resident had seen flies in the room prior to the maggots coming out of his thigh and crawling in his skin folds. Interview with LPN #2 on 8/7/19 at 4:26 PM at the nurses station confirmed she was assigned to care for Resident #22 on 6/18/19. Continued interview with LPN #2 confirmed .I did see maggots . Telephone interview with CNA #3 on 8/12/19 at 2:01 PM revealed, .the facility was full of flies and gnats and (named Resident #22) had made complaints about them . Interview with the Dietary Manager on 8/13/19 at 1:57 PM in the West dining room revealed a month ago the connection in the drain of the three compartment sink had come down and was fixed by maintenance through reattachment. Continued interview revealed the floor under the dishwasher and garbage disposal needed to be repaired. The floor was old and the water would pool and not go down the drain. Interview with the Maintenance Director on 8/13/19 at 2:01 PM in the West dining room confirmed the water had cracked the floor in the kitchen where water was pooling on the floor. Interview with the Dietary Manager on 8/15/19 at 12:30 PM in the Dietary Department confirmed .the garbage disposal was probably holding water. Continued interview with the Dietary Manager confirmed the dryer underneath the garbage disposal and sink had been used to dry the floors and the vacuum cleaner had been used to pick up excess water. Interview with a Family Member on 8/15/19 at 1:27 PM in room [ROOM NUMBER] on the front hall revealed she observed flies every time she came to visit her family member. Interview with the Administrator on 8/21/19 in the Social Services office confirmed he knew the Illuminated Trap in the right part of the back hall was not working. Telephone interview with the Pest Service Specialist on 8/26/19 at 9:49 AM revealed the Service Specialist had been servicing the facility for a year and was the primary Specialist. Continued interview with the Service Specialist confirmed when he would see things he would report it to management and they were supposed to fix it and it was a partnership between the facility and the Pest Service. Continued interview with the Service Specialist confirmed the issues with the flies and gnats were a sanitation and structural problem. Continued interview confirmed .when you see pests activities like this it is a sign that it (named facility) was not cleaned regularly .",2020-09-01
136,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,600,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility neglected to provide necessary services to a reisdent by failing to supervise a resident with known exit-seeking behavior resulting in the resident's elopement from the facility for 1 (Resident #10) of 3 residents reviewed for elopement risk. This failure placed Resident #10 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on 9/25/18 at 12:30 PM in the conference room. The Immediate Jeopardy was effective from 5/15/18 and is ongoing. The findings include: Review of undated facility policy, Elopement/Wandering revealed .The intent of the facility is to maintain resident safety by identifying residents who are at risk of wandering/elopement behavior .An elopement/wandering assessment will be completed upon admission and quarterly thereafter .Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately .Care Plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated; patterns identified; and the causes determined .A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained in social services; kept at nurses' station and receptionist desk . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 scored 3 on the Brief Interview for Mental Status indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #10 required supervision with transfers, dressing, toileting; limited assistance with grooming; and extensive assistance with bathing. Medical record review of Baseline Admission Care Plan dated 7/19/18 revealed Resident #10 was at risk for possible wandering related to Dementia. Medical record review of the Comprehensive Care Plan dated 7/27/18 revealed Resident #10 was at risk for elopement as evidenced by exit-seeking behavior, wandering about the facility; asking staff to open the front door. Continued review revealed approaches included: 1. Observe resident for tailgating (following visitors out door) when visitors are in the building. 2. Use verbal and, if necessary, physical cues for redirection to persuade exit-seeking behaviors. 3. Seek a referral for a mental health evaluation from primary care physician as needed. 4. Refer to Social Services as needed. 5. Reevaluate elopement risk at least quarterly. 6. Provide staff supervision for resident when attending out-of-facility activity. 7. Chaplain services PRN (as needed) for emotional and psychosocial needs of the resident. Medical record review of Nursing Notes dated 7/20/18 revealed .exit seeking . asking multiple staff members which door to leave from .packing personal items throughout facility . Continued review of Nursing Notes dated 7/22/18 revealed .continues to be exit-seeking .has not actually opened any outer doors .wanders oblivious to where room is .carrying bag of clothes and linen around stating he is taking them to his momma's right around the corner .has opened outer door beside his room twice this shift . Medical record review of Event Note dated 7/30/18 revealed .Resident was noted missing as dinner trays were being passed. All available staff searched the perimeter of the building as well and two staff members drove their cars around the neighborhood and surrounding streets. Resident was located wandering a street over and was brought back to the building by staff . Surveyor traced a route to the location where the resident was found on 7/30/18 after he eloped. The route included going down a hill; across a 3 lane busy road (hospital access road) with a speed limit of 40 miles per hour and no sidewalk; then turned onto a busier street for a total of 0.45 miles from the facility. Review of a written statement by Certified Nurse Aide (CNA) #9 dated 8/6/18 revealed .Last time I seen (Resident #10) was around 3:45 PM when I clocked out for lunch. He was walking around the building. I came back from lunch about 4:15 PM. I started to check my patients and laying patients down. Dinner trays came out I passed them then started to feed patients. I went into Resident #10's room to feed a patient and noticed (Resident #10) tray was not opened so I started to look for him, I walk the building 3x (3 times) , I couldn't find him, then I told the nurse and supervisor. Then the supervisor called an elopement and everyone started to look, No one seen him, so (Named supervisor, RN #2) said she was going to ride around. She was going Old Hickory Boulevard and I went up Larkin Springs Road to Neely's Bend. I noticed him walking. I stopped beside him and told him to get in the car. He got inside and I called the nursing home to let them know I found him. We returned and he came in and started back walking around . Review of a statement from an unsampled resident dated 8/6/18 revealed .(named resident) saw (Resident #10) in the courtyard which was enclosed, with some family members of another resident. She then saw him by the door stating he was going outside to his truck to find some cigarettes. She states she then saw him leave with the family members (of another resident) . Review of facility investigation dated 7/30/18 revealed when Resident #10 was returned to the facility and asked why he left the facility he stated he was heading to my momma's house around the corner. Interview with the Social Worker on 9/11/18 at 8:57 AM in the conference room revealed Resident #10 was ambulatory. Continued interview revealed he likely exited behind visitors out the front door at an unknown time and was missed at meal time when a search was started. Further interview revealed he was found within 15 minutes and returned to the facility unharmed. Continued interview revealed he was placed on 1:1 monitoring; his daughter was called and she agreed with his transfer to a secure unit; and remained on 1:1 monitoring until his transfer on 8/3/18. Further interview revealed he was a known wandering risk and was in the elopement book (a notebook of resident pictures to identify residents at risk of elopement) kept at the front desk. Interview with CNA #9 on 9/11/18 at 9:50 AM in the conference room revealed Resident #10 was walking around the facility when she went on break at 3:40 PM. Continued interview revealed meal time was between 5:00 PM and 5:30 PM; she was handing out trays; and she noticed Resident #10 was missing. Further interview revealed she walked around the building 3 times but did not find him. Continued interview revealed she went to the Charge Nurse who announced the facility was missing a resident. Further interview revealed the Charge Nurse went one direction in her car and CNA #9 went the other way in her car. Continued interview revealed CNA #9 found Resident #10 at the intersection of Larkin Springs Road and Neely's Bend Road; picked him up; and returned to the facility. Further interview revealed Resident #10 stated he was going to visit some friends and he walked out with some people. Interview with CNA #9 on 9/24/18 at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. Telephone interview with CNA #12 on 9/24/18 at 5:07 PM revealed Resident #10 was constantly trying to get out and he was destined to leave the facility. Continued interview revealed he hung by the door, asking how to get out, but she never saw him leave the facility. Interview with the Administrator on 9/11/18 at 1:45 PM in the conference room stated Resident #10 had exited the building with visitors and walked down the street. Continued interview with the Administrator confirmed the facility failed to supervise Resident #10 adequately to prevent him from eloping from the facility. Interview with CNA #9 on 9/24/18 at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. In summary the last time Resident #10 was seen was at 4:00 PM when he was in the courtyard during smoke break. At 5:20 PM he had not eaten his dinner and was determined to be absent from the facility. At 6:00 PM he was found 0.45 miles from the facility, a distance which cannot be reached in 15 minutes.",2020-09-01
137,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,656,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to implement the Care Plan for a resident who was found unresponsive with no pulse or respirations who was a full code (life saving measures to include chest compressions, intubation, advanced medications, and transfer to hospital) for 1 (Resident #11) of 3 residents reviewed for death; and failed to supervise a resident adequately to prevent his elopement from the facility for 1(Resident #10) of 9 records review for elopement. This failure placed Resident #10 and #11 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 12:30 PM in the conference room. The Immediate Jeopardy was effective from [DATE] and is ongoing. An extended survey was conducted on [DATE] and [DATE] - [DATE]. The findings include: Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #11 had been in the hospital [DATE] - [DATE] for Acute [MEDICAL CONDITION]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was considered to be severely cognitively impaired. Continued review of the MDS revealed Resident #11 required extensive assistance with transfers and personal hygiene; was dependent on 1 person for dressing and bathing; and was always incontinent of bowel and bladder. Medical record review of the Physician order [REDACTED]. transfer to hospital. Further review revealed the form was signed by the resident's sister who was the resident's Power of Attorney. Medical record review of a facility Physician's Note dated [DATE] revealed Resident #11 was .profoundly cachectic and debilitated gentleman requiring multitudinous rehospitalization for management of an [DIAGNOSES REDACTED] due to continued aspiration. At this time he does remain with full course of treatment indicated on his POST form . Medical record review of the Comprehensive Care Plan dated [DATE] revealed .Resident has Advanced Directives on record. Full Code .Resident's Advanced Directives are in effect and their wishes and directions will be carried out in accordance with their Advanced Directives on an ongoing basis through next review date .Staff to follow Advanced Directives for Full Code . Medical record review of Nursing Notes dated [DATE] at 8:00 PM by Registered Nurse #1 revealed the .Resident at the beginning of the shift resting without distress. The outgoing nurse reported the patient came back from the hospital but not doing well, c/o (complained of) no pain checked his blood which was 305 (blood glucose level) and cover with s/s (sliding scale insulin) as ordered on ABT (antibiotics) which was given at 2100 (9:00 PM) r/t (related to) PNA (pneumonia) temp (temperature) 98.4 also changed his tube feeding, and flushed, sat (oxygen saturation) 100% (percent) with O2 at 2L (oxygen at 2 liters per minute) treatment at coccyx and was done, respiration even and nonlabored skin warm and dry upon entering the room again checking on him and the roommate about the 3rd time noticed that his face had changed and unresponsive. Checked on him and he was not breathing anymore, informed the family members who came to the facility and was here until the body was removed . Medical record review of the Event Note dated [DATE] revealed the event was .death - CPR not performed . Continued review revealed .Resident found absent of vitals by nurse. CPR not performed as she believed he was a DNR (Do Not Resuscitate) . Further review revealed the resident's sister was notified at 3:00 AM; the Nurse Practitioner (NP) was notified at 4:00 AM; and the Medical Director was notified at 8:00 AM. Continued review revealed no first aid/treatment given. Review of facility investigation of an undated written statement from RN #1 revealed .On [DATE] this nurse came to work to take over from the day nurse who said this patient (Resident #11) was in critical condition. This night nurse then started monitoring this patient by taking the vital signs, sat 100% on O2 2L, pulse 63 at the same time around 2200 (10:00 PM) tech called this nurse to the room to look at the patient bottom area with skin breakdown. This nurse helped to apply dressing at the coccyx. When the patient was coughing there was so much mucus coming and this nurse decided to suction the patient after given (giving) the patient medication and suctioning him he relaxed and this nurse continue(d) with medication pass. This nurse later went to the patient again around 2330 (11:30 PM) to check on him he was still breathing but the last time this nurse checked on the patient around 0130 - 0200 (1:30 AM - 2:00 AM) the patient was limp and his mouth blue (was) not breathing this nurse checked pulse none and he was gone (resident had expired). Called the family to inform them. The NP was informed and the DON (Director of Nursing) also was informed with a message left on voice mail and an order to release the body to the funeral home given by v.o. (verbal order) (from the NP). Patient body picked up by (Named funeral home) at 0600 (6:00 AM). Patient family was present . Interview with the Administrator and Director of Nursing (DON) on [DATE] at 1:45 PM in the conference room revealed the Administrator confirmed RN #1 failed to perform CPR on a resident who was a full code thus failing to follow the Care Plan. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 scored 3 on the Brief Interview for Mental Status indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #10 required supervision with transfers, dressing, toileting; limited assistance with grooming; and extensive assistance with bathing. Medical record review of Baseline Admission Care Plan dated [DATE] revealed Resident #10 was at risk for possible wandering related to Dementia. Medical record review of the Comprehensive Care Plan dated [DATE] revealed Resident #10 was at risk for elopement as evidenced by exit-seeking behavior, wandering about the facility; asking staff to open the front door. Continued review revealed approaches included: 1. Observe resident for tailgating (following visitors out door) when visitors are in the building. 2. Use verbal and, if necessary, physical cues for redirection to persuade exit-seeking behaviors. 3. Seek a referral for a mental health evaluation from primary care physician as needed. 4. Refer to Social Services as needed. 5. Reevaluate elopement risk at least quarterly. 6. Provide staff supervision for resident when attending out-of-facility activity. 7. Chaplain services PRN (as needed) for emotional and psychosocial needs of the resident. Medical record review of Nursing Notes dated [DATE] revealed .exit seeking . asking multiple staff members which door to leave from .packing personal items throughout facility . Continued review of Nursing Notes dated [DATE] revealed .continues to be exit-seeking .has not actually opened any outer doors .wanders oblivious to where room is .carrying bag of clothes and linen around stating he is taking them to his momma's right around the corner .has opened outer door beside his room twice this shift . Medical record review of Event Note dated [DATE] revealed .Resident was noted missing as dinner trays were being passed. All available staff searched the perimeter of the building as well and two staff members drove their cars around the neighborhood and surrounding streets. Resident was located wandering a street over and was brought back to the building by staff . Surveyor traced a route to the location where the resident was found on [DATE] after he eloped. The route included going down a hill; across a 3 lane busy road (hospital access road) with a speed limit of 40 miles per hour and no sidewalk; then turned onto a busier street for a total of 0.45 miles from the facility. Review of a written statement by Certified Nurse Aide (CNA) #9 dated [DATE] revealed .Last time I seen (Resident #10) was around 3:45 PM when I clocked out for lunch. He was walking around the building. I came back from lunch about 4:15 PM. I started to check my patients and laying patients down. Dinner trays came out I passed them then started to feed patients. I went into Resident #10's room to feed a patient and noticed (Resident #10) tray was not opened so I started to look for him, I walk the building 3x (3 times) , I couldn't find him, then I told the nurse and supervisor. Then the supervisor called an elopement and everyone started to look, No one seen him, so (Named supervisor, RN #2) said she was going to ride around. She was going Old Hickory Boulevard and I went up Larkin Springs Road to Neely's Bend. I noticed him walking. I stopped beside him and told him to get in the car. He got inside and I called the nursing home to let them know I found him. We returned and he came in and started back walking around . Review of a statement from an unsampled resident dated [DATE] revealed .(named resident) saw (Resident #10) in the courtyard which was enclosed, with some family members of another resident. She then saw him by the door stating he was going outside to his truck to find some cigarettes. She states she then saw him leave with the family members (of another resident) . Review of facility investigation dated [DATE] revealed when Resident #10 was returned to the facility and asked why he left the facility he stated he was heading to my momma's house around the corner. Interview with the Social Worker on [DATE] at 8:57 AM in the conference room revealed Resident #10 was ambulatory. Continued interview revealed he likely exited behind visitors out the front door at an unknown time and was missed at meal time when a search was started. Further interview revealed he was found within 15 minutes and returned to the facility unharmed. Continued interview revealed he was placed on 1:1 monitoring; his daughter was called and she agreed with his transfer to a secure unit; and remained on 1:1 monitoring until his transfer on [DATE]. Further interview revealed he was a known wandering risk and was in the elopement book (a notebook of resident pictures to identify residents at risk of elopement) kept at the front desk. Interview with CNA #9 on [DATE] at 9:50 AM in the conference room revealed Resident #10 was walking around the facility when she went on break at 3:40 PM. Continued interview revealed meal time was between 5:00 PM and 5:30 PM; she was handing out trays; and she noticed Resident #10 was missing. Further interview revealed she walked around the building 3 times but did not find him. Continued interview revealed she went to the Charge Nurse who announced the facility was missing a resident. Further interview revealed the Charge Nurse went one direction in her car and CNA #9 went the other way in her car. Continued interview revealed CNA #9 found Resident #10 at the intersection of Larkin Springs Road and Neely's Bend Road; picked him up; and returned to the facility. Further interview revealed Resident #10 stated he was going to visit some friends and he walked out with some people. Interview with CNA #9 on [DATE] at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. Telephone interview with CNA #12 on [DATE] at 5:07 PM revealed Resident #10 was constantly trying to get out and he was destined to leave the facility. Continued interview revealed he hung by the door, asking how to get out, but she never saw him leave the facility. Interview with the Administrator on [DATE] at 1:45 PM in the conference room stated Resident #10 had exited the building with visitors and walked down the street. Continued interview with the Administrator confirmed the facility failed to supervise Resident #10 adequately to prevent him from eloping from the facility and failed to follow the Care Plan to prevent elopement. Interview with CNA #9 on [DATE] at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. In summary the last time Resident #10 was seen was at 4:00 PM when he was in the courtyard during smoke break. At 5:20 PM he had not eaten his dinner and was determined to be absent from the facility. At 6:00 PM he was found 0.45 miles from the facility, a distance which cannot be reached in 15 minutes.",2020-09-01
138,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,658,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to follow acceptable standards of clinical practice by failing to perform Cardiopulmonary Resuscitation (CPR) on a resident who was a found unresponsive with no pulse or respirations who was a full code (chest compressions, intubation, advanced medications, and transfer to hospital) for 1 (Resident #11) of 3 residents reviewed for death. This failure placed Resident #11 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM in the conference room. The Immediate Jeopardy was effective from [DATE] and is ongoing. An extended survey was conducted on [DATE], and [DATE] - [DATE]. The findings include: Review of an undated facility policy, Cardiopulmonary Resuscitation, revealed .CPR will be attempted for any resident who is found to have no palpable pulse and/or discernable respirations unless there is a written physician order [REDACTED].If a resident is found unresponsive and without respirations a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall promptly initiate CPR for residents .CPR will be continued by facility staff until EMS (Emergency Medical Services) arrives to assume responsibility for providing CPR .Upon identifying a resident with a change of condition which presents as an unresponsive condition: 1. Activate the facility emergency response process: Announce CODE BLUE (a means to notify staff a resident has no pulse and/or respirations) and includes retrieving resident medical record. 2. Assess resident for status of breathing and check for pulse. 3. Check the medical record for advance directive status. 4. Retrieve emergency cart and Automated External Defibrillator if available. 5. If resident record indicates CPR is to be instituted then initiate BLS if a pulse and/or respirations are undetectable .The Staff Development Coordinator will maintain an updated list of personnel for recertification (CPR/BLS) purposes and notify staff of recertification . Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #11 had been in the hospital [DATE] - [DATE] for Acute [MEDICAL CONDITION]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was considered to be severely cognitively impaired. Continued review of the MDS revealed Resident #11 required extensive assistance with transfers and personal hygiene; was dependent on 1 person for dressing and bathing; and was always incontinent of bowel and bladder. Medical record review of the Physician order [REDACTED]. transfer to hospital. Further review revealed the form was signed by the resident's sister who was the resident's Power of Attorney. Medical record review of a facility Physician's Note dated [DATE] revealed Resident #11 was .profoundly cachectic and debilitated gentleman requiring multitudinous rehospitalization for management of an [DIAGNOSES REDACTED] due to continued aspiration. At this time he does remain with full course of treatment indicated on his POST form . Medical record review of Nursing Notes dated [DATE] at 8:00 PM by Registered Nurse #1 revealed the .Resident at the beginning of the shift resting without distress. The outgoing nurse reported the patient came back from the hospital but not doing well, c/o (complained of) no pain checked his blood which was 305 (blood glucose level) and cover with s/s (sliding scale insulin) as ordered on ABT (antibiotics) which was given at 2100 (9:00 PM) r/t (related to) PNA (pneumonia) temp (temperature) 98.4 also changed his tube feeding, and flushed, sat (oxygen saturation) 100% (percent) with O2 at 2L (oxygen at 2 liters per minute) treatment at coccyx and was done, respiration even and nonlabored skin warm and dry upon entering the room again checking on him and the roommate about the 3rd time noticed that his face had changed and unresponsive. Checked on him and he was not breathing anymore, informed the family members who came to the facility and was here until the body was removed . Medical record review of the Event Note dated [DATE] revealed the event was .death - CPR not performed . Continued review revealed .Resident found absent of vitals by nurse. CPR not performed as she believed he was a DNR (Do Not Resuscitate) . Further review revealed the resident's sister was notified at 3:00 AM; the Nurse Practitioner (NP) was notified at 4:00 AM; and the Medical Director was notified at 8:00 AM. Continued review revealed no first aid/treatment given. Review of facility investigation of an undated written statement from RN #1 revealed .On [DATE] this nurse came to work to take over from the day nurse who said this patient (Resident #11) was in critical condition. This night nurse then started monitoring this patient by taking the vital signs, sat 100% on O2 2L, pulse 63 at the same time around 2200 (10:00 PM) tech called this nurse to the room to look at the patient bottom area with skin breakdown. This nurse helped to apply dressing at the coccyx. When the patient was coughing there was so much mucus coming and this nurse decided to suction the patient after given (giving) the patient medication and suctioning him he relaxed and this nurse continue(d) with medication pass. This nurse later went to the patient again around 2330 (11:30 PM) to check on him he was still breathing but the last time this nurse checked on the patient around 0130 - 0200 (1:30 AM - 2:00 AM) the patient was limp and his mouth blue (was) not breathing this nurse checked pulse none and he was gone (resident had expired). Called the family to inform them. The NP (Nurse Practitioner) was informed and the DON (Director of Nursing) also was informed with a message left on voice mail and an order to release the body to the funeral home given by v.o. (verbal order) (from the NP). Patient body picked up by (Named funeral home) at 0600 (6:00 AM). Patient family was present . Review of facility investigation revealed RN #1 was suspended on [DATE] pending the investigation. Continued review revealed a note from RN #1 dated [DATE] stating she resigned. Further review of her employee file revealed she was hired on [DATE]; she renewed her CPR certification on [DATE] with an expiration date of [DATE]. Interview with CNA #4 on [DATE] at 10:30 AM in the conference room revealed she came in at 11:00 PM on [DATE] for her shift. Continued interview revealed RN #1 stated Resident #11 was in bad shape. Further interview with CNA #4 revealed the resident was lying in bed with his eyes closed, pale, with shallow respirations. Continued interview revealed RN #1 told her the resident was actively dying to keep an eye on him. Further interview with CNA #4 revealed Resident #11 never opened his eyes all night and did not respond when the CNA turned him and performed hygiene care. Continued interview revealed the morning of [DATE] RN #1 came to tell her the resident had expired so she went in to perform post mortem care. Interview with the Administrator and Director of Nursing (DON) on [DATE] at 1:45 PM in the conference room revealed the DON was aware of Resident #11's death when she came into work on [DATE] and notified the Administrator shortly after, then the investigation was initiated. Continued interview revealed when a nurse discovers a resident who is unresponsive he/she will ask someone to bring the resident's record to the room where they will determine the resident's code status. Further interview revealed if the resident is a full code, CPR will be initiated while one staff member obtains the emergency cart; one staff member calls 911; and one staff member is available to open the doors for the Emergency Medical Services. Further interview revealed the Administrator did not feel it was a system failure but one nurse who failed to use her brain. and the Administrator confirmed RN #1 failed to perform CPR on a resident who was a full code.",2020-09-01
139,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,678,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to adequately monitor and intervene for a serious medical condition when a Registered Nurse (RN) failed to perform cardiopulmonary resuscitation (CPR) on a resident who was found unresponsive with no pulse or respiration who was a full code (life-saving measures to include chest compressions, airway management, medications, and transfer to hospital) for 1 (Resident #11) per investigation of 9 records, 6 of which did not have advanced directives; 1 did not have a POST; and 1 POST was signed 2 weeks after it was initially written. This failure placed Resident #11 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM in the conference room. The Immediate Jeopardy was effective from [DATE] and is ongoing. An extended survey was conducted on [DATE], and [DATE] - [DATE]. The findings include: Review of an undated facility policy, Cardiopulmonary Resuscitation, revealed .CPR will be attempted for any resident who is found to have no palpable pulse and/or discernable respirations unless there is a written physician order [REDACTED].If a resident is found unresponsive and without respirations a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall promptly initiate CPR for residents .CPR will be continued by facility staff until EMS (Emergency Medical Services) arrives to assume responsibility for providing CPR .Upon identifying a resident with a change of condition which presents as an unresponsive condition: 1. Activate the facility emergency response process: Announce CODE BLUE (a means to notify staff a resident has no pulse and/or respirations) and includes retrieving resident medical record. 2. Assess resident for status of breathing and check for pulse. 3. Check the medical record for advance directive status. 4. Retrieve emergency cart and Automated External Defibrillator if available. 5. If resident record indicates CPR is to be instituted then initiate BLS if a pulse and/or respirations are undetectable .The Staff Development Coordinator will maintain an updated list of personnel for recertification (CPR/BLS) purposes and notify staff of recertification . Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #11 had been in the hospital [DATE] - [DATE] for Acute [MEDICAL CONDITION]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was considered to be severely cognitively impaired. Continued review of the MDS revealed Resident #11 required extensive assistance with transfers and personal hygiene; was dependent on 1 person for dressing and bathing; and was always incontinent of bowel and bladder. Medical record review of the Physician order [REDACTED]. transfer to hospital. Further review revealed the form was signed by the resident's sister who was the resident's Power of Attorney. Medical record review of a facility Physician's Note dated [DATE] revealed Resident #11 was .profoundly cachectic and debilitated gentleman requiring multitudinous rehospitalization for management of an [DIAGNOSES REDACTED] due to continued aspiration. At this time he does remain with full course of treatment indicated on his POST form . Medical record review of Nursing Notes dated [DATE] at 8:00 PM by Registered Nurse #1 revealed the .Resident at the beginning of the shift resting without distress. The outgoing nurse reported the patient came back from the hospital but not doing well, c/o (complained of) no pain checked his blood which was 305 (blood glucose level) and cover with s/s (sliding scale insulin) as ordered on ABT (antibiotics) which was given at 2100 (9:00 PM) r/t (related to) PNA (pneumonia) temp (temperature) 98.4 also changed his tube feeding, and flushed, sat (oxygen saturation) 100% (percent) with O2 at 2L (oxygen at 2 liters per minute) treatment at coccyx and was done, respiration even and nonlabored skin warm and dry upon entering the room again checking on him and the roommate about the 3rd time noticed that his face had changed and unresponsive. Checked on him and he was not breathing anymore, informed the family members who came to the facility and was here until the body was removed . Medical record review of the Event Note dated [DATE] revealed the event was .death - CPR not performed . Continued review revealed .Resident found absent of vitals by nurse. CPR not performed as she believed he was a DNR (Do Not Resuscitate) . Further review revealed the resident's sister was notified at 3:00 AM; the Nurse Practitioner (NP) was notified at 4:00 AM; and the Medical Director was notified at 8:00 AM. Continued review revealed no first aid/treatment given. Review of facility investigation of an undated written statement from RN #1 revealed .On [DATE] this nurse came to work to take over from the day nurse who said this patient (Resident #11) was in critical condition. This night nurse then started monitoring this patient by taking the vital signs, sat 100% on O2 2L, pulse 63 at the same time around 2200 (10:00 PM) tech called this nurse to the room to look at the patient bottom area with skin breakdown. This nurse helped to apply dressing at the coccyx. When the patient was coughing there was so much mucus coming and this nurse decided to suction the patient after given (giving) the patient medication and suctioning him he relaxed and this nurse continue(d) with medication pass. This nurse later went to the patient again around 2330 (11:30 PM) to check on him he was still breathing but the last time this nurse checked on the patient around 0130 - 0200 (1:30 AM - 2:00 AM) the patient was limp and his mouth blue (was) not breathing this nurse checked pulse none and he was gone (resident had expired). Called the family to inform them. The NP (Nurse Practitioner) was informed and the DON (Director of Nursing) also was informed with a message left on voice mail and an order to release the body to the funeral home given by v.o. (verbal order) (from the NP). Patient body picked up by (Named funeral home) at 0600 (6:00 AM). Patient family was present . Review of facility investigation of a written statement by Licensed Practical Nurse (LPN) #1 dated [DATE] revealed .During our shift (RN #1) asked me to help her find and set up a suction machine for (Resident #11). I left her in his room after we set the machine up. A while later I was at the NS (nurses' station) desk charting when (RN #1) came passing by with her med cart stating He died . When I asked who? She said (Resident #11) and proceeded toward the end of North Hall where her rooms are . Review of facility investigation of an interview between the DON and Certified Nurse Aide (CNA) #4 dated [DATE] revealed .When I came on he (Resident #11) had his eyes closed and lying in the bed. The nurse said he was in bad shape and just got back from the hospital. I saw him 30 minutes before (RN #1) found him. I heard the tube feeding of his roommate beeping and asked (RN #1) to check on him. She never said anything to me about being a full code or DNR . Review of facility investigation of an interview between the DON and CNA #5 dated [DATE] revealed .I walked past (RN #1) shortly after he passed away. All she said was she just had a patient die. That's the only thing I knew or heard . Review of facility investigation revealed RN #1 was suspended on [DATE] pending the investigation. Continued review revealed a note from RN #1 dated [DATE] stating she resigned. Further review of her employee file revealed she was hired on [DATE]; she renewed her CPR certification on [DATE] with an expiration date of [DATE]. Review of facility investigation revealed CNAs were not included in continued education on CPR yet are expected to participate in a Code Blue if a resident is found unresponsive. Telephone interview with LPN #1 on [DATE] at 10:05 AM revealed RN #1 had told her Resident #11 had passed away. Continued interview revealed the paperwork was on the chart to indicate if a resident was a DNR or full code. Further interview revealed if someone else is available that person can check the chart for the resident status but if not you may have to do it yourself. Continued interview revealed after you determine the code status then you decide if you are going to call a code (if you notify staff a resident has stopped breathing and has no pulse). Review of facility policy on CPR revealed if a resident is found unresponsive and without respirations a licensed staff member who is certified in CPR/BLS shall promptly initiate CPR for residents. Interview with CNA #4 on [DATE] at 10:30 AM in the conference room revealed she came in at 11:00 PM on [DATE] for her shift. Continued interview revealed RN #1 stated Resident #11 was in bad shape. Further interview with CNA #4 revealed the resident was lying in bed with his eyes closed, pale, with shallow respirations. Continued interview revealed RN #1 told her the resident was actively dying to keep an eye on him. Further interview with CNA #4 revealed Resident #11 never opened his eyes all night and did not respond when the CNA turned him and performed hygiene care. Continued interview revealed the morning of [DATE] RN #1 came to tell her the resident had expired so she went in to perform post mortem care. Further interview revealed the brother and sister arrived at the facility. Interview with the Administrator and Director of Nursing (DON) on [DATE] at 1:45 PM in the conference room revealed the DON was aware of Resident #11's death when she came into work on [DATE] and notified the Administrator shortly after, then the investigation was initiated. Continued interview revealed when a nurse discovers a resident who is unresponsive he/she will ask someone to bring the resident's record to the room where they will determine the resident's code status. Further interview revealed if the resident is a full code, CPR will be initiated while one staff member obtains the emergency cart; one staff member calls 911; and one staff member is available to open the doors for the Emergency Medical Services. Continued interview revealed some CNAs are CPR certified and can participate in a code while others can bring the cart; call 911; and open doors. Further interview revealed the Administrator did not feel it was a system failure but one nurse who failed to use her brain. and the Administrator confirmed RN #1 failed to perform CPR on a resident who was a full code.",2020-09-01
140,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,689,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to supervise a resident with known exit-seeking behavior resulting in the resident's elopement from the facility for 1 (Resident #10) of 3 residents reviewed for elopement risk. This failure placed Resident #10 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on 9/25/18 at 12:30 PM in the conference room. The Immediate Jeopardy was effective from 5/15/18 and is ongoing. The findings include: Review of undated facility policy, Elopement/Wandering revealed .The intent of the facility is to maintain resident safety by identifying residents who are at risk of wandering/elopement behavior .An elopement/wandering assessment will be completed upon admission and quarterly thereafter .Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately .Care Plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated; patterns identified; and the causes determined .A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained in social services; kept at nurses' station and receptionist desk . Review of undated facility policy, Missing Resident, revealed .Notify the Charge Nurse .Room to room check will be conducted to identify all residents .Check all areas of the facility including bathrooms, closets, shower and tub rooms .Check areas outside the facility .If the resident has not been found within 15 minutes, or after a search of the facility and immediately outside the building the Charge Nurse will notify the police or local law enforcement agency; notify family or responsible party; notify attending physician; notify other regulatory agencies .When the resident returns to the facility the Charge Nurse will examine the resident for injuries; contact attending physician and report findings and condition of resident .A complete and thorough root cause analysis of the elopement should be done to prevent recurrence, ensure policies and procedures and systems are effective, and to protect other residents . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 scored 3 on the Brief Interview for Mental Status indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #10 required supervision with transfers, dressing, toileting; limited assistance with grooming; and extensive assistance with bathing. Medical record review of Baseline Admission Care Plan dated 7/19/18 revealed Resident #10 was at risk for possible wandering related to Dementia. Medical record review of the Comprehensive Care Plan dated 7/27/18 revealed Resident #10 was at risk for elopement as evidenced by exit-seeking behavior, wandering about the facility; asking staff to open the front door. Continued review revealed approaches included: 1. Observe resident for tailgating (following visitors out door) when visitors are in the building. 2. Use verbal and, if necessary, physical cues for redirection to persuade exit-seeking behaviors. 3. Seek a referral for a mental health evaluation from primary care physician as needed. 4. Refer to Social Services as needed. 5. Reevaluate elopement risk at least quarterly. 6. Provide staff supervision for resident when attending out-of-facility activity. 7. Chaplain services PRN (as needed) for emotional and psychosocial needs of the resident. Medical record review of Nursing Notes dated 7/20/18 revealed .exit seeking . asking multiple staff members which door to leave from .packing personal items throughout facility . Continued review of Nursing Notes dated 7/22/18 revealed .continues to be exit-seeking .has not actually opened any outer doors .wanders oblivious to where room is .carrying bag of clothes and linen around stating he is taking them to his momma's right around the corner .has opened outer door beside his room twice this shift . Medical record review of Event Note dated 7/30/18 revealed .Resident was noted missing as dinner trays were being passed. All available staff searched the perimeter of the building as well and two staff members drove their cars around the neighborhood and surrounding streets. Resident was located wandering a street over and was brought back to the building by staff . Surveyor traced a route to the location where the resident was found on 7/30/18 after he eloped. The route included going down a hill; across a 3 lane busy road (hospital access road) with a speed limit of 40 miles per hour and no sidewalk; then turned onto a busier street for a total of 0.45 miles from the facility. Review of a written statement by Certified Nurse Aide (CNA) #9 dated 8/6/18 revealed .Last time I seen (Resident #10) was around 3:45 PM when I clocked out for lunch. He was walking around the building. I came back from lunch about 4:15 PM. I started to check my patients and laying patients down. Dinner trays came out I passed them then started to feed patients. I went into Resident #10's room to feed a patient and noticed (Resident #10) tray was not opened so I started to look for him, I walk the building 3x (3 times) , I couldn't find him, then I told the nurse and supervisor. Then the supervisor called an elopement and everyone started to look, No one seen him, so (Named supervisor, RN #2) said she was going to ride around. She was going Old Hickory Boulevard and I went up Larkin Springs Road to Neely's Bend. I noticed him walking. I stopped beside him and told him to get in the car. He got inside and I called the nursing home to let them know I found him. We returned and he came in and started back walking around . Review of a statement from an unsampled resident dated 8/6/18 revealed .(named resident) saw (Resident #10) in the courtyard which was enclosed, with some family members of another resident. She then saw him by the door stating he was going outside to his truck to find some cigarettes. She states she then saw him leave with the family members (of another resident) . Review of facility investigation dated 7/30/18 revealed when Resident #10 was returned to the facility and asked why he left the facility he stated he was heading to my momma's house around the corner. Interview with the Social Worker on 9/11/18 at 8:57 AM in the conference room revealed Resident #10 was ambulatory. Continued interview revealed he likely exited behind visitors out the front door at an unknown time and was missed at meal time when a search was started. Further interview revealed he was found within 15 minutes and returned to the facility unharmed. Continued interview revealed he was placed on 1:1 monitoring; his daughter was called and she agreed with his transfer to a secure unit; and remained on 1:1 monitoring until his transfer on 8/3/18. Further interview revealed he was a known wandering risk and was in the elopement book (a notebook of resident pictures to identify residents at risk of elopement) kept at the front desk. Interview with CNA #9 on 9/11/18 at 9:50 AM in the conference room revealed Resident #10 was walking around the facility when she went on break at 3:40 PM. Continued interview revealed meal time was between 5:00 PM and 5:30 PM; she was handing out trays; and she noticed Resident #10 was missing. Further interview revealed she walked around the building 3 times but did not find him. Continued interview revealed she went to the Charge Nurse who announced the facility was missing a resident. Further interview revealed the Charge Nurse went one direction in her car and CNA #9 went the other way in her car. Continued interview revealed CNA #9 found Resident #10 at the intersection of Larkin Springs Road and Neely's Bend Road; picked him up; and returned to the facility. Further interview revealed Resident #10 stated he was going to visit some friends and he walked out with some people. Interview with CNA #9 on 9/24/18 at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. Telephone interview with CNA #12 on 9/24/18 at 5:07 PM revealed Resident #10 was constantly trying to get out and he was destined to leave the facility. Continued interview revealed he hung by the door, asking how to get out, but she never saw him leave the facility. Interview with the Administrator on 9/11/18 at 1:45 PM in the conference room stated Resident #10 had exited the building with visitors and walked down the street. Continued interview with the Administrator confirmed the facility failed to supervise Resident #10 adequately to prevent him from eloping from the facility. Interview with CNA #9 on 9/24/18 at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. In summary the last time Resident #10 was seen was at 4:00 PM when he was in the courtyard during smoke break. At 5:20 PM he had not eaten his dinner and was determined to be absent from the facility. At 6:00 PM he was found 0.45 miles from the facility, a distance which cannot be reached in 15 minutes.",2020-09-01
158,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2020-01-28,609,D,1,0,GTVW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of Misappropriation of Property to the State Survey Agency timely for 1 resident (Resident #1) of 5 residents reviewed. The findings included: Review of the facility policy titled Abuse Protocol, last revised 11/2019, showed .The facility must .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made .in accordance with State Law . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 8/15/19 showed .[MEDICATION NAME] ([MEDICATION NAME]) 325 mg (milligrams) 5 mg tablet .every 4 hours .pain . Review of a facility investigation dated 1/1/2020 showed Licensed Practical Nurse (LPN) #6 contacted the facility pharmacy for a refill of Resident #1's [MEDICATION NAME] (pain medication). The pharmacy informed the LPN that the pharmacy had dispensed 1 card containing 30 tablets of the medication to the facility on [DATE] (5 days earlier) for Resident #1. The facility completed an investigation but was unable to locate the missing medication. The resident was refunded the cost of the medication. During an interview on 1/28/2020 at 12:00 PM, the Regional Director of Administration stated .(the facility) was unable to determine what happened to the missing narcotics and that was why (the facility) had not reported the missing narcotics to the local or state agencies . In summary, the facility was unable to locate 30 tablets of [MEDICATION NAME] dispensed by the pharmacy for Resident #1 on 1/1/2020. As of 1/28/2020 the facility had not reported the missing medication to the State Survey Agency (28 days later).",2020-09-01
159,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-04-04,657,D,1,0,RMJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to update a care plan for 1 of 4 sampled residents (Resident #4) following a fall. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and needed extensive assistance of 2 people with transfers. Review of Falls Log indicated Resident #4 had falls on 1/25/18 and 1/27/18. Observation on 4/2/18 at 9:30 AM revealed Resident #4's bed was in a low position with a fall mat on the floor next to her bed. Review of the Care Plan dated 8/10/16 revealed the plan had not been updated to include a fall mat or placing the bed in a low position. Interview with the Director of Nursing (DON) on 4/4/18 at 12:23 PM, in the DON's office, revealed the care plan should have been updated after the interventions were initiated.",2020-09-01
160,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-04-04,659,G,1,0,RMJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to follow the plan of care for 1 of 4 sampled residents (Resident #1). The facility's failure to follow the plan of care for transfers resulted in actual harm to Resident #1. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] for palliative care. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was completely dependent upon staff to conduct all Activities of Daily Living (ADL's) and required maximum assist of 2 staff for transfers. Medical record review of the resident's Plan of Care dated 2/12/17 revealed .Alteration in ADL's related to dementia, immobility .total dependent care .transfer (with) max assist x (of) 2 (staff) . Medical record review of the Departmental Notes for Nursing dated 6/6/17 at 12:30 PM revealed the Hospice Certified Nursing Assistant (CNA) was getting the resident out of bed and transferring to a shower chair when the resident slid down the CNA's leg to the floor. The transfer was conducted solely by the Hospice CN[NAME] Interview with the Administrator on 4/11/18 at 1:15 PM, by phone, confirmed the Hospice CNA did not follow the plan of care for a 2-person transfer.",2020-09-01
161,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-04-04,689,G,1,0,RMJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure 1 of 4 residents (Resident #1) was kept safe from falls by contracted staff caring for residents. The facility's failure to ensure a safe transfer resulted in actual harm to Resident #1. The findings included: Review of the facility's policy titled Fall Risk Evaluation, Prevention, and Intervention reviewed 1/17/17 revealed .VII Procedure .D. When a fall occurs: 1. Assess for injuries, and provide treatment as necessary . The policy did not address not moving the resident. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Plan of Care dated 2/12/17 revealed .Alteration in ADL's related to dementia, immobility .total dependent care .transfer (with) max assist x (of) 2 (staff) . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and was totally dependent on staff for all Activities of Daily Living (ADL's) and required the extensive assistance of 2 people for transfers. Medical record review of a Fall Risk Evaluation dated 3/21/17 revealed the resident was assessed as a high risk for falls. Review of the Departmental Notes for Nursing dated 6/6/17 and timed 12:30 PM revealed the contracted Hospice Certified Nursing Assistant (CNA) was getting the resident out of bed to transfer to a shower chair when the resident slid down the CNA's leg to the floor. The Hospice CNA called for assistance. The resident was examined in the shower room with no apparent injury .no redness or bruising noted . The family and physician were notified. Medical record review of Departmental Notes for Nursing dated 6/6/17 and timed 1:53 PM revealed .Noted right lateral ankle bruising/blueness with [MEDICAL CONDITION] and scratch. Resident frowns when ankle is touched . Continued review revealed the family was at bedside. Further review revealed the physician was notified and x-rays were ordered. Review of the Resident #1's x-rays completed on 6/6/17 indicated non-displaced fractures of the left distal femur, right trimalleollar, left distal tibia and distal fibula, and the right distal femoral. The x-ray reports further indicated the bones were diffusely severely osteopenic. Medical record review of Departmental Notes for Nursing dated 6/12/17 revealed the Nurse Practitioner had discussed the patient's status with the resident's family including .no need for inpatient evaluation if patient cannot undergo surgery, cancel transfer to hospital . Continued review revealed the Administrator had also discussed obtaining additional x-rays which must be performed at the hospital and the family declined .due to pain in moving her . Review of the investigation by the facility, dated 6/6/17 indicated the Hospice CNA attempted to transfer the resident to a shower chair. The resident was heavier than the CNA expected and the resident slid down the CNA's leg to the floor as an assisted fall. The Registered Nurse (RN) assessed the resident in the shower room and did not identify any injuries. The facility identified the Hospice CNA was not familiar with the resident or the care plan to determine how many people needed to assist the resident for transfer. A Post Fall Assessment Huddle was completed on 6/16/17 and identified that the Hospice CNA is to call for assistance. The huddle concluded that the resident initially did not have any injuries but was later found to have multiple injuries after x-rays were completed for the resident. Review of the (name) Hospice Education for the Hospice CNA revealed the last documented training for Resident Lifting and Transfers was completed on 1/31/12 and the last competency checks provided were dated (MONTH) and (MONTH) of 2011. Review of the contract between the hospice and the facility dated 5/2/07 indicated that all staff possessed the education, skills, and training necessary to provide facility services. Review of the Nursing Facility Services Agreement between hospice and the facility dated 5/2/07, revealed .Qualifications of Personnel (b) (i) are duly licensed, credentialed, certified and/or registered as required under applicable state laws (ii) possess the education, skills, training, and other qualifications necessary to provide Facility Services . Observations on 4/2/18 at 8:45 AM and 4/4/18 at 8:05 AM revealed Resident #1 was in her room. The resident was lying in bed with her arms contracted to her chest and her right leg was bent at the knee. Interview with the Administrator on 4/2/18 at 10:30 AM, in the MDS office, indicated all falls were investigated by Risk Management. Interview with Registered Nurse (RN) #19 on 4/3/18 at 8:00 AM, by phone, revealed when she was notified of the fall, the resident had already been transferred to the shower chair and was in the shower room. The RN assessed the resident at that time and did not see any obvious deformities or swelling. The resident was nonverbal and did not appear to be in any distress at the time. Further interview revealed the RN was approached by the resident's family member approximately 1 to 2 hours later and the resident appeared to be in pain when her lower extremities were touched. Continued interview revealed the RN then reassessed the resident and noticed swelling and discoloration to lower extremities. Interview with the Director of Nursing (DON) on 4/3/18 at 1:10 PM, in the MDS office confirmed if a fall occurs in the facility the resident should be assessed by a nurse before moving. Interview with Family Member #2 on 4/4/18 at 8:05 AM, in the resident's room, indicated the family comes to the facility at meals times to assist the resident with eating. Family Member #2 indicated the resident had been bed ridden at home for approximately [AGE] years prior to becoming a resident at the facility and had been mostly cared for by family at home. The family stated the resident was lying in bed on the day of the fall, and when they came to feed her the family member sat on the bed next to the resident and the resident made a face and groaned. The family member pulled the cover back and noticed the leg was swollen and discolored. The nurse was notified and x-rays were ordered. The family member stated the resident had increased pain but this has been controlled with a change in medications. Interview with Certified Nursing Assistant (CNA) #20 on 4/4/18 at 8:10 AM, by phone, revealed when she answered the call light the resident was on the floor in a sitting position with her legs bent beside her. Continued interview revealed she helped the Hospice CNA transfer the resident into the shower chair, and then immediately notified the charge nurse of the incident. Further interview revealed the resident had not appeared to be in distress due to the resident had not exhibited any crying or moaning at the time of the fall. Interview with the Hospice CNA on 4/4/18 at 10:30 AM, by phone revealed she was attempting to give the resident a shower. She sat the resident up on the side of the bed and locked the shower chair next to the bed for transfer. When she realized the resident was too heavy to lift by herself she slid the resident down her leg to the floor and put the call light on for assistance. When assistance from a facility CNA came, they transferred the resident to the shower chair and she took the resident to the shower prior to the resident being assessed by the nurse. She stated this was the first time she had worked with the resident and was not aware of the need for a 2 persons assist, and was not aware of where to look to find the information. Interview with the Administrator on 4/4/18 at 11:30 AM, in the MDS office, indicated the training for the Hospice CNA's were required prior to them assisting residents at the facility, along with a background check and proof of certification. Continued interview with the Administrator revealed the facility does not require the hospice agency to provide updated training documentation. Interview with the Administrator on 4/11/18 at 1:15 PM, by phone revealed the Hospice CNA was not using a gait belt to transfer the resident. The Administrator stated that they have numbers above each resident's bed who need help with transferring; 1 would need assistance of 1 person, 2 would need assistance of 2 people.",2020-09-01
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
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
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
233,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2019-05-21,609,D,1,0,JKQQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review and interviews, the facility failed to ensure an allegation of abuse was reported timely to the facility Administrator and to other officials (State Survey Agency and Adult Protective Services) in accordance with Federal and State law for 1 resident (#1) of 3 residents reviewed for Abuse on 3 nursing units for 3 sampled residents. The findings included: Review of facility policy Patient Protection and Response Policy for Allegation/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation dated 12/11/17 revealed .6. Reporting Policy .Any partner having either direct or indirect knowledge of any event that might constitute abuse .must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse . Review of a facility investigation dated 4/30/19 revealed Certified Nursing Assistant (CNA) #2 reported to the charge nurse on 4/30/19 she witnessed possible abuse by CNA #1 toward Resident #1 on the evening of 4/29/19. Continued review revealed the charge nurse notified Administration of the allegation and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) interviewed CNA #2. Further review revealed CNA #2 reported she witnessed CNA #1 grab the arm of Resident #1 and forcefully push her back into her wheelchair with an open hand. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely cognitive impaired. Continued review revealed the resident required extensive assistance of 2 persons for bed mobility and extensive assistance of 1 person for transfers. Telephone interview with CNA #1 on 5/21/19 at 10:20 AM revealed she put her hands on the shoulder of the resident to ease her back into her chair because she was afraid the resident would fall. Interview with the Administrator on 5/21/19 at 10:50 AM, in the Conference Room, confirmed the facility failed to report an allegation of abuse within 2 hours and failed to follow facility policy.",2020-09-01
234,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2018-08-16,609,D,1,0,Y10D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure an allegation of abuse was reported timely to the state agency for 1 resident (#3) of 3 residents reviewed for abuse of 3 sampled residents. The findings included: Review of facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation revised 12/11/17 revealed .6. Reporting Policy .It is the policy of this facility that 'abuse' allegations .are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #3 was admitted to the facility 12/8/12 with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was moderately cognitive impaired and required extensive assistance for bed mobility, transfers, and personal hygiene. Review of a facility investigation dated 7/25/18 revealed on 7/25/18 at approximately 3:30 PM Resident #3 reported to her granddaughter a Certified Nursing Assistant (CNA) had gotten irritated with her, choked her, and threw water on her about a week ago. Continued review revealed the granddaughter reported the allegation to the nurse. Further review revealed the nurse interviewed Resident #3 and then reported the allegation to the appropriate administrative personnel, who initiated an investigation. Continued review revealed on 7/26/18 the resident changed her report of the incident and stated the CNA actually hit her on the leg, but did not choke her. Further review revealed the alleged incident was not reported to the state survey agency. Interview with the Director of Nursing (DON) on 8/16/18 at 1:00 PM, in the Conference Room, confirmed the facility failed to report the alleged incident to the state survey agency and the facility failed to follow facility policy.",2020-09-01
235,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,329,D,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, facility documentation, medical record review, and interview, the facility administered unnecessary medications for 2 residents (#3 and #24) of 15 residents reviewed for medication errors. The findings included: Review of the facility policy Preparation and General Guidelines dated 6/2016, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered .The Medication Administration Record [REDACTED]. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of untitled facility documentation dated 8/10/17, revealed .Med (Medication) cart nurse .(Licensed Practical Nurse (LPN) #5) was on lunch break .(Resident #3) had a scheduled dose of [MEDICATION NAME] (narcotic pain medication) 10 mg (milligrams) due .patient's husband, requesting the medication be given .(Registered Nurse (RN) #2) .administered the medication .signed out of the narcotic count log and the IMAR (electronic medication administration record) .(LPN #5) returned from lunch, he (LPN #5) noted the medication would not scan in IMAR due to already being signed out but administered anyway (LPN #5 administered another dose) . Telephone interview with LPN #5 on 10/18/17 at 9:15 AM, revealed on 8/10/17, LPN #5 returned from lunch, obtained a dose of the scheduled [MEDICATION NAME] 10 mg for Resident #3, administered the medication, returned to the medication cart, began to sign out the narcotic on the resident's [MEDICATION NAME] record sheet, and noted the narcotic had already been signed out for the scheduled dose by RN #2. Continued interview confirmed LPN #5 had administered a second dose of [MEDICATION NAME] and reported the medication error to his Charge Nurse, RN #1. Further interview confirmed LPN #5 had not followed the facility's policy for safe medication administration. Interview with the Director of Nursing on 10/19/17 at 4:34 PM, in the conference room, confirmed Resident #3 received an unnecessary dose of [MEDICATION NAME]. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 3, indicating severely impaired cognitive abilities. Medical record review of the Nurse's Notes dated 10/26/17 for Resident #24, written by RN #4, revealed .8:30 PM Pt (patient) is screaming @ (at) the top of her lungs, combative, trying to throw herself into the floor. PRN (as needed) and scheduled [MEDICATION NAME] given (anti-anxiety medication) outcome not effective. Pt is threatening staff. (On call physician service) paged (on-call medical service) .NP (Nurse Practitioner) gave (an order to RN #4) .1 mg [MEDICATION NAME] IM (intramuscular) x1 dose now for increased agitation and combative behavior. Interview with RN #4 on 12/4/17 at 3:28 PM, in the conference room, confirmed the order for [MEDICATION NAME] had been initially written incorrectly for an oral dose and re-written incorrectly [MEDICATION NAME] 2MG/ML VIAL Give 1mg (1ml) IM .Verbal order .(on call physician service) . Further interview revealed RN #4 was counseled not to include concentrations when writing future orders. Telephone interview with LPN #8 on 12/4/17 at 3:43 PM confirmed RN #4 received the order for a 1 time dose of [MEDICATION NAME] 1 mg IM on 10/26/17 for Resident #24. Further interview revealed he borrowed from another resident's supply of [MEDICATION NAME] at 8:30 PM and incorrectly administered a 1ml (2 mg) IM dose to Resident #24. Further interview revealed LPN #8 did not use the [MEDICATION NAME] supplied in the facility's emergency medication box because he wanted to administer the [MEDICATION NAME] quickly. Continued interview revealed LPN #8 discovered the medication error during counting (reconciling the number of controlled medications at shift change) with the oncoming night shift nurse, there was a shortage of a half milliliter (0.5 ml in the 4 ml multi-dose [MEDICATION NAME] vial supplied by the pharmacy). During the interview, LPN #8 stated the sign out sheet for the [MEDICATION NAME] was reviewed for the first time during the counting procedure and he realized a double dose had been administered. Interview confirmed the pharmacy information printed on the [MEDICATION NAME] sign-out sheet read [MEDICATION NAME] 2 mg/ml .Inject 0.5-1mg (0.25-0.5 ml) . Continued interview confirmed LPN #8 had not read the information on the vial of [MEDICATION NAME] and administered 2 mg instead of the ordered 1 mg dose. Interview revealed the error was reported to RN #3, the night shift supervisor. Further interview revealed LPN #8 had participated in the facility-wide in-service conducted on 10/19/17 What Are the Eight Rights of Medication Administration Safety. Continued interview confirmed he did not follow the third right Right Dose when he administered the double dose of [MEDICATION NAME] on 10/26/17. Telephone interview with the night shift nursing supervisor, RN #3, on 12/5/17 at 11:08 AM, confirmed LPN #8 initially reported the medication error of 10/26/17 to her. Continued interview revealed I wasn't sure if I was the one responsible to report it (the medication error) to (on call physician service) .it happened 2-3 hours before I came on duty . Interview continued and confirmed RN #3 did not report the medication error to her supervisor on the morning of 10/27/17. Further interview confirmed RN #3 had not initiated the facility's Medication Error Checklist and Report after LPN #8 reported the medication error. Interview with the Assistant Director of Nursing on 12/4/17 at 2:42 PM, in the conference room, confirmed Resident #24 received a double dose of [MEDICATION NAME] and RN #3 failed to report the medication error to the on call physician and to initiate an incident report. Continued interview revealed the [MEDICATION NAME] order was transcribed incorrectly by RN #4 and confirmed nursing principles for accurate recording and transcription of telephone orders had not been shared with the facility's nurses who receive and transcribe orders.",2020-09-01
236,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,333,J,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility contract, review of the Practical Nurse Program code of conduct, medical record review and interviews, the facility failed to prevent significant medication errors for 3 residents (#1, #4, #11) of 15 residents reviewed for medication errors. Resident #1 received 9 medications in error prescribed for Resident #2. The error resulted in Resident #1 becoming sedated, having decreased respirations, requiring multiple doses of [MEDICATION NAME] (medication used to treat an overdose of opioids in an emergency situation). Resident #4 did not receive his prescribed medications, including a diuretic, an oral diabetic medication to control elevated blood sugars, a beta blocker (a medication which carries a precaution of not discontinuing suddenly), and a blood thinner to prevent blood clots in a resident with a fractured femur through 7 shifts, from the evening of 8/25/17 through 8/27/17. Resident #11 had an non-prescribed [MEDICATION NAME] medication administered on 4/9/17. The facility's failure to ensure medications were administered to the correct resident and failure to ensure residents received all prescribed medications, resulted in significant medication errors and placed Resident #1, #4, and #11 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Nursing Home Administrator (NHA) and Director of Nursing (DON), were informed of the Immediate Jeopardy on 12/4/17, at 9:00 AM in the Administrator's office. The IJ was effective 4/9/17 and is ongoing. Noncompliance continues at the severity of J level. An extended survey was conducted from 12/4/17 through 12/5/17. The facility was cited Substandard Quality of Care at F-333(J). The findings included: Review of the facility policy Preparation and General Guidelines dated 6/2016, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered .The Medication Administration Record [REDACTED]. Review of the contract between the facility and the technical college with the practical nursing program Clinical Affiliation Agreement . dated 5/10/16, revealed .While enrolled in clinical experience at the Facility .students .will be subject to applicable policies of the Institution (NHC Healthcare Fort Sanders) and the Affiliate (Practical Nurse Program) .Institution shall be responsible for supervising students at all times while present at the Facility for clinical experience .Affiliate shall retain complete responsibility for patient care providing adequate supervision of students at all times .Students will not be expected nor allowed to perform services in lieu of staff employees . Review of the (Practical Nurse Program) Code of Conduct undated, revealed .When giving meds (medications) YOU ARE RESPONSIBLE to use the correct patient identifiers-Never Ever Assume .Respect and ensure the safety and well-being of the patients .act to obtain appropriate supervision . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status, indicating severe cognitive impairment. Further review of the MDS revealed he required extensive assist for most activities of daily living. Medical record review revealed Resident #1 began receiving hospice services 8/5/17, with a [DIAGNOSES REDACTED]. Medical record review of the Physician Orders and the Medication Administration Record [REDACTED]. Continued review revealed Resident #1 had PRN (as needed) medications of [MEDICATION NAME] for pain or fever, [MEDICATION NAME] for anxiety and [MEDICATION NAME] sulfate for pain or air hunger. Continued review of the MAR for August, September, and (MONTH) (YEAR), revealed the resident had received one dose each of the [MEDICATION NAME], and [MEDICATION NAME] sulfate in (MONTH) (YEAR), and did not receive any PRN medications in (MONTH) or (MONTH) (YEAR). Medical record review revealed Resident #2, who was the roommate of Resident #1, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Orders and the Medication Administration Record [REDACTED]. Medical record review of Resident #1's Nurse's Note dated 10/6/17 revealed .At 10:15 AM pt (patient) given incorrect medication of Roommates (Resident #2) .Meds (medication) given [MEDICATION NAME] (narcotic pain medication) .insulin (medication to treat [MEDICAL CONDITION]) .NP (Nurse Practitioner) was in building .ORDERS immediately given and instituted .IV (intravenous fluids) D5W (5% [MEDICATION NAME] in water/to treat low blood glucose) .[MEDICATION NAME] (medication to treat narcotic overdose in an emergency situation) . Medical record review of Resident #1's Hospice General Inpatient Admission Note dated 10/6/17 revealed .Current uncontrolled symptoms .Respiratory Distress .Medication reaction response . Medical record review and review of facility documentation for 10/6/17 through 10/7/17 revealed Resident #1 received 25 doses of [MEDICATION NAME] after he received Resident #2's extended release [MEDICATION NAME]. Telephone interview with the Student Nurse (student nurse assigned to License Practical Nurse (LPN) #1 on the morning of 10/6/17) on 10/11/17 at 1:05 PM, confirmed .She (LPN #1 precepting the student nurse) hadn't come in room yet .I wasn't sure if coming to give meds with me .I usually don't give meds myself .I didn't know to check with resident .I thought she was in close distance behind me but she wasn't .I gave .insulin in left upper arm .Then gave the meds .made sure he (Resident #1) swallowed them .It was fast .I know I messed up horribly . Continued interview confirmed she gave Resident #2's medications to Resident #1 without LPN #1 present in the room. Telephone interview with LPN #1 (nurse assigned to Resident #1 on morning of 10/6/17) on 10/11/17 at 1:55 PM, confirmed .She (Student Nurse) walked up to cart while pulling (Resident #2) meds and (LPN #1) drew up insulin .Pulled his (Resident #2) picture up .showed her (Student Nurse) picture .I told her to hang on one second and I walked back to cart .when walk back in she (Student Nurse) was walking towards the sharps containers from (Resident #1's) bed .I said did you give that insulin She (Student Nurse) said yes .Then I said where are those pills? .She (Student Nurse) said I gave them to him too .The student said she didn't ask resident name . Continued interview with LPN #1 confirmed the student nurse gave Resident #2's medications to Resident #1 while she (LPN #1) was not present in the room. Interview with the Director of Nursing (DON) on 10/11/17 at 4:14 PM in the conference room, confirmed Resident #1 received Resident #2's medications on 10/6/17 at 10:15 AM which included aspirin (medication to treat pain) 325 mg tablet, [MEDICATION NAME] (medication to treat constipation) 5 mg tablet, [MEDICATION NAME] (medication to treat depression) 10 mg tablet, [MEDICATION NAME] (medication to treat Diabetes) 28 units, [MEDICATION NAME] sodium (medication to treat constipation) 100 mg tablet, [MEDICATION NAME] ER (extended release) ( medication to treat moderate to severe pain) 180 mg tablet, duloxetine DR (delayed release) (medication to treat depression, anxiety and nerve pain) 60 mg capsule, cranberry (supplement to prevent urinary tract infections) 450 mg tablet and a vitamin B complex (vitamin to prevent vitamin deficiency) capsule. Interview with the Nurse Practitioner on 10/12/17 at 9:11 AM, in the conference room, confirmed .If he (Resident #1) hadn't gotten [MEDICATION NAME] it would have killed him .I would consider it a significant med error, could cause their death . Interview with the Director of Nursing (DON) on 10/12/17 at 9:33 AM, in the conference room, confirmed .It was a significant med error . placing Resident #1 in Immediate Jeopardy. Telephone interview with the Medical Director on 10/16/17 at 4:41 PM, confirmed Resident #1 was at risk for respiratory collapse due to the medication error. Continued interview confirmed the medication error jeopardized the resident's safety. Telephone interview with the Pharmacy Consultant on 10/16/17 at 3:20 PM, confirmed .Gave a naive (no previous exposure) pt a large long acting medication ([MEDICATION NAME] ER) . Continued interview with the Pharmacy Consultant confirmed Resident #1 received significant medication error on 10/6/17. Telephone interview with the Clinical Instructor on 10/17/17 at 11:54 AM, confirmed .The students are not to give meds to residents without licensed personnel . Interview with the DON on 10/17/17 at 4:45 PM, in the conference room, confirmed .My nurse was responsible for the event on 10/6/17; she holds a license and was to supervise the student nurse . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of untitled facility documentation dated 8/28/17, revealed .On Friday 8/25/17 the house supervisor .(Registered Nurse #2) discharged (Resident #4) out of the .system .Patient did not receive medications on 8/26/17 or 8/27/17 . Medical record review of Medication and Treatment Administration Record Report, dated 8/2017, revealed Resident #4 was prescribed the following medications: [REDACTED]. Continue review revealed Resident #4 did not receive the prescribed evening medications on 8/25/17, and did not receive any of the 14 medications on 8/26/17 or 8/27/17. Interview with RN #1 (nurse supervisor) on 10/17/17 at 9:30 AM, in the 2nd floor nursing station, confirmed Resident #4 had not received his medications for a full weekend due to being discharged from the computer system. Interview continued and revealed the medication nurses .were not being vigilant. Interview with RN #2 on 10/18/17 at 1:25 PM, in the conference room, confirmed RN #2 had accidentally discharged Resident #4 during the afternoon of 8/25/17. Continued interview revealed .Once I contacted the pharmacy, I thought they would re-enter his medications and they (medications) would not have to be checked in at the facility . Continued interview revealed the routine process was for medications entered into the IMAR (electronic medication administration record) by the pharmacy to be waiting in a que for the facility's house supervisor to review and confirm for accuracy, and medications would then .populate on the IMAR for the nurses to give . Interview confirmed the evening and night nurse supervisors would have received a flashing notice of any resident's medications waiting to be checked in and Resident #4's medications waiting in the que were not checked in from 8/25/17 through 8/27/17. Continued interview revealed, over the weekend, as each oncoming shift supervisor logged in (to the IMAR software), Resident #4 would have continued in the que and needed to be checked in. Further interview confirmed the resident did not receive his medications, including a diuretic, an oral diabetic medication to control elevated blood sugars, a beta blocker (a medication which carries a precaution of not discontinuing suddenly), and a blood thinner to prevent blood clots in a resident with a fractured femur through 7 nursing shifts, from the evening of 8/25/17 through 8/27/17. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of untitled facility documentation undated, revealed .Nurse gave wrong patch on 04/09/2017 .Placed a nitro patch ([MEDICATION NAME] to prevent chest pain) instead of a nicotine patch ([MEDICATION NAME] to aid smoking cessation) .Nurse stated got distracted was very busy on floor . Further review of the facility documentation revealed it was signed by LPN #4. Interview with LPN #4 on 10/18/17 at 2:30 PM, in the conference room, revealed, .I had been interrupted a few times already that morning and can't remember if it (the Nitro-Patch) scanned without a problem .or didn't get scanned by me .a lot of dynamics going on, he didn't feel well and his wife was wanting him to go to church . Further interview confirmed the Nitro-Patch was imprinted with the name and dosage of the medication and the error was discovered the following morning by another nurse. Interview continued and confirmed LPN #4 had not verified the right medication prior to administration. Interview with the DON on 10/19/17, at 4:34 PM, in the conference room, confirmed Resident #4's medication error and Resident #11's medication error were significant medication errors. Noncompliance continues at a J level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit an Acceptable Allegation of Compliance. Refer to F490, and F520",2020-09-01
237,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,441,D,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility Infection Control Manual, review of the Infection Control Policy, medical record review, and interview, the facility failed to follow contact isolation infection control guidelines for 1 resident (#16) of 7 residents reviewed for Extended Spectrum Beta Lactamases (ESBL) (an antibiotic resistant micro-organism) in their urine. The findings included: Review of the facility Infection Control Manual revised 10/1/08, revealed .use Contact Precautions for patients known or suspected to be infected or colonized with epidemiologically significant microorganisms that can be transmitted by direct contact with patient or indirect contact with environmental surfaces or patient care equipment .Place the patient who contaminates the environment or who does not or cannot assist in maintaining appropriate hygiene or environmental control in a private room .May allow resident to stay with roommate if total care for transfers/mobility . Review of the Infection Control Policy for ESBL, VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]), MRSA (Methicillin-Resistant Staphylococcus Aureus) in the urine dated 9/26/17, revealed .initiate contact precautions .Resident may stay with roommate, if urine is contained . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 scored 5 out of 15 for the Brief Interview for Mental Status indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the resident required extensive assist for most activities of daily living and was incontinent of bladder. Medical record review of Resident #15's Urinalysis Report dated 9/18/17 revealed .LEUK[NAME]YTE ESTERASE (white blood cells associated with infection) .LARGE . Medical record review of Resident #15's Microbiology Report dated 9/18/17 revealed .Urine .Escherichia coli (E.coli) .ESBL . Medical record review of the Care Plan dated 9/22/17 revealed Resident #15 was placed on contact isolation on 9/22/17. Further review revealed Resident #15's family requested the resident not be treated with antibiotics on 9/26/17. Medical record review of Resident #15's Nurse's Note dated 9/26/17 revealed .(urinary) catheter placed .ESBL urine contained . Medical record review revealed Resident #15 and Resident #16 were roomates at that time. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].coli, and Chronic Atrial Fibrillation. Medical record review of the MDS dated [DATE] revealed Resident #16 was unable to complete the Brief Interview for Mental Status, indicating severe cognitive impairment. Further review of the MDS revealed she required extensive assist for most activities of daily living. Medical record review of Resident #16's Nurse's Note dated 9/26/17 revealed .Family upset about pt (patient) being in bedroom c (with) pt in contact isolation. Pt moved to different room per family request .UA (urinalysis) obtained .per family request . Medical record review of Resident #16's Microbiology Report dated 9/26/17 revealed .URINE .Escherichia coli . Medical record review of Resident #16's Nurse's Note dated 9/30/17 revealed .Contact isolation initiated for ESBL .proteus mirabilis urine culture . Medical record review of the Care Plan dated 10/2/17 revealed Resident #16 was placed on contact isolation and had a history of [REDACTED]. Interview with Licensed Practical Nurse (LPN) #7 on 10/9/17 at 1:11 PM, at the 2nd floor nurses station, confirmed Resident #15 was placed on contact isolation on 9/22/17. Telephone interview with Resident #16's granddaughter on 10/9/17 at 7:19 PM confirmed .Asked her to be tested on Tuesday (9/26/17) .All the infected resident's stuff was on Grandmother side of room .Her (Resident #15) food tray .cups had been thrown on her side of the room .My grandmother used that resident's toilet .The other resident catheter was emptied in there .she (Resident #16) touched things in the room . Interview with Registered Nurse (RN) #1 on 10/10/17 at 9:50 AM, in the Director of Nursing (DON's) office, confirmed .She (Resident #16) is prone to get infections .She is a carrier of [DIAGNOSES REDACTED] (Clostridium difficile, a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) . Telephone interview with the Nurse Practitioner on 10/10/17 at 11:10 AM, confirmed .tested her (Resident #16) because in room with (Resident #15) .They both have E. coli and ESBL .The urine was contained in the brief . Interview with the Assistant Regional Nurse on 10/10/17 at 4:30 PM, in the conference room, revealed the facility felt the risk was minimal for Resident #16 and confirmed the Assistant Regional Nurse did not know why the facility had not planned to move Resident #16 on 9/26/17, when the other affected residents were moved. Interview with the Assistant Director of Nursing (Infection Control Nurse) on 10/16/17 at 9:50 AM, in the conference room, confirmed the facility failed to follow the facility policy by not moving Resident #15 to another room once she was diagnosed with [REDACTED].#16 to be exposed to ESBL during the dates of 9/18/17 through 9/26/17.",2020-09-01
238,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,490,J,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility contract, review of the Practical Nurse Program code of conduct, medical record review and interviews the Administrator failed to ensure there were not significant medication errors for 3 residents (#1, #4 and #11) of 15 residents reviewed for medication errors. Resident #1 received 9 medications in error prescribed for Resident #2. The error resulted in Resident #1 becoming sedated, having decreased respirations, requiring multiple doses of [MEDICATION NAME] (medication used to treat an overdose of opioids in an emergency situation). Resident #4 did not receive his prescribed medications, including a diuretic, an oral diabetic medication to control elevated blood sugars, a beta blocker (a medication which carries a precaution of not discontinuing suddenly), and a blood thinner to prevent blood clots in a resident with a fractured femur from the evening of 8/25/17 through 8/27/17. Resident #11 had an non-prescribed [MEDICATION NAME] (a medication patch with [MEDICATION NAME] which is used to treat chest pain, by relaxing and widening blood vessels) medication administered on 4/9/17. The Administrator's failure to ensure medications were administered to the right residents and failure to ensure Resident #4 received all prescribed medications, resulted in significant medication errors and placed Resident #1, #4, and #11 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Nursing Home Administrator (NHA) and Director of Nursing (DON), were informed of the Immediate Jeopardy on 12/4/17, at 9:00 AM in the Administrator's office. The IJ was effective 4/9/17 and is ongoing. Noncompliance continues at the severity of J level. An extended survey was conducted from 12/4/17 through 12/5/17. The facility was cited Substandard Quality of Care at F-333(J). The findings included: Medical record review revealed the facility had medication errors for Residents #1, #3, #4, #6, #7, #8, #9, #10, #11 and #24 between 2/28/17 and 10/26/17. The medication errors for Residents #1, #4, and #11 were significant medication errors. Interview with the DON on 10/16/17 at 10:33 AM, in the conference room, with review of the medication errors revealed Resident #7, #8, and #9 on 2/28/17; 3/9/17; and 3/20/17 consecutively, the wrong narcotic was administered after borrowing medications. Further interview revealed the medication errors for Resident #10 on 3/31/17 and Resident #11 on 4/9/17 involved 2 residents who received other residents' medications. Continued interview revealed Resident #3's medication error on 8/10/17, occurred when the assigned nurse disregarded 2 medication safety checks. Further interview revealed Resident #6's medication error on 9/17/17 involved an incorrect order entry of an antibiotic medication by the nurse responsible for addressing quality issues with the nursing staff. Continued interview confirmed the medication errors were seen as isolated events with individual nurses counseled. Further interview with the DON regarding the medication errors and whether all contributing factors were addressed, revealed .I am not going to be able to show you a conclusion to each investigation . and confirmed a plan of correction for each medication error was not developed. Further interview confirmed the Administrator led the Quality Improvement Committee and failed to identify and implement corrective measures to address medication administration errors. Interview with the DON on 10/17/17 at 5:15 PM, in the conference room, confirmed .There isn't a written process for investigation of medication errors .we don't do a root cause analysis (for medication incidents) .only for untoward events. Interview with the Regional Consultant on 12/4/17 at 1:34 PM, in the conference room, confirmed the facility was responsible to perform root cause analysis of all medication errors in an effort to prevent future medication errors. Interview with the NHA, DON and Regional Consultant on 12/5/17 at 3:41 PM, in the conference room, confirmed each of the facility's medication errors had been considered to be isolated events and not included in the quality improvement committee work. Continued interview confirmed the Administrator, Director of Nurses, and Medical Director failed to monitor and observe for safe administration of medications. Noncompliance continues at a J level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit an Acceptable Allegation of Compliance. Refer to F-333 (J) and F-520 (J)",2020-09-01
239,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,502,D,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to obtain accurate laboratory results for 1 resident (#5) of 14 residents reviewed for medication errors. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED]. Medical record review of Physician order [REDACTED]. D5NS (5% [MEDICATION NAME] in normal saline intravenous) 200 cc (cubic centimeters) bolus, 125 cc/hr (hour) x1 liter. 20 (milligram) [MEDICATION NAME] ([MEDICATION NAME]) after bolus (5% [MEDICATION NAME] in normal saline) . Medical record review of the Medication and Treatment Administration Record Report dated 8/2017 revealed Resident #5 received a D5W 200 ml bolus at 2:33 PM on 8/29/17 and [MEDICATION NAME] ([MEDICATION NAME]) 20 mg IV at 2:36 PM on 8/29/17 PM. Medical record review of the Medication and Treatment Administration Record Report dated 8/20/17 and the daily skilled Nurse's Notes did not reflect when the [NAME]exlate 30 mg PO now had been administered. Medical record review of physician progress notes [REDACTED].Repeat K (potassium) .waiting .will give IVF (intravenous fluids) .[MEDICATION NAME] . Medical record review of Physician order [REDACTED].DC (discontinue) PO (by mouth) K .[NAME]xelate (medication to lower Potassium levels) 30 mg . Medical record review of Resident #5's Chemistry Report dated 8/29/17 revealed a critical potassium level of 7.3 (normal range 3.5-5.1) collected at 5:00 AM, released at 9:17 AM, and called as a critical level to the facility. Medical record review of Resident #5's Chemistry Report dated 8/29/17 revealed a critical potassium level of 7.3 collected at 5:00 AM, released at 12:49 PM, and called as a critical level to the facility. Medical record review of Resident #5's Laboratory Report dated 8/29/17 revealed a potassium level of 4.4 collected at 9:57 AM, released at 12:14 PM, and not called to the facility. Interview with RN #2 on 10/18/17 at 1:25 PM, in the conference room, revealed, as the house supervisor on 8/29/17, her duties included calling critical lab values to the Physician following telephone notification by the lab. Further interview revealed an elevated potassium level of 7.3 was called to the Physician on 8/29/17 and a repeat blood draw to verify the potassium level was ordered. Continued interview revealed RN #2 received a second call from the lab for Resident #5 on 8/29/17, with a report of a critical potassium level of 7.3. Interview continued and confirmed Resident #5 received the now dose of [NAME]exlate. Further interview confirmed, when the printed copies of Resident #5's Chemistry Reports were received at the facility, RN #2 noted the repeated potassium value of 4.4 had not been called to the facility. Continued interview confirmed the repeat lab, drawn at 9:57 AM, requested by the Physician, indicated a potassium level of 4.4 and was not called to the facility. In summary, the facility did not receive telephone notification from the lab for the potassium level of 4.4, collected at 9:57 AM, by Physician order [REDACTED]. The facility did receive a second telephone notification of the critical potassium level of 7.3 (rerun as a lab quality control measure from the 5:00 AM blood sample). The nursing staff failed to identify whether the second critical potassium level called to the nursing home was obtained from the second blood specimen drawn. The second notification of the critical potassium level of 7.3 (exactly the same value as the first critical level) was acted on by the nursing staff and Resident #5 received [NAME]exlate to lower his potassium level.",2020-09-01
240,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,520,J,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility Quality Improvement Committee documents, medical record review, and interview, the Quality Improvement Committee failed to identify and implement corrective measures to address medication administration errors for 10 residents (#1, #3, #4, #6, #7, #8, #9, #10, #11 and #24) of 15 residents reviewed. The Quality Improvement Committee failed to ensure systems were in place for residents to receive medications as ordered by the physician and to be free of significant medication errors. The facility's failure to ensure medications were administered to the right resident resulted in a significant medication errors and placed Residents #1, #4, and #11 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Nursing Home Administrator (NHA) and Director of Nursing (DON), were informed of the Immediate Jeopardy on 12/4/17, at 9:00 AM in the Administrator's office. The IJ was effective 4/9/17 through 12/5/17 and is ongoing. Noncompliance continues at the severity of J level. An extended survey was conducted on 12/4/17 through 12/5/17. The facility was cited Substandard Quality of Care at F-333(J). The findings included: Review of the facility's (MONTH) (YEAR) Quality Improvement Committee meeting revealed the minutes included initiation of a facility-wide QAPI (quality assessment/performance improvement) Plan. Review of the Goals in the QAPI Plan revealed, Priority will be set for those goals that are considered high-risk, high-volume or problem-prone areas . Continued review revealed the 6 current high priority identified areas did not include medication administration. Review of the facility's Quality Improvement Committee meeting minutes from 1/19/17 through 9/21/17 revealed medication administration errors were not identified by the committee. Medical record review revealed the facility had medication errors for Residents #1, #3, #4, #6, #7, #8, #9, #10, #11 and #24 between 2/28/17 and 10/26/17. The medication errors for Residents #1, #4, and #11 were significant medication errors. Interview with the Director of Nurses (DON) on 10/16/17 at 10:33 AM, in the conference room, confirmed a significant medication error occurred on 10/6/17, when Resident #1 received [MEDICATION NAME] ER (extended release) 180 mg (milligrams), a medication that was ordered for the resident's roommate, put him in an acute condition (sedation and respiratory depression requiring [MEDICATION NAME] administration, a medication used to treat an overdose of opioids in an emergency situation) . Interview with the DON on 10/16/17 at 10:33 AM, and on 10/17/17 at 4:55 PM, in the conference room, and review of the medication errors from 2/28/17 through 9/17/17, revealed: 2/28/17 - Residents #7 received one dose of a wrong narcotic, not the prescribed narcotic pain medication, due to a borrowing error. Interview confirmed the DON had counseled the Licensed Practical Nurse (LPN) responsible for the medication error. 3/9/17- Resident #8 received one dose of a wrong narcotic, not the prescribed narcotic pain medication, due to a borrowing error. Interview confirmed the DON had counseled the LPN responsible for the medication error. 3/20/17- Resident #9 received one dose of a wrong narcotic, not the prescribed narcotic pain medication, due to a borrowing error. Continued interview revealed there was an actual form and procedure to have 2 nurses verify the correct medication was borrowed. Further interview confirmed the DON had counseled the LPN responsible for the medication error. 3/31/17 - Resident #10 received 1 dose of Pramipexole VK 0.5 mg (Anti-[MEDICAL CONDITION] medication), prescribed for the resident's roommate. Continued interview with the DON confirmed he had counseled LPN #6 and had not investigated the circumstances beyond the human error made by a LPN .employed for at least [AGE] years . 4/9/17 - Resident #11 had a Nitro-Patch ([MEDICATION NAME] Patch) administered without an order, and was not discovered for 24 hours. Interview confirmed the DON had counseled Licensed Practical Nurse (LPN) #4 who had placed the wrong patch ([MEDICATION NAME] Patch) on Resident #11. Further interview confirmed no further facility investigation or interventions were done related to the significant medication error. 8/10/17 - Resident #3 received an extra dose of [MEDICATION NAME] when her assigned nurse disregarded 2 medication administration safe checks and gave a second dose in error. During interview the DON stated LPN #5 had been counseled by LPN #2 following the medication error on 8/10/17. 8/28/17 - Resident #4 did not receive any of his prescribed medications for 7 consecutive nursing shifts, from 8/25/17 through 8/27/17, and the error was not discovered until 8/28/17. Interview revealed the medication error began on the evening of 8/25/17, after Resident #4 was discharged from the facility computer system in error. During interview, the DON stated he counseled Registered Nurse (RN) #2 related to Resident #4's erroneous discharge and confirmed the additional 7 staff nurses responsible for Resident #4's care were not interviewed or included in the investigation. 9/17/17 - Resident #6 did not have an antibiotic administered as prescribed. Interview revealed an order entry for an antibiotic was not completed correctly, and resulted in Resident #6 receiving an antibiotic every day, instead of the physician ordered every other day interval, resulting in the resident receiving 1 extra dose of the antibiotic. Further interview revealed LPN #2, identified as the LPN who assisted the DON with IMAR (electronic medication record) and quality concerns, was responsible for the medication error and was counseled. Review of Medication Error Report filed on 10/27/17 to address the 10/26/17 medication error revealed Resident #24 received a double dose of [MEDICATION NAME] when Registered Nurse (RN) #4 failed to transcribe the medication order correctly and LPN #8 failed to follow the 8 rights of medication administration. Continued review revealed the nurse supervisor on duty (RN #3) failed to notify the on call physician service and initiate a Medication Error Report. Interviews with LPN #8, RN #3 and RN #4 revealed the 3 licensed nurses had not followed the directions received during the (MONTH) (YEAR) in-services related to safe medication administration. Interview with the DON on 10/16/17 at 10:33 AM, in the conference room, regarding the medication errors and whether all contributing factors were being addressed, revealed .I am not going to be able to show you a conclusion to each investigation . and confirmed a plan of correction for each medication error was not developed. Telephone interview with the facility's consulting Pharmacist on 10/16/17 at 3:20 PM, revealed, .Everything is automated now .All I know about what has been given is from what is on the IMAR (electronic medication administration record) .the only medication error I have been involved in happened last week (Resident #1's 10/6/17 medication error). Telephone interview with the facility's Medical Director on 10/16/17 at 4:20 PM, revealed, .They called right after the mistake occurred (the 10/6/17 medication error for Resident #1) .We understood this gentleman was not doing well .on Hospice .but didn't want to hasten his demise .nothing to be gained by moving him to a higher level of care, not sure he would have survived the transfer .If steps hadn't been taken immediately, he would have suffered respiratory collapse . Interview with the Medical Director and review of the medication errors from 4/9/17 to the present time revealed the medication errors were not all known to him. Continued interview confirmed the medication errors had not been brought to the QAPI committee. Sounds like we need to increase medication error awareness .all medication errors should be reviewed by the committee. Interview with the DON on 10/17/17 at 5:15 PM, in the conference room, confirmed .There isn't a written process for investigation of medication errors .we don't do a root cause analysis (for medication incidents) .only for untoward events. Interview by phone with the facility's consulting Pharmacist on 10/18/17 at 2:40 PM, revealed, .I didn't know about the incident with the Nitro-Patch ([MEDICATION NAME] Patch) before today .If you look at the facility's responsibilities, the DON (Director of Nurses) is supposed to let us know about these medication errors. Noncompliance continues at a J level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit an Acceptable Allegation of Compliance. Refer to F-333 (J) and F-490 (J)",2020-09-01
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
259,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-05-01,609,D,1,0,22N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to report an allegation of abuse within 2 hours to the State Survey Agency for 1 resident (#4) of 3 residents sampled for abuse, of five sampled residents. The findings included: Review of facility policy, Abuse, (undated) revealed .if you have reasonable suspicion that a crime has occurred against a resident .Federal Law Requires that you report your suspicion directly to .the State Survey Agency . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored a 14 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review of a Nursing Note dated 3/26/19 at 10:00 PM revealed .Pt (patient) A&O (alert and oriented) .some confusions (at) times . Medical record review of a Nursing Note dated 4/11/19 at 4:00 AM revealed .went to check on pt .not responding in usual manner .very lethargy .speech sluggish . Continued review revealed the resident was transferred to a local hospital with altered mental status and a urinary tract infection [MEDICAL CONDITION]. Review of the facility investigation dated 4/24/19 revealed a caseworker with Adult Protective Services (APS) contacted the facility on 4/24/19 and advised them while Resident #4 was in the hospital the resident alleged she was sexually abused by an unidentified male staff member at the facility sometime prior to her hospitalization on [DATE]. Further review revealed the facility did not report the allegation to the State Survey Agency. Interview with the Director of Nursing and the Risk Manger on 4/30/19 at 6:00 PM, in the conference room, confirmed the facility failed to report an allegation of abuse to the State Agency within 2 hours of notification of the allegation. In summary, the facility was aware of an allegation of abuse on 4/24/19 and as of 4/30/19, the facility had not reported the allegation of abuse to the State Survey Agency (7 days).",2020-09-01
260,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-07-26,225,D,1,0,RMD011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency for 1 resident (#5) of 3 residents reviewed for abuse of 5 sampled residents. The findings include: Review of the facility policy Abuse dated 11/2016 revealed .The facility must ensure that all alleged violations involving mistreatment, neglect, exploitation, mistreatment, misappropriation of resident property or abuse .are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Brief Interview for Mental Status (BIMS) dated 5/22/17 revealed Resident #5 was severely cognitively impaired. Medical record review of a psychiatric progress note dated 6/6/17 revealed Resident #5 was reported to have periods of extreme agitation and was noted to show a significant overall decline, altered mental status, and was unable to focus. Review of a facility investigation dated 6/12/17 revealed the granddaughter of Resident #5 reported to the Assistant Director of Nursing (ADON) during a visit her grandmother stated a partner at the facility had slapped her. Continued review revealed Resident #5 could not identify the partner nor could she state when the alleged incident occurred. Further review revealed the resident did not report the alleged incident until the granddaughter told the resident .tell .about the lady that slapped you from here . Continued review revealed Resident #5 stated a woman had slapped her in the face when she was at the beauty shop and the person had short and long hair. Further review revealed the resident stated the incident happened a few days ago .down on .old highway .at the building with bricks .beauty shop . Continued review revealed the Risk Manager informed the granddaughter a complete investigation would be conducted and she (Risk Manager) would notify the police, but the granddaughter stated .No I am going to take her so it will not alert anyone . Interview with the Risk Manager on 7/26/17 at 10:00 AM, in Conference room [ROOM NUMBER], confirmed an allegation of abuse involving Resident #5 was reported to the facility on [DATE] and the facility failed to report the allegation to the state survey agency timely.",2020-09-01
268,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-10-11,323,D,1,0,19XQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure fall interventions were in place for 1 resident (#3) of 4 residents reviewed for falls. The findings included: Review of the facility's policy, Falls Prevention, revised dated 9/25/14, revealed .3. Interventions .d. implement appropriate interventions immediately . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the post fall assessment dated [DATE], at 7:45 AM, revealed staff responding to alarm sounding. Resident was found on the floor with wheelchair tipped, supine position. Resident reports that he was trying to get back in bed. Head to toe assessment negative for obvious deformity or injury at this time. However, he does c/o (complain) pain in back, his hips, and a headache. ROM (range of motion) NCB (no change base line) .Interventions .assess for need for anti-tip bars for w/c(wheelchair), add sensor pad to w/c . Review of the care plan updated on 9/11/17, revealed the new intervention for falls was the sensor pad alarm to the w/c. Observation on 10/9/17, at 2:20 PM, in the room of Resident #3, revealed the sensor pad alarm was not in the resident's wheelchair. Interview with a Licensed Practical Nurse (LPN) #1 at the time of observation confirmed the sensor pad alarm was not in the resident's wheelchair. Continued interview with the LPN confirmed the sensor pad alarm was to be in place as part of the falls intervention.",2020-09-01
269,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2018-10-17,580,D,1,0,RHRF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to immediately report a fall to the supervising nurse and failed to immediately report a fall with injury to the responsible party for 1 Resident (#1) of 8 residents reviewed for falls, of 10 sampled residents on 1 of 11 nursing units observed. The findings included: Review of the facility policy Resident Condition Change Notification (revised 1/7/2010) revealed .an acute patient status change .are reported to the medical staff immediately .resident .patient representative are to be notified when there is a patient status change .resident's condition, medical staff notification and orders .interventions .effectiveness .patient .or patient representative notification is documented . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15/15 (cognitively intact); had no symptoms of [MEDICAL CONDITION]; had limited range of motion in the upper and lower extremities; had urinary and fecal incontinence; was non-ambulatory; and was dependent on staff with maximum assistance of one person for all activities of daily living. Continued review revealed Resident #1 had a history of [REDACTED]. Review of the facility investigation dated 10/11/18 at 5:45 AM revealed during incontinence care Certified Nurse Aide (CNA) #1 ran out of supplies and left the resident lying on her back on the bed while she went to retrieve more supplies from outside the room. Continued review revealed when CNA #1 returned to the room to (2 minutes later) she observed Resident #1 seated on the floor, to the right side of the bed, with her back against the bedframe. Further review of the investigation revealed CNA #1 did not immediately notify her supervising nurse when she found Resident #1 in the floor, but instead summoned a co-worker (CNA #2) to assist her with lifting Resident #1 back onto the bed. Continued review revealed neither CNA #1 nor CNA #2 reported the resident's fall to the supervising nurse or to the off-going or oncoming nurse or oncoming CNA during the shift report. Further review revealed Resident #1 exhibited symptoms of swelling and skin discoloration to the right leg on 10/11/18 around 4:45 PM (approximately 11 hours later). Continued review revealed Licensed Practical Nurse (LPN) #1 did not notify the responsible party for Resident #1 of the resident's change in condition until 10/12/18 around 7:00 AM (12 hours after the swelling and discoloration was noted). Telephone interview with CNA #1 on 10/16/18 at 8:15 PM confirmed the CNA did not immediately report finding Resident #1 on the floor to her supervising nurse or to the oncoming nurse or oncoming CN[NAME] Further interview confirmed CNA #1 failed to follow facility policy. Telephone interview with LPN #1 on 10/17/18 at 10:05 AM revealed she was first aware of Resident #1's change in condition on 10/11/18 at 4:45 PM and was unaware the resident had fallen earlier that day. Continued interview confirmed LPN #1 failed to notify the resident's responsible party of the change in condition until the following morning (12 hours after the change in condition had been identified and treatment initiated). Interview with the Director of Nursing (DON) and the Risk Manager on 10/17/18 at 5:05 PM, in the conference room, confirmed the facility failed to follow facility policy, failed to notify Resident #1's responsible party of the change in the condition, and failed to report Resident #1's fall to the supervising nurse.",2020-09-01
270,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-12-16,580,D,1,0,DCNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to notify the responsible party of a fall for 1 resident (#2) of 3 residents reviewed for change in condition. The findings included: Review of the facility policy, Resident Condition Change Notification, last revised 11/2016, revealed .The medical staff .and .patient (resident) representative are to be notified when there is a patient status change . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a facility fall investigation dated 11/21/19 revealed Resident #2 fell on [DATE] at approximately 4:00 AM. Review of a facility document dated 11/23/19 revealed the responsible party for Resident #2 was not notified of the fall until 11/23/19 at approximately 6:30 PM (2days after the fall). Interview with the Director of Nursing on 12/16/19 at 7:15 PM, in the conference room, confirmed the facility failed to notify the responsible party for Resident #2 of the resident's fall on 11/21/19. Further interview confirmed the responsible party was not notified until 11/23/19 (2 days later) and the facility failed to follow facility policy.",2020-09-01
275,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-10-23,609,D,1,0,2B9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility document review, medical record review, and interview, the facility failed to report an incident of misappropriation of resident property to the appropriate agency within the prescribed time frame. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #2 scored 15 on the Brief Interview for Mental Status indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was always continent of bowel and bladder. Review of a summary dated 8/9/19 by the Administrator revealed .(named Resident #2) came to my office today to let me know that she had misplaced $350 that her son brought her. She said that he brought her the money so that she could go to her pain clinic. I asked her why she had that much money and she said that the clinic only took cash. She said that she thought she put it in her drawer. I asked her to see if we could help her find it and she said that she needed the money asap. I told her that it was not the responsibility of the facility to reimburse monies that are lost. She was very upset because she did not have extra money for the doctor's office . Interview with the Administrator and DON on 10/23/19 at 11:40 AM in the conference room revealed the resident was talking loudly in the foyer about missing money so the Administrator asked the resident into her office. The resident stated she had lost her money she needed to pay the pain clinic. The resident had not spoken to Social Services. The resident said she initially put the money in her bra then into the locked top drawer of her bedside cabinet. The resident is the only one who has a key to the top drawer. The Administrator and DON looked at the video footage and saw no one enter or leave the room other than staff. They investigated the incident but did not report it since the resident had stated she lost the money and was not at that point accusing anyone of taking it.",2020-09-01
276,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-10-23,610,D,1,0,2B9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documents, medical record review, and interview the facility failed to conduct a thorough investigation of an alleged misappropriation of resident property. The findings included: Review of facility policy, Abuse Prevention, revised 3/27/13, revealed .The facility has a zero tolerance for abuse .The resident will not be subjected to mistreatment, neglect, or misappropriation of property .A criminal background check shall be initiated on any potential employee .All new employees will receive training on Abuse Prevention policies and procedures during the initial orientation period .Existing employees will receive ongoing training regarding Abuse Prevention .Employees who have been accused of resident abuse will be suspended from resident care duties until the investigation has been completed .An individual observing an incident of Resident abuse or suspected Resident abuse must immediately report the incident to their supervisor . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #2 scored 15 on the Brief Interview for Mental Status indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was always continent of bowel and bladder. Review of a summary dated 8/9/19 by the Administrator revealed .(named Resident #2) came to my office today to let me know that she had misplaced $350 that her son brought her. She said that he brought her the money so that she could go to her pain clinic. I asked her why she had that much money and she said that the clinic only took cash. She said that she thought she put it in her drawer. I asked her to see if we could help her find it and she said that she needed the money asap. I told her that it was not the responsibility of the facility to reimburse monies that are lost. She was very upset because she did not have extra money for the doctor's office . Review of a summary from the Administrator dated 8/15/19 revealed .Over the next few days we looked in her room and in laundry but could not find the money. She discharged home. I called to see if she had found it but she had not. I decided that I would help her out. I bought her a $350 VISA gift card and took it to her at her apartment. She declined the gift card and said she didn't know how to use it. I told her I would get her the cash. Her son came and picked it up today. I called her and she was very happy about being reimbursed . Interview with the Administrator and DON on 10/23/19 at 11:40 AM in the conference room revealed the resident was talking loudly in the foyer about missing money so the Administrator asked the resident into her office. The resident stated she had lost her money she needed to pay the pain clinic. The resident had not spoken to Social Services. The resident said she initially put the money in her bra then into the locked top drawer of her bedside cabinet. The resident is the only one who has a key to the top drawer. The Administrator and DON looked at the video footage and saw no one enter or leave the room other than staff. They investigated the incident but did not report it since the resident had stated she lost the money and was not at that point accusing anyone of taking it.",2020-09-01
277,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2020-01-29,689,D,1,0,7MVB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to prevent an accident for 1 resident (Resident #1) of 3 sampled residents, resulting in the resident falling out of bed. The findings included: Review of the facility's policy titled Bed Bath, last revised 2/2018, showed .Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #1 had short and long term memory problems and was severely impaired for daily decision making skills. The resident was incontinent of bowel and bladder and was totally dependent on staff for bed mobility and personal hygiene with 1 person assist. Review of a facility investigation dated 1/23/2020 showed Certified Nurse Assistant (CNA) #3 was giving Resident #1 a bed bath. When the CNA turned away from the resident to get a brief for the resident, the resident rolled out of the bed onto the floor. The resident had a hematoma on the right side of her head and scrapes on both knees and was sent to the Emergency Department (ED) for evaluation. The resident was discharged from the hospital to a different long term care facility on 1/28/2020. Review of a handwritten statement dated 1/23/2020 and signed by CNA #3 showed .I had turned her (Resident #1) over on her side then I was getting .brief .I turned back around her legs was (were) hanging off the bed. I tried to grab her but wasn't strong enough to pull her back .she rolled on the floor . During an interview on 1/28/2020 at 11:00 AM, Licensed Practical Nurse (LPN) #1 stated CNA #3 placed Resident #1 on her left side with her back to the CN[NAME] The CNA needed items that were placed behind her and when the CNA turned to obtain the needed items, the resident started to fall off of the bed. The CNA was unable to catch the resident; resulting in the resident falling on the floor.",2020-09-01
278,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,580,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, interview, and observation, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical, mental and psychosocial status for 1 resident (#7) of 6 residents reviewed for accidents and incidents, of 8 sampled residents. The facility's failure to immediately inform the physician or Nurse Practitioner (NP) of a significant change in the resident's pain intensity and the resident's physical condition (swollen and bruised bilateral knees and resulting fractures) placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy titled Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Medical record review of the resident's Medication Administration Record (MAR) and nursing notes for (MONTH) (YEAR) revealed Resident #7 was to have a pain assessment every shift (7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM), and had an order for [REDACTED]. Further review of the MAR and nursing notes revealed the resident rated her pain as 0 daily and did not require any of the as needed [MEDICATION NAME] until [DATE], after she was diagnosed with [REDACTED]. Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Head to toe assessment performed, no injury noted .Sister .Dr (physician) .notified. Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of Resident #7's MAR revealed on [DATE] the resident's pain was 6 out of 10 (with 10 being the most severe pain) on the 7:00 AM to 7:00 PM shift and was administered [MEDICATION NAME] 7.5 mg at 8:00 AM. Medical record review of a telephone order dated [DATE] at 10:45 AM, revealed .Bilateral hips & (and) L (left) shoulder x-ray .fall .VORB (verbal order read back) (name of the former Director of Nursing) . Continued review of the order revealed the order was a verbal order written by a Registered Nurse (RN) and received from the former Director of Nursing (DON). Further review revealed the order was signed by the Nurse Practitioner (NP) on [DATE]. Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays were ordered. Medical record review of the radiology report dated [DATE] revealed no fracture or dislocation of the shoulder or hips was present. Medical record review of the nursing notes and the resident's MAR from [DATE] - [DATE] revealed the resident complained of pain daily that was rated between 5 and 7 on a scale of ,[DATE], with 10 being the worse pain and [MEDICATION NAME] 7.5 mg was given. Further review revealed no documentation the physician or NP was notified of the resident's increased pain or increased need for pain medication. Medical record review of nurse's notes dated [DATE] at 12:30 PM, revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board for today (indicating the resident needed to be seen by the physician or the NP) . Medical record review of the resident's MAR and nursing notes for [DATE] and [DATE] revealed the resident continued to rate her pain at 6 out of 10, with [MEDICATION NAME] 7.5 mg administered for pain. Further review revealed no documentation the physician or NP was notified of the resident's increased pain, increased need for pain medication, or of the swollen and bruised knees. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed a verbal order for x-ray of bilateral knees was written by an RN, verbally given by the NP. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Continued review of the report revealed documentation the DON and a family member of the resident were notified of the results of the x-ray on [DATE] at 9:10 PM and 9:20 PM. Medical record review of a nursing note dated [DATE], with no time, revealed, Called results to (former DON) and sister .Re: (regarding) knee film . Further medical record review revealed no documentation the physician or NP were notified the resident had fractures in both legs. Medical record review of the resident's MAR and nursing notes from [DATE] through [DATE] revealed the resident continued to have pain daily, rated at ,[DATE] on a ,[DATE] scale, and was given [MEDICATION NAME] 7.5 mg. Further review revealed no documentation the NP or physician was notified of the resident's increased pain, increased need for pain medication, bruising or swelling in the knees, or the x-ray results indicating the resident had bilateral fractures. Medical record review of the office visit History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary completed by the orthopedic surgeon dated [DATE], revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission .the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Telephone interview with the NP on [DATE] at 9:25 AM, revealed she remembered she gave the order for the x-ray on [DATE] because the resident was still having pain. Telephone interview with CNA #8 on [DATE] at 10:55 AM, revealed she was making her last round around 6:45 AM on [DATE], and went in to change the resident's bed sheet. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then the staff put the resident back to bed. CNA #8 stated the resident grabbed her knees after she fell . Interview with RN #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came in [DATE] for the 7:00 AM to 7:00 PM shift, she was informed Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain and she gave the resident pain medication to try to keep her comfortable. Continued interview with RN #2 revealed she was not working [DATE], [DATE], and [DATE]. RN #2 stated on [DATE] when she returned to work, the resident still had not been seen by the Nurse Practitioner or the physician, but stated the NP was at the nurses' station so she asked if she could get x-rays of the knees of Resident #7. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain until [DATE]. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated on [DATE] the resident was in so much pain the CNAs reported the resident would scream when she was turned. RN #4 stated she went in to talk with Resident #7 who stated her knees hurt her badly. RN #4 stated both knees were swollen and black and blue. RN #4 stated at this time there was a sign posted at the nurse's station to notify the supervisor before calling the physician or NP so she went to the Assistant Director of Nursing (ADON) and reported the resident was in severe pain. RN #4 stated the ADON said they had done x-rays and they were all negative. RN #4 then replied .no, we have not x-rayed the knees . The ADON replied it was too late to call the physician and just place it on the Dr.'s Board (used to list residents who need to be seen by the physician or NP on the next visit) for the resident to be seen the next day. RN #4 stated on [DATE] she saw the physician and the NP in the facility but they never came to the floor to see Resident #7 and when she reminded the ADON Resident #7 needed to be seen, the ADON replied to her the physician and NP were not seeing residents that day. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE] when she was on duty. Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed after the fall the resident was in a lot of pain all the time. CNA #4 stated when she turned the resident, she would scream out in pain in her knees. The resident's knees were swollen and bruised. When asked if the complaint of pain was different after the fall the CNA replied .absolutely . CNA #4 stated the nurses told the CNAs they had been instructed to put the resident on the doctor's board and the resident could wait until the physician came. Interview with the DON (who was the ADON at the time of the incident) on [DATE] at 11:00 AM, in the Resting Lounge, revealed she could not remember the nurses saying anything to her about the resident having swollen or bruised knees, and if they had told her, she would have told them to call the physician or NP. During observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, the nurse presented a piece of paper, which she stated she had taken down from the nurses' station, .Staff are never to call Dr. (Medical Doctor) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The sign had the DON's name at the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management before calling the physician. When asked when the sign was taken down from the nurses' station, the nurse replied when they found out they were being sued. Interview with the Regional Quality Specialist (RQS) on [DATE] at 3:20 PM, in the Resting Lounge, revealed, when asked what she would have expected the nursing staff to do when the resident continued to complain of pain, the Regional Quality Specialist replied .would have expected a call placed to the provider . Telephone interview with the resident's physician on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any change in resident status including increased pain, the physician stated he would expect to be called for any changes. The physician further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7 she observed the knees swollen and the resident told the CNA she had fallen out of bed. CNA #17 reported to RN #4 the resident's pain on turning and was informed the RN had been instructed to put it on the doctor's board by the ADON. CNA #17 asked nursing again on [DATE] and was told the doctor had still not seen the resident. Interview with RN #2 on [DATE] at 5:45 PM, at the 400 hall nurses' station, revealed when she left on [DATE] the results of the x-rays of the bilateral knees for Resident #7 had not returned. She returned to work on [DATE], read the x-ray results, and was in contact with the DON per text messaging. Further interview confirmed she did not call the physician or NP with the results of the x-rays. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed, when asked when he became aware of the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would expect the physician to be notified, the Medical Director replied all fractures should be called to the physician or the person on call. Telephone interview with the NP on [DATE] at 6:20 PM, revealed she could not remember clearly if she was notified of the results of the bilateral knee x-rays and replied .I'm sorry I don't . The NP stated when she got home she would look at her notes and see if she had any notations of notification of the results. Telephone interview with the NP on [DATE] at 9:11 PM, revealed the NP had reviewed her notes for Resident #7 and found no notation of being notified of the results of the bilateral knee x-rays. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator's Office, revealed during review of nursing notes for [DATE] and [DATE], the Administrator confirmed she did not see documentation the physician or NP had been notified of the results of the bilateral knee x-rays. When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services came in (MONTH) of (YEAR).",2020-09-01
279,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,600,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record review, review of the facility's investigation, interview, and observation, the facility failed to prevent neglect for 1 resident (#7) of 6 residents reviewed for neglect, of 8 residents reviewed. The facility's failure to prevent neglect resulted in a delay in receiving services and treatment after a fall with fractures, with Resident #7 experiencing intense pain, and placing Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F600 at a scope and severity of J which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy titled Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications . Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change .no injury noted . Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side . Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed Resident #7 was prescribed [MEDICATION NAME]-APAP 7XXX,[DATE] milligrams (mg) every 4 hours as needed (PRN) for pain on [DATE]; [MEDICATION NAME] 50 mg every 12 hours for pain on [DATE]; and [MEDICATION NAME] 12 mcg (micrograms)/HR (per hour) patch every 72 hours for pain on [DATE] prior to the fall. Medical record review of the (MONTH) MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays of the hips and shoulder were ordered. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the radiology report for the bilateral hips and left shoulder x-rays dated [DATE] revealed no fracture or dislocation. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:10 PM, revealed the resident still had complaints of pain related to the fall and pain medications were given as ordered. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:30 PM revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) board for today (indicating the resident was to be seen by the physician or Nurse Practitioner) . Further medical record review revealed no documentation the resident was seen by the physician or Nurse Practitioner (NP) on [DATE]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 2:30 AM, revealed the resident woke up at night complaining of pain in the legs and knees and pain medication was given. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of the radiology report and nursing notes dated [DATE] revealed the x-ray results was reported to the Director of Nursing (DON). Further review revealed no documentation the physician or NP were notified of the bilateral fractures. Further review revealed the nurse scheduled an appointment for Resident #7 to be seen by an orthopedic physician on [DATE]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] revealed Resident #7's bilateral knees remained bruised. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review revealed the first documentation the resident was seen by a physician following the fall on [DATE] was on [DATE] when the resident was sent to the orthopedic physician's office. Medical record review of the History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. Further review revealed Resident #7 had significant osteoporotic appearing bone with significant arthritis and previous tibial hardware in both legs. The resident had bilateral distal femur fractures. The resident was admitted to the hospital because of the severity of the knee fractures. Medical record review of the hospital Death Summary completed by the orthopedic surgeon dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Telephone interview with the NP on [DATE] at 9:25 AM, revealed she remembered Resident #7 had a fall. The NP stated she gave the order for x-ray of both knees on [DATE] because the resident was still hurting. Telephone interview with CNA #8 on [DATE] at 10:55 AM revealed she was making her last round around 6:45 AM on [DATE] and went into Resident #7's room to change the resident. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help, the nurse came in to assess the resident, and they put the resident back to bed. CNA #8 stated the resident grabbed her knees after she fell . Interview with Registered Nurse (RN) #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came in to work on [DATE] for the 7:00 AM to 7:00 PM shift, she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, so she texted the Director of Nursing (DON) at 9:30 AM, and was given verbal permission to get x-rays of the shoulder and bilateral hips. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain. RN #2 further stated she knew the resident was in pain. Continued interview with RN #2 revealed she did not work [DATE], [DATE], and [DATE]. On [DATE], when she returned to work, the resident still had not been seen by either the doctor or the Nurse Practitioner (NP), but the NP was at the nurses' station, so she asked if she could get x-rays of the knees for Resident #7. The nurse stated when she got the x-ray report on [DATE] she scheduled an appointment with an orthopedic surgeon for [DATE]. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain prior to [DATE]. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated Resident #7 was not a complainer and usually would not volunteer to tell you she was hurting. RN #4 stated on [DATE] the resident was in so much pain, the CNAs reported the resident would scream when she was turned. RN #4 stated she then went in to talk with Resident #7, who stated her knees hurt badly. RN #4 stated both knees were swollen and black and blue. RN #4 stated on [DATE] there was a sign posted at the nurses' station to go to the supervisor before calling the physician, so she went to the Assistant Director of Nursing (ADON). The RN told the ADON the resident was in severe pain and the ADON asked .from what . RN #4 replied, .probably from the fall she had . According to RN #4, the ADON stated they had performed x-rays and they were all negative. RN #4 informed the ADON, .no, we have not x-rayed the knees . The ADON replied it was too late to call the physician and to place the resident on the Dr.'s Board (place to notify the physician or NP residents who need to be seen on next visit) for the resident to be seen the next day. RN #4 stated on [DATE], she saw the physician and the NP in the facility, but they never came to the floor to see Resident #7. RN #4 revealed when she spoke to the ADON on [DATE], she reminded her Resident #7 needed to be seen. The ADON replied the physician and NP were not seeing residents that day. RN #4 stated she did not work on [DATE], [DATE], and [DATE]. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE] when she was on duty and she had reported to the ADON the resident needed to be seen. RN #4 further confirmed Resident #7 was never a good eater, but was not eating as much since the accident, and the resident was in pain. RN #4 further confirmed she administered the resident pain medication as much as possible to keep her comfortable. Interview with the Restorative Aide on [DATE] at 9:50 AM, in the Resting Lounge, revealed she had worked with Resident #7 multiple times doing Range of Motion (ROM). The Restorative Aide stated after the fall on [DATE], the resident didn't want her to do ROM on her legs at all. The Restorative Aide stated the resident told her she had a fall and was in .so much pain . The Restorative Aide further stated the resident was also moaning, and her complaint of pain was different from her normal baseline and .enough to get my attention . Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed Resident #7 was never really one to complain of pain but would close her eyes and crunch up her face when in pain. CNA #4 stated before the fall when she would turn the resident, she would complain of pain and may complain more on rainy or cold days. After the fall, the resident was in a lot of pain all the time. CNA #4 stated when she turned the resident, she would scream out in pain and complained her knees were hurting. The CNA stated the resident's knees were swollen and bruised. CNA #4 stated she was working [DATE], and it was either [DATE] or [DATE], when she first noticed the bruising and swelling of both knees of Resident #7 and notified the nurse. When asked if the resident's complaints of pain were different after the fall, the CNA replied .absolutely . CNA #4 stated the resident was screaming with intense pain, especially on turning. CNA #4 stated the nurses told the CNAs nursing had been instructed to put it on the doctor's board and the resident's condition could wait until the physician came. CNA #4 stated she felt the nurses on the floor and the CNAs did everything they could do, but she .laid there several days in pain . Telephone interview with the former DON (who was DON at the time of the incident) on [DATE] at 10:15 AM, revealed he did not remember anything about the incident. The DON confirmed several days after the fall, when he was told the resident was complaining of knee pain and the nurses had seen bruising, he told the nurse to obtain x-rays of the knees and an orthopedic appointment. During observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, the nurse presented a piece of paper, which she stated she had taken down from the nurses' station, .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The sign had the DON's name typed at the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management before calling the physician. When asked when the sign was taken down from the nurses' station, the nurse replied when they found out they were being sued. RN #4 confirmed she saw a big change in Resident #7after the fall where she didn't eat as well and she didn't want to be changed by the CNAs. Interview with the Regional Quality Specialist on [DATE] at 3:20 PM, in the Resting Lounge, revealed, when asked what she would have expected the nursing staff to do when the resident continued to complain of pain, and especially knee pain, the Regional Quality Specialist replied .would have expected a call placed to provider . Telephone interview with the attending physician (medical doctor) on [DATE] at 3:45 PM revealed, when asked what he would have expected the nursing staff to do for any change in resident status including increased pain or swelling and bruising of both knees, the physician stated he would have expected to be called regarding these changes. The physician further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7, she observed the knees swollen and the resident stated she had fallen out of bed. The CNA informed RN #4 the resident's knees were swollen and painful on turning. The CNA stated RN #4 said she had been told to put it on the doctor's board. CNA #17 confirmed both knees were swollen and the resident complained of a lot of pain on [DATE]. The CNA stated she asked nursing again on [DATE] about the resident being seen by the physician and was told the doctor had still not seen the resident. Interview with CNA #18 on [DATE] at 4:15 PM, in the upper 400 hall shower room, revealed Resident #7's legs and knees were swollen and she .screamed . when turned and would say .Oh Please, Please, Please . during ADL (activities of daily living) care. The CNA further stated she asked staff everyday if anything had been done for the resident, such as an x-ray, and was told no. Interview with RN #2 on [DATE] at 5:45 PM, at the 400 hall nurses' station, revealed when she left work on [DATE] the results of the x-rays of the bilateral knees for Resident #7 had not returned. RN #2 stated when she came in on [DATE], she read the x-ray results and was in contact with the DON per text messaging. RN #2 stated she received a text from the DON, ortho (orthopedic physician) appointment ? When the RN was asked who gave the order for Resident #7 to go to the orthopedic physician's office, the nurse replied the DON. The RN stated she then started calling around to orthopedics and many did not want to see the resident due to the resident's previous surgery and hardware in her leg. The RN stated she talked to the resident, who could not remember the name of the orthopedic she had previously seen. RN #2 stated she kept calling and finally got in touch with the orthopedic who had done the previous surgery and made an appointment for Monday,[DATE]. When RN #2 was asked if she had given the resident or the Power of Attorney (POA) the option of going to the hospital or waiting to go to the orthopedic surgeon, the RN replied she did not but didn't know if anyone else had. When RN #2 was asked how Resident #7 was from [DATE] until the doctor appointment on [DATE], the RN replied the same. RN #2 stated they kept the resident comfortable with the [MEDICATION NAME], and [MEDICATION NAME] the resident had been prescribed prior to the accident on [DATE]. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed, when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. When asked what would be his plan of care, the physician replied he would ask the resident and/or family if they wanted to go to the hospital, go to the physician, or did they need to be seen now. Telephone interview with the NP on [DATE] at 9:11 PM, revealed the NP had reviewed her notes for Resident #7 and found no notation of being notified of the results of the bilateral knee x-rays. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator's Office, revealed during review of nursing notes for [DATE] and [DATE], the Administrator did not see the physician or NP had been notified of the results of the bilateral knee x-rays. When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services came in (MONTH) of (YEAR). Continued interview with the Administrator confirmed when asked if the documentation showed the physician or the NP had been made aware of the results of the bilateral knee x-rays the Administrator shook her head back and forth and stated .no .",2020-09-01
280,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,656,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to implement a comprehensive care plan for 1 resident (#7) of 6 residents reviewed for accidents and incidents, of 8 sampled residents. The facility's failure to implement the care plan interventions resulted in impacted fractures of both lower extremities and placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective 11/11/17 and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Medical record review of Resident #7's care plan, reviewed and updated 9/1/17, revealed for the problem of self-care deficit related to bedbound status, the resident's approach included .Bed mobility extensive assist of two . Medical record review of the Interdisciplinary Care Plan (used by the Certified Nurse Assistants (CNAs)), not dated, revealed Resident #7 was a two person assist for bed mobility. Review of the facility's incident report dated 11/11/17 at 6:45 AM revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Resident did not strike her head. Head to toe assessment performed, no injury noted .Two CNAs will be needed to turn resident on air mattress to prevent further falls . Review of the resident's care plan and assessment revealed the resident required a two person assist for bed mobility prior to the accident on 11/11/17. Review of the facility's investigation revealed a written statement completed by CNA #8 dated 11/11/17, which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of nursing notes dated 11/11/17 revealed the resident complained of pain in the hips and left shoulder and x-rays of the bilateral hips and left shoulder were ordered. Medical record review of the radiology report dated 11/11/17 revealed .Minimal to moderate [MEDICAL CONDITION] changes to the right hip .Moderate to severe [MEDICAL CONDITION] changes of the left hip . No fracture, dislocation, [MEDICAL CONDITION] changes or destructive [MEDICAL CONDITION] of the left shoulder were present. Medical record review of the resident's care plan revealed on 11/13/17 .noodles to bed . had been added as an intervention for at risk for falls due to decrease in mobility. Medical record review of a physician's telephone order dated 11/16/17 at 1:30 PM revealed an order for [REDACTED]. Medical record review of the radiology report dated 11/16/17 revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Interview with the Administrator on 7/10/18 at 9:00 AM, in the Conference Room, revealed Resident #7 did have a fall in (MONTH) of (YEAR) when a CNA turned the resident in the bed and the resident fell to the floor. Continued interview with the Administrator revealed the resident should have been turned by 2 staff members. When asked if the resident was care planned for 2 staff members the Administrator stated yes. Telephone interview with CNA #8 on 7/10/18 at 10:55 AM revealed she was making her last round around 6:45 AM on 11/11/17 when she went into Resident #7's room. The CNA stated when she went to change the resident she noticed something on her sheet, so she decided she would change the sheet. CNA #8 stated the resident had always grabbed the hand rail to hold when she turned but for some reason she did not get a grip on the hand rail. The CNA stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then they put the resident back to bed. CNA #8 stated the resident grabbed her knees after she fell . When CNA #8 was asked had she been turning Resident #7 by herself, the CNA responded she had always turned the resident by herself. When CNA #8 was asked how did she know if a resident was a 1 person or a 2 person assist for bed mobility or transfer, the CNA stated .by word of mouth .asked other CNAs . Interview with Registered Nurse (RN) #3 on 7/10/18 at 12:05 PM, in the Conference Room, revealed each nurses' station had a CNA binder book which had the Interdisciplinary Care Plans for the CNAs to follow and included assistance needed for Activities of Daily Living (ADL). Interviews with 16 CNAs on 7/10/18 and 7/11/18 revealed all but 2 (CNA #8 and #11) knew about the CNA binders at each nurses' station. Interview with CNA #11 on 7/10/18 at 5:18 PM, at the 300 Hall nurses' station, revealed when asked about the CNA binder, he replied .never used it . Telephone interview with the former Director of Nursing (DON) on 7/11/18 at 10:15 AM, revealed when he was asked if he was aware Resident #7 was care planned for a 2 person assist during bed mobility, he replied no, she was a 2 person assist only for transfer from bed to chair. The DON stated he did remember implementing a practice change to deflate the air mattress before doing care and turning. Interview with the Regional Quality Specialist on 7/11/18 at 3:20 PM, in the Resting Lounge, revealed when the Regional Quality Specialist was asked what she would have expected when a CNA stated she was not aware of the CNA Care Guides, which documented assistance needed for ADLs, the Regional Quality Specialist replied .would have expected all CNAs would have been in-serviced on the Care Guides . Refer to F-689",2020-09-01
281,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,658,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based review of facility's policies, review of Rules and Regulations of Registered Nurses, review of Tennessee Code Annotated, medical record review, facility investigation review, interview, and observation, the facility failed to assure the services provided met professional standards of quality and acceptable standards of clinical practice for 1 resident (#7), of 8 residents reviewed. The facility's failure to ensure care was provided within professional scope of practice resulted in Resident #7 sustaining bilateral fractures, nursing staff ordering interventions without consulting with physician services, and placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective 11/11/17 and is ongoing. The findings include: Review of the facility's policy titled Change in a Resident's Condition or Status dated 12/28/16 revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician .when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Review of the Tennessee Rules and Regulations of Registered Nurses Chapter 1000-01 revised June, (YEAR) revealed .3 .(a) Responsibility .Registered nurses are liable if they perform delegated functions they are not prepared to handle by education and experience and for which supervision is not provided. In any patient care situation, the registered nurse should perform only those acts for which each has been prepared and has demonstrated ability to perform, bearing in mind the individual's personal responsibility under the law . Review of the Tennessee Code Annotated 63-7-103 Practice of professional nursing and professional nursing defined revealed .(F) .(b) Notwithstanding subsection (a), the practice of professional nursing does not include acts of medical [DIAGNOSES REDACTED]. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated 11/11/17, which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of nurse's notes dated 11/11/17 at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays had been ordered. Medical record review of a telephone order dated 11/11/17, at 10:45 AM, revealed .Bilateral hips & (and) L (left) shoulder x-ray .fall .VORB (verbal order read back) (name of the former Director of Nursing) Continued review of the order revealed the order was a verbal order written by a Registered Nurse (RN) and given by the former Director of Nursing (DON). Medical record review of the radiology report for the hips and left shoulder dated 11/11/17 revealed no fracture or dislocation of left shoulder or hips was present. Medical record review of nurse's notes dated 11/14/17 at 12:30 PM, revealed the resident's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board (meaning the resident was on the list to be seen by the physician) for today . Medical record review of a physician's telephone order dated 11/16/17 at 1:30 PM, revealed a verbal order for x-ray of bilateral knees given by the Nurse Practitioner (NP). Medical record review of the radiology report dated 11/16/17 revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of a nursing progress note dated 11/16/17 revealed the DON was notified of the results of the x-ray on 11/16/17 at 9:10 PM. Continued review of the nursing progress note and the radiology report revealed no documentation the physician or NP had been notified. Medical record review of a nurse's note dated 11/17/17 revealed .spoke to resident's sister .to notify her of resident's orthopedic appt (appointment) . Medical record review revealed there was no documentation of an order for [REDACTED].>Telephone interview with the Nurse Practitioner (NP) on 7/10/18 at 9:25 AM, confirmed she gave the order for the x-ray of the knees on 11/16/17 because the resident was still in pain. Interview with RN #2 on 7/10/18 at 11:30 AM, at a location outside the facility, revealed when she came to work on 11/11/17 for the 7:00 AM to 7:00 PM shift, she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, so she texted the DON at 9:30 AM and was given verbal permission by the DON to order x-rays of the shoulder and bilateral hips. Continued interview with RN #2 revealed when she returned to work on 11/16/17 the resident still had not been seen by the Nurse Practitioner (NP) or the physician, but the NP was at the nurses' station, so she asked if she could get x-rays of the knees of Resident #7. Telephone interview with RN #4 on 7/10/18 at 1:00 PM, revealed on 11/13/17 and 11/14/17 there was a sign posted at the nurses' station to notify the supervisor before calling the physician or NP, so she reported to the Assistant Director of Nursing (ADON) Resident #7 was having knee pain and x-rays of the knees had not been done. The ADON instructed RN #4 to place the resident on the Dr.'s Board. RN #4 confirmed Resident #7 was not seen by the physician or the NP on 11/13/17 or 11/14/17. Telephone interview with the former DON (who was DON at time of the incident) on 7/11/18 at 10:15 AM, revealed he didn't remember anything about the incident. The DON confirmed several days after the fall, when he was made aware the resident was having a lot of pain and swelling and bruising of both knees, he instructed the nurses to get x-rays and an orthopedic appointment. Observation and interview with RN #4 on 7/11/18 at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. Continued interview with RN #4 revealed the nurses were to call management first. Interview with the Regional Quality Specialist on 7/11/18 at 3:20 PM, in the Resting Lounge, revealed she was in the building at least monthly 2-3 days at a time. When asked if she had ever seen the sign regarding not to call the physician or NP, the Regional Quality Specialist stated she had not seen it and the DON (who was ADON at time of incident) had told her there was no sign. When asked what she would have expected the nursing staff to do when the resident continued to complain of pain, and especially knee pain, the Regional Quality Specialist replied .would have expected a call placed to the provider . Interview with RN #2 on 7/13/18 at 5:45 PM, at the 400 hall nurses' station, revealed when she left work on 11/16/17, the results of the x-rays of the bilateral knees for Resident #7 had not returned. RN #2 stated when she returned to work on 11/17/18 she read the x-ray results and was in contact with the DON per text messaging. RN #2 stated she received a text from the DON regarding .ortho (orthopedic physician) appointment? . When the RN was asked who gave the order for Resident #7 to go to the orthopedic's office, the nurse replied the DON. Telephone interview with the Medical Director, attending physician, on 7/13/18 at 5:59 PM, revealed when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . Interview with the Administrator on 7/13/18 at 6:05 PM, at the 400 hall nurses' station, revealed when shown the nurses' notes of 11/16/17, of the results of the x-rays and the physician was not noted as being notified, and on 11/17/17 when the staff made an appointment with an orthopedic surgeon without a physician's orders [REDACTED].(DON) is not a Doctor .",2020-09-01
282,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,689,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to prevent an avoidable accident for 1 resident (#7) of 6 residents reviewed for accidents, of 8 sampled residents. The facility's failure to prevent an avoidable accident resulted in a fall, in which Resident #7 sustained bilateral impacted knee fractures, and placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F689 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Medical record review of the Fall Risk Evaluation dated [DATE] revealed Resident #7 scored 16 (score of 10 or higher placed the resident at risk for falls). Medical record review of Resident #7's care plan reviewed and updated [DATE], revealed for the problem of self-care deficit, related to bedbound status, the resident's approach included .Bed mobility extensive assist of two . Medical record review of the Interdisciplinary Progress Notes dated [DATE] revealed Resident #7 required extensive assist of two persons for bed mobility. Medical record review of the Interdisciplinary Care Plan (used by the Certified Nursing Assistants), not dated, revealed Resident #7 was a two person assist for bed mobility. Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Resident did not strike her head. Head to toe assessment performed, no injury noted .Sister .Dr (physician) .notified. Two CNAs (Certified Nursing Assistants) will be needed to turn resident on air mattress to prevent further falls . Continued review revealed the resident was care planned and assessed as a 2 staff assist for bed mobility prior to the accident. Review of the facility's investigation revealed a written statement completed by CNA #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays were ordered. Medical record review of the radiology report dated [DATE] revealed .Minimal to moderate [MEDICAL CONDITION] changes to the right hip .Moderate to severe [MEDICAL CONDITION] changes of the left hip . No fracture or dislocation of the left shoulder was present. Medical record review of the Fall Risk Evaluation dated [DATE] revealed Resident #7 scored 18 (score of 10 or higher placed the resident at risk for falls). Review of the 5 WHYs worksheet (a worksheet used to ask 5 why questions to determine the root cause of a problem and implement interventions to prevent recurrence) revealed the worksheet was incomplete for the resident's accident. Further review revealed Define the problem: Resident slid out of bed . Further review revealed 5 boxes on the worksheet under why is it happening? with an area to answer why it happened, followed by why is that? and then a space to continue answering until the root cause was found. Further review revealed only 1 of the 5 why boxes was completed with, Air mattress unstable on edge of bed and then an arrow drawn to the side stating, use two CNAs to change or reposition resident, an intervention that was already to be done. Medical record review of nurse's notes dated [DATE] at 12:10 PM, revealed the resident still had complaints of pain related to the fall. Medical record review of the Interdisciplinary Progress Notes dated [DATE] revealed, IDT (Interdisciplinary Team) clinical post fall [DATE], slide from air mattress during care. 0 (no) injurys (injuries) .foam noodles added to bed . Medical record review of the resident's care plan revealed on [DATE] .noodles to bed . had been added as an intervention for at risk for falls due to decrease in mobility. Medical record review of nurse's notes dated [DATE] at 12:30 PM, revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board for today (indicating the resident was to be seen by the physician or Nurse Practitioner) . Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Continued review revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM, and the family was notified of the results at 9:20 PM. Medical record review of nurse's notes dated [DATE] revealed the bilateral knees remained bruised. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. Further review revealed Resident #7 had significant osteoporotic appearing bone with significant arthritis and previous tibial hardware in both legs. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary dated [DATE], revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interview with the Administrator on [DATE], at 9:00 AM, in the Conference Room, confirmed Resident #7 had a fall in (MONTH) (YEAR). Continued interview with the Administrator revealed when asked if the resident was assisted by 1 or 2 people, the Administrator stated only one. When asked how many staff members were to assist the resident the Administrator replied .2 . Telephone interview with the Nurse Practitioner (NP) on [DATE] at 9:25 AM, revealed she remembered Resident #7 had a fall. The NP stated she gave the order for the x-ray of the knees on [DATE] because the resident was still hurting. Telephone interview with CNA #8 on [DATE] at 10:55 AM, revealed she was making her last round around 6:45 AM on [DATE], and went to change Resident #7 when she noticed something on her sheet, so she decided she would change the sheet. CNA #8 stated the resident had always grabbed the hand rail to hold onto when she turned, but for some reason she did not get a grip on the hand rail. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then the staff put the resident back to bed. CNA #8 stated the resident was .shaking really bad and I couldn't even get her vital signs . CNA #8 stated the resident grabbed her knees after she fell . When CNA #8 was asked had she been turning Resident #7 by herself, the CNA responded she had always turned the resident by herself. When CNA #8 was asked how did she know if a resident was a 1 person or a 2 person assist for bed mobility or transfer, the CNA stated .by word of mouth .asked other CNAs . Interview with Registered Nurse (RN) #3 on [DATE] at 12:05 PM, in the Conference Room, revealed each nurses' station had a CNA binder book which had the Interdisciplinary Care Plans for the CNAs to follow, and included assistance needed for Activities of Daily Living (ADL). Interviews with 16 CNAs on [DATE] and [DATE] revealed all but 2 (CNA #8 and #11) knew about the CNA binders at each nurses' station and where to find the information needed for resident care. Interview with CNA #11 on [DATE] at 5:18 PM, at the 300 hall nurses' station, revealed he didn't use the care guides and didn't know anything about them. Interview with RN #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came to work on [DATE] for the 7:00 AM to 7:00 PM shift, she was informed Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, and obtained x-rays of the shoulder and hips. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain until [DATE], when an order to obtain x-rays of the bilateral knees was given by the NP. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated on [DATE] the CNAs reported the resident would scream when she was turned. RN #4 stated she went in to talk with Resident #7 who stated her knees hurt her badly. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE]. Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed when she turned the resident she would scream out in pain in her knees. The resident's knees were swollen and bruised. When she was working [DATE] and it was either [DATE] or [DATE] when she notified the nurse of the swelling and bruising of both knees of Resident #7. Telephone interview with the former DON (who was DON at time of the incident) on [DATE] at 10:15 AM, revealed he didn't remember anything about the incident. When asked if he was aware the resident was care planned for a 2 person assist during bed mobility, he replied she was a 2 person assist only for transfer from bed to chair. The former DON stated he did remember they implemented a practice change to deflate the air mattress before doing care and turning residents. Interview with the Regional Quality Specialist on [DATE] at 3:20 PM, in the Resting Lounge, revealed she was in the building at least monthly ,[DATE] days at a time. The duties of the Regional Quality Specialist included survey readiness, compliance, review of policies and procedures, and performance improvement plans. When asked when she became aware of the accident of [DATE], the Regional Quality Specialist stated on Monday [DATE] when she came into the facility. When the Regional Quality Specialist was asked what she would have expected when a CNA stated she was not aware of the CNA Care Guides which documented assistance needed for ADLs, the Regional Quality Specialist replied .would have expected all CNAs would have been in-serviced on the Care Guides . Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7 she observed the knees swollen and the resident told the CNA she had fallen out of bed. CNA #17 reported to RN #4 about the knees being swollen and pain on turning and was informed the RN had been instructed to add the resident to the doctor's board by the ADON. CNA #17 confirmed both knees were swollen and the resident complained of a lot of pain on [DATE]. Interview with CNA #18 on [DATE] at 4:15 PM, in the upper 400 hall shower room, revealed Resident #7's legs and knees were swollen and she .screamed . when turned and would say .Oh Please, Please, Please . begging during changing. The CNA further stated she asked nursing everyday if anything had been done for the resident, such as an x-ray and was told no. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed the facility discussed falls during the morning meetings and reviewed the 24 hour reports. The facility conducted a Risk Management meeting weekly where they went through all falls for the week. The Administrator stated their process .now . during the risk meeting was to look at interventions to see if the intervention was appropriate, pulling each chart, reviewing the nursing notes and trying to do a better and thorough job. The Administrator confirmed they were not doing this in-depth meeting at the time of Resident #7's accident. The Administrator confirmed if they had been doing the type of risk meeting they were doing now, including reading the nurses notes, they would have been aware of the accident. They would have included a teachable moment for the CNA regarding use of the Care Guides and provided more staff education. The Administrator further stated she could not say at the time of the incident that they read the accident reports out loud or discussed the interventions during the meetings but .We do now . When asked when they started doing the new process regarding incident reports the Administrator stated it was after [DATE] when the previous DON left. Telephone interview with the Medical Director on [DATE] at 5:59 PM, revealed, when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . The MD confirmed all fractures should be called to the physician or the person on call. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator' Office, confirmed she became aware of the fall and fractures for Resident #7 when Adult Protective Services (APS) came in (MONTH) of (YEAR). The Administrator confirmed the incident resulting in bilateral fractures involving Resident #7 was not discussed for implementation of a corrective action plan.",2020-09-01
283,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,697,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, interview, and observation, the facility failed to ensure pain management was provided to 1 resident (#7) of 6 residents reviewed for accidents, after a fall which resulted in bilateral impacted knee fractures. The facility's failure to identify the cause of pain and provide interventions placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F697 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Rheumatology Consultation dated [DATE] revealed .has symptoms of chronic widespread pain. She is exquisitely sensitive to any sort of palpation of her extremities, particularly her lower extremities .would put her under pain amplificatio[DIAGNOSES REDACTED] . Medical record review of the Medication Administration Record [REDACTED]. Medical record review of psychiatric recommendations and progress notes dated [DATE] revealed Resident #7 complained of pain as a 10 (extreme pain) on a scale of 1 to 10. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review of Resident #7's MAR for (MONTH) (YEAR) revealed the resident had a pain assessment completed every shift (7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM) and the resident's pain was 0 every day until [DATE], after the resident was diagnosed with [REDACTED]. Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees . Medical record review of the MAR indicated [REDACTED]. Medical record review of the (MONTH) MAR indicated [REDACTED]. Medical record review of Resident #7's (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays were ordered. Medical record review of the radiology report dated [DATE] revealed no fracture or dislocation of the shoulder or hips was present. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:10 PM, revealed Resident #7 still had complaints of pain related to the fall. Continued review revealed pain medication was given as ordered. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:30 PM, revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board for today (indicating the resident needed to be seen by the physician or the Nurse Practitioner) . Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the (MONTH) MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Impacted fracture (left) involving the distal femoral metaphysis .Old internally fixated proximal tibial fracture . Continued review revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM. Review of the radiology report and nursing notes revealed no documentation the physician was notified. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary dated [DATE], revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Telephone interview with the Nurse Practitioner (NP) on [DATE] at 9:25 AM, revealed she remembered she gave the order for the x-ray of the knees on [DATE] because the resident was still having pain. Telephone interview with CNA #8 on [DATE] at 10:55 AM, revealed she was making her last round around 6:45 AM on [DATE], and went in to change the resident's bed sheet. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then they put the resident back to bed. CNA #8 stated the resident was .shaking really bad and I couldn't even get her vital signs . CNA #8 stated the resident grabbed her knees after she fell . Interview with Registered Nurse (RN) #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came in [DATE] (for the 7:00 AM to 7:00 PM shift) she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident in the resident's room who complained of pain in the left shoulder and left hip. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain and she gave the resident pain medication to try to keep her comfortable. RN #2 further stated she knew Resident #7 was in pain. Continued interview with RN #2 revealed she was not working [DATE], [DATE], and [DATE]. RN #2 stated on [DATE] when she returned to work the resident still had not been seen by the Nurse Practitioner or the physician, but stated the NP was at the nurses' station so she asked if she could get x-rays of the knees of Resident #7. The nurse further revealed when she read the report on [DATE] from the bilateral knee x-rays she scheduled an appointment with an orthopedic surgeon for [DATE]. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain until [DATE]. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated Resident #7 was not a complainer and usually would not volunteer to tell you she was hurting. RN #4 stated on [DATE] the resident was in so much pain the CNAs reported the resident would scream when she was turned. RN #4 stated she went in to talk with Resident #7 who stated her knees hurt her badly. RN #4 stated both knees were swollen and black and blue. RN #4 stated at this time there was a sign posted at the nurse's station to notify the supervisor before calling the physician or NP so she went to the Assistant Director of Nursing (ADON) and reported the resident was in severe pain. RN #4 stated the ADON said they had done x-rays and they were all negative. RN #4 then replied .no, we have not x-rayed the knees . The ADON replied it was too late to call the physician and just place it on the Dr.'s Board (which is used to list residents who need to be seen by the physician or NP on the next visit) for the resident to be seen the next day. RN #4 stated on [DATE] she saw the physician and the NP in the facility but they never came to the floor to see Resident #7 and when she reminded the ADON Resident #7 needed to be seen, the ADON replied to her the physician and NP were not seeing residents that day. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE] when she was on duty. RN #4 further revealed Resident #4 was never a good eater, but after the incident the resident was not eating as much and the resident was in a lot of pain. RN #4 further confirmed she administered the resident pain medications that had been previously prescribed as much as possible to keep her comfortable. Interview with the Restorative Aide on [DATE] at 9:50 AM, in the Resting Lounge, revealed she had worked with Resident #7 multiple times doing Range of Motion (ROM). The Restorative Aide stated after the fall on [DATE] the resident didn't want her to do ROM on her legs at all because of the pain. The Restorative Aide stated the resident told her she had a fall and was in .so much pain . The Restorative Aide further stated the resident was also moaning and her complaint of pain was different from her normal baseline and .enough to get my attention . Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed Resident #7 was never really one to complain of pain but would close her eyes and crunch up her face. CNA #4 stated before the fall when she would turn the resident, the resident would complain of pain, and maybe even more on rainy or cold days. But after the fall, the resident was in a lot of pain all the time. CNA #4 stated when she turned the resident, she would scream out in pain in her knees. The resident's knees were swollen and bruised. When asked if the complaint of pain was different after the fall the CNA replied .absolutely . CNA #4 stated the resident was screaming with intense pain especially on turning. CNA #4 stated the nurses told the CNAs they had been instructed to put the resident on the doctor's board and the pain could wait until the physician came. CNA #4 stated she felt the nurses on the floor and the CNAs did everything they could do but the lady .laid there several days in pain . Telephone interview with the former DON (who was DON at time of the accident) on [DATE] at 10:15 AM, confirmed he was notified several days after the fall the resident was having a lot of pain. During observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, RN #4 presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. RN #4 confirmed she saw a big change in Resident #4 after the fall where she didn't eat as well and she didn't want to be changed because of the pain. Interview with the Regional Quality Specialist on [DATE] at 3:20 PM, in the Resting Lounge, revealed she was in the building at least monthly ,[DATE] days at a time. When asked what she would have expected the nursing staff to do when the resident continued to complain of pain the Regional Quality Specialist replied .would have expected a call placed to the provider . Telephone interview with the attending physician (Medical Doctor) on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any increased pain, the MD stated he would expect to be called for any changes. The MD further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7 she observed the knees swollen and the resident told the CNA she had fallen out of bed. CNA #17 reported to RN #4 about the resident's pain on turning and was informed the RN had been instructed to put it on the doctor's board by the ADON. CNA #17 confirmed the resident complained of a lot of pain on [DATE]. CNA #17 asked nursing again on [DATE] and was told the doctor had still not seen the resident. Interview with CNA #18 on [DATE] at 4:15 PM, in the upper 400 hall shower room, revealed Resident #7's legs and knees were swollen and she .screamed . when turned and would say .Oh Please, Please, Please . begging during changing. The CNA further stated she asked nursing everyday if anything had been done for the resident, and was told no. Interview with RN #2 on [DATE] at 5:45 PM, at the 400 hall nurses' station, revealed when she left on [DATE] the results of the x-rays of the bilateral knees for Resident #7 had not returned. She returned to work on [DATE], read the x-ray results, was in contact with the DON per text messaging, and an appointment was made for [DATE]. When RN #2 was asked how Resident #7 was during [DATE] until the doctor appointment on [DATE], the RN replied the same. RN #2 stated they (nursing) kept the resident comfortable with the [MEDICATION NAME], and [MEDICATION NAME] the resident was prescribed prior to the fall. In summary, Resident #7 experienced an avoidable accident on [DATE]. From [DATE] until [DATE] Resident #7 experienced significant increase in pain from her baseline level. On [DATE] an x-ray was completed on the bilateral knees indicating bilateral knee fractures. Resident #7 was not seen by a physician at the facility from [DATE] through [DATE], when she was sent out to see an orthopedic physician, and the facility failed to provide interventions to address the cause of newly increased pain, bilateral leg fractures from a fall on [DATE]. Resident #7 was admitted to the hospital from the orthopedic physician's office for repair of the fractures and palliative care. The resident expired on [DATE].",2020-09-01
284,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,777,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review a facility incident report, interview, and observation, the facility failed to obtain an order by the physician or Nurse Practitioner (NP) prior to obtaining x-rays and failed to promptly notify the ordering physician or NP the results of the x-rays, for 1 resident (#7) of 8 sampled residents. Failure to obtain a physician's orders [REDACTED].#7 experiencing pain, and placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective 11/11/17 and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's incident report dated 11/11/17 at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change .no injury noted . Medical record review of nurse's notes dated 11/11/17 at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays had been ordered. Medical record review of a telephone order dated 11/11/17, at 10:45 AM, revealed Bilateral hips & (and) L (left) shoulder x-ray .fall .VORB (verbal order read back) (name of the Director of Nursing). Continued review of the order revealed the order was a verbal order written by a Registered Nurse and given by the Director of Nursing (DON). Further review revealed the order was signed by the Nurse Practitioner (NP) on 11/16/17. Medical record review of the radiology report for the shoulder and hip x-rays dated 11/11/17 revealed no fracture or dislocation. Medical record review of a physician's telephone order dated 11/16/17 at 1:30 PM, revealed a verbal order from the NP for x-ray of bilateral knees. Medical record review of the radiology report dated 11/16/17 revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of a nursing progress note dated 11/16/17 revealed the DON was notified of the results of the x-ray on 11/16/17 at 9:10 PM, and the family was notified of the results at 9:20 PM. Further review of the radiology report and nursing notes revealed no documentation the physician or NP were notified of the results of the radiology report indicating the resident had fractures. Telephone interview with the Nurse Practitioner (NP) on 7/10/18 at 9:25 AM, revealed she remembered giving the order for the x-ray of the knees on 11/16/17 because the resident was still hurting. Interview with RN #2 on 7/10/18 at 11:30 AM, at a location outside the facility, revealed when she came to work 11/11/17 for the 7:00 AM to 7:00 PM shift she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, so she texted the DON at 9:30 AM and was given verbal permission to obtain x-rays of the shoulder and bilateral hips from the DON. Continued interview with RN #2 revealed she was not working 11/13/17, 11/14/17, and 11/15/17. RN #2 stated on 11/16/17, when she returned to work, the resident still had not been seen by the NP or the physician, but the NP was at the nurses' station so she asked the NP if she could get x-rays of the knees of Resident #7. Telephone interview with the former DON (who was DON at time of the incident) on 7/11/18 at 10:15 AM, revealed he did remember several days after the fall, when he was made aware the resident was having a lot of pain and her knees were swollen and bruised, he instructed the nurses to get x-rays. Observation and interview with RN #4 on 7/11/18 at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Doctor) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. Continued interview with RN #4 revealed the nurses were to call management first. Telephone interview with the attending physician on 7/11/18 at 3:45 PM, revealed he did not remember the facility calling him for any changes to Resident #7 or for any further orders. Interview with RN #2 on 7/13/18 at 5:45 PM, at the 400 hall nurses' station, revealed when she left work on 11/16/17, the results of the x-rays of the bilateral knees for Resident #7 had not returned. RN #2 stated when she returned to work on 11/17/18, she read the x-ray results and was in contact with the DON per text messaging. Further interview revealed she did not contact the physician or the NP with the results. Telephone interview with the Medical Director, who was the resident's attending physician, on 7/13/18 at 5:59 PM, revealed when asked did he know about the bilateral fractures of Resident #7 he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. Interview with the Administrator on 7/13/18 at 6:05 PM, at the 400 hall nurses' station, revealed when shown the nurses' notes dated 11/16/17, with the results of the knee x-rays, the Administrator confirmed the physician was not noted as being notified. Telephone interview with the NP on 7/13/18 at 9:11 PM, revealed the NP had researched her notes related to Resident #7 and found no notation of being notified of the results of bilateral knee x-rays. Interview with the Administrator on 7/14/18 at 9:00 AM, in the Administrator's Office, confirmed during review of nursing notes for 11/16/17 and 11/17/17, the Administrator did not see any documentation the physician or NP had been notified of the results of the bilateral knee x-rays. The Administrator replied .don't see anything .",2020-09-01
285,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,835,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, interview, and observation, the Administrator failed to ensure facility policies were implemented, physicians were notified timely of changes in condition, and residents were free from neglect, avoidable accidents, and pain. The Administrator's failure resulted in a resident having an avoidable accident and a delay in receiving services and treatment after a fall with fractures, with Resident #7 experiencing intense pain, and placing Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side) Review of the facility's incident report and investigation dated [DATE] at 6:45 AM, revealed Certified Nursing Assistant (CNA) #8 was changing Resident #7's bed linen without assistance of a second staff person, and Resident #7 fell in the floor landing on her knees. Medical record review of the resident's nursing notes and Medication Administration Record [REDACTED]. Further review revealed the physician nor Nurse Practitioner (NP) was notified of the resident having pain, bruising or swelling in her knees and was not assessed at any time after the fall by the physician or NP. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Impacted fracture (left) involving the distal femoral metaphysis .Old internally fixated proximal tibial fracture . Medical record review of nursing notes, radiology reports, and physician's orders revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM, and the family was notified of the results at 9:20 PM, but there was no documentation the physician or NP was notified of the results. Further review revealed Registered Nurse (RN) arranged an appointment with an orthopedic physician for [DATE] and there was no physician's order for the orthopedic consult. Medical record review of the nursing notes and MAR for [DATE] through [DATE] revealed the resident continued to experience pain, swelling, and bruising in her knees and legs. Further review revealed no documentation the physician or NP was notified of the pain or results of the x-rays, and no documentation the resident was assessed by the physician or NP. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it is quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary by the orthopedic surgeon dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interviews with CNA #8, RN #2, RN #4, CNA #4 during investigation [DATE] - [DATE] revealed the resident continued to complain of severe pain and staff reported the resident's condition to the DON and Assistant Director of Nursing (ADON), who failed to ensure the physician or NP was notified of the resident's condition and assessed the resident. Staff interviews revealed the physician and NP were not notified of the resident's pain or results of the x-rays indicating the resident had bilateral fractures, and the physician and NP did not assess the resident. Telephone interview with the former DON (who was DON at time of the incident) on [DATE] at 10:15 AM, revealed he didn't remember anything about Resident #7's accident. Continued interview with the DON revealed he did remember several days after Resident #7's fall when he was made aware the resident was having a lot of pain. Observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management first. Telephone interview with the attending physician on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any change in resident status including increased pain or swelling and bruising of both knees, the physician stated he would expect to be called for any changes. The MD further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed she had not seen the sign hanging at the nursing station to call the nurse supervisor before calling the physician or NP. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed when asked when did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator' Office, confirmed during observation of nursing notes for [DATE] and [DATE] the Administrator did not see any documentation the physician or NP had been notified of the results of the bilateral knee x-rays. The Administrator replied .don't see anything . When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services (APS) came in (MONTH) of (YEAR). The Administrator stated she didn't remember if she was present or not at the facility for the morning meeting when the fall should have been discussed, but at the time of the fall they were not reading the incidents out loud and the assumption was the DON was looking at all nursing notes of residents with falls. Continued interview with the Administrator confirmed, when asked if the documentation showed the physician or the NP had been made aware of the results of the bilateral knee x-rays, the Administrator shook her head back and forth and said .no . Further interview with the Administrator revealed QA meetings were conducted on [DATE] and [DATE] at which time only number of incidents and location of the incidents were presented. Continued interview revealed no fractures were reported during these meetings.",2020-09-01
286,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,837,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, observation, and interviews, the governing body failed to ensure implemention of policies regarding the management and operation of the facility. The governing body's failure placed 1 resident (#7) of 6 residents of 8 residents reviewed for accidents and incidents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident required extensive assist of 2 staff for bed mobility which include turning from side to side. Medical record review of the care plan updated [DATE] revealed Resident #7 required extensive assistance of 2 for bed mobility. During the survey conducted [DATE] - [DATE], investigation revealed on [DATE] at 6:45 AM, Resident #7 was turned in bed by 1 Certified Nursing Assistant (CNA), instead of 2 CNAs as required, and the resident fell to the floor, landing on her knees. The nurse gave the resident Tylenol for knee pain. X-rays were completed on [DATE] of bilateral hips and left shoulder. The results of the x-rays were negative. Resident #7 continued to complain of pain, especially on turning. Interview with Registered Nurse (RN) #4 on [DATE] revealed on [DATE] Resident #7 was in so much pain the CNAs reported the resident would scream when she was turned. RN #4 assessed Resident #7 and found both knees to be swollen and bruised. According to RN #4 on [DATE] a sign was posted at the nurses station to call the supervisor before calling the physician or the Nurse Practitioner (NP), so RN #4 reported to the Assistant Director of Nursing (ADON) who instructed the nurse to place a note on the Dr's Board (list for physician or NP know the residents needed to be seen the next visit). The physician and the NP were in the facility on [DATE] but did not see Resident #7. Resident #7 continued to have pain on turning from [DATE] until on [DATE], when RN #2 approached the NP, who was at the nursing station and bilateral knee x-rays were ordered. Results of the bilateral knee x-rays revealed bilateral knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee). Neither the physician nor the NP were notified of the results of the bilateral knee x-rays. The Director of Nursing (DON) instructed RN #2 by text messaging to make an orthopedic physician's appointment without a physician's orders [REDACTED]. Resident #7 expired on [DATE]. Interview with the Regional Quality Specialist on [DATE] revealed she was in the facility monthly at least ,[DATE] days at a time. Continued interview with the Regional Quality Specialist revealed her duties while in the facility included survey readiness, compliance of policies and procedures, system breakdown, and performance improvement plans. Further interview revealed the Regional Quality Specialist was unaware of the sign hanging at the nurses' station not to call the physician or NP before calling the nursing supervisor. Continued interview revealed the Regional Quality Specialist was to be notified of all fractures but was unaware of the fractures to Resident #7 until [DATE]. When the Regional Quality Specialist was asked what she would have expected the nursing staff to do when the resident continued to complain of pain and especially with the knees swollen and bruised, the Regional Quality Specialist replied she .would have expected a call placed to the provider . When the Regional Quality Specialist was asked what she would have expected when a CNA stated she was not aware of the CNA Care Guides which documented assistance needed for Activities of Daily Living, the Regional Quality Specialist replied .would have expected all CNAs would have been in-serviced on the Care Guides .",2020-09-01
287,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,867,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of facility investigation, review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, and interview, the QAPI committee failed to identify and correct quality deficiencies resulting in an avoidable accident where Resident #7 rolled out of bed during care and received bilateral leg fractures that were not identified for 5 days and the resident was not assessed and treated by a physician for another 4 days after x-ray results. The QAPI's failure placed 1 resident (#7) of residents reviewed in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective on [DATE] and is ongoing. The findings include: Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Review of the facility's policy titled Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change .Two Certified Nursing Assistants (CNAs) will be needed to turn resident on air mattress to prevent further falls . Further review revealed Resident #7 required 2 person assist with bed mobility prior to the incident. Review of the facility's investigation revealed a written statement completed by CNA #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures and was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed the facility conducted Quality Assurance meetings monthly with the Administrator, Director of Nursing (DON), Staff Development Coordinator, Medical Director, Dietary Manager, Social Services, Activities, Infection Control Director, Rehab Director, Human Resources, Medical Records Director, Registered Dietician, MDS Coordinator, Maintenance Director, a CNA, a Nurse, Respiratory Therapist, Wound Care Nurse, and Pharmacy Consultant (at least quarterly). The Administrator stated they go through each department, investigations, customer satisfaction, family satisfaction, revised policies, discharges, falls, and trends. The Administrator stated they discussed falls during the morning meetings and reviewed the 24 hour reports. The facility conducted a Risk Management meeting weekly where they go through all falls for the week. The Administrator stated .now . during the risk meeting they were looking at interventions to see if the intervention was appropriate, pulling each chart, reviewing the nursing notes, and trying to do a better and through job. The Administrator stated they were not doing this in-depth meeting when the previous DON was at the facility at the time of Resident #7's fall. The Administrator confirmed if they had been doing the type of risk meeting they were doing now, including reading the nurses notes, they would have been aware of the accident and the days following the accident, including the resident's continued complaints of pain with the swelling and bruising of both knees. Further interview with the Administrator confirmed if they had been doing the new process at the time of the incident they would have also included a teachable moment for the CNA regarding use of the Care Guides and provided more staff education. The Administrator further stated she was not sure at the time if they read the incident reports out loud or discussed the interventions during the meetings but .We do now . When asked when the new process for reviewing incidents started the Administrator replied after [DATE] when the prior DON left. The Administrator stated we review verbally now, including nursing notes for days after an incident, but the previous DON did not see the value in doing this process. Telephone interview with the Medical Director on [DATE] at 5:59 PM, revealed when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator's Office, revealed when asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services came in (MONTH) of (YEAR). The Administrator stated she didn't remember if she was present or not at the facility for the morning meeting when the fall should have been discussed, but at the time of the fall they were not reading the incidents out loud, and the assumption was the DON was looking at all nursing notes of residents with falls. Continued interview revealed the facility conducted QA meetings on [DATE] and [DATE], at which time only numbers and locations of accidents and incidents was presented. Further interview confirmed no fractures were reported to the committee at either committee meeting and the facility had not made any type of systemic correction or performance improvement related to the events involving Resident #7 on [DATE].",2020-09-01
303,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2019-11-27,569,D,1,0,GP5R11,"> Based on review of facility policy, review of resident funds accounts, and interviews, the facility failed to provide conveyance of personal funds within 30 days of discharge, transfer, or death for 4 residents (#5, #7, #8 and #9) of 39 residents reviewed for resident funds accounts. The findings included: Review of the facility policy Resident Refund Policy, last revised 3/20/17 revealed .To ensure that all resident accounts reconciled and maintained according to federal and state regulations .Any Resident refunds due shall be submitted, via email, with the appropriate documentation, to the Regional Field Controller (RFC) for approval . Review of resident funds accounts on 11/26/19 revealed the following: Resident #5 had $2631.50 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/6/19 (81 days earlier). Resident #7 had $497.00 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/16/19 (71 days earlier). Resident #8 had $175.75 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/25/19 (62 days earlier). Resident #9 had $40.00 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/29/19 (58 days earlier). Interview with the Administrator on 11/27/19 at 9:30 AM, in her office, revealed .it was brought to my attention in (MONTH) (2019) we (facility) had multiple outstanding past due refunds .contacted the Regional Director of Operations .to prevent a hardship on the corporation it was decided to pay a couple of the largest refunds monthly . Interview with the Business Office Manager on 11/27/19 at 9:45 AM, in the Administrator's office, revealed .I send a list of discharges to the corporate office at the end of each month . In summary, the facility failed to provide conveyance of resident funds within 30 days of discharge for Residents #5, #7, #8, and #9.",2020-09-01
309,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-05-03,602,D,1,0,IO8511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, observation, and interview, the facility failed to prevent misappropriation of a narcotic patch for 1 resident (#1) of 6 residents reviewed for misappropriation of property. The findings included: Review of the facility policy Abuse Prevention Program dated 8/17 revealed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property .Protect our residents from abuse by anyone . Medical record review revealed Resident #1 was admitted to the facility on [DATE], and was readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of the facility's investigation dated 4/8/18 at 5:30 PM, revealed Resident #1 called for LPN #2, and reported the other nurse had told her she was sent to change her pain patch. When LPN #2 checked the patch she discovered the pain patch missing but the [MEDICATION NAME] (clear dressing) was intact. When the facility was able to contact LPN #1 she stated she was trying to replace the torn [MEDICATION NAME] covering the patch, and accidently removed the patch with the torn [MEDICATION NAME]. She had discovered it in her scrub pocket late that night when doing laundry. On 4/9/18 at approximately 7:00 AM, LPN #1 reported to the Director of Nurses office, and was escorted to HR (Human Resources). At this time LPN #1 returned the patch to the facility. The facility noted the LPN had red eyes and unusual speech patterns. She was taken to the lab for a drug screen, which was failed due to urine failing to have a temperature with in the acceptable range. This was considered a positive and LPN #1 was terminated. Observation and interview with Resident #1 on 5/1/18 at 10:00 AM, in her room revealed on Sunday morning 4/8/18, LPN #1 was a new nurse her hair was blue, she asked me to stand up and I told her I couldn't. She said I'll have to put your pain patch on in the bed. I told her I didn't think it was time for it to be changed, but she said (LPN #2) said it was. She took off the old patch and folded it up in a small piece of gauze. Then she put something on my back, but when (LPN #1) checked she said she didn't put a new patch on. Interview with LPN #2 on 5/1/18 at 10:15 AM, on the 200 Central Hall revealed Resident #1 told her that girl told me you sent her in here to change my patch. I asked her if the girl had blue hair and she said yes that's her. I checked her patch. There was a [MEDICATION NAME] with the date and her (LPN #1's) initials but no patch. The old patch had been removed but she did not put on a new patch. Continued interview revealed somewhere between 9:45 AM, and 10:00 AM, she had observed LPN #1 flipping through my MAR (Medication Administration Record), and around 10:00 AM, (LPN #1) told me (Resident #4) wanted her 12:00 PM, pain pills and asked me if I had given them. She asked me if I wanted her to take the medicine to her and I told her no. Then about 11:30 AM, she told me (Resident #6) wanted a pain pill, and asked me if I wanted her to take it to him, again I told her no. Further interview revealed she had reported both incidents to the RN supervisor. She stated I went and told (RN #1) that she kept asking me if I wanted her to give my residents their pain medications. Interview with RN #1 on 5/1/18 at 12:10 PM, via telephone revealed, (LPN #2) came to me and said (Resident #1) had stated (LPN #1) had removed her patch. The [MEDICATION NAME] was there but there was not patch. It was dated and (LPN #1's) initials were on it. She identified her as the blue haired girl. (LPN #1) was working as a CNA (certified nurse aide) that day; she had no business in the MAR, or dealing with the medications. I told her to just be a CNA for today, and to forget about passing medication, just to do patient care. I had to redirect her a couple of times. She took the [MEDICATION NAME] (pain medication) patch off and kept it. Further interview revealed (LPN #1) had been complaining of being sick, and not long after she took the patch off, she said she was sick, and asked to leave and he had told her to go ahead and leave. Interview with LPN #1 on 5/1/18 4:30 PM, via telephone revealed When I took off the old [MEDICATION NAME], the patch must have come off with it. I reapplied the new [MEDICATION NAME] initialed and dated it. I didn't realize the patch was still on the old [MEDICATION NAME] until I found it in my scrub pocket. Further interview revealed LPN #1 stated as a CNA I should have reported to the nurse, but I am used to being the nurse and I had never worked as a CNA before. I didn't think anything about fixing the [MEDICATION NAME]. Review of facility documents, Daily Assignment Sheets for 3/29/18 through 4/8/18 revealed LPN #1 had worked as a CNA on 3/29, 3/30, 3/31, 4/1, 4/7 and 4/8/2018. Interview with CNA #2 on 5/2/18 at 8:45 AM, in the conference room revealed at approximately 2:00 PM, she (LPN #1) was in (Resident #1's) room, I walked down the hall, the resident's back was towards the door, and she (LPN #1) was standing at her back, as I walked by I heard her say (LPN #2) told me to come in and change your patch. Interview with the Administrator on 5/2/18 at 1:48 PM, in the conference room confirmed the facility failed to prevent misappropriation of a narcotic patch for Resident #1.",2020-09-01
310,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-09-07,609,D,1,0,OSU511,"> Based on review of the facility policy, facility investigation review, and interviews the facility failed to ensure staff report an allegation of abuse in a timely manner. The findings include: Review of the facility policy Abuse Investigation and Reporting dated 8/13/17, revealed .Reporting .2. Suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours . Review of afacility investigation dated 7/4/18, revealed while the facility was interviewing staff for an alleged allegation, CNA #4 made an allegation of abuse regarding CNA #3. During the interview CNA #4 revealed the allegation happened late (MONTH) or early June, and CNA #4 had not reported the allegation. Interview with the Director of Nursing (DON) on 9/4/18, at 10:40 AM, in the DON's office, confirmed CNA #4 had not reported the allegation of abuse regarding CNA #3 in a timely manner.",2020-09-01
324,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-07-19,223,D,1,0,POC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation review, time detail review, and interviews, the facility failed to ensure 1 resident (#1) was free from verbal abuse of 4 residents reviewed for abuse of 4 sampled residents. The findings included: Review of the facility's policy titled Reporting Abuse to Community Management last revised 12/2016, revealed .It is the responsibility of our employees, community consultants, Attending Physicians, family members, visitors .to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown origin and theft or misappropriation of resident property to community management .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability .Mental abuse is defined as, but is not limited to humiliation, harassment . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 10/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, dressing, eating, and hygiene/bathing, and limited assistance for ambulation. Review of a facility investigation revealed a statement from the Director of Nursing (DON) dated 6/20/17 at approximately 2:00 PM. Further review revealed while the DON was reviewing emails received the previous week (while on vacation), one of the email messages stated VERY URGENT from Certified Nursing Assistant (CNA) #4. Continued review revealed the email was dated 6/17/17 at 12:01 AM. Further review revealed CNA #4 was told by CNA #2 she (CNA #2) overheard Licensed Practical Nurse (LPN) #2 tell Resident #1 to Shut the f*** up. Continued review revealed CNA #2 was in the resident's room talking with the sitter for the resident LPN #2 the room and said .'with the two of yawl in here he's still yelling' then (LPN#2) approached the resident to yell at him saying SHUT THE F*** UP . Further review of a telephone interview conducted with CNA #2 by the Director of Quality (DQ) on 6/20/17 revealed on the evening of 6/16/17 CNA #2 was visiting residents and staff at the facility. Continued review revealed CNA #2 was friends with the sitter and was in the resident's room talking with the sitter when LPN #2 entered the room and stated .there are two of you in this damn room and you can't keep him (Resident #1) quiet .(LPN #2) .went over to (Resident #1) and got in his face and told him to 'shut the f*** up' . Further review of a signed statement from the sitter for Resident #1 revealed the sitter was in the room at the time of the alleged incident and .On (MONTH) 16, (YEAR) a nurse by the name of (LPN #2) came into (Resident #1) room yelling at (CNA #2) and myself about shutting (Resident #1) up. Then she (LPN #2) walked up to (Resident #1) and told him to 'shut the f*** up' before storming out of the room . Continued review revealed the facility investigation began on 6/20/17 (4 days later) and LPN #2 was notified by voicemail of an alleged allegation and was told she was not allowed on the premises until further notice. Interview with LPN #1 on 7/18/17 at 2:00 PM, in the conference room, revealed at times the resident would continually yell and you could hear him outside yelling Help, Help, Help. Further interview revealed LPN #1 would .assess the resident for pain, offer food, and offer a quiet environment .some days nothing seemed to help . Telephone interview with CNA #2 on 7/18/17 at 4:00 PM revealed she was on medical leave and was in the facility to visit because she was bored and the facility was her second home. Continued interview revealed the CNA knew Resident #1's sitter so she went in to chat with her and while she was talking to the sitter LPN #2 came in to give Resident #1 his medications. Further review revealed a .few minutes later the resident was still yelling .the door flew open and (LPN #2) walked in and stated 'there are 2 of you in here I don't understand why you can't keep him quiet' .and then (LPN #2) walked over to the (resident) and was in his face and said 'I need you to shut the f*** up and be quiet' .You are irritating me and getting on my damn nerves . Continued interview revealed CNA #2 and the sitter discussed who they should report this to and CNA #2 decided to report the incident to CNA #4, who stated he would email the DON. Further interview confirmed Resident #1 was verbally abused by LPN #2 and CNA #2 was aware she needed to report the incident immediately to a supervisor or charge nurse but failed to do so. Continued interview revealed LPN #2 remained in the facility for the rest of her shift. Interview with the DON on 7/18/17 at 5:00 PM, in the DON's office, confirmed the resident was verbally abused by LPN #2 and the facility failed to investigate the allegation timely.",2020-09-01
325,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-07-19,225,D,1,0,POC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to promptly report and investigate an allegation of abuse to the appropriate facility staff for 1 resident (#1) of 4 residents reviewed for abuse of 4 sampled residents. The findings included: Review of the facility's policy titled Reporting Abuse to Community Management last revised 12/2016, revealed .It is the responsibility of our employees, community consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown origin and theft or misappropriation of resident property to community management .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability .Mental abuse is defined as, but is not limited to humiliation, harassment .Employees, community consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nursing Supervisor on duty .any individual observing an incident of resident abuse or suspected resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or Charge Nurse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 10/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, dressing, eating, and hygiene/bathing, and limited assistance for ambulation. Review of a facility investigation revealed a statement from the Director of Nursing (DON) dated 6/20/17 at approximately 2:00 PM. Further review revealed while the DON was reviewing emails received the previous week (while on vacation), one of the email messages stated VERY URGENT from Certified Nursing Assistant (CNA) #4. Continued review revealed the email was dated 6/17/17 at 12:01 AM. Further review revealed CNA #4 was told by CNA #2 she (CNA #2) overheard Licensed Practical Nurse (LPN) #2 tell Resident #1 to Shut the f*** up. Continued review revealed CNA #2 was in the resident's room talking with the sitter for the resident LPN #2 the room and said .'with the two of yawl in here he's still yelling' then (LPN#2) approached the resident to yell at him saying SHUT THE F*** UP . Further review of a telephone interview conducted with CNA #2 by the Director of Quality (DQ) on 6/20/17 revealed on the evening of 6/16/17 CNA #2 was visiting residents and staff at the facility. Continued review revealed CNA #2 was friends with the sitter and was in the resident's room talking with the sitter when LPN #2 entered the room and stated .there are two of you in this damn room and you can't keep him (Resident #1) quiet .(LPN #2) .went over to (Resident #1) and got in his face and told him to 'shut the f*** up' . Further review of a signed statement from the sitter for Resident #1 revealed the sitter was in the room at the time of the alleged incident and .On (MONTH) 16, (YEAR) a nurse by the name of (LPN #2) came into (Resident #1) room yelling at (CNA #2) and myself about shutting (Resident #1) up. Then she (LPN #2) walked up to (Resident #1) and told him to 'shut the f*** up' before storming out of the room . Continued review revealed the facility investigation began on 6/20/17 (4 days later) and LPN #2 was notified by voicemail of an alleged allegation and was told she was not allowed on the premises until further notice. Telephone interview with CNA #2 on 7/18/17 at 4:00 PM revealed CNA #2 was aware she needed to report the incident immediately to a supervisor or charge nurse, but failed to do so. Interview with the DON on 7/18/17 at 5:00 PM revealed she was out of the facility and did not review her email until 6/20/17. Continued interview revealed staff had been educated to verbally tell someone of any allegations of abuse. Continued interview confirmed the facility failed to report and investigate an allegation of abuse timely.",2020-09-01
326,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,224,D,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, review of personnel files, observation, and interview, the facility failed to prevent neglect of 1 resident (#1) of 3 residents reviewed for neglect. The findings included: Review of the facility policy, Care Rounding & Risk Prevention Continuous And Responsive Engagement Rounding Review, undated, revealed .Actively, not passively, provide care and do so continuously. Hourly rounding is not as important as continuous rounding that moves with purposeful intent .Round at shift change .Typically, a round includes checking on the status of the 4 Ps: Pain Assessment Potty (toileting) needs Positioning Possessions (in reach of the Resident, including call button) . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 2/6/17 revealed .Reposition every 2 hours during the day when in bed or chair. Reposition during the night every 2 hours . Further review revealed the resident required supervision with transfer, mobility using a walker, bed mobility (and at times 1 staff support with bed mobility) and toileting. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Medical record review of the MDS, Functional Abilities dated 7/14/17 revealed bed mobility, transfer, and toilet use coded 2 (limited assistance); walk in room and corridor, locomotion on and off unit, dressing and personal hygiene coded 1 (supervision, oversight). Medical record review of the Medication Record for 8/2017 revealed .[MEDICATION NAME] 3 mg (milligrams) tablet- 1 tab by mouth at bedtime ([MEDICAL CONDITION]) .[MEDICATION NAME] 30 mg tablet- 1 tab by mouth at bedtime .Major [MEDICAL CONDITION] .[MEDICATION NAME] (anti-anxiety medication) 2 mg tablet .Hour of Sleep For Anxiety .Monitor for [MEDICAL CONDITION]- Hour of sleep . Continued review revealed on 8/18/17 the nurse had initialed the resident had been monitored for [MEDICAL CONDITION] after receiving medications for anxiety and sleep. Review of the Safety Event Entry dated 8/19/17 at 7:30 AM revealed the resident was found on the floor, covered with a blanket, by the Day Nurse. The resident told her she had been .laying there all night . The resident was not harmed and the family and physician were notified with neuro (neurolgical) checks initiated. Review of the personnel files for Registered Nurse (RN) #1 dated 8/19/17 revealed .Written Warning .Medication was documented as being given to Resident #1 at 2116 (9:16) pm and was actually given at approximately 10 pm. Per [MEDICAL CONDITION] flow sheet, nurse documented that resident was not having difficulty sleeping without having physically checked the patient who had fallen in the floor . Review of the Associate Corrective Action Form for Certified Nursing Assistant (CNA) #3 dated 8/19/17 revealed .Final Written Warning .CNA failed to make walking rounds with night shift and physically check on residents. One of the residents (#1) she was accepting care for had fallen onto the floor. This patient was not found for another 1.5 hrs . Continued review revealed CNA #1 was terminated for not following the facility's policy for rounding. Review of the General Investigation Form dated 9/3/17 revealed Resident (#1) was on the floor for an undetermined about (amount) of time. She had not been rounded on since 10 pm the previous night. CNAs did not do walking rounds. Resident found at 0730ish (around 7:30 AM). No injury. Formal investigation done by DON (Director of Nursing) and ED (Executive Director) .what led to this event .Laziness on the part of CNAs involved. They did not check on resident for 10 hours .Per .night shift RN, she was still in her regular clothes when she received her night meds . Observation and interview of Resident #1 on 9/5/17 at 11:25 AM, in the resident's room, revealed the resident was sitting in her chair with her son present. Interview confirmed she did have a fall during the night of 8/18/17 but was not injured. Continued interview confirmed she was unable to get herself up or get to the call light and she laid on the floor until the next morning when a nurse entered her room. Further interview confirmed she expected a staff member would check on her during the night. Interview with CNA #1 on 9/5/17 at 1:12 PM, by telephone, confirmed she was one of the two CNAs responsible for the care of Resident #1 on 8/18/17 on night shift. Continued interview confirmed Resident #1 was independent and rang the call bell if she needed assistance. Further interview confirmed the nurse gave her medication at 10:00 PM and her door was closed. Continued interview confirmed no one told her she had to go into every room on every round. Further interview confirmed she did not enter Resident #1's room after 10:00 PM on 8/18/17. Interview with RN #1 on 9/5/17 at 3:50 PM, by telephone, confirmed she was working the night shift on 8/18/17 and was responsible for the care of Resident #1. Further interview confirmed she administered medications to the resident at 10:00 PM and neither she or the 2 CNAs entered the residents room for the duration of the night shift. Continued interview confirmed she checked on every resident when the shift started and the CNAs were to make rounds on every resident every 2 hours and at shift change. Interview with CNA #2 on 9/5/17 at 4:00 PM, by telephone, confirmed she was pulled from the 7th floor to work on the 5th floor on 8/18/17 for the night shift to help out. Continued interview confirmed CNAs were expected to check on all residents every 2 hours. Further interview confirmed they went in residents' rooms to do rounds together, but did not enter Resident #1's room to check on her because CNA #1 knew the residents so, I just followed her lead. Interview with the Director of Nursing (DON) on 9/6/17 at 12:35 PM, in the conference room, confirmed Resident #1 had a fall on 8/18/17, sometime after 10 PM, and was found in her room lying on the floor by the day nurse at approximately 7:30 AM on 8/19/17. Continued interview confirmed CNA #1 and CNA #2 did not check on the resident all night. Further interview confirmed RN #1 administered medication to the resident at approximately 10:00 PM and did not check on the resident after that time. Continued interview confirmed CNA #1 and #2 were suspended pending the investigation and then terminated because they did not follow the facility protocol. Further interview confirmed CNAs were expected to make Continuous and Responsive Engagement Rounding, which assessed the 4 P's and were to see each resident approximately every 2 hours.",2020-09-01
327,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,280,G,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol review, medical record review, review of facility falls investigations, and interview, the facility failed to develop and implement interventions to prevent falls for 5 residents (#7, #3, #4, #5, and #6), of 7 residents reviewed for falls, of 69 residents assessed as at risk for falls. The facility's failure resulted in a fractured ankle (harm) for Resident #7. The findings included: Review of the facility policy, Care Plans - Comprehensive Person-Centered revised 5/2017 revealed .The comprehensive, person-centered care plan will .Incorporate identified problem areas .Reflect currently recognized standards of practice for problem areas and conditions .Identifying problem areas and their causes, and developing interventions .are the endpoint of an interdisciplinary process .Care planning interventions are chosen only after careful data gathering, proper sequencing of events .and relevant clinical decision making .The Interdisciplinary Team must review and update the care plan .When the desired outcome is not met .When the resident has been readmitted to the community from a hospital stay; and at least quarterly . Medical record review revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Safety Event Entries (facility investigation conducted post falls) dated 7/6/17, 7/7/17 (2 of 3 falls on this date), 8/24/17, 9/3/17, and 9/4/17, revealed the resident sustained [REDACTED]. Continued review revealed the resident sustained [REDACTED]. Review of a Safety Event Entry dated 7/7/17 4:06 PM revealed .Resident found on floor beside her bed. 3rd fall this shift .What type of injury(s) was sustained? Fracture (Major) . Medical record review of a nurses note dated 7/7/17 at 4:44 PM revealed .Call received from Dr (physician) .stating .resident has a left tibular (ankle) fx (fracture) . Medical record review of the care plan dated 7/7/17 revealed the care plan was not revised or updated to reflect new interventions to prevent falls after the falls on 7/7/17. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 7/8/17 revealed the resident sustained [REDACTED]. Medical record review of the care plan dated 9/5/17 revealed the care plan was updated on 9/5/17 to include .Falls .Resident re-education to call for assistance with transfers post fall 7/8/17 .start date 9/5/17 . Continued review revealed the care plan was not updated until 60 days after the fall occured. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Safety Event Entry dated 8/7/17 revealed the resident had an unwitnessed fall in her room on this date. Medical record review of the care plan dated 4/17/17 revealed the care plan was not revised to include a new intervention to prevent falls after the fall on 8/7/17. Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 8/13/17 revealed the resident had an unwitnessed fall and was sent to the hospital for evaluation. Medical record review of the care plan dated 8/21/17 revealed the care plan had not been revised to include a new fall intervention after the resident's fall on 8/13/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 8/18/17 revealed the resident sustained [REDACTED]. Medical record review of the care plan dated 8/23/17 revealed .Falls .at risk for falls r/t (related to) hx (history) of falls with fx (fracture) . Continued review revealed the care plan was not revised to reflect new interventions after returning to the facility from a hospitalization . Interview with the Director of Quality on 9/8/17 at 8:20 AM, in the conference room, confirmed Resident #6 had alarms ordered previously for fall prevention on 6/14/17. Continued interview confirmed the resident was discharged to the hospital on [DATE], and the alarm was discontinued at that time. Further interview confirmed the facility failed to revise the resident's care plan when she returned from the hospital, and the current care plan was not accurate. Continued interview confirmed the care plans for Residents #3, #4, #5, and #7 were not revised to include new interventions to prevent further falls after the post-falls investigations had been completed. The facility's failure resulted in Resident #7 sustaining a fractured ankle (tibula). Refer to F-323",2020-09-01
328,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,323,G,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol review, medical record review, review of facility falls investigations, interview, and observation, the facility failed to provide supervision to prevent falls for 5 residents (#7, #3, #4, #5, and #6), of 7 residents reviewed for falls, of 69 residents assessed as at risk for falls. The facility's failure resulted in a fractured ankle (harm) for Resident #7. The findings included: Review of the facility protocol, Falls Clinical Protocol, dated 12/2016 revealed .Treatment/Management .the associate and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of consequences of falling. If underlying causes cannot be readily identified or corrected, associates will try various relevant interventions, based on assessment of the nature or category of falling .Monitoring and follow-up .The community associates will monitor and document the individuals response to interventions intended to reduce falling .If the individual continues to fall, the nursing associate and physician will re-evaluate the situation and .will re-evaluate the continued relevance of current interventions . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. Continued review of the functional status revealed the resident required limited assistance for toileting and dressing and supervision for bed mobility, transfer, ambulation and personal hygiene. Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 8, indicating the resident was at high risk for falls, and .A Score of 5 or greater = (equals) High Risk . Medical record review of a nurses note dated 7/6/17 at 3:39 PM, revealed .Witnessed fall at 1530 (3:30 PM) Resident tripped on the carpet as she was walking toward her room No s/s (signs or symptoms) or c/o (complaints of) pain or discomfort .Walker was being used for assistance . Review of a Safety Event Entry (entries for falls investigations) dated 7/6/17 revealed .Witnessed fall. Resident was using walker for assistance to her room but tripped on the carpet. No injuries noted .Event increased the need for monitoring or evaluation . Continued review revealed no documentation the increased monitoring or evaluation was completed. Continued review revealed no other new interventions were implemented after the fall to prevent future falls. Medical record review of a nurse's note dated 7/7/17 at 8:25 AM revealed .Witnessed fall from standing position with walker to couch then slid off edge to floor .no visible injury . Review of a Safety Event Entry dated 7/7/17 8:36 AM, revealed .Resident attempting to sit on couch from standing position, sat on edge of couch and slid to floor .Location where the event occurred? Reception Area .No Harm .Event increased the need for monitoring or evaluation . Continued review revealed no documentation the increased monitoring or evaluation had been completed, and there were no other new interventions implemented to prevent future falls. Medical record review of a nurse's note dated 7/7/17 at 12:09 PM revealed .Resident having extreme agitation. Found walking down hall with no pants on. Nonsensical word salad (incoherent jumble of words), crying, received order .to administer 1 mg (milligram) lorazepam (anti-anxiety medication, same as Ativan) IM (intramuscular) q 6h PRN (every 6 hours as needed). First dose administered at this time . Medical record review of a nurses note dated 7/7/17 at 1:55 PM, revealed .Resident fell in bathroom. All clothes had been removed and she soiled herself. Gotten up off the floor with a gait belt and assist x 3 (with 3 persons) .Left ankle xray (swollen and painful) .Additional dose of 1 mg Ativan (anti-anxiety medication) IM also given at this time . Medical record review revealed no interventions were implemented after the fall on 7/7/17 to prevent future falls. Medical record review of a nurses note dated 7/7/17 at 3:59 PM, revealed .Resident found on floor by her bed. Third fall this shift .Resident is now in wheelchair at the nurse's station . Review of a Safety Event Entry dated 7/7/17 at 4:06 PM revealed .Resident found on floor beside her bed. 3rd fall this shift. 2nd fall occurred 4 hours prior in the bathroom. Resident was naked and had urinated on herself at that time. Unknown why she fell the third time. She is unable to articulate .What type of injury(s) was sustained? Fracture (Major) . Medical record review of a nurses note dated 7/7/17 at 4:44 PM revealed .Call received from Dr (physician) .stating .resident has a left tibular fx (fracture) .1640 (4:40 PM)- resident transported by EMS (emergency medical services) . Medical record review of a nurses note dated 7/7/17 at 11:59 PM, revealed .Resident arrived back from hospital via EMS .No new orders given. Resident has boot on broken ankle and is now resting in bed . Medical record review revealed no new interventions to prevent further falls had been implemented after the third fall on 7/7/17 at 4:06 PM. Medical record review revealed the resident was hospitalized from [DATE] to 7/13/17, and again on 8/4/17 to 8/24/17. Continued review revealed Resident #7 was readmitted to the facility on [DATE]. Medical record review of a falls risk assessment dated [DATE] revealed a score of 14 (score of 5 or higher indicates High Risk). Review of a Safety Event Entry dated 8/24/17 at 5:08 PM revealed .Witnessed fall. Resident was attempting to transfer without assistance . Medical record review revealed no new interventions were implemented after the fall on 8/24/17 to prevent future falls. Review of a Safety Event Entry dated 9/3/17 at 4:32 PM revealed .Resident attempting to stand from wheelchair, with non-weight bearing status d/t (due to) LLE (left lower extremity) fracture .fell to floor .denies injuries . Continued medical record review revealed no new interventions were implemented after the fall to prevent future falls. Review of a Safety Event Entry dated 9/4/17 at 3:57 PM revealed . Unwitnessed fall. Resident attempted to ambulate/transfer without assistance . Continued medical record review revealed no new interventions were implemented to prevent future falls. Interview with the Quality Director on 9/7/17 at 11:30 AM, in the conference room, confirmed Resident #7 had suffered a fractured ankle as a result of the 2nd fall that occurred on 7/7/17. Continued interview confirmed no new interventions were implemented after the fall to address safety concerns, and Resident #7 continued to have falls on 8/24/17, 9/3/17, and 9/4/17, with no new interventions implemented to prevent falls. Continued interview confirmed the facility failed to adequately assess the safety needs and implement interventions to prevent falls for Resident #7, which resulted in harm to the resident. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required limited assistance of 1 for bed mobility, transfers, and ambulation in the room and hallway. Review of a Safety Event Entry dated 5/18/17 at 12:44 PM, revealed .unwitnessed fall. Resident assisted to her w/c (wheelchair) x 3 staff .No Injury . Medical record review of a Falls assessment dated [DATE] revealed score of 4, indicating the resident was a low risk for falls. Medical record review revealed no new interventions were implemented to prevent future falls after the fall on 5/18/17. Medical record review of an Interdisciplinary Note dated 7/8/17 revealed .Resident was in the sitting position without her 02 (oxygen) when this nurse arrived. Resident had fallen on the floor while attempting to use her potty chair unassisted .small abrasions on the 1st and 2nd toe on the left foot and to the 2nd toe on the right foot . Review of Resident #3's Care Plan revealed, .Resident reeducation to call for assistance with transfers post fall 7/8/17 . Continued review revealed the intervention was implemented on 9/5/17, two months after the resident's fall, and no other new interventions were implemented in a timely manner. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing and toilet use and the resident used a wheelchair for mobility. Continued review revealed the resident had a history of [REDACTED]. Review of a Safety Event Entry dated 8/7/17 revealed .Was informed by .Rehab Tech that resident was in (on) the floor .W/C (wheelchair) was on it's side .no injuries noted . Medical record review of a Falls assessment dated [DATE] revealed a score of 8, indicating the resident was a high risk for falls. Medical record review revealed no interventions were implemented after the fall on 8/7/17 to prevent future falls. Observation of Resident #4 on 9/7/17 at 11:30 AM, revealed the resident seated in a wheelchair in the resident's room with her daughter visiting. Attempted interview was unsuccessful as the resident was unable to answer questions. Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility and transfers. Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 9, indicating the resident was a high risk for falls. Review of the Safety Event Entry dated 8/13/17 revealed .Writer .heard alarm start sounding and went .to residents room .resident lying on the floor on right side .alert and oriented x 2 (oriented to person and place) stated that she was trying to get up and walk to BR (bathroom) (resident does not walk) .large pumpknot noted to right side of forehead, skin tears x 2 to LUE (left upper extremity), red area around eye .order received to transfer to ED (emergency department) for evaluation and treatments . Medical record review of an Interdisciplinary Note dated 8/13/17 revealed .@ (at) 250 (2:50) pm Resident returned to facility .Large purple/red area noted to right side face . Medical record review revealed no new interventions were implemented after the fall on 8/13/17 to prevent future falls. Medical record review revealed Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident had short and long term memory impairment and severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, transfer, and required extensive assistance of 1 staff for locomotion using a wheelchair or walker. Medical record review of a CT Scan (type of xray) report dated 7/14/17 revealed .There is diffuse bone demineralization . Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 8, indicating the resident was at high risk for falls. Medical record review of an Interdisciplinary Note dated 8/18/17 at 10:50 AM, revealed .Resident noted to be on back .resident was attempting to ambulate from her w/c when her leg buckled and she fell on to the floor . Review of a Safety Event Entry dated 8/18/17 revealed The resident stood up from her w/c, her leg buckled and she fell on to the floor. Her left leg was deformed and she was sent to the ER (emergency room ) . Medical record review of an xray report dated 8/18/17 revealed .displaced fracture of the proximal left femur .Underlying generalized demineralization . Medical record review revealed no new interventions were implemented after the fall on 8/18/17, or after Resident #6 returned to the facility on [DATE], to prevent future falls. Interview with the Director of Quality on 9/8/17 at 8:20 AM, in the conference room, confirmed the facility failed to follow the falls protocol to identify and implement pertinent interventions to prevent future falls for Residents #7, #3, #4, #5, and #6. The facility's failure resulted in a fractured ankle for Resident #7.",2020-09-01
358,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-09-06,225,D,1,0,KIGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility staff failed to report an allegation of abuse timely for 1 resident (#1) of 3 residents reviewed for abuse. Review of the facility policy Patient Protection and Response to Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, dated 11/28/16, revealed .Reporting Policy .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, or misappropriation of patient property must report the event immediately . Review of a facility investigation revealed a witness statement completed by Certified Nursing Assistant (CNA) #3 dated 8/10/17. Further review revealed CNA #3 alleged she witnessed CNA #4 stuff a wash cloth in the mouth of Resident #1 on 8/6/17 (4 days prior) and .(CNA #4) told her (Resident #1) that she better shut up because she had[***]all over her and we were cleaning her up . Continued review revealed CNA #3 reported the allegation to CNA #2 and Registered Nurse (RN) #1 on 8/10/17. Further review revealed CNA #2 and CNA #3 reported the allegation to Licensed Practical Nurse (LPN) #2 on 8/10/17 before the start of the evening shift (7:00 PM) and LPN #2 immediately called the Director of Nursing. Medical record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview Mental Status score of 8 (moderate cognitive impairment). Continued review revealed the resident was resistant with care 1-3 days during the 7 day look back period. Further review revealed the resident required maximum assist with transfers, dressing, and personal hygiene with 2 person assist. Interview with the Director of Nursing (DON) on 9/5/17 at 11:35 AM, in the conference room, confirmed she was notified by LPN #2 on 8/10/17 at approximately 7:00PM of the allegation of abuse (4 days after the alleged incident). Interview with CNA #2 on 9/6/17 at 7:00 AM, in the conference room, revealed .was working with (CNA #3) on Sunday (8/10/17) .she (CNA 3#) told me would not believe what (CNA #4) had done to (Resident #1) .ask if she reported it .she said no . Interview with RN #1 on 9/6/17 at 7:15 AM, in the conference room, revealed . was leaving work (8/10/17) that morning .had clocked out . (CNA #2) called me over to the table and made (CNA #3) tell me what (CNA #4) had done on Wednesday (8/6/17) .DON was not there that morning so I planned to catch her the next morning . Telephone interview with LPN #2 on 9/6/17 at 11:55 AM revealed .was on break (8/10/17) when 2 night shift CNA's were getting ready to start their shift told me what had happened (on 8/6/17) .immediately called the DON . Interview with the DON on 9/6/17 at 9:00 AM, in the conference room, confirmed she would have expected to have been notified immediately of the allegation of abuse and the facility failed to do so. Interview with the Administrator on 9/6/17 at 9:05 AM, in the conference room, revealed facility staff .should have followed the policy as they were trained . Continued interview confirmed the facility failed to follow facility policy.",2020-09-01
359,FORT SANDERS SEVIER NURSING HOME,445129,731 MIDDLE CREEK RD,SEVIERVILLE,TN,37862,2017-05-18,225,D,1,0,M21J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, review of employee time punches, and interview the facility failed to report an allegation of abuse to the state agency and failed to suspend an employee after an allegation of abuse for 1 resident (#1) of 3 residents reviewed. The findings included: Review of the facility policy, Abuse-Adult, revised 2/15 revealed .all alleged violations .involving .abuse .are reported immediately or as soon as possible (but not to exceed 24 hours after discovery of the incident) to the administrator (or his/her designated representative) .Any employee suspected or involved in abuse will be sent home immediately and not return to work until the investigation is complete .State survey and certification agency should be notified as soon as possible but not to exceed 24 hours after discovery of the incident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #1 was discharged to home on 3/28/17. Medical record review of a Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview for Mental Status score (a test for cognitive ability) of 13/15 indicating the resident was cognitively intact for daily decision making skills. Review of the facility investigation dated 3/27/17 revealed Resident #1 alleged Certified Nursing Assistant (CNA) #1 yelled at the resident when he assisted her in the bathroom on 3/25/17 at 2:30 PM. Review of CNA #1's time punches revealed CNA #1 worked 6:18 AM - 7:00 PM on 3/25/17 and 6:16 AM - 7:09 PM on 3/26/17. Telephone interview with Resident #1 on 5/15/17 at 3:47 PM, confirmed the resident reported the incident with CNA #1 to Licensed Practical Nurse (LPN) #1 on 3/25/17 immediately following the incident. Interview with LPN #1 on 5/16/17 at 4:22 PM, in the conference room confirmed Resident #1 reported CNA #1 had yelled at her while assisting the resident in the bathroom. Further interview confirmed CNA #1 continued to work after the alleged incident on 3/25/17 and on 3/26/17. Continued interview confirmed LPN #1 did not report the incident to the Administrator or the Director of Nursing (DON). Interview with the DON on 5/17/17 at 10:43 AM, in the conference room confirmed the DON was not aware of the alleged incident until Resident #1 told her on the morning of 3/27/17 at 8:30 AM. Interview with the Administrator on 5/17/17 at 11:25 AM, in the conference room confirmed he was not notified of the alleged incident which occurred on 3/25/17 until the morning of 3/27/17. Continued interview confirmed the facility failed to suspend CNA #1 pending the investigation results and failed to report the allegation of abuse to the state agency per facility policy.",2020-09-01
367,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2020-02-21,552,D,1,0,D6D711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, interviews, the facility failed to obtain consent for administration of a medication for 1 resident (Resident #1) of 3 residents reviewed for medication administration, resulting in Resident #1 receiving an appetite stimulant without approval from the resident or the resident's representative. The findings included: Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 11/17/2017 showed .Our facility shall promptly notify the resident .and representative of changes in the resident's medical/mental condition and/or status . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] showed the resident scored a 6 (severe cognitive impairment) on the Brief Interview Mental Status. The resident required extensive assist for bed mobility and transfers with 2 person assist and required extensive assist for Activities of Daily Living with 1 person assist. The resident was always incontinent of urine and frequently incontinent of bowel. Review of a Practitioner's Order dated 1/27/2020, not timed, showed .Orders .[MEDICATION NAME] (appetite stimulant) 7.5 mg (milligrams) PO (by mouth) q (every) hs (hour of sleep) x (times) 7 days then (increase) to 15 mg q hs . Review of the medical record showed no documentation consent for the appetite stimulant was received from the resident or the resident's representative. During an interview on 2/21/2020 at 10:00 AM Resident #1 stated the resident's daughter .takes care of everything . During an interview on 2/21/2020 at 11:55 AM, Registered Nurse (RN) #1 stated an order for [REDACTED].#1 for her to get permission from Resident #1's daughter prior to administration of the medication. During an interview on 2/21/2020 at 12:15 PM, the Nursing Supervisor stated the facility should have obtained family consent prior to administration of the appetite stimulant. During a telephone interview on 2/21/2020 at 2:15 PM, LPN #1 stated she had not been notified a signature was needed prior to administration of Resident #1's appetite stimulant. During a telephone interview on 2/21/2020 at 2:30 PM, the Assistant Director of Nursing confirmed there was no documentation to indicate consent was obtained prior to administration of the appetite stimulant to Resident #1.",2020-09-01
368,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2018-04-30,569,D,1,0,0TGD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed to refund the balance of a Patient Trust Fund, within the required time frame, for one discharged Resident (#2) of 6 residents reviewed for Patient Trust Funds. The findings included: Review of the facility policy Resident AR (Accounts Receivable) Refund Policy not dated revealed . will review and credit balances for appropriate refund, and issue refund within 30 days based on the following: .There are no funds due to the facility by a third party payer, i.e. an insurance secondary to Medicare .Any refund will be payable to the resident, or responsible party when applicable . Medical record review revealed Resident #2 was admitted to the facility on [DATE], and discharged on [DATE] with the [DIAGNOSES REDACTED]. Review of a facility document Trial Balance dated 4/25/18 revealed Resident #2 had a balance of #213.13 in his Patient Trust Fund. Interview with Resident #2's daughter, on 4/25/18 at 11:45 AM, via telephone revealed Resident #2 had discharged from the facility on 1/8/18, and neither she nor Resident #2 had received a refund check, or any notification from the facility in reference to closing his Patient Trust Account. Interview with the Business Office Assistant, on 4/25/18 at 2:00PM, in the conference room confirmed Resident #2 discharged from the facility on 1/8/18. The facility did not send a Resident Fund Management Service statement to the resident within 30 days, disclosing the balance of his Patient Trust Account. Interview with the Business Office Manager, on 4/25/18 at 2:40 PM, in the conference room confirmed Resident #2 had met the criteria for his Patient Trust Fund to be refund as of 2/12/18. Further interview confirmed the facility failed to follow their AR Refund Policy, and had not issued a refund check for Resident #2's Patient Trust Account within the required time frame.",2020-09-01
382,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2017-06-15,225,D,1,0,25IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, and interview the facility failed to suspend an employee after an allegation of abuse for 1 resident (#1) of 4 residents reviewed. The findings included: Facility Policy review of the Abuse Prevention Policy and Procedure, revised 8/2016, revealed .report all allegations of abuse immediately to the Director of Nursing and Administrator .all employees are required to immediately notify the administrative or nursing supervisory staff that is on duty .so the resident's needs can be attended to immediately and investigation can be undertaken promptly .the charge nurse .will examine the resident .document findings in the clinical records .immediately initiate the Investigation protocol .any employee suspected of abuse, neglect, or mistreatment must be suspended as soon as the incident is reported pending outcome of the investigation .Do not wait . Medical record review revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Continued review revealed the patient was discharged from the facility on 6/8/17. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, required extensive assistance of 2 person with transferring, dressing, toileting, and personal hygiene, required extensive assistance of 1 person with walking in room and locomotion on unit, and supervision with eating. Medical record review of a Nursing Note dated 5/23/17 at 4:53 AM revealed .resident rang out for assistance to the restroom .both CNAs (certified nursing assistant) responded to help .resident was very inappropriate towards CNAs by cussing them out and threatening to get them fired .resident accused one CNA of pushing her in the wheelchair .CNA was only guiding .towards the chair .not the first time resident has cussed out these CNAs . Facility investigation review dated 5/23/17 revealed the incident occurred on 5/23/17 at 4:30 AM and at 6:40 AM Licensed Practical Nurse (LPN) #1 (days shift nurse) received the complaint and notified the Director of Nursing (DON) at 6:55 AM. Further review the DON interviewed the resident at 8:30 AM and revealed .stated .she put her light on at about 5:00 or 5:30 am this morning .two nurses came into the room .told them she had .to the bathroom .they (CNAs) wanted her to use the bedpan .she was supposed to be using the toilet .felt this made them mad .one (CNA) was in front of her .one behind the wheelchair .one behind the wheelchair pushed her down into the wheelchair causing her left leg to hurt .she told them nurse behind her .she was going to get her fired .going to tell her son .he would get a lawyer . Review at 10:00 AM the Social Worker interviewed the resident who stated 2 Registered Nurses (RN) came to her room to get her in her wheelchair and assist her to the bathroom .1 RN that was older with dark hair pushed her by her neck . Interview with LPN #1 on 6/13/17 at 11:53 AM in the conference room revealed .work dayshift .when I came in I got report .she (nightshift nurse) only told me the resident was all the time threatening staff with her attorney's .nothing was said about the resident making an allegation of abuse .the two CNAs on dayshift went to do the resident's blood pressure and the resident told them she had 2 CNAs last night and the older one .was helping her into her wheelchair from the bed .the CNA pushed her .said it hurt her and she felt she had been injured all over again .I reported it . Interview with RN #1 on 6/13/17 at 12:08 PM in the conference room revealed .I was assigned to her (resident) .(CNA #3) and (CNA #4) came out and informed me they were getting patient in wheelchair to go to restroom .(CNA #4) was going to assist her .because she was going to miss the wheelchair .I was new .I didn't know (to call supervisor) .(CNA #4) didn't go in room any more that night .I didn't assess her .I didn't know I was suppose to afterward . Interview with the Nurse Practitioner (NP) on 6/13/17 at 1:25 PM in the conference room revealed .she constantly complained .she did not want to be here .she was assessed and there were no signs of abuse .we did order some x-rays and they were negative . Interview with CNA #1 on 6/13/17 at 1:40 PM in the conference room revealed .me and (CNA #2) .had gone in to do her vital signs .said she had been abused .said .that girl last night .tall one .pushed her in her chair .we went and told (LPN #1) . Interview with CNA #2 on 6/13/17 at 2:50 PM in the conference room revealed .me and (CNA #1) .went in to her room cause her light was on .stated she came here for therapy not to be abused .said the CNA had pushed her down and hurt her leg .she didn't name the person .we told the (LPN #1) . Interview with CNA #3 on 6/14/17 at 6:00 AM in the conference room revealed .we had to help her to her wheelchair .I stood in front of her .(CNA #4) stood behind her .when she was fixing to sit she was going to miss the wheelchair .(CNA #4) put her hands on her hips to help assist her into the wheelchair so she would not miss it and fall .she said (CNA #4) pushed her .she was going to get her fired .we assisted her to the bathroom and back to bed .we told (RN #1) about what happened . Interview with CNA #4 on 6/14/17 at 6:15 AM in the conference room revealed .she was cussing .we got her up on the side of the bed .she got up .she was going to miss the wheelchair .I gently helped ease her over into the wheelchair so she would not fall and hurt herself .said you quit shoving me around .she was going to get someone fired .we assisted her to the restroom and back to bed .we mentioned it to the nurse I didn't take it serious .I finished working out the shift . Interview with the Administrator on 6/14/15 at 7:00 AM in the conference room revealed .we did discipline (RN #1) since she did not report the incident immediately and did not send (CNA #4) home . Interview with the Administrator and the DON on 6/15/17 at 9:25 AM in the Administrator's office confirmed the facility failed to report an allegation of abuse immediately to the DON and the Administrator and failed to suspend CNA #4 pending the investigation results per facility policy.",2020-09-01
383,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2018-10-30,609,D,1,0,B4T611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the facility policy review, medical record review, review of facility investigation, and interview, the facility failed to ensure all allegations of abuse or neglect were reported immediately to the Administrator and the State Survey Agency within 2 hours for 1 resident (#1) of 3 residents reviewed for abuse or neglect on 3 of 3 nursing units sampled. The findings included: Review of facility policy Abuse Prevention Policy and Procedure, last revised 2/26/18, revealed .1 .All alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately to the Administrator and Director of Nursing . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of a facility investigation dated 10/4/18 revealed Resident #1 told Registered Nurse (RN) #2 on 10/1/18 that RN #1 did not give her all her medications. Continued review revealed RN #2 reported the allegation to the Assistant Director of Nursing (ADON) on 10/1/18, but the allegation was not reported to the Administrator or the Director of Nursing (DON). Further review revealed the incident was reported to the DON by the resident's daughter on 10/4/18. Interview with the Administrator and the DON on 10/29/18 at 2:00 PM, in the Conference Room, confirmed no one reported the allegation to them until 10/4/18 (3 days later). Telephone interview with the Administrator on 10/30/18 at 8:35 AM confirmed the ADON failed to report the allegation to the DON or the Administrator. In summary, the allegation of neglect was not reported to the DON, the Administrator, or State Survey Agency until 10/4/18 (3 days later) and the facility failed to follow facility policy.",2020-09-01
398,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-07-11,252,D,1,0,RIJH11,"> Based on facility policy review, observation, and interview the facility failed to maintain a homelike environment by eliminating odors in 1 of 2 Television rooms observed in 5 of 5 observations. The findings included: Review of the facility policy, Day Room and Lounge Cleaning, not dated revealed .clean and sanitary, neat appearing and odor-free day rooms and lounges . Observation on 7/10/17 at 11:00 AM, in the South TV room revealed a foul odor, 8 residents present and unable to determine if the odor was related to a particular resident. Observation on 7/10/17 at 12:30 PM, revealed a foul odor present in the South TV room. Observation of the South wing on 7/10/17 at 7:50 PM, revealed a strong foul odor was present in the South wing TV room. Observation/Interview with LPN on 7/10/17 at 8:55 PM, in the South wing TV room confirmed the room had a foul odor described by LPN as an old urine smell. Interview with Director of Environmental Services on 7/11/17 at 10:48 AM, in the South TV room confirmed the room had a foul odor. Further interview revealed the staff had shampooed the carpet 7/10/17 PM, and the upholstery was cleaned 7/11/17 AM.",2020-09-01
399,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-07-11,312,D,1,0,RIJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility's policy, medical record review, observation and interview, the facility failed to provide nail care for 1 resident (#1) of 4 residents reviewed. The findings included: Review of the facility policy, Infection Control-Fingernail Maintenance not dated revealed .Necessary attention will be given to residents fingernails to maintain cleanliness as needed .Fingernails should be kept clean .clinical staff will provide fingernail care as necessary . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored 3 out of 15 on the Brief Interview for Mental Status indicating severe cognitive impairment, and required extensive assistance for personal hygiene. Observation on 7/10/17 at 12:51 PM, of Resident #1 in the dining room revealed the resident seated at a dining table in a wheel chair. The resident was feeding himself; bilateral hands were observed with dark present on the right hand under the thumbnail and fingernails. Observation of Resident #1 on 7/10/17 at 7:45 PM, in the resident's room revealed his fingers and thumb nails on his right hand with thick dark debris underneath the nails. Interview with Registered Nurse Assistant Director of Nursing (ADON) on 7/10/17 at 7:50 PM, at the North wing nursing station revealed nail care is to be done during showers, or during a bed bath. Observation/Interview with Licensed Practical Nurse on 7/10/17 at 8:25 PM, in Resident #1's room confirmed the resident's fingernails and thumb nail on his right hand had dark thick debris underneath the nails. Further interview confirmed the resident had not received nail care as he should have.",2020-09-01
413,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2018-08-22,761,D,1,0,JFHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observations, and interviews, the facility failed to ensure narcotics were stored under lock and key for one resident (#8) of 8 residents reviewed for medication storage and failed to follow procedures during narcotic reconciliation on 1 of 5 medication carts on 1 of 5 wings of the facility observed for narcotic reconciliation. The findings included: Review of facility policy Controlled Medication and Drug Diversion, last revised 7/24/18, revealed .2. At each shift change or when keys are rendered a physical inventory of all controlled medication is conducted by two staff .this is completed as follows .a. the nurse .surrendering the keys will read from the controlled substance accountability book the name of the resident and the medications to be accounted .oncoming nurse .will locate the medication .count the remaining medication and report .the amount of medication remaining .6. Controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely locked area with restricted access until .destroyed by the facility's director of nursing, administrator, and consultant pharmacist . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged home 8/1/18. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (narcotic) .10 (milligrams) .give one tablet by mouth four times a day as needed .pain . Interview with the Assistant Director of Nursing (ADON) on 8/20/18 at 2:30 PM, in the chapel, revealed on the evening of 8/1/18 she was given Resident #8's [MEDICATION NAME] for destruction by Licensed Practical Nurse (LPN #3), who had removed them from the medication cart after Resident #8 was discharged . Continued interview revealed the ADON did not immediately secure the narcotics in the secure medication storage lock box, but instead placed them in an unlocked desk drawer in her unlocked office and on 8/3/18 when the ADON attempted to retrieve the [MEDICATION NAME], the narcotics were missing from the desk drawer. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to secure Resident #8's discontinued narcotics under lock and key in a secure area and failed to follow facility policy. Observation of a narcotic drug reconciliation (narcotic count) with LPN #8 and LPN #9 on 8/21/18 at 12:03 AM, of the D wing medication cart, revealed LPN #8 and LPN #9 completed the narcotic count without naming the resident or the name of each narcotic and did not simultaneously verify the remaining quantity of each narcotic medication compared to the narcotic inventory control card. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to ensure narcotics were verified and reconciled during a narcotic count and the facility failed to follow facility policy.",2020-09-01
414,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2017-09-27,241,D,1,0,QHMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and staff interview, the facility failed to provide dignity covers for catheter bags for 2 (Resident #3 and Resident #10) of 3 sampled residents. This had the potential to affect all 15 residents who had catheters. Failure to provide dignity covers for catheter drainage bags had the potential to demean patients. The findings included: Review of the facility's policy titled, Catherization Care, revised of 9/7/17, indicated, .13. Routinely check to ensure .Drainage bag is covered with a privacy cover unless resident requests otherwise. 1. Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/25/17 at 12:00 PM, Resident #3 was observed eating lunch in room [ROOM NUMBER]. The drainage bag for the catheter was attached to the bed. The catheter drainage bag which had approximately 300 cubic centimeters (cc) of urine was visible and did not have a dignity cover on it. 2. On 9/25/17 at 1:30 PM, Resident #10 was observed lying in his bed in room [ROOM NUMBER]. The drainage bag for the catheter which was observed hanging on the bed with approximately 200 cc's of urine was visible without a dignity cover. During an interview on 9/25/17 at 12:30 PM, on the 200 Hallway, Certified Nursing Assistant #1 confirmed the drainage bag for the catheter should have a cover over it. During an interview on 9/25/17 at 2:40 PM, in the conference room, the Director of Nursing (DON) stated all catheter drainage bags should have a dignity cover on them. The DON further stated the facility has ordered new dignity bags for the catheter drainage bags and the facility is currently using pillowcases to cover the catheter drainage bags until the new dignity bags arrive.",2020-09-01
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
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
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
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
475,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2020-02-19,600,D,1,0,XNV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to prevent abuse for 1 resident (Resident #3) of 6 residents reviewed for abuse, resulting in Resident #3 being hit by another resident. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, dated 5/8/2019, showed .It is the organization's intention to prevent the occurrence of abuse . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . No injuries were noted. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #3 dated 8/30/2019 and reviewed on 11/13/2019 revealed the resident had an intermittent [MEDICAL CONDITION] and would cuss at staff and make threats toward roommates. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #3 scored an 8 (moderate cognitive impairment) on the Brief Interview for Mental Status. The resident had no behaviors during the look back period. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Care Plan dated 1/24/2020 showed Resident #1 was assessed for behaviors including verbal aggression toward others, including yelling and threatening others, and physical aggression toward others. Review of an admission MDS dated [DATE] showed the Resident #1 had short and long term memory problems and had exhibited verbal behaviors towards others 1-3 days during the look back period. During an interview on 2/19/2020 at 2:02 PM, Certified Nursing Assistant (CNA) #1 stated .(Resident #3) was upset .(Resident #1) was punching (Resident #3) on his head . During an interview on 2/19/2020 at 2:55 PM, CNA #2 stated .heard (Resident #3) hollering .went to check on him .(Resident #1) was hitting (Resident #3) .told him we can't hit other people . During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to prevent abuse to Resident #3.",2020-09-01
476,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2020-02-19,609,D,1,0,XNV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to report an allegation of abuse to the State Survey Agency within 2 hours for 1 resident (Resident #3) of 6 residents reviewed for abuse. The findings include: Review of the facility's policy Abuse, Neglect and Misappropriation of Property, dated 5/8/2019, revealed .all alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . The incident was reported to the State Survey Agency on 2/6/2020 at 4:14 PM (the next day). Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to report the incident to the State Survey Agency within 2 hours after the incident occurred. Refer to F-600",2020-09-01
477,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-06-12,600,D,1,0,TEPY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, and interviews the facility failed to prevent abuse for 2 (#1 and #2) of 5 residents reviewed for abuse. The findings included: Review of the undated facility policy Abuse, Neglect and Misappropriation or Property, revealed .It is (facility's) policy to prevent the occurrence of abuse .willful means non-accidental .the individual must have acted deliberately, not that the individual must have intended to cause harm .If a Stakeholder observes a resident exhibiting any form of abuse toward another resident, the Stakeholder will intervene immediately to interrupt the incident and remove and/or separate the residents involved . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of an Annual MDS dated [DATE], revealed a BIMS score of 7, indicating severe cognitive impairment. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/18 at 11:18 AM, via telephone, revealed I was in the East Wing Nurses Station across from the two residents; I was only about ten feet away from them. (Resident #2) came up to (Resident #1), and (Resident #1) asked (Resident #2) how he was doing. (Resident #2) replied he was coming to see what he was doing. I think he (Resident #1) said fine how are you? (Resident #2) replied he had come to look at the ladies, asses because he knew that was what (Resident #1) was doing. That upset (Resident #1), and (Resident #1) called (Resident #2) a Son of a [***] , at that point I stood up and said something like, now (Resident #1) don't talk like that, and he said I don't give a damn, I watched them for a minute, and then I started out from the nurses' station. I'm not sure who swung first, but they both began to swing at, and hit each other. Further interview confirmed based on what she had witnessed the two residents had intentionally hit each other. Interview with the Assistant Director of Nursing (ADON) on 6/11/18 at 3:32 PM, in the conference room, confirmed she had conducted the facility investigation, and based on interviews, and witness statements Resident #1 and Resident #2 had willingly and deliberately exchanged punches to each other, and the facility failed to prevent abuse of two residents.",2020-09-01
480,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,600,E,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, review of the facility's investigation, and interviews the facility failed to protect residents from abuse for 4 residents (#3, #6, #7, and #8) of 14 residents reviewed for abuse. The findings include: Review of the undated facility policy, Abuse, Neglect and Misappropriation or Property, revealed .It is (facility's) policy to prevent the occurrence of abuse .Abuse includes physical abuse, mental abuse, verbal abuse .willful means non-accidental .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents .regardless of .ability to comprehend . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident had short and long term memory deficits and moderately impaired cognitive skills for daily decision making . Observation and interview with Resident #3 on 9/10/18 at 1:40 PM, in Resident #3's room, revealed the resident was awake, alert, and lying in bed. Continued observation revealed the resident did not appear fearful or anxious at this time. Interview with Resident #3 revealed no recollection of the incident. Interview with the Speech Pathologist (SLP) on 9/12/18 at 9:25 AM, in the conference room, revealed they were bringing in the meal trays. (Identified resident) was walking around. (Resident #3) had just been served, and (Identified resident) came up behind her and reached around and picked up her milk. (Resident #3) had a verbal outburst .HEY and flailed her arm up; that action and her verbal outburst appeared to be what provoked (Identified resident) to hit her on her left upper arm. (Identified resident) did intentionally hit her; it wasn't an accident. She intended to strike her. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment. Continued review revealed Resident #6 required extensive assistance with bed mobility, transfers, mobility, personal hygiene, and toilet use. Review of a facility investigation dated 8/19/18, revealed an identified resident directed harsh, foul language at Resident #6during a random encounter. Continued review revealed the identified resident had a history of [REDACTED]. Observation and interview on 9/10/18 at 2:20 PM with Resident #6 in her room revealed the resident seated in a wheelchair, well-groomed, and without fearfulness or anxiety. Interview at this time revealed Resident #6 could not recall anything happening, but stated I think one of them talked bad to me. Interview with Certified Nursing Assistant (CNA) #2 on 9/11/18 at 5:55 PM, in the conference room revealed, (Resident #6) was coming out of her room in her Wheel chair (w/c) she stood up, about that time the identified resident came out of his room. I was coming out of a Room on B hall, and the CNA (Certified Nurse Aide) from A hall said (Resident #6) is standing up, so I took off towards her. Her roommate was yelling, and she had come to the hall to get help. (Identified resident} was yelling at her you stupid [***] sit down in that f---ing (used entire word) chair. I've told you not to be standing and to not come out of your room. I (referring to CNA #2) am going towards them, telling him I've got this, but he keeps on coming towards us and cursing her. I sat her down in her chair, and am trying to calm her, and he keeps cursing. I took her out of the room, and rolled her up the hall to the nurse. He followed us and said I own these people, and own the halls. He was speaking in a threatening tone, and it frightened (Resident #6). He was directly speaking to (Resident #6). Medical record review revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Continued review revealed physical behavioral symptoms directed towards others occurring 1 to 3 days during the assessment period. Review of a Care Plan dated 3/14/16, for Resident #7 revealed .8/16/18 Res (resident) to Res altercation .Separate Residents .15 minute checks . Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE], revealed a BIMS score of 8 indicating moderate cognitive impairment. Review of a Care Plan dated 6/21/18 for Resident #8 revealed 8/16/18 Res to Res altercation .Staff education .8/21/18 DC 15 minute checks . Review of the facility's investigation dated 8/24/18, revealed (Resident #7) .stated both residents entered the dining room doorway at the same time. (Resident #8) .called .(Resident #7) a [***] , and (Resident #7) .slapped .( Resident #8) across the face. (Resident #8) . reported she then slapped .(Resident #7) across the face. When (Resident #8) .was interviewed she stated she was going out to smoke .someone got in front of her, she told them to stop pushing, the other resident had slapped her in the face and she returned the slap. Continued review revealed the facility has two separate smoking times for both residents to eliminate the possibility of these two residents interacting. Observation/interview with Resident #7 on 9/10/18 at 1:50 PM, in the smoke shack, revealed the resident seated in a chair. Continued observation revealed no aggressive behavior observed. Interview with Resident #7 at this time revealed the resident stated, I just hit her; I don't know why. Observation/interview with Resident #8 on 9/10/18 at 2:00 PM, in the smoke shack revealed the resident was unable to recall the incident, and stated she hadn't had any problems with anybody. Interview with the Environmental Services Staff member on 9/10/18 at 3:00 PM, in the conference room, revealed she had witnessed at least part of the altercation between Resident #7 and Resident #8. I was coming out of laundry, and overheard (Resident #8) calling (Resident #7) a [***] . I took off running up there to see what was going on. I saw (Resident #8) had her hand on (Resident #7)'s side and (Resident #7) had her hand on (Resident #8)'s face. I don't know who hit who first, I saw them hitting at the same time. They were both willfully swinging at each other with open hands. Interview with the Administrator on 9/13/18 at 4:40 PM, in the conference room, confirmed the facility had failed to follow their abuse policy, and had failed to protect residents (#3, #6, #7, and #8) from abuse.",2020-09-01
481,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,677,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility documentation review, and interview, the facility failed to provide assistance with bathing to maintain personal hygiene for 1 resident (#1) of 3 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Continued review revealed the resident required extensive assistance with toileting, and personal hygiene. Review of a facility document, Bathing Report, dated 7/20/18 through 8/6/18, revealed no documentation Resident #1 received scheduled showers on 7/19/18, 7/23/18, 7/28/18, or 8/4/18. Interview with the Director of Nursing on 9/11/18 at 4:21 PM, in the conference room confirmed the facility failed to provide assistance with bathing for 4 of 7 scheduled showers.",2020-09-01
482,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,684,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed to provide 1 antipsychotic medication and 1 antianxiety medication as ordered for 1 resident (#9) of 3 residents reviewed. The findings include: Review of the facility policy, Medication Administration Guidelines, dated 5/16 revealed .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time . Medical record review revealed Resident #9 was admitted to the facility on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of the Physician Order Sheet dated 9/7/18, revealed .[MEDICATION NAME] .5 mg Tablet by mouth three times a day .Ziprasidone HCL 80 mg twice daily . Review of the Medication Administration Record [REDACTED].Ziprasidone HCL 80 mg (milligram) give one cap (capsule) by mouth twice a day with food .16:00 (4:00 PM) and AM . with no documentation the medication was administered at 4:00 PM on 9/7/18. Continued review revealed .[MEDICATION NAME] .5 mg Tablet Give one tab (tablet) by mouth three times a day 6:00 (AM), 14:00 (2:00 PM), 20:00 (8:00 PM) with no documentation the medication was administered at 2:00 PM or 8:00 PM on 9/7/18. Interview with Licensed Practical Nurse (LPN) #6 on 9/12/18 at 12:00 PM, in the conference room, confirmed she had not given Resident #9 his 8:00 PM, dose of .5 mg of [MEDICATION NAME] (antianxiety medication). I figured his medication would be here soon and I would give it then. I didn't think a .5 mg of [MEDICATION NAME] would make much difference. I did not attempt to obtain the medication from the E-box (emergency box) or contact the pharmacy. Interview with LPN #3 on 9/12/18 at 12:40 PM, in the conference room, confirmed Resident #9's [MEDICATION NAME] and Ziprasidone HCL (antipsychotic medication) had not been delivered to the facility by the pharmacy at the time they were scheduled to be administered. Continued interview confirmed she did not administer Resident #9 a scheduled 2:00 PM dose of .5 mg [MEDICATION NAME] or his 4:00 PM scheduled dose of 80 mg Ziprasidone HCL. Continued interview confirmed LPN #3 did not attempt to obtain the 2:00 PM, dose of .5 mg [MEDICATION NAME] from the E-box. Interview with the Director of Nursing on 9/12/18 at 4:10 PM, in the conference room, confirmed Resident #9 did not receive his 4:00 PM scheduled dose of Ziprasidone 80 mg, and did not receive his 2:00 PM and 8:00 PM dose of .5 mg [MEDICATION NAME]. Continued interview revealed it was her expectation if a medication was unavailable for a resident the Physician was to be notified for a new order. Continued interview confirmed they had access to a local pharmacy, and [MEDICATION NAME] was available in the E-box, but had not been utilized. Further interview confirmed the facility failed to provide Resident #9 his medications as ordered.",2020-09-01
483,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,692,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility documentation, and interview, the facility failed to follow a recommendation from the Registered Dietitian for an oral Nutritional Supplement for weight loss for 1 resident (#1) of 3 residents reviewed for weight loss. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of a facility document, Weights, revealed Resident #1's weight on 7/23/18 was 220.4 pounds, and on 7/31/18 was 211.8 pounds, indicating a weight loss of 8.6 pounds or 3.9% in 8 days. Review of a Nutrition Note dated 8/1/18, revealed .Res (resident) obese/[MEDICAL CONDITION] and wt. (weight) Review of the Medication Administration Record [REDACTED] Review of Physician Telephone Orders dated 8/1/18 through 8/6/18, revealed no order for Med pass 90 ml TID. Interview with the Director of Nursing on 9/11/18 at 4:21 PM, in the conference room, confirmed Resident #1 did have weight loss during admission. Continued interview confirmed the Registered Dietitian's recommendation on 8/1/18 for Med Pass 90 ml 3 times daily was not followed and facility failed to provide the recommended oral supplement for weight loss.",2020-09-01
491,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-02-14,600,D,1,0,CEZ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 (Resident #2) of 4 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prevention Program Updated 1/19/17 revealed .It is the policy of this facility to prevent resident abuse . Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #9 revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Continued review revealed the resident exhibited no behaviors during the review period. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of an MDS dated [DATE] for Resident #2 revealed the resident was rarely/never understood. Continued review revealed no behaviors were exhibited during the review period. Observation on 2/12/18 at 10:25 AM, of Resident #2, in her room on the secure unit revealed the resident seated on the side of her bed. Continued observation revealed the resident was awake and alert, however did not answer questions appropriately. Review of the facility investigation dated 1/19/18 revealed .At 12:53 PM (Resident #2) was struck four times on the left shoulder by (Resident #9) after she wondered into his room .Upon attempting to enter (resident #9's) room, she (Resident #2) backed out; he followed her out, and then struck her four times on the left shoulder with an open hand . Review of a Progress Note dated 1/19/18 at 3:06 PM, for (Resident #3) revealed .Resident opened door to (Resident #9's) room attempting to enter. Resident began backing out of room at which time (Resident #9) struck 3-4 times making contact to left shoulder . Interview on 2/14/18 at 12:00 PM, with[NAME]Lowhorn DON, in the conference room confirmed Resident #9, did willfully hit Resident #2 in attempt to remove her from his room, and the facility failed to prevent abuse for one resident #2.",2020-09-01
492,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-02-14,812,F,1,0,CEZ811,"> Based on facility policy review, observation, and interview, the facility failed to maintain the dish machine to ensure dishes were sanitized; failed to properly sanitize dishes in the 3 compartment sink; failed to maintain kitchen equipment and floors in a clean and sanitary manner; and failed to properly store and label dry foods and refrigerated food items, affecting 84 of 87 residents on census. The findings included Review of the facility policy Dishwashing: Machine dated (YEAR) revealed .The Dining Services staff shall maintain the operation of the dish machine according to established procedure and manufacturer guidelines .to ensure effective cleaning and sanitizing .if the dish machine cannot be repaired in a timely manner, the facility will utilize manual dishwashing procedure . Review of the facility policy Sanitation Solution dated (YEAR) revealed .Bleach may be used as a sanitizer when prepared according to the following guidelines .1 Tablespoon bleach + l gallon of water . Review of the facility policy Cleaning Rotation dated (YEAR) revealed .Equipment and utensils will be cleaned .Items cleaned after each use: .Can opener .Work tables and counters .Items cleaned daily: Stove top .Microwave oven .Kitchen and dining room floors .Items cleaned monthly .Ice machines . Review of the facility policy Storing Utensils, Tableware, and Equipment dated (YEAR) revealed .Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination . Review of the facility policy Food Storage dated (YEAR) revealed .Label all food items. The label must include the name of the food and the date by which it should be sold, consumed, or discarded .Dry storage guidelines to be followed .store dry food on shelves .six inches off the floor . Review of the facility policy Labeling and Dating of Foods dated (YEAR) .All foods stored will be properly labeled and dated .all ready to eat foods .will be re-dated with the date the item was opened and a use by date . Review of the facility policy Dishwashing: Manual dated (YEAR) revealed .QAC (Quaternary Ammonium) typically 200-400 PPM .The concentration of chemical or hot water will be tested before cleaning .and recorded on the three compartment sink log sheet .The pots and pans will be drained and air-dried . Observation on 2/12/18 at 9:00 AM, with the Certified Dietary Manager (CDM), in the kitchen revealed the following [NAME] The steamer with dried debris on the interior sides and bottom, and on the outside handle. B. 3 of 3 work tables with dried and flaky debris on the top work area, and the bottom storage areas. C. Juice Machine with dried sticky debris on the base of the machine, and around dispensing spouts. D. Deep Fryer with thick debris on the interior sides, and splash guard, also food particles from the day prior in a fryer basket. E. Stove top and burners with various types of thick dried and burnt debris. F. Ice Machine with dark pink slimy debris on the spill guard and inside of the door. [NAME] Microwave with dried debris on the interior top, sides, carousel, and bottom. H. Can Opener with dried debris on the blade and base I. Cutlery Rack with dried, and sticky debris on the top and knife storage slots. [NAME] Kitchen floor had multiple areas of dried food/beverage debris, and small particles paper. Continued observation with the CDM, in the dish room revealed a low temperature dish machine. Further Observation revealed the machine was not dispensing sanitizer into the sanitizing cycle in 3 of 3 cycles observed. Interview on 2/12/18 at 9:15 AM, with the CDM revealed the dishes would be washed and sanitized in the 3 compartment sink, and no dishware had been returned to the kitchen for usage. Observation on 2/12/18 at 9:17 AM, with the CDM, in the kitchen revealed the following items available for resident consumption: [NAME] 5# bag of oats approximately 3/4 full, open to air, and no label with an open date or use by date. B. 1# bag of dry gravy mix approximately 1/2 full, open to air, and no label with an open date or use by date. C. 10# box of Elf Graham crackers approximately 1/2 full open and on the floor. Further observation with the CDM, of a reach in cooler revealed the following beverages available for resident consumption [NAME] 12 four ounce bowls with canned pears with no label or use by date. B. 10 eight ounce glasses with various beverages with no label or use by date. C. 6 one quart decanters filled with no label or use by date. Further observation of the kitchen with the CDM revealed [NAME] 2 of 12 two inch quarter steam table pans stored wet, and with dried food debris. B. 2 of 5 4 inch quarter steam table pans stored wet, and with dried food debris. Interview on 2/12/18 at 9:40 AM, with the CDM, confirmed the facility failed to maintain the dish machine to ensure proper sanitation of dishes, and failed to maintain clean and sanitary kitchen equipment, utensils, and floors. Further interview confirmed the facility failed to properly store and label foods in the dry storage area and in 2 of 2 reach in coolers. Observation on 2/12/18 at 10:05 AM, with the CDM in the kitchen revealed 2 dietary employees washing dishes in the 3 compartment sink. Further observation revealed no sanitizer testing strips were available to use. Interview on 2/12/18 at 10:08 AM, with the Cook confirmed she had not tested the sanitizer solution in the three compartment sink prior to washing dishes.",2020-09-01
493,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2019-06-11,609,D,1,0,MC9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, medical record review, and interviews, the facility failed to report an injury of unknown injury involving bodily injury for 1 resident (#1) of 3 residents reviewed for injuries of unknown origin. The findings include: Review of facility policy Abuse Prevention Policy Updated 1/19/17 revealed .All personnel must promptly report any incident of resident abuse, mistreatment or neglect, including injuries of unknown origin .when the source of the injury was not observed or known by any person . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum (MDS) data set [DATE] revealed Resident #1 scored a 4 (severe cognitive impairment) on the Brief Interview for Mental Status. Medical record review of a nursing progress note dated 5/27/19 at 3:16 PM revealed .c/o (complains of) increased pain to right hip .(named physician) informed .received a new order to obtain right hip x-ray . Medical record review of a Mobile Radiology Report dated 5/27/19 revealed .There is a right hip hemiarthroplasty in normal position. A moderately displaced [MEDICAL CONDITION] trochanter is present. Surgical staples are present in the proximal right thigh laterally. No other fracture dislocation or other abnormalities of the right hip are present .Conclusion .Displaced [MEDICAL CONDITION] trochanter, new . Interview with Licensed Practical Nurse (LPN) #2 on 6/10/19 at 4:20 PM, in the conference room, revealed .on 5/27/19 she (Resident #1) started having some hip pain even with her PRN (as needed) medication .she had started to complain of pain in her hip, her medication was not as effective as it had been. I called the doctor and told him and he ordered a right hip x-ray .I am not aware of anything out of the ordinary occurring, the only thing different was an increased complaint of pain. No one reported anything from any shift (increased pain or injury) . Telephone interview with LPN #2 on 6/11/19 at 9:40 AM revealed .when I came in on the 27th around 6:30 PM .(LPN #1) reported .(Resident #1) had complained of increased pain and the x-ray technician was here .I picked up the x-ray results off the fax early on the 28th and passed them to the day shift nurse .during the night she never complained of pain .and there weren't any non-verbal signs of pain or any discomfort .I am not aware of anything happening, any incidents or a fall that would have attributed to the fracture. I know now I should have checked the fax machine and reported the results immediately . Interview with the Director of Nursing (DON) on 6/11/19 at 11:25 AM, in the conference room, revealed .on Tuesday morning about 10:30 AM, I was notified of the x-ray results of a lesser trochanter fracture on (Resident #1's) right side. I immediately started an investigation .during the interviews with staff no one was aware of any incidents or occurrences that would have attributed to a fracture. I was not able to identify anything indicating abuse/neglect or concerns related to quality of care . Continued interview confirmed the x-ray was obtained at approximately 6:30 PM on 5/27/19 and the x-ray report was faxed to the facility on [DATE] at approximately 7:00 AM. Further interview revealed the DON was notified of the results at approximately 10:30 AM and .I should have been notified immediately when the results were reviewed by the nurse at 7:00 AM . Continued interview confirmed the facility failed to report an injury of unknown origin timely to the State survey agency and the facility failed to follow facility policy.",2020-09-01
514,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-04-24,600,J,1,0,G6YR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent neglect for 1 of 6 (Resident #1) residents reviewed, which resulted in Resident #1 exiting the facility, was found sitting in a creek containing water and sustained hypothermia (dangerously low body temperature) and a hematoma (swelling and bruising)around her right eye. The facility's failure to prevent neglect placed Resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). F-600 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM, in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The Wandering, Unsafe Resident policy, revised (MONTH) 2014 documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, was ambulatory with an unsteady gait and used a walker, and wandering occurred 1-3 days of the assessment period. Medical record review of Resident #1's Baseline Care Plan, dated 3/12/19, revealed the resident was at risk for elopement as evidenced by wandering and the intervention was ensure staff is aware of resident's wander risk, and exit alarms. Review of the facility's list of residents at risk for elopement revealed Resident #1 was not included on the list from 3/12/19 - 3/18/19. Medical record review of Resident #1's nurses' note dated 3/17/19 at 3:13 PM documented, .Wandering into resident's room and pushing on exit door handles . Review of the facility investigation dated 3/18/19 revealed, on 3/18/19 at approximately 2:00 AM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. Emergency Management Agency and Search and Rescue Dog (K9) responded. At approximately 4:45 AM, Resident #1 was found sitting in a creek embankment containing water by Emergency Management Services and was transported to the hospital. Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Medical record review of an acute care hospital Hospitalist Progress Note dated 3/18/19 at 9:40 AM documented, .Assessment Plan: 1.[MEDICAL CONDITION], 2. UTI (urinary tract infection), 3. Hypothermia secondary to prolonged exposure outside in the cold. Initial temperature 92.2 (Fahrenheit) (normal body temperature 98.6) on arrival resolved with bear (Bair) hugger (warming device) .[MEDICAL CONDITION] (elevated potassium level) . Review of the (Named Hospital) history and physical dated 3/18/19 documented, The ER patient (Resident #1) was found to have [MEDICAL CONDITION](elevated heart rate) hypertension (elevated blood pressure) as well as hypothermia patient started on Bair hugger (warming device) .Vital Sign Ranges Last 24 Hours 92.2 F (Fahrenheit) -98.2 F (normal body temperature 98.6 F) .patient has hematoma around the right eye . The (Named) Police Department (PD) report number documented, .3/18/19 at approximately 0304 (3:04 AM) hours dispatched to a missing person endangered .Nursing staff and officers searched the facility and immediate areas .0331 (3:31 AM) hrs (hours) EMA (Emergency Management Agency) K9 (Search and Rescue dog) notified .0411 (4:11 AM) K9 began track .As we were tracking (Resident #1's) scent, we were notified that (Resident #1) was seen lying in the embankment. Once verified that it was (Resident #1), she was transported by EMS (Emergency Management Services) to (named hospital) . Observations on 3/21/19 and 4/22/19 revealed the facility had 7 entrance/exit doors with keypads that required a code to open or enter/exit: 1 Front Main entrance/exit doorway; 1 Dining Room exit doorway; 1 100 hall end of hall exit doorway; 1 patio entrance/exit doorway; 1 200 hall end of hall exit doorway; 1 300 hall vending machine entrance/exit doorway visible from the nurse's station; 1 300 hall end of hall exit doorway. Observations on 3/21/19 at 2:00 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. Observations on 4/23/19 at 2:10 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. There had been a recent rain and the creek was slightly deeper than the observation on 3/21/19. Interview with the DON on 3/21/19 at 3:37 PM, in the Family room, the DON stated, She (Resident #1) was found sitting in the creek, water was to her waist while sitting in the creek. Legs were wet. Top was dry. She was disoriented. The Search and Rescue dog with the policeman found her with help of the fire department. Interview with Certified Nursing Assistant (CNA) #4 on 4/22/19 at 1:34 AM, in the 300 hallway, CNA #4 was asked if she sat in the hallway most nights. CNA #4 stated, Yeah, we all do when we finish rounds . CNA #4 was asked if she heard any door alarms sounding on the shift 7:00 PM - 7:00 AM beginning 3/17/19. CNA #4 stated, No. I didn't. Interview with the Maintenance Director on 4/22/19 at 4:20 PM in the Family Room, the Maintenance Director confirmed the Front Main entrance door code had been posted on the code box beside the door both at the entrance and exit code box .on that day (3/18/19) I immediately came in around 5:30 (AM) and checked all exit doors to verify working properly .I pulled open every code box at the exit doors and checked the wiring to make sure working properly .All batteries were working properly, however I went ahead and ordered all new batteries and .replaced all batteries in every code box .I then went into the ceiling above 200 hall exit door and opened the junction box and made sure all wiring was correct and tight, the wiring was working but it was discolored so I replaced it over the 200 hall exit door .I inserviced all day and night shift staff of the elopement policy and procedure and we did .drill (elopement scenario) for each shift . Interview with Licensed Practical Nurse (LPN) #1 on 4/22/19 at 4:52 PM, in the Family Room, LPN #1 was asked if she heard any door alarms sounding on the shift 7:00 PM - 7:00 AM beginning on 3/17/19. LPN #1 stated, I don't recall any alarms going off. LPN #1 stated, No, I was at the desk. LPN #1 was asked if Resident #1 had been observed walking to or past the nurses' station. LPN #1 stated, No. Interview with Registered Nurse (RN) #1 on 4/22/19 at 5:55 PM, in the Family Room, RN #1 was asked if she heard any door alarms sounding. RN #1 stated, Not that I recall. RN #1 was asked if she watched the 200 hall while CNA #1 was helping on the other hall. RN #1 stated, I watched for call lights. RN #1 was asked if she could see down the hall. RN #1 stated, No, I was at the desk. RN #1 was asked if Resident #1 had been observed walking to or past the nurses' station. RN #1 stated, No. RN #1 confirmed her witness statement. RN #1 stated, .That night (named Resident #1) had been up and down the (200) hallway .At 2:00 AM I peeked in her (Resident #1) room to check on her and she was not in her room .I asked (named CNA #1) did you see her leave her room and she said no .I then told all staff to begin searching in all rooms, bathrooms, closets everywhere as well as outside . Interview with CNA #2 on 4/22/19 at 6:47 PM, in the Family Room, CNA #2 stated, I saw (Named Resident #1) going down the hall, 200 hall .directed her back into her room about 12:15 (AM). I went back to my hall on 300. CNA #2 was asked if she heard any door alarms sounding that night. She stated, No. CNA #2 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #2 stated, No. Interview with CNA #3 on 4/22/19 at 7:05 PM, in the Family room, CNA #3 stated, I asked (Named CNA #1) to help me with a resident on 100 hall around 1:30 (AM). She came to room [ROOM NUMBER] .She left the room after 15 to 20 minutes . CNA #3 was asked if she heard any door alarms sounding that night. She stated, No. CNA #3 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #3 stated, No. Telephone interview with CNA #1 on 4/22/19 at 7:20 PM, CNA #1 stated, .I ate my meal between 12 (AM) and 1(AM). Meal was in the breakroom. I heated it up in the breakroom across from the nurses' station. Nobody was particularly watching the room (Resident #1's room). Others were watching for lights (resident call lights) or listening for the lights. I left to help (Named a CNA) for about 10 minutes. I did rounds. She (Resident #1) was by her door. I directed her back in her room. I finished my round, probably 4 people, and 2 rooms. Then went and heated my meal. I had a light going off. I went and answered the lights. Went to the bathroom a couple of times. Her door was shut. CNA #1 was asked who was monitoring the hall, particularly Resident #1's room, while she was off the hall. CNA #1 stated, Not sure. I was in/out rooms. CNA #1 was asked if she heard any door alarms sounding that night. CNA #1 stated, No .CNA #1 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #1 stated, No .saw her (Resident #1) wander out of her room and down the hall toward the nurses' station or walk in her room . A second telephone interview with CNA #1 on 4/22/19 at 7:30 PM, CNA #1 confirmed her witness statement. She stated, .The last time I saw (named Resident #1) was approximately 12:15 AM. I redirected her back to her room. She said she was going to bed and closed the door .At approximately 2:00 AM the nurse (RN #1) said (named Resident #1) was not in her room, did I know where she was .that is when we started searching the facility and the grounds . Interview with the Administrator on 4/23/19 at 9:25 AM, in the Family Room, the Administrator stated, I could see how going into other people's rooms could lead to exiting. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, the DON stated, I looked back at the nurses' notes for the day before (day prior to the elopement) During that day, based on the nurses' notes, she was wandering that day and went to an exit door and exhibited those behaviors .Going to exit doors . The DON was asked what her expectations were for monitoring a resident with behaviors of wandering/at risk for elopement. The DON stated, .I would not expect them to be left alone. Be kept in sight. I would expect a visual . Record review of maintenance records of the Resident Monitoring Systems: Check operation of door monitors and patient wandering system dated 3/6/19 - 4/17/19 revealed, the logs were completed weekly and passed inspection. Review of the Emergency Power Generators logbook dated 3/8/19 - 4/16/19 were completed weekly and passed inspection. The facility's failure to monitor and supervise a cognitively impaired resident resulted in Resident #1 wandering away from the facility during the night and suffering from hypothermia and a hematoma around her right eye. The facility's corrective action plan included the following: On 3/18/19 the facility did the following: [NAME] A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. [NAME] Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. [NAME] DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19 - 4/24/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. [NAME] Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
515,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-04-24,609,J,1,0,G6YR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of a facility investigation, medical record review, and interviews, the facility failed to report an allegation of neglect to the State Survey Agency timely for 1 of 6 (Resident #1) residents reviewed for neglect. Resident #1 eloped and the incident was not reported to the State Survey Agency within 2 hours. The facility's failure to report neglect timely placed Resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). F-609 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM, in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The facility's Abuse Prevention Policy & Procedure, revised 2/26/18 documented, .All allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the state survey agency, adult protective services and to all other agencies as required, per state and federal guidelines .Immediately means as soon as possible, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed, Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, wandering occurred 1-3 days of the assessment period, had an unsteady gait and used a walker when ambulating. Medical record review of Resident #1's Baseline Care Plan, dated 3/12/19, revealed the resident was at risk for elopement as evidenced by wandering and the intervention was ensure staff is aware of resident's wander risk, and exit alarms. Medical record review of Resident #1's nurses' note dated 3/17/19 at 3:13 PM revealed, .Wandering into resident's room and pushing on exit door handles . Review of the facility investigation dated 3/18/19 revealed, on 3/18/19 at approximately 2:00 AM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. At approximately 4:45 AM, Resident #1 was found lying in a creek embankment containing water and transported to the hospital. Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Medical record review of an acute care hospital Hospitalist Progress Note dated 3/18/19 at 9:40 AM documented, .Assessment Plan: 1.[MEDICAL CONDITION], 2. UTI (urinary tract infection), 3. Hypothermia secondary to prolonged exposure outside in the cold. Initial temperature 92.2 (Fahrenheit) (normal body temperature 98.6) on arrival resolved with bear (Bair) hugger (warming device) .[MEDICAL CONDITION] (elevated potassium level) .Hematoma (bruising and swelling) around the right eye . Interview with the DON on 3/21/19 at 2:55 PM in the Family Room, the DON stated, .The Administrator reported (the incident to the State) that morning after she (Resident #1) was taken to the ER (emergency room ) . Interview with the Administrator on 4/22/19 at 2:00 AM in the Family Room, the Administrator stated, .I was notified 3:13 (AM) by phone from the night shift RN (Registered Nurse) a resident had eloped .I called the DON to inform her of the elopement . Review of the facility self-report revealed the incident was reported to the state survey agency on the morning of 3/18/19 (at 7:13 AM approximately 5 hrs and 13 minutes after the incident). The facility's corrective action plan included the following: On 3/18/19 the facility did the following: [NAME] A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. [NAME] Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. [NAME] DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19-4/24/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. [NAME] Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
516,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-04-24,689,J,1,0,G6YR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment that provided adequate supervision to prevent elopement for 1 of 6 (Resident #1) cognitively impaired, vulnerable sampled residents reviewed who had elopement behaviors/risk. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with known wandering behavior, who was missing for approximately 2 hours from the facility before the staff realized she had eloped from the facility. Resident #1 had eloped from the facility and was not located until approximately 4.5 hours later when she was found lying in a creek embankment containing water and suffered from hypothermia (dangerously low body temperature) and hematoma (swelling and bruising) around her right eye. This resulted in an IJ for Resident #1. The facility identified 9 cognitively impaired residents who were independently mobile via ambulation or wheelchair with wandering behaviors. The facility reported a total census of 57 residents. F-689 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The facility's Wandering, Unsafe Resident policy, undated documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as detailed monitoring plan will be included . Medical record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 5 day Minimum Data Set ((MDS) dated [DATE] revealed, Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, wandering occurred 1-3 days of the assessment period, had an unsteady gait and used a walker with ambulation. The Baseline Care Plan dated 3/12/19 documented, .PROBLEM Date: 3/12/19 I am at risk for elopement as evidenced by .Wandering .Other encephalitis (symbol for increased) agitation (symbol for increased) confusion Ambulatory .3-18-19 - Elopement - Resident Sent to ER (emergency room ) c (with) minor injuries . Review of the facility's list of residents at risk for elopement revealed Resident #1 was not included on the list from 3/12/19 - 3/18/19. Medical record review included the following notes that documented Resident #1 displayed impaired cognitive status. A Nurse's Note dated 3/14/19 3:36 AM documented, .Some confusion . A Nurse's Note dated 3/14/19 4:40 PM documented, .Some confusion noted . A Nurse's Note dated 3/14/19 11:53 PM documented, Resident up in room rearranging belongings. Stated she got OOB (out of bed) at 6:00 pm thinking her son was coming to take her to get her mail but he did not come .Up in the hall requesting toilet paper, but some was found to be already in place in her room . A Nurse's Note dated 3/17/19 3:13 PM documented, .increased confusion. When helping resident get dressed this morning resident kept attempting to put her shirt on as her pants. Walked out of her room several times asking for the bathroom .Wandering into residents room and pushing on exit door handles . A Nurse's Note dated 3/18/19 6:10 AM (late entry) documented, Pt (patient) not in her (Resident #1's) room all rooms searched completely .Police notified and given information of incident . A Police Department incident report dated 3/18/19 at 3:01 AM to 4:45 AM documented, (Named Nurse and Certified Nursing Assistant (CNA)) informed officers that (Resident #1) left the facility between 0000-0030 (12:00 AM-12:30 AM) hours .last seen wearing a pink sweatshirt, blue pants, possibly wearing slippers, and suffers from dementia .stated (Resident #1) had been wandering around all-night in the hallway .0331 (3:31 AM) hours EMA (Emergency Management Agency) K9 (Search and Rescue dog) notified .0411 (4:11 AM) hours - K9 began track Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Review of the (Named Hospital) history and physical dated 3/18/19 documented, The ER patient (Resident #1) was found to have [MEDICAL CONDITION](elevated heart rate) hypertension (elevated blood pressure) as well as hypothermia patient started on Bair hugger (warming device) .Vital Sign Ranges Last 24 Hours 92.2 F (Fahrenheit) -98.2 F (normal body temperature 98.6 F) .patient has hematoma around the right eye . Observations on 3/21/19 at 2:00 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. Observations on 4/23/19 at 2:10 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. There had been a recent rain and the creek was slightly deeper than the observation on 3/21/19. A telephone interview with Certified Nursing Assistant (CNA) #1 on 3/21/19 at 1:30 PM, CNA #1 was asked when was the last time she saw Resident #1. CNA #1 stated, I saw her about 12:15 (AM). Took her to her room, put her to bed and closed the door . Interview with the DON on 3/21/19 at 3:37 PM, in the Family room, the DON stated, She (Resident #1) was found sitting in the creek, water was to her waist while sitting in the creek. Legs were wet. Top was dry. She was disoriented. The Search and Rescue dog with the policeman found her with help of the fire department. Interview with Registered Nurse (RN #1) on 4/22/19 at 5:55 PM, in the Family Room, RN #1 was asked when was the last time she saw Resident #1. RN #1 stated, Can't recall exact time I last saw her. She was going in other rooms and coming in/out hallway .Just thought I'd check in on her. It was 2:00 AM. Checked the room. Asked (named CNA) if she had seen her leave . Interview with CNA #2 on 4/22/19 at 6:47 PM, in the Family Room, CNA #2 was asked when was the last time she saw Resident #1. CNA #2 stated, I saw her going down the hall .about 12:15 AM. I went back to my hall on 300 . CNA #2 was asked if she heard any door alarms sounding that night. CNA #1 stated, No . A telephone interview with CNA #1 on 4/22/19 at 7:20 PM, CNA #1 stated, .I heated up my meal in the breakroom across from the nurses' station. Nobody was particularly watching the room. I went about 1:30 (AM) and helped (named CNA). I had a light going off I went and answered the lights. Went to the bathroom a couple of times. CNA #1 was asked who was monitoring the hall. CNA #1 stated, Not sure. I was in/out rooms. CNA #1 was asked if she heard any door alarms sounding that night. CNA #1 stated, No Interview with the Administrator on 4/23/19 at 9:25 AM, in the Family Room, the Administrator stated, I could see how going into other people's rooms could lead to exiting. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, the DON stated, I looked back at the nurses' notes for the day before (day prior to the elopement) During that day, based on the nurses' notes, she was wandering that day and went to an exit door and exhibited those behaviors .Going to exit doors . The DON was asked what her expectations were for monitoring a resident with behaviors of wandering/at risk for elopement. The DON stated, .I would not expect them to be left alone. Be kept in sight. I would expect a visual . The facility failed to ensure a safe environment for Resident #1 when they had no knowledge of her location for approximately 4.5 hours. Resident #1 had been assessed and documented as cognitively impaired with risk for elopement as evidenced by wandering behaviors and eloped from the facility on 3/18/19. She was found 4.5 hours later on 3/18/19 lying in a creek embankment containing water. The facility's corrective action plan included the following: On 3/18/19 the facility did the following: [NAME] A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. [NAME] Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. [NAME] DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19-4/24/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. [NAME] Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
526,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,684,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to follow physician's treatment orders for 1 of 3 (Resident #3) sampled residents reviewed for wound care and treatment. The findings included: Medical record review revealed Resident#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].Cleanse lt (left) lower leg with wound cleaner, pat dry, apply dry 4x4's . and wrap with [MEDICATION NAME] qd (every day)/prn (as needed) one time a day for arterial/venous ulcers (.) (MONTH) reapply if dressing becomes soiled or dislodged as needed . Review of physician's orders [REDACTED].Cleanse rt (right) lower leg with wound cleaner, pat dry, apply dry 4x4's . and wrap with [MEDICATION NAME] qd/prn. one time a day for venous/arterial ulcers (.) (MONTH) reapply if dressing becomes soiled or dislodged as needed . Observation in Resident #3's room on 7/16/18 at 3:00 PM revealed the dressings on Resident #3's bilateral lower extremities were dated 7/13/18. The dressings were not changed and treatments were not provided on 7/14/18 or 7/15/18 as ordered by the physician. Interview with Licensed Practical Nurse (LPN) #1 on 7/16/18 at 3:30 PM in Resident #3's room, LPN #1 confirmed Resident #3's bilateral lower extremities dressings were dated 7/13/18. The facility failed to ensure wound treatments were changed according to physician's orders [REDACTED].",2020-09-01
527,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,773,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to obtain laboratory (lab) tests as ordered and failed to promptly notify the physician of a critical laboratory result for 1 of 3 (Resident #9) sampled residents reviewed for laboratory services. The findings included: Review of the undated (Named Facility) Lab Protocol documented, .Lab results are pulled from (Named Lab Company) system daily Monday-Friday by designated personnel and reviewed by DON (Director of Nursing) and ADON (Assistant Director of Nursing) .All critical labs are to be called to facility per (Named Lab Company) Monday-Friday. Nurses are to accept critical lab reports and call MD (Medical Doctor) with results. Monday-Friday if labs are called after hours then 3-11 supervisor/charge nurses are to take critical lab results and report to MD/DNP (Doctorate Nurse Practitioner) . Medical record review for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #9 was assessed with [REDACTED].#9 was severely cognitively impaired. Review of a physician order [REDACTED].[MEDICATION NAME] Suspension (generic [MEDICATION NAME]) 125 mg/5ml (125 milligrams in 5 milliliters) give 8 ml by mouth every 12 hours for anticonvulsant . Review of a physician order [REDACTED].[MEDICATION NAME] level every 3 months starting on 5/1/18 . The [MEDICATION NAME] level result dated 5/1/18 was low at 7.0 ug/ml (units per gram/milliliter) with a reference range of 10.0-20.0 ug/ml. The physician ordered a one time dose of [MEDICATION NAME] suspension 500 mg (milligram) to be given on 5/2/18. Review of a physician order [REDACTED].Repeat [MEDICATION NAME] level one time . There was no documentation this repeat [MEDICATION NAME] level was obtained as ordered. Review of a physician order [REDACTED]. This [MEDICATION NAME] level result was at a critical level high of 25.4 ug/ml. The physician was notified and gave an order to hold the [MEDICATION NAME] Suspension until 5/25/18 and to repeat the [MEDICATION NAME] level on 5/24/18. There was no documentation this repeat [MEDICATION NAME] level was performed. Review of a physician order [REDACTED].Repeat [MEDICATION NAME] level on 5/24/18 . There was no documentation that this repeat level was obtained. The physician visited the resident on 5/25/18 and ordered a STAT( immediate) [MEDICATION NAME] level to be drawn. This STAT [MEDICATION NAME] level result was high at 23.5 ug/ml. The physician decreased the [MEDICATION NAME] suspension dosage to 7 ml two times a day and ordered a repeat [MEDICATION NAME] level to be drawn in one week. There was no documentation this repeat [MEDICATION NAME] level was performed as ordered. A Nurses note dated 5/31/18 revealed the physician was notified again of the high [MEDICATION NAME] level result dated 5/25/18 with an order obtained to further decrease the [MEDICATION NAME] Suspension dose to 6 ml twice a day and to repeat a [MEDICATION NAME] level on 6/7/18. The 6/7/18 [MEDICATION NAME] level result was a critical high level of greater than 34. The laboratory result form documented the critical high level was called to (Named Licensed Practical Nurse) on 6/8/18 at 7:49 AM. There was no documentation the physician was notified of this critical high result until 6/9/18. The physician discontinued the [MEDICATION NAME] dose until 6/12/18 and ordered a recheck of the [MEDICATION NAME] level to be drawn on 6/11/18. The 6/11/18 level result was within normal limits of 12.7 ug/ml. The physician restarted the [MEDICATION NAME] suspension dosage at 5 ml two times a day on 6/12/18. Observations of Resident #9 on 7/18/18 at 10:30 AM revealed him to be alert, up in a geri chair at bedside watching television and voiced no complaints. Interview with the Unit Manager on 7/18/18 at 7:50 AM, in the Conference room, the Unit Manager was asked about the missed labs and delay in physician notification of the critical lab result and the Unit Manager stated, I am not sure what happened about the 5/2/18 lab order, I do know the 5/24/18 lab order was canceled by the laboratory and was not sure why was not aware of the redraw order for the first of (MONTH) .I saw that critical lab (on 6/9/18) for 6/7/18 and had the LPN handle that on 6/9/18. Not sure why the nurse did not inform the physician of that critical lab. The resident never displayed any symptoms of toxicity. Interview with the Nurse Practitioner on 7/18/18 at 10:00 AM, in the Conference room, the Nurse Practitioner (NP) involved in Resident #9's care was asked about the missed labs and delay in notification of the critical high [MEDICATION NAME] level and the NP stated, I was not aware the levels were not drawn on the first of June, (Named Resident #9) had no signs/symptoms during that time, I decreased his [MEDICATION NAME] slowly .I do expect to be notified of critical lab results. The facility failed to ensure that laboratory tests were obtained as ordered and failed to ensure prompt notification of a critical [MEDICATION NAME] level on Resident #9.",2020-09-01
528,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,806,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on menu review, tray card review, medical record review, observations and interviews, the facility failed to ensure nourishing, palatable meals, honoring resident preferences were served to 1 of 3 (Resident #1) sampled residents reviewed for nutrition. The findings included: Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The record revealed Resident #1 with an order dated 6/15/18 for a Mechanical Soft Diet. Resident #1 was assessed on the 1/26/18 Annual and the 4/25/18 Quarterly Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #1 was independent with decision making skills and required extensive assistance with Activities of Daily Living (ADLs). Further medical record review revealed the only Dietary Progress note to date in (YEAR) was dated 6/14/18 and documented Resident #1 had a 3% (percent) weight loss that month and a recommendation to liberalize her diet was noted. A Nurse's note dated 6/19/18 documented, Patient complaint of meal not being what she wants .she wants to talk to dietary supervisor . There was no documentation in the medical record the Dietary Manager or the Registered Dietician had conducted a follow up visit to address the 6/19/18 request made by the resident. There were no dietary notes in the medical record documenting the frequent trips to the grocery or attempts to accommodate Resident #1's food preferences. The Care Plan did not address Resident #1's food complaints/preferences/attempts to accommodate. Review of the Noon meal Menu for 7/15/18 revealed Roast Beef, Mashed Potatoes, Capri Mix Vegetables, Banana Cream Pie, and Dinner Roll to be served. The Noon meal Menu for 7/16/18 revealed Baked Chicken, Greens, Cornbread, and Strawberries with topping to be served. Observations on 7/15/18 at 12:20 PM of the noon meal revealed Resident #1 served Roast Beef, Vegetable Medley, and a Baked Sweet Potato. The Roast Beef and Sweet Potato were listed on the tray card as dislikes. The resident was observed to be eating the Sweet Potato and stated, .had one last night, get them frequently, have to eat something . Observations on 7/16/18 at 12:50 PM of the noon meal revealed Resident #1 served Baked Chicken, Greens, and a Baked Sweet Potato. The Sweet Potato was listed on the tray card as a dislike. The resident was observed to be eating the Sweet Potato and stated, .3 days in a row for Sweet Potatoes . Review of the tray card used in dietary to plate each meal for Resident #1 revealed the following foods listed as dislikes: No milk, juice, bread, chicken and dumplings, yams, roast beef, gravy or pork. Interview with the Dietary Manager on 7/11/18 at 10:30 AM, in the Conference room, the Dietary Manager stated, .(Named Resident #1) has given me a long list of dislikes on her tray cards .she is very picky, complains a lot about the food .we make frequent trips to the grocery for her meals . Interview with Resident #1 on 7/11/18 at 12 Noon, in the resident room, Resident #1 stated, .I have given the dietary manager a list of my likes and dislikes but they can't get that right . Interview with the Dietary Manager on 7/15/18 at 12:05 PM, in the Conference room, the Dietary Manager was asked to provide evidence such as notes and receipts of foods purchased to address the complaints/preferences of Resident #1 and stated, I don't have any receipts where I've bought food for her . Interview with the Director of Nursing (DON) on 7/18/18 at 11:15 AM, the DON was asked who completed the care plans related to dietary/food issues and stated, .Dietary would put those on the care plan. The DON was asked the care plan expectations regarding Resident #1's frequent food complaints and stated, I would expect all her dietary complaints, preferences and all that has been done to address them to be on the care plan. The facility failed to provide evidence the food complaints/preferences of Resident #1 were addressed, failed to ensure that food preferences were honored for Resident #1, and failed to ensure a variety of foods were served to Resident #1.",2020-09-01
548,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,607,D,1,0,BRJH11,"> Based on review of facility policy, and interview, the facility abuse policy failed to accurately identify the reporting time of an abuse allegation. The findings included: Review of the undated facility policy entitled Abuse, Neglect and Exploitation of Residents revealed .Investigating and Reporting .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator as soon as possible .An investigation MUST be directed by the Administrator, designee immediately and no later than twenty-four (24) hours of their knowledge of the alleged incident .The Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulation .The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . Review of the facility policy entitled Abuse Reporting revealed .Reporting Guidance Federal Regulation .requires reporting of alleged violations of abuse .immediately to the administrator and to the appropriate state agencies in accordance with state law .CMS (Centers for Medicare & Medicaid Services) has defined 'immediately' as as soon as possible, but not to exceed 24 hours after forming suspicion .The facility must report abuse .within 24 hours after the reasonable cause threshold (suspicion) is concluded. If serious bodily injury has been sustained by a resident, the incident will be reported immediately but not later than 2 hours after forming suspicion . Interview with the Administrator and the Regional Nurse on 1/24/18 at 9:00 AM in the conference room confirmed the facility policy failed to .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .",2020-09-01
549,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,609,D,1,0,BRJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the investigation documentation, and interview, the facility failed to report an allegation of abuse immediately or no later than 2 hours for 3 residents (#4, #8, #9) of 7 residents reviewed for abuse. The findings included: Review of the undated facility policy entitled Abuse, Neglect and Exploitation of Residents revealed .Investigating and Reporting .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator as soon as possible .An investigation MUST be directed by the Administrator, designee immediately and no later than twenty-four (24) hours of their knowledge of the alleged incident .The Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulation .The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . Review of the facility policy entitled Abuse Reporting revealed .Reporting Guidance Federal Regulation .requires reporting of alleged violations of abuse .immediately to the administrator and to the appropriate state agencies in accordance with state law .CMS (Centers for Medicare & Medicaid Services) has defined 'immediately' as as soon as possible, but not to exceed 24 hours after forming suspicion .The facility must report abuse .within 24 hours after the reasonable cause threshold (suspicion) is concluded. If serious bodily injury has been sustained by a resident, the incident will be reported immediately but not later than 2 hours after forming suspicion . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation documentation involving Resident #4 revealed the staff to resident abuse allegation occurred on 10/21/17 at 6:00 PM and the Administrator was notified on 10/22/17 at 4:00 PM, 22 hours after the occurrence. The State Agency was notified on 10/23/17 at 4:47 PM, 46 3/4 hours after the occurrence. The facility failed to report the abuse allegation to the Administrator and the State Agency immediately or not later than 2 hours. Interview with the Administrator and the Regional Nurse on 1/24/18 at 9:00 AM in the conference room confirmed the facility failed to timely report an allegation of abuse to the Administrator and the State Agency. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Progress Note dated 11/30/17 at 7:20 PM revealed .Received result of Left shoulder x-ray. Results read, fracture involving distal clavicle with minimal displacement. Message sent to NP (Nurse Practitioner). Call placed to on call for primary physician. On call MD (Medical Doctor) returned call and order received to place a sling to LUE (Left Upper Extremity) and leave in place until further notice . Review of facility investigation documentation revealed the Administrator was not notified on 11/30/17 when the facility received Resident #8's x-ray results. Interview with the Administrator and Director of Nursing (DON) on 1/23/18 at 3:15 PM in the Administrator's office confirmed the Administrator and the State Agency were not notified of Resident #8's injury of unknown origin immediately or within the 2 hour timeframe per the regulatory requirement. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Progress Note dated 11/6/17 at 6:12 AM for Resident #9 revealed .New order for xray of left humerus and left ulnar radial on 11/6/17 for swelling and discoloration . Medical record review of a Nursing Progress Note dated 11/7/17 at 2:31 AM for Resident #9 revealed .On 11/6 residents x-ray results came back around 930p (PM) showing Acute moderate displaced (L) (Left) humeral neck fracture. No fracture, destructive [MEDICAL CONDITION] or other abnormalities of the (L) forearm. Made DON and night time supervisor aware . Further review revealed at 10:00 PM the on-call physician had been notified and at 10:20 PM the resident's daughter had been notified. Medical record review of an assessment dated [DATE] signed by the Attending Physician revealed Resident #9 had an .acute left humerus fracture without fall. Possibly when rolled to clean her, fracture with underlying [MEDICAL CONDITION] . Review of the facility investigation documentation and the medical record revealed the Administrator had not been notified of the xray results, received by the facility on 11/6/17 at around 9:30 PM, until the morning of 11/7/17, when the incident was reported to the State Agency. Interview of the facility Administrator and DON on 1/23/18 at 3:15 PM in the Administrator's office, confirmed the Administrator and the State Agency were not notified of the injury of unknown origin immediately or within the 2 hour timeframe per the regulatory requirement.",2020-09-01
550,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,656,D,1,0,BRJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to develop a comprehensive plan of care for 1 resident (#9) of 9 sampled residents. The findings included: Review of facility Policy and Procedure MDS/Care Plans undated, revealed .The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetable to meet a resident's medical, nursing, mental and psychological needs which are identified in the comprehensive assessment and lead to the resident's highest obtainable level of independence .Procedure .When making decisions about the care plan .a. Determine whether the problem needs an intervention. b. Evaluate the resident's goals, wishes, (advance directives), strengths and needs. c. Design interventions that address cause, not symptoms. d. Establish which items need further assessment or review . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. Medical record review revealed an assessment of Resident #9 signed by the Attending Physician dated 11/7/17 of an .acute left humerus fracture without fall. Possibly when rolled to clean her, fracture with underlying [MEDICAL CONDITION] . Medical record review of the Plan of Care initiated 9/2/16 and revised on 11/17/17 revealed no objectives, goals, or interventions to direct staff in providing care and services to Resident #9 whose condition was compromised after a fracture and who had a [DIAGNOSES REDACTED]. Interview with the Administrator and the Director of Nursing in the Administrator's office on 1/24/18 at 11:30 AM confirmed the care plan for Resident #9 failed to identify objectives, goals, and interventions to direct the staff in the care of the resident with a compromised condition.",2020-09-01
563,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-07-18,600,D,1,0,9S4C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to prevent physical abuse of 1 (Resident #2) of 4 residents reviewed for abuse/neglect. Findings include: Review of facility policy Abuse, Neglect, and Exploitation of Residents, revealed .The facility will not condone resident abuse by anyone including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, resident representative, family members, legal guardians, sponsors, friends or other individuals .All personnel are required to promptly report any incident or suspected incident of resident abuse .Upon receiving reports of physical or sexual abuse the nursing supervisor will immediately examine the resident .An immediate investigation will commence and a stated and signed statement from the person reporting the incident will be obtained .It is the responsibility of all staff to identify inappropriate behavior towards residents, which may include but is not limited to use of derogatory language; rough handling of residents; ignoring residents while giving care; directing residents who need toileting assistance to urinate/defecate in their clothing, etc .Physical abuse is the inappropriate physical contact with a resident which harms or is likely to harm a resident. This includes but is not limited to hitting, slapping, pinching, spitting at, kicking, etc .The facility will provide abuse prohibition training to all new employees and volunteers. All staff will receive this training on an annual basis . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored 0 on the Brief Interview for Mental Status indicating he was unable to answer the questions. Continued review of the MDS revealed Resident #2 required extensive assistance of 2 people for transfers, dressing, toileting, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Review of facility investigation of a written statement by Certified Nurse Aide (CNA) #1 revealed she was .in the middle of a round walking up to the front when she heard yelling. She heard a nurse yell at a resident as she looked down the hall and heard her say let go of my necklace you stupid [***] . She had him by the hands and had bite him was continuing yelling had his hands up to his neck and this point I had went back to my hall. I came back up to the front to her walking out the doors and was gone for about 30 minutes. Continued review revealed a clarification note by the Administrator in which CNA #1 was asked if she saw Licensed Practical Nurse (LPN) #1 actually bite down with teeth showing or did she see nurse's mouth on resident's hand. Further review revealed CNA #1 did not see the nurse actually bite but rather her lips on the resident's hand. Further review revealed the Administrator asked CNA #1 if she saw the resident had a grip on the nurse and CNA #1 said it appeared the resident had a hold of something with the nurse. Continued review revealed the Administrator asked CNA #1 if the nurse had the resident by the hands or the resident had the nurse by the hands and she said it looked like the nurse had the resident but couldn't see that clearly to say 100%. Review of facility investigation of an interview dated 6/4/18 between the Administrator, Acting Assistant Director of Nursing, and LPN #1 revealed LPN #1 stated a resident had his hands around her neck. Continued review revealed the Administrator asked if the LPN did anything inappropriate to the resident and LPN #1 stated I yelled at him to let me go. Further interview revealed the Administrator asked LPN #1 if she touched the resident in any way and she stated she had bitten the resident because I panicked and didn't know what to do because he was choking me. Continued interview revealed the Administrator clarified with LPN #1 if she bit down or put her mouth on resident hand and she said she put her mouth on his hand and her teeth did make contact with resident's hand. Further interview revealed the Administrator asked how the resident got his hands around her neck and LPN #1 stated I was behind him locking his wheelchair and he reached behind him and grabbed my throat. I didn't know how to get free. We were in the hallway and nobody was coming to help. Continued interview revealed the Administrator watched the video there were several staff members in the hallway and the description of the event did not make sense with the nurse being able to bite the resident while his hands were around her neck. Further interview revealed LPN #1 was suspended immediately. Review of facility investigation of a written statement by LPN #1 revealed I went up to the resident to help move him. I reach around the back of his wheelchair to unlock his wheels to move him when he reached backward and grabbed me by the neck. I panicked at that time and tried to release his hands from me but was unable causing me to panic further. I was at him to let go but he would not. Nobody was coming to help so I bite his hand to try and see if he would let go. He loosed his grip at that time and I was able to slip away. He had the necklace I had on in his hands so I grab the necklace and got it away from him. Interview with the Administrator and DON on 7/18/18 at 10:40 AM in the conference room revealed revealed there were no teeth marks, abrasions, or skin issues with the resident. Further interview revealed LPN #1 stated her teeth made contact with his hand because she had panicked. Continued interview revealed the Administrator terminated LPN #1 to err on the side of the resident even though she could not prove the nurse bit the resident because there were no teeth marks, but the nurse had yelled at the resident and called him a [***] which the Administrator confirmed constituted verbal abuse.",2020-09-01
564,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-10-18,802,E,1,0,J1T311,"> Based on facility document review, observation, and interview, the facility failed to deliver meal trays to residents in a timely manner resulting in late meals and cold food for 95 residents of 259 residents. The findings included: Review of the Meal Cart Order revealed breakfast trays are to be served from 6:40 AM - 8:10 AM; lunch trays are to be served from 11:10 AM - 12:40 PM; and dinner trays are to be served from 4:35 PM - 5:55 PM. Observation of tray delivery on 10/9/18 revealed trays which were supposed to be delivered to A Hall at 12:05 PM arrived at 12:25 PM; trays supposed to be delivered to B Hall at 12:20 PM arrived at 12:27 PM; trays supposed to be delivered to C Hall at 12:30 PM arrived at 12:45 PM; and trays supposed to be delivered to D Hall at 12:40 PM arrived at 12:55 PM. Observation of tray delivery on 10/17/18 revealed trays which were supposed to be delivered to A Hall at 12:05 PM arrived at 12:35 PM; trays supposed to be delivered to B Hall at 12:20 PM arrived at 12:52 PM; trays which were supposed to be delivered to C Hall at 12:30 PM arrived at 12:55 PM; and trays which were supposed to be delivered to D Hall at 12:40 PM arrived at 1:00 PM. Observation of tray delivery on 10/18/18 revealed trays which were supposed to be delivered to B Hall at 12:20 PM were delivered at 12:40 PM; trays which were to be delivered to C Hall at 12:30 PM were delivered at 12:55 PM; and trays to be delivered to D Hall were delivered at 1:07 PM. Observation of residents on the C and D Halls on 10/17/18 revealed the staff offered them fluids and snacks while they waited for lunch. Review of facility census revealed there were 25 residents on A Hall; 23 residents on B Hall; 26 residents on C Hall; and 21 residents on D Hall during the 3 observations. Observation of the food temperatures for all 3 meals for 9/2018 and 10/2018 revealed they were appropriate when the food was placed on the plates in the dietary department. Interviews with 10 residents on the A, B, C, and D halls on 10/17/18 and 10/18/18 revealed their meal trays were late frequently and sometimes the food was cool when they received their trays. Telephone interview with the complainant on 10/8/18 at 4:33 PM revealed she has had complaints for 5 months about food being delivered late. Continued interview revealed, on Memory Care, they had not received lunch at 1:15 PM and the complainant was told it would be close to 2:00 PM when they would eat. Further interview revealed the complainant asked the Administrator if the evening meal would be pushed back from 4:30 PM because they ate so late and she responded Absolutely not. They have plenty of snacks on Memory Care. And this is a one time thing. Interview with the Administrator and DON on 10/17/18 at 3:25 PM in the conference room revealed there were issues with food cart delivery. Continued interview revealed the Administrator sat in the kitchen for a day to observe the tray line and food preparation. Further interview revealed the problem was the staff did not start the tray line on time since they started it at 11:30 AM which was the time the first cart was to be delivered. Continued interview revealed the dietary staff now starts the tray line at 10:50 AM so the trays can be delivered on time. Further interview revealed there were complaints about the food being cold when it was delivered and the Administrator found the warmers in the bottom of the covered food worked but the overall plate warmers were not turned on soon enough so the bottom plates were warm but the top ones were cold. Continued interview revealed one of the dietary staff now watched the clock to alert staff how much time they have left before the next cart is due to be delivered. Further interview revealed the dietary staff is now documenting the time the carts get to the units so the Administrator can trend which halls, which meals, and which deliverer have problems. Continued interview the Administrator confirmed the times at which the trays reached the halls were not consistent with the expected times of arrival. Interview with the Dietary Manager on 10/18/18 at 10:50 AM in the conference room revealed there had been concerns with the food delivery but hours were changed in the department and she is in the kitchen making sure the tray line is started on time and trays are going out on time. Continued interview revealed often the trays sit on the halls for a while after they leave the kitchen and before they are passed to the residents. Further interview revealed the food is sent out hot; is temped before it leaves the kitchen; and the plates have a warmer and dome lid. Continued interview revealed the Dietary Manager felt the problem with residents complaining of cold food lies not with dietary but with the hall staff not passing out the trays in a timely manner.",2020-09-01
565,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2020-01-09,686,D,1,0,5J8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to provide complete and weekly assessments for pressure ulcers for 1 of 3 sampled residents (Resident #2) reviewed with pressure ulcers. The findings include: The facility's undated policy titled, Skin Care Guideline, documented, .When an open area is identified .Document evaluation of wound in electronic medical record including .Location and staging .Size (length .width .depth .Weekly skin evaluations are completed and documented . Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan documented, .Focus .11/23/2019 stage 2 right ankle .Interventions .Weekly Wound Assessment . The Progress Notes dated 11/22/19 documented, .resident has open area on right outer foot .measures 0.4 cm (centimeters) x (by) 1 cm . There was no stage of the pressure injury. The Progress Notes dated 12/5/19 documented, .has stage 2 pressure ulcer on right mid outer foot, white center with pink edges, no drainage . There were no measurements of the pressure injury. The Progress Notes dated 1/2/20 documented, .outer right foot .measures 0.5 cm x 0.5 cm . There was no stage of the pressure injury. The Progress Notes dated 1/6/20 documented, .wound to right outer foot is 1 cm x 1 cm . There was no stage of the pressure injury. Medical record review from 11/22/19 - 1/6/20, showed the only wound assessments performed were on 11/22/19, 12/5/19, 1/2/20, and 1/6/20. Observation in the resident's room on 12/27/19 at 10:07 AM, showed Resident #2 had 2 small open areas to the right outer foot. The facility was unable to provide documentation that weekly wound assessments and complete wound assessments with measurements and staging were performed for Resident #2's pressure injury. During an interview conducted on 12/27/19 at 12:10 PM, the Wound Care Nurse was asked about Resident #2's pressure injury on her right foot. The Wound Care Nurse stated, .started (MONTH) 23rd .one is almost healed .still working on the other spot .is a stage 2 . During a phone interview conducted on 1/9/20 at 9:30 AM, the Director of Nursing (DON) confirmed weekly wound assessments and complete wound assessments with measurements and staging were not performed and stated, .not getting assessed correctly .",2020-09-01
575,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,600,K,1,0,TIWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigations, review of personnel files, review of employee attendance records (time punch), and interview, the facility failed to prevent mental, physical, and verbal abuse for 6 residents (#4, #2, #3, #1, #17 and #18) of 15 residents reviewed. The facility's failure to prevent abuse resulted in psychological abuse to Resident #4 and placed Residents #4, #2, #3, #1, #17 and #18 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F 600 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy was effective 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, . 'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating Resident #4 was moderately cognitively impaired. Continued review revealed Resident #4 required limited assistance for all Activities of Daily Living (ADLs). Medical record review of Resident #4's current Care Plan initiated on 5/15/17 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #4 was on a regular diet and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and Certified Nursing Assistant (CNA) #7 and CNA #2 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Continued review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed Licensed Practical Nurse (LPN) #1 was talking in a demeaning way and restricting drinks from Resident #4. Continued review revealed on 2/20/18, CNA #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .There have been several occasions that (LPN #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee. I would take it to her anyways .Anytime that (LPN #1) tells me that residents can't do or have certain things, I always check with someone else .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .(LPN #1) is a good nurse but she does seem to focus on the two residents (Resident #2) and (Resident #4) . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time. I have been sneaking and giving coffee to the residents if they ask. (Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it. Since (LPN #1) has been gone (Resident #4) now takes a shower . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #7 reported on 2/20/18 she was not aware of any abuse in the facility, but LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things . Further review revealed LPN #4 reported on 2/20/18 . (LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room .Since (LPN #1) has not been here (Resident #4) now attends activities and comes out of her room more. (Resident #4) now takes a shower since (LPN #1) has been gone . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed, in an interview conducted on 2/21/18 between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review revealed Resident #4 did not report it to anyone sooner because she was afraid of retaliation from LPN #1. Continued review of the facility investigation revealed the facility substantiated the allegation of abuse and terminated LPN #1. Interview with Resident #4 on 3/13/18 at 11:20 AM, in the resident's room, confirmed, .The only challenge I had .1 of the nurses was less than nice to me .(LPN #1) .she was always so mean .I asked others have I done something to her .once I had a rash and she reached across grabbed my arm and almost jerked me out of bed to look at it . Continued interview confirmed, while she was at physical therapy, .someone had ransacked my purse .garment bag .happened 2-3 times .the CNAs told me who it was .and it was (LPN #1) .it got to where I was refusing to go to physical therapy .refusing to go out to eat .I felt so violated .now that I am working out (working with physical therapy) my headaches are getting better .less intense .activities helping .and coffee .(LPN #1) would say 'you didn't eat your meal so no coffee' .went a week or two without coffee .if she was here I wouldn't come out of my room .didn't say anything initially because I didn't want to have repercussions .I honestly felt hatred from her .I asked to make a call .she just yelled and pointed 'go back to your room' . Continued interview confirmed Resident #4 told LPN #1 about her room being .ransacked . and LPN #1 responded .well is anything missing . and when Resident #4 said No LPN #1 responded .well what's the problem then . Further interview confirmed since LPN #1 had been gone, Resident #4 had been getting out of her room for meals and physical therapy. Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed she was made aware of abuse allegations by LPN #1 during an interview with Resident #4 on 2/21/18. Continued interview confirmed .a lot of these girls (on the locked unit) are new .no excuse .(LPN #1's abusive behavior) was brought to my attention on the 21st .brought (Resident #4) to my office on the 21st . where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her, and made her fearful to leave her room. Further interview confirmed LPN #1 had been dealing with stress and the facility offered her counseling and .provided her with everything we (the facility) could for stress . Continued interview confirmed the facility discussed allegations of abuse in morning meetings with department heads and clinical staff, did daily rounds where she talked with staff and residents, and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Further interview confirmed Resident #4 had been more active in therapy and the DON had noticed a difference in Resident #4's mood since LPN #1 had been terminated. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 6 out of a possible 15, indicating the resident was severely cognitively impaired. Continued review revealed Resident #2 required limited assistance for all ADLs except toileting, which required extensive assistance. Further review revealed Resident #2 did not have a swallowing disorder. Medical record review of Resident #2's current Care Plan initiated on 8/12/16 indicated the resident was at risk for dehydration. Continued review revealed Resident #2 was a vegetarian, under her ideal body weight, prefers to sleep late, and likes to eat paper and styrofoam. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #2 was on a vegetarian diet, not on fluid restrictions, and was to be provided diet and liquids as ordered. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and LPN #4 and CNA #2 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Continued review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed LPN #1 was talking in a demeaning way and restricting drinks from Resident #2. Continued review revealed on 2/20/18, CNA #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .Anytime that (LPN #1) tells me that residents can't do or have certain things, I always check with someone else .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .(LPN #1) is a good nurse but she does seem to focus on the two residents (Resident #2) and (Resident #4) . Further review revealed CNA #4 reported .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to her sternly and talks to her rudely. (LPN #1) will not allow her to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/19/18 .(LPN #1) talks mean to (Resident #2) .will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Further review revealed in a second interview, LPN #4 reported on 2/20/18 .(Resident #2) was not allowed to have water (LPN #1) would not let her. (LPN #1) would yell at (Resident #2) and tell her to go to her room, be quiet, don't do that you know better, stand up straight, or don't do your feet like that . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #8 reported on 2/19/18 .(LPN #1) was verbally abusive to (Resident #2) .(LPN #1) is mean to her and she has seen her 'jerk her up from a chair, grab her walker' and push (Resident #2) and the walker very fast to her room . Interview with CNA #3 on 3/12/18 at 11:04 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies. Continued interview confirmed .One of the nurses that worked here .(LPN #1) .it's a fine line as far as verbal .she would make her (Resident #2) get out of bed .she (Resident #2) didn't want to get up .kind of thought it was abuse .thought they (Administration) knew .(Resident #2) likes to play in water .I gave it to her anyway . Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .still gave it (water to Resident #2) .(continued) for 2 weeks .(LPN #1) has a stern voice . Interview with CNA #4 on 3/12/18 at 11:14 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water because she would play in it .I gave it anyway .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice .then (LPN #1) wasn't here after that . Interview with CNA #6 on 3/13/18 at 10:27 AM, at the Lighthouse nurses' station, confirmed the CNA had knowledge of the facility abuse policy and chain of command. Continued interview confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNAs say they told them (Administration) before and it doesn't get fixed . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Annual MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed Resident #3 required limited assistance for all ADLs except personal hygiene, which required extensive assistance. Further review revealed Resident #3 did not have a swallowing disorder. Medical record review of Resident #3's current Care Plan initiated on 3/20/18 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #3 was not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and LPN #4 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) would not allow (Resident #3) anything to drink other than at meal times. I would sneak and give (Resident #3) water but if (LPN #1) caught you she would make us go and take it away from the resident . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #5 reported he had not witnessed any abuse occur in the facility and had no knowledge of anyone not being allowed food or drink when the residents ask. CNA #5 continued to report Resident #3's fluids were limited per LPN #1, because she was washing out her medication (diluting her medication from drinking too much water). Interview with CNA #5 on 3/13/18 at 10:13 AM, at the Lighthouse nurses' station, confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard about it . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication effects by drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that .I proceeded giving it (water) to (Resident #3) .not sure if there was a (physician's) order .I took her word for it . Continued interview confirmed he did not report an allegation of abuse to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .but there's a lot of things in the nursing field .don't like it but do it anyway .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing .everybody here are very good people . Review of LPN #1's Personnel File revealed LPN #1 was employed at the facility beginning 10/23/09, was placed on administrative leave on 2/20/18, and terminated on 3/8/18, following a planned medical leave initiated on 2/17/18. Continued review revealed LPN #1's last day worked was 2/16/18. Further review revealed LPN #1 completed Preventing, Recognizing, and Reporting Abuse education on 1/12/18 and Resident Rights education on 12/6/17. Continued review revealed no documentation a background check had been completed. Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Continued interview confirmed .come to believe at different occasions (LPN #1) has lied to me .had to move her .it was related to interactions with other staff members . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #1's BIMS score was 3, indicating the resident was severely cognitively impaired. Continued review revealed Resident #1 required extensive 2 person physical assistance for bed mobility, transfers, dressing, bathing, and required limited assistance for eating. Medical record review of Resident #1's current Care Plan initiated on 9/22/17 indicated the resident required assistance from staff with grooming and personal hygiene, displayed socially inappropriate/disruptive behavior, and frequently yelled out. Continued review revealed interventions including .Do not argue with (Resident #1) .Discuss with (Resident #1) options for appropriate channeling of anger .Talk with (Resident #1) in calm voice when behavior is disruptive . Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #1's hand twice during a shower on 2/14/18, and after Resident #1 smacked CNA #1 back, CNA #1 said .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the alleged abuse of Resident #1 in the shower, but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Continued review revealed the facility terminated CNA #1 for violation of the facility abuse policy. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .I was helping in shower room (on 2/14/18) .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 stated .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Interview with CNA #6 on 3/14/18 at 9:32 AM, in the conference room, confirmed .it was me and a student (CNA Trainee #1) at the time .I could hear a slap .I can't remember if the resident reacted .I didn't say anything .I know I should have .I was kind of shocked at first .I work with her (CNA #1) every day .(ADON) came to me .I told her everything .the truth .I'm not going to lie .honestly I have no excuse .I apologized to the resident and the facility . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #17 was severely cognitively impaired. Continued review revealed Resident #17 required extensive 2 person physical assistance for all ADLs. Medical record review of Resident #17's current Care Plan initiated on 6/2/14 indicated the resident was at risk for decline in social interaction related to Dementia and at risk for elopement. Continued review revealed Resident #17 required staff to approach resident in a positive and calm accepting manner. Medical record review of the Physician Recapitulation orders dated (MONTH) (YEAR) revealed Resident #17 was ordered an appetite stimulant by mouth twice daily to increase appetite for 30 days. Continued review revealed Resident #17 was on a pureed diet with nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room on 2/14/18. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had her finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at (Resident #17's) hand and smacked it really hard .(Resident #17) said 'oooh' .I could describe (Resident #17's) reaction as surprised .it all happened so fast .I made eye contact with (CNA #1) .(Resident #17) didn't scream or yell .was like 'ooooh' . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #18 was severely cognitively impaired. Continued review revealed Resident #18 required extensive assistance for all ADLs and 1 person physical assistance for eating. Further review revealed Resident #18 did not have a swallowing disorder and was on a mechanically altered therapeutic diet. Medical record review of Resident #18's current Care Plan initiated on 7/13/16 indicated the resident was at risk for dehydration and required encouragement for good nutritional intake and was to be provided diet, snacks, and liquids as ordered. Continued review revealed Resident #18 had a history of [REDACTED]. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #18 was on a pureed no added salt diet with low concentrated sweets, nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 take a food tray from Resident #18 before her meal was finished on 2/14/18, and Resident #18 became upset. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed the facility terminated CNA #1 for violation of the facility abuse policy. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact. Review of CNA #1's Personnel File revealed CNA #1 was employed at the facility beginning 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Further review revealed CNA #1 completed Preventing, Recognizing, and Reporting Abuse education on 3/16/17. Review of CNA #1's employee attendance record ending the week of 2/21/18 revealed her last shift ended on 2/15/18 at 2:05 PM, 1 day after the allegations of abuse on 2/14/18 occurred. Interview with the ADON on 3/13/18 at 2:59 PM, in the conference room, confirmed .I was told by (LPN #5) that (CNA Trainee #1) reported (CNA #1) smacked a resident .not sure if that was the correct terminology .was not 100% sure . Interview with the Activities Director on 3/14/18 at 8:45 AM, in the conference room, confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you thought it .she said she went home and thought about it .I then took it to .her floor supervisor (LPN #5) . Interview with RN #1 (RN responsible for the CNA Training Program) on 3/14/18 at 9:02 AM, in the conference room, confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times .hand in hand when hired on and review abuse policy . Continued interview confirmed RN #1 and the ADON were investigating the hot line call allegation of abuse for LPN #1 when allegations of CNA #1's abuse were brought to their attention .I didn't know until later that night . Continued interview confirmed RN #1 had a telephone conversation with CNA Trainee #1 and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Further interview confirmed during her last in-service education held on 2/16/18, she felt the staff were not able to identify specific examples of abuse, such as restricting fluids, because it is .kind of a fine line . Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, revealed .when you report to the person you're supposed to .it gets swept under the rug .wanted to go to the highest person .only one in her office .(DON or ADON) that's who I tried to go to first but they were not in . Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed .I didn't understand it (the allegations reported by CNA Trainee #1) to be abuse at that time .I took it as a complaint .I can't remember the specifics .she could've said smacked .never asked specifics . Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he did not know why staff on the locked unit did not report abusive behaviors. Further interview revealed the Administrator stated, staff were educated to .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .we don't have cameras .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse .",2020-09-01
576,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,609,K,1,0,TIWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility investigations, medical record review, review of personnel files, and interview, the facility failed to report in a timely manner mental, physical, and verbal abuse for 6 residents (#4, #2, #3, #1, #17 and #18) of 15 residents reviewed for abuse. The facility's systematic failure to report allegations of abuse immediately to administration, and within 2 hours to the state authorities, including the State Survey Agency, as required by Federal regulations, placed Residents #4, #2, #3, #1, #17 and #18 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F 609 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy is effective 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of resident/patient's property .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .(alleged violations), are reported immediately to the Administrator/Director of Nursing of the center . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating Resident #4 was moderately cognitively impaired. Continued review revealed Resident #4 required limited assistance for all Activities of Daily Living (ADLs). Medical record review of Resident #4's current Care Plan initiated on 5/15/17 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #4 was on a regular diet and not on fluid restrictions. Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed Licensed Practical Nurse (LPN) #1 was talking in a demeaning way and restricting drinks from Resident #4. Continued review revealed on 2/20/18, Certified Nursing Assistant (CNA) #4 reported .There have been several occasions that (LPN #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2 reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time .(Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #7 reported on 2/20/18 LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things .(LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed, in an interview conducted on 2/21/18 between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review revealed Resident #4 did not report it to anyone sooner because she was afraid of retaliation from LPN #1. Continued review of the facility investigation revealed the facility substantiated the allegation of abuse and terminated LPN #1. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed after the facility became aware on 2/21/18 LPN #1 had mentally abused Resident #4, the facility did not report the abuse to the state authorities, including the State Survey Agency. Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed she was made aware of abuse allegations by LPN #1 during an interview with Resident #4 on 2/21/18 where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her, and made her fearful to leave her room. Continued interview confirmed the facility discussed allegations of abuse in morning meetings with department heads and clinical staff, did daily rounds where she talked with staff and residents, and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 6 out of a possible 15, indicating the resident was severely cognitively impaired. Continued review revealed Resident #2 required limited assistance for all ADLs except toileting, which required extensive assistance. Further review revealed Resident #2 did not have a swallowing disorder. Medical record review of Resident #2's current Care Plan initiated on 8/12/16 indicated the resident was at risk for dehydration. Continued review revealed Resident #2 was a vegetarian, under her ideal body weight, prefers to sleep late, and likes to eat paper and styrofoam. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #2 was on a vegetarian diet, not on fluid restrictions, and was to be provided diet and liquids as ordered. Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed LPN #1 was talking in a demeaning way and restricting drinks from Resident #2. Continued review revealed on 2/20/18, CNA #4 reported . (LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2 reported on 2/20/18 .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to her sternly and talks to her rudely. (LPN #1) will not allow her to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4 reported on 2/19/18 .(LPN #1) talks mean to (Resident #2) .will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Further review revealed in a second interview, LPN #4 reported on 2/20/18 .(Resident #2) was not allowed to have water (LPN #1) would not let her. (LPN #1) would yell at (Resident #2) and tell her to go to her room, be quiet, don't do that you know better, stand up straight, or don't do your feet like that . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #8 reported on 2/19/18 .(LPN #1) was verbally abusive to (Resident #2) .(LPN #1) is mean to her and she has seen her 'jerk her up from a chair, grab her walker' and push (Resident #2) and the walker very fast to her room . Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #2 by LPN #1 to the state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Interview with CNA #3 on 3/12/18 at 11:04 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies. Continued interview confirmed .(LPN #1) would make her (Resident #2) get out of bed .she (Resident #2) didn't want to get up .kind of thought it was abuse .thought they (Administration) knew . Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .(continued) for 2 weeks . Interview with CNA #4 on 3/12/18 at 11:14 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water because she would play in it .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice . Interview with CNA #6 on 3/13/18 at 10:27 AM, at the Lighthouse nurses' station, confirmed the CNA had knowledge of the facility abuse policy and chain of command. Continued interview confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNAs say they told them (Administration) before and it doesn't get fixed . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Annual MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed Resident #3 required limited assistance for all ADLs except personal hygiene, which required extensive assistance. Further review revealed Resident #3 did not have a swallowing disorder. Medical record review of Resident #3's current Care Plan initiated on 3/20/18 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #3 was not on fluid restrictions. Review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4 reported on 2/20/18 .(LPN #1) would not allow (Resident #3) anything to drink other than at meal times. I would sneak and give (Resident #3) water but if (LPN #1) caught you she would make us go and take it away from the resident . Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #3 by LPN #1 to the state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Interview with CNA #5 on 3/13/18 at 10:13 AM, at the Lighthouse nurses' station, confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard about it . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication effects by drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that . Continued interview confirmed he did not report an allegation of abuse to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing . Review of LPN #1's Personnel File revealed LPN #1 was employed at the facility beginning 10/23/09, was placed on administrative leave on 2/20/18, and terminated on 3/8/18. Continued review revealed LPN #1's last day worked was 2/16/18. Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #1's BIMS score was 3, indicating the resident was severely cognitively impaired. Continued review revealed Resident #1 required extensive 2 person physical assistance for bed mobility, transfers, dressing, bathing, and required limited assistance for eating. Medical record review of Resident #1's current Care Plan initiated on 9/22/17 indicated the resident required assistance from staff with grooming and personal hygiene, displayed socially inappropriate/disruptive behavior, and frequently yelled out. Continued review revealed interventions including .Do not argue with (Resident #1) .Discuss with (Resident #1) options for appropriate channeling of anger .Talk with (Resident #1) in calm voice when behavior is disruptive . Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #1's hand twice during a shower on 2/14/18, and after Resident #1 smacked CNA #1 back, CNA #1 said .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the alleged abuse of Resident #1 in the shower, but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Continued review revealed staff did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .I was helping in shower room .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 stated .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Interview with CNA #6 on 3/14/18 at 9:32 AM, in the conference room, confirmed .it was me and a student (CNA Trainee #1) at the time .I could hear a slap .I can't remember if the resident reacted .I didn't say anything .I know I should have .(ADON) came to me .I told her everything . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #17 was severely cognitively impaired. Continued review revealed Resident #17 required extensive 2 person physical assistance for all ADLs. Medical record review of Resident #17's current Care Plan initiated on 6/2/14 indicated the resident was at risk for decline in social interaction related to Dementia and at risk for elopement. Continued review revealed Resident #17 required staff to approach resident in a positive and calm accepting manner. Medical record review of the Physician Recapitulation orders dated (MONTH) (YEAR) revealed Resident #17 was ordered an appetite stimulant by mouth twice daily to increase appetite for 30 days. Continued review revealed Resident #17 was on a pureed diet with nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room on 2/14/18. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed staff did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had her finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at (Resident #17's) hand and smacked it really hard .(Resident #17) said 'oooh' . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #18 was severely cognitively impaired. Continued review revealed Resident #18 required extensive assistance for all ADLs and 1 person physical assistance for eating. Further review revealed Resident #18 did not have a swallowing disorder and was on a mechanically altered therapeutic diet. Medical record review of Resident #18's current Care Plan initiated on 7/13/16 indicated the resident was at risk for dehydration and required encouragement for good nutritional intake and was to be provided diet, snacks, and liquids as ordered. Continued review revealed Resident #18 had a history of [REDACTED]. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #18 was on a pureed no added salt diet with low concentrated sweets, nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 take a food tray from Resident #18 before her meal was finished on 2/14/18, and Resident #18 became upset. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed staff did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact. Review of CNA #1's Personnel File revealed CNA #1 was employed at the facility beginning 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Review of CNA #1's employee attendance record ending the week of 2/21/18 revealed her last shift ended on 2/15/18 at 2:05 PM, 1 day after the allegations of abuse on 2/14/18 occurred. Interview with the Activities Director on 3/14/18 at 8:45 AM, in the conference room, confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you thought it .she said she went home and thought about it . Interview with RN #1 (RN responsible for the CNA Training Program) on 3/14/18 at 9:02 AM, in the conference room, confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times . Continued interview confirmed RN #1 and the ADON were investigating the hot line call allegation of abuse for LPN #1 when allegations of CNA #1's abuse were brought to their attention .I didn't know until later that night . Continued interview confirmed RN #1 had a telephone conversation with CNA Trainee #1 and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed she did not report CNA #1's abuse immediately because .had to get my daughter from daycare, so I left and went home and knew I was working again the next day .that's when I reported it . Continued interview confirmed she did not know why she did not report it immediately stating .Honestly no, I don't know .we were really busy .I was a little bit nervous .hadn't been there very long .only on the floor a week or two .whenever this happened .made the report with a woman .I don't know her name .the very next day (RN #1) called me for more information .wanted to go to the highest person I could .there's been a lot of talk .when you report to the person you're supposed to .it gets swept under the rug .wanted to go to the highest person .only one in her office .(DON or ADON) that's who I tried to go to first but they were not in . Interview with the DON on 3/14/18, at 10:40 AM, in the conference room confirmed .(ADON) tried calling me on the 15th at night .I was picking up my grandson .was out of cell service at that point in time .at 8:30 PM-9:00 PM I was made aware of reports of inappropriate treatment .didn't write down when I was called .I didn't tell (ADON) to report it (the State Survey Agency) .I didn't understand it to be abuse at that time .I took it as a complaint .we reported it (the State Survey Agency) .on the 16th .got a hotline call too .on the 16th .started investigation Interview with DON on 3/20/18 at 12:50 PM, in the conference room, confirmed she did not know why staff did not immediately report LPN #1's abuse to administration. Continued interview confirmed the facility did not report the allegation of abuse for Resident #2 and #3 by LPN #1 to the to the state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Further interview confirmed the facility did not report the allegation of abuse to the State Authorities including the State Survey Agency for Resident #4 by LPN #1 after they became aware on 2/19/18. Continued interview confirmed the facility failed to follow their abuse policy. Refer to F-600",2020-09-01
577,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,835,K,1,0,TIWR11,"> Based on facility policy review, review of facility investigations, and interview, the Administer failed to ensure residents were free from mental, physical, and verbal abuse; to ensure allegations of abuse were reported immediately to facility administration and within two hours to State Authorities, including the State Survey Agency; and to ensure facility training was implemented to prevent abuse. The Administrator's failure placed 6 residents (#4, #2, #3, #1, #17, #18) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Immediate Jeopardy is effective 2/14/18 and was removed 3/21/18. The facility provided an acceptable Allegation of Compliance (AoC), with a compliance date of 3/21/18, and a revisit survey conducted 4/9/18 - 4/10/18 validated the corrective actions implemented by the facility removed the Immediacy of the Jeopardy. Noncompliance continues for F-835 at an [NAME] level for the facility's monitoring of the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes implemented by the facility. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of unknown Source and Misappropriation of resident/ patient's property .'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .( alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center. Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed on 2/14/18, Certified Nursing Assistant (CNA) #1 physically abused Residents #1 and #17 and removed a food tray from Resident #18 who had not finished her meal. Continued review revealed staff witnessed the abuse and did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Continued review revealed the facility became aware on 2/19/18 that Licensed Practical Nurse (LPN) #1 was instructing staff to withhold fluids from Residents #2, #3, and #4 and staff witnessed LPN #1 verbally abusing Resident #2 and #4. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #2 and #3 by LPN #1 to State Authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Continued review revealed after the facility became aware on 2/21/18 LPN #1 had mentally abused Resident #4, the facility did not report the abuse to the State Authority. Interviews with CNA #3, CNA #4, CNA #5, CNA #6 on 3/12/18 and 3/13/18 revealed they all witnessed actions by LPN #1 that met the facility's definitions of abuse but did not stop the LPN from abusing residents and did not report the LPN's actions to administration. Interviews with CNA #4 and CNA #6 revealed they did not report abuse to administrative staff because they thought facility administration did not act on allegations of abuse. Interview with Registered Nurse (RN) #1 (RN responsible for the CNA Training Program) on 3/14/18, at 9:02 AM, in the conference room confirmed, RN #1 had a telephone conversation with (CNA Trainee #1) and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Further interview confirmed during her last in-service education held on 2/16/18 she felt the staff were not able to identify specific examples of abuse such as restricting fluids because it is .kind of a fine line . Continued interview confirmed she had discussions with staff about abuse but had .nothing in writing . Interview with CNA #6 on 3/14/18, at 9:32 AM in the conference room confirmed she and CNA Trainee #1 witnessed CNA #1 slap Resident #1. CNA #6 stated .I didn't say anything .I know I should have . Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed she witnessed CNA #1 slap Resident #17's hand and Resident #1's hand on separate occasions. Further interview confirmed CNA Trainee #1 was trained on abuse, and did not report it immediately because .had to get my daughter from daycare, so I left and went home and knew I was working again the next day .that's when I reported it . Continued interview confirmed she did not know why she did not report it immediately stating . when you report to the person you're supposed to .it gets swept under the rug . Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Further interview confirmed he did not know why staff on the locked unit did not report abusive behaviors .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse . Interview with the DON on 3/20/18 at 12:41 PM, in the conference room, confirmed the DON was aware of alleged abuse on 2/15/18 and did not start an investigation until 2/16/18. Interview confirmed the DON was aware on 2/19/18 of an ongoing concern with staff understanding of abuse and reporting, but no change was implemented to correct the issue. Telephone interview with the Administrator on 3/21/18 at 8:42 AM, confirmed the Administrator identified a concern with staff understanding and reporting abuse on 2/16/18, but no change had been implemented. Refer to F-600 (K); F-609 (K); F-841 (K); F-867 (K); F-943 (K). Validation of the AoC was completed 4/9/18 - 4/10/18 through review of facility documentation, observations, and interviews. Surveyors verified the AoC by: 1. Review of the facility's documentation revealed leadership staff conducted interviews with 100% of all alert and oriented residents with on 3/15/18 as part of their investigation for allegations of abuse. Continued review revealed there were no concerns on 3/15/18 regarding any further allegation of abuse. 2. Review of the facility education log book ensuring that 100% of all staff, including contract employees, was educated by the Activity Director, Director of Clinical Education, and Human Resource Director utilizing the Team Member Interview Tool was completed on 3/21/18. Education occurred between 3/15/18 - 3/21/18. Further review revealed 100% of staff were educated on the facility abuse policy and completed an interactive posttest with a score of 100% on 3/21/18, with the exception of 1 staff member who was unavailable. The staff member was educated on 3/21/18 via telephone by Director of Nursing and was not permitted to work until completion of the interactive posttest which was completed on 3/23/18. Review of the Team Member Interview Tool, posttest, and interviews with the facility leadership staff on 4/9/18 and 4/10/18 confirmed 100% of the active staff had been educated on abuse and facility policies by 3/21/18. 3. Review of the facility's Skin and Body Audit documentation revealed all residents underwent a body audit on 3/15/18, completed by the MDS Coordinators, Wound Care Nurse, ADON, and Unit Manager and no concerns related to abuse were identified. 4. Review of facility documentation revealed every resident representative was contacted either in person or by phone to determine if the resident they represented had ever been abused or ever witnessed abuse at the facility. Further review revealed the Activity Director completed the interviews of 60 out of the 82 resident representatives on 3/15/18, 22 representatives did not return the facility's 2 contact attempts. 5. Review of facility documentation revealed every resident representative was mailed information including a summary of Resident Rights, name and telephone number of the local Ombudsman, education regarding abuse and how to report abuse, and facility's Care Line number and website. 6. Review of facility in-service documentation revealed the Governing Body was provided education by the Regional Vice President (RVP) regarding clarification of the facility abuse policy and Abuse Coordinator on 3/15/18 at 9:00 AM. Interviews conducted on 4/9/18 and 4/10/18 with the Governing Body confirmed knowledge of the facility abuse policy, state, and federal regulations for reporting abuse, and the role of the abuse coordinator. 7. Review of facility in-service documentation revealed the Medical Director was provided education by the administrator on 3/28/18 regarding his roles and responsibilities. Telephone interview with the Medical Director on 4/10/18, at 10:50 AM confirmed knowledge of the facility abuse policy and his responsibilities. Further interview confirmed has been in attendance for QAPI meetings on 3/14/18 and 3/21/18, and has given the facility recommendations for educating staff on the importance of abuse and abuse reporting, as verified in meeting minutes. 8. Review of facility orientation packet revealed the addition of a new 50 question Abuse Test and Abuse Education Posttest. Interviews with the facility leadership on 4/9/18 and 4/10/18 confirmed the education will be verified by the DON or a Registered Nurse before staff can provide direct patient care. 9. Review of the Resident Council Meeting Minutes dated 3/16/18 and interview with the Resident Council President on 4/9/18, at 3:05 PM, in the dining hall confirmed all 20 residents in attendance were educated on Resident Rights and abuse. Interviews conducted on 4/9/18 and 4/10/18 with 4 cognitively intact residents who did not attend the resident council meeting on 3/16/18 confirmed they were recently informed of their rights and abuse by facility staff. 10. Review the facility log book of continuing audits which began on 3/15/18 included interviews with 10 staff members per week regarding abuse and abuse reporting and will continue every week for 8 weeks. Interview with the RVP on 4/10/18 at 12:50 PM confirmed the weekly audits will continue after the 8 weeks, as long as they are needed, but no less than quarterly. Observation on 4/9/18 at 10:30 PM revealed the Clinical Educator and ADON were conducting staff interviews as part of the facility audit process in relation to abuse and abuse reporting. 11. Review of the facility Quality Assurance Performance Improvement (QAPI) meeting minutes dated 3/14/18, 3/21/18, 3/27/18, and 3/29/18, revealed the facility continued to review audits regarding staff knowledge of abuse and abuse reporting. 12. Observation on 4/9/18 and 4/10/18 revealed the RVP and Director of Clinical Operations were present at the facility. 13. Verification through interviews with 5 contracted Housekeeping and Physical Therapy employees was conducted during the revisit survey on 4/9/18 to confirm the staff's understanding of facility policies for abuse and abuse reporting. 14. Verification through interviews with 1st shift licensed nurses and Certified Nurse Assistants (CNAs) was conducted during the revisit survey on 4/9/18 between 10:00 AM and 2:45 PM to confirm the staff's understanding of abuse and abuse prohibition. 15. Verification through interviews with 2st shift licensed nurses and CNAs was conducted during the revisit survey on 4/9/18 between 2:00 PM and 4:00 PM to confirm the staff's understanding of abuse and abuse prohibition. 16. Verification through interviews with 3st shift licensed nurses and CNAs was conducted during the revisit survey on 4/9/18 between 10:00 PM and 11:30 PM to confirm the staff's understanding of abuse and abuse prohibition. 17. Verification through interviews with Leadership Staff, including the Medical Director and RVP, on 4/9/18 and 4/10/18 were conducted to confirm understanding of the facility's abuse policy, their role and responsibility in ensuring resident safety, abuse reporting, and the facility's system for monitoring compliance. 18. Interviews were conducted with 8 residents during the revisit survey on 4/9/18 and 4/10/18 revealed no residents had concerns about being abused or seeing any other resident being abused. 19. Attempts made to contact 3 resident representatives with 1 successful interview on 4/10/18 at 2:31 PM revealed no concerns regarding abuse or witnessed abuse. Further interview confirmed the representative was recently educated by facility staff on abuse and how to report abuse. 20. During the revisit survey conducted on 4/9/18 and 4/10/18, the facility was made aware of an allegation of neglect by a family member of a former resident. The facility followed state and federal regulations in reporting the allegation of neglect in a timely manner.",2020-09-01
578,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,841,K,1,0,TIWR11,"> Based on facility policy review, review of facility investigations, Quality Assurance and Performance Improvement (QAPI) committee documentation, and interview, the Medical Director failed to participate in the implementation of resident care policies to ensure all residents were protected from abuse. The Medical Director's failure placed 6 residents (#4, #2, #3, #1, #17, #18) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The IJ was effective on 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of unknown Source and Misappropriation of resident/ patient's property .'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .( alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center . Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed on 2/14/18, Certified Nursing Assistant (CNA) #1 physically abused Resident #1 and #17 and removed a food tray from Resident #18 who had not finished her meal. Continued review revealed staff wtinessed the abuse and did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Continued review revealed the facility became aware on 2/19/18 that Licensed Practical Nurse (LPN) #1 was instructing staff to withhold fluids from Residents #2, #3, and #4 and staff witnessed LPN #1 verbally abusing Resident #2 and #4. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Review of facility Quality Assurance and Process Improvement Meeting (QAPI) meeting minutes dated 2/21/18 revealed the Medical Director attended the QAPI meeting. Telephone interview with the Medical Director on 3/21/18 at 9:12 AM, confirmed he had been made aware of residents not being provided water and he reviewed labs for those residents. Continued interview revealed the Medical Director was a member of the QAPI program and stated he had knowledge of .a couple of staff fired due to abuse . The Medical Director stated he had no further input, other than the medical assessment, into any other facility changes or updates to facility policy as a result of alleged abuse. The Medical Director stated, .I leave that up to them . Refer to F-600 (K); F-609 (K); F-867 (K); F-943 (K).",2020-09-01
579,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,867,K,1,0,TIWR11,"> Based on facility policy review, review of facility investigations, review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, and interview, the QAPI committee failed to identify and report abuse, as well as, implement corrective action plans to prevent abuse. The QAPI's failure placed 6 residents (#4, #2, #3, #1, #17, #18) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The IJ was effective on 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of unknown Source and Misappropriation of resident/ patient's property .'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .( alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center . Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed on 2/14/18, Certified Nursing Assistant (CNA) #1 physically abused Resident #1 and #17 and removed a food tray from Resident #18 who had not finished her meal. Continued review revealed staff witnessed the abuse and did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Continued review revealed the facility became aware on 2/19/18 that Licensed Practical Nurse (LPN) #1 was instructing staff to withhold fluids from Residents #2, #3, and #4 and staff witnessed LPN #1 verbally abusing Resident #2 and #4. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #2 and #3 by LPN #1 to state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Continued review revealed after the facility became aware on 2/21/18 LPN #1 had mentally abused Resident #4, the facility did not report the abuse to state authorities, including the State Survey Agency. Interview with the Director of Nursing (DON) on 3/20/18 at 12:41 PM, in the conference room, confirmed the DON was aware of alleged abuse on 2/15/18 and did not start an investigation until 2/16/18. Interview confirmed the DON was aware on 2/19/18 of an ongoing concern with staff understanding of what constituted abuse and staff reporting of abuse. Interview with the DON on 3/20/18 at 12:48 PM, in the conference room, and review of the QAPI meeting attendees and meeting minutes, confirmed the DON was part of the QAPI team and a meeting was held on 2/21/18. During the QAPI meeting the identified concern with staff understanding and reporting of abuse was not brought to QAPI for discussion and implementation of a corrective action plan. Telephone interview with the Administrator on 3/21/18 at 8:42 AM, confirmed the Administrator identified a concern with staff understanding and reporting abuse on 2/16/18. Review of the QAPI meeting minutes with the Administrator on 3/21/18 at 8:48 AM, by phone, confirmed the Administrator was part of the QAPI team and attended the meeting held on 2/21/18. The Administrator confirmed the concern of staff understanding and reporting of abuse was not discussed in QAPI for implementation of a corrective action plan. Refer to F-600 (K); F-609 (K); F-835 (K); F-841 (K); F-943 (K).",2020-09-01
580,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,943,K,1,0,TIWR11,"> Based on review of facility investigation, review of facility abuse training documentation, review of personnel files, and interview, the facility failed to implement an effective training program for staff on the prohibition and reporting of all forms of abuse and neglect. The facility's systematic failure placed 6 Residents (#4, #1, #2, #3, #17, and #18) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy was effective 2/14/18 and is ongoing. The findings included: Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed on 2/20/18, Certified Nursing Assistant (CNA) #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .There have been several occasions that (Licensed Practical Nurse (LPN) #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee. I would take it to her anyways .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time. I have been sneaking and giving coffee to the residents if they ask. (Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it. Since (LPN #1) has been gone (Resident #4) now takes a shower .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to (Resident #2) sternly and talks to her rudely. (LPN #1) will not allow (Resident #2) to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA #7 reported on 2/20/18 she was not aware of any abuse in the facility but LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things . Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed LPN #4 initially denied witnessing anything she considered abuse on 2/16/18 but reported on 2/19/18 . (LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room .Since (LPN #1) has not been here (Resident #4) now attends activities and comes out of her room more. (Resident #4) now takes a shower since (LPN #1) has been gone . Continued review revealed on 2/19/18, LPN #4 reported .(LPN #1) talks mean to (Resident #2) . will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Continued review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed on 2/20/18 CNA #5 reported he had not witnessed any abuse occur in the facility and had no knowledge of anyone not being allowed food or drink when they asked. CNA #5 continued to report Resident #3's fluids were limited per LPN #1, because she was washing out her medication (diluted medication effects from drinking too much water). Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed in an interview conducted on 2/21/18, between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review of the facility abuse investigation initiated on 2/16/18 revealed on 2/14/18, CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room, took a food tray from Resident #18 before her meal was finished, and smacked Resident #1's hand twice during a shower. Continued review revealed CNA Trainee #1 reported CNA #1 saying to Resident #1 in the shower after Resident #1 smacked CNA #1 .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the shower allegation but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Review of the facility's required education orientation revealed it consisted of review of the facility's abuse policy and Hand in Hand training. Continued review revealed an annual computer based training course Preventing, Recognizing, and Reporting Abuse which included definitions of abuse, how to report abuse, scenarios regarding abuse, and a post test. Review of LPN #1's Personnel File revealed LPN #1 was hired on 10/23/09, started a planned medical leave on 2/17/18, was placed on administrative leave on 2/20/18, and terminated on 3/8/18. Continued review revealed LPN #1's last day worked was 2/16/18. Further review revealed LPN #1 completed the required Preventing, Recognizing, and Reporting Abuse education on 1/12/18. Review of CNA #1's Personnel File revealed CNA #1 was hired on 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Further review revealed CNA #1 completed the required Preventing, Recognizing, and Reporting Abuse education on 3/16/17. Review of CNA Trainee #1's Personnel File revealed CNA Trainee #1 was hired on 1/22/18 and had not started the Preventing, Recognizing, and Reporting Abuse computer based education prior to working on the unit but completed the required abuse training provided in orientation. Interview with CNA #3 on 3/12/18, at 11:04 AM, in the Lighthouse Dining Room confirmed .One of the nurses that worked here .(LPN #1) .it's a fine line as far as verbal .she would make her (Resident #2) get out of bed .she didn't want to get up .make her get up .kind of thought it was abuse .thought they (Administration) knew .(Resident #2) likes to play in water .I gave it to her anyway Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .still gave it (water to Resident #2) .(went on) for 2 weeks .(LPN #1) has a stern voice . Review of CNA #3's education documentation revealed CNA #3 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/4/18. Interview with CNA #4 on 3/12/18, at 11:14 AM in the Lighthouse Dining Room confirmed abuse .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water .because she would play in it .I gave anyway .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice .then (LPN #1) wasn't here after that . Review of CNA #4's education documentation revealed CNA #4 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Interview with CNA #5 on 3/13/18, at 10:13 AM, at Lighthouse nurses' station confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication from drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that (water) .I proceeded giving it to her .not sure if there was a (physician's) order .I took her word for it . Continued interview confirmed he did not report (allegations of abuse) to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .but there's a lot of things in the nursing field .don't like it but do it anyway .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing .everybody here are very good people . Review of CNA #5's education documentation revealed CNA #5 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Interview with CNA #6 on 3/13/18, at 10:27 AM, at the Lighthouse nurss' station confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNA's say they told them before and it doesn't get fixed . Review of CNA #6's education documentation revealed CNA #6 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Interview with the Activities Director on 3/14/18, 8:45 AM in the conference room confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you she thought it .she said she went home and thought about it .I then took it to .her floor supervisor (LPN #5) .did not report it to (the administrator) .reported it to her supervisor . Interview with RN #1 on 3/14/18, at 9:02 AM, in the conference room confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times .hand in hand when hired on and review abuse policy .do (computer based) training .usually go around .in-services .reviewing with them different types of abuse and how to report it .when just reviewing .go over the policy .in classes more in depth . Continued interview confirmed RN #1 had a telephone conversation with (CNA Trainee #1) and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Further interview confirmed during her last in-service education held on 2/16/18 she felt the staff were not able to identify specific examples of abuse such as restricting fluids because it is .kind of a fine line . Continued interview confirmed she had discussions with staff about abuse but had .nothing in writing . Interview with CNA #6 on 3/14/18, at 9:32 AM in the conference room confirmed .it was me and a student at the time .I could hear slap .I don't think she said anything .I can't remember if the resident reacted .I didn't say anything .I know I should have .I was kind of shocked at first .I work with her every day .(ADON) came to me .I told her everything .the truth .I'm not going to lie .honestly I have no excuse .I apologized to the resident and the facility . Review of CNA #6's education documentation revealed CNA #6 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Telephone interview with CNA Trainee #1 on 3/14/18, at 9:47 PM, confirmed .I was helping in the shower room that day (2/14/18) .after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at her hand and smacked it really hard .(Resident #17) said 'oooh' .I could describe (Resident #17's) reaction as surprised .it all happened so fast .couldn't tell you what (Resident #17's) face looked like .I made eye contact with (CNA #1) .(Resident #17) didn't scream or yell .was like 'ooooh' . Continued interview confirmed .I was helping in shower room again .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Continued interview confirmed the next time she witnessed abuse was .lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact . Further interview confirmed CNA Trainee #1 was trained on abuse, and did not report it immediately because .had to get my daughter from daycare, so I left and went home and knew I was working again the next day .that's when I reported it . Continued interview confirmed she did not know why she did not report it immediately stating .Honestly no, I don't know .we were really busy .I was a little bit nervous .hadn't been there very long .only on the floor a week or 2 .whenever this happened .made the report with a woman .I don't know her name .the very next day (RN #1) called me for more information . Interview with the DON on 3/14/18, at 10:40 AM, in the conference room confirmed .at 8:30 PM-9:00 PM I was made aware of reports of inappropriate treatment .didn't know it was an allegation of abuse .(CNA Trainee #1) came forth and gave some information .I didn't understand it to be abuse at that time .I took it as a complaint .I can't remember the specifics .she could've said smacked .never asked specifics . Further interview confirmed the staff was educated on abuse by computer based training which had tests. Continued interview confirmed .a lot of these girls (on the locked unit) are new .no excuse .(LPN #1's abusive behavior) was brought to my attention on the 21st .brought (Resident #4) to my office on the 21st . where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her and made her fearful to leave her room. Further interview confirmed the DON conducted daily rounds where she talked with staff and residents and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Interview with the Administrator on 3/14/18, at 5:23 PM, in the conference room confirmed he did not know why staff on the locked unit did not report abusive behaviors. Further interview confirmed staff were educated to .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse . Refer to F-600 and F-609",2020-09-01
604,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,157,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician the ordered urine analysis (U/A) and culture was not obtained for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Policy for MD/RP (Medical Doctor/Responsible Party) Notifications, undated revealed .PURPOSE: To keep the physician, who is in charge of the medical care .informed of the resident's medical condition .STANDARD: Notification of the physician .should occur promptly, according to federal regulations, when there is a change in the resident's condition . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].U/A + (and) culture . Medical record review of the Lab Log, with Licensed Practical Nurses (LPN's) #2 and #3 present, revealed the 3/23/17 U/A order was documented in the Lab Log to be obtained on 3/24/17. Further review revealed a written notation .Unable to Obtain . Interview with LPN's #2 and #3 on 5/9/17 at 3:00 PM at the 1 East nursing station confirmed the 3/23/17 U/A and culture order had been documented in the Lab Log and the facility was not able to obtain a specimen. When the LPN's were asked if the physician had been notified the U/A had not been obtained, the LPN's confirmed the facility failed to notify the physician until 5/8/17. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:25 PM in the Administrator's office confirmed the facility failed to notify the physician the U/A had not been obtained and seek further instructions.",2020-09-01
605,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,225,E,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse for 1 resident (#1), failed to report 2 allegations of abuse timely for 2 residents (#3, #4), and failed to thoroughly investigate allegations of abuse for 3 residents (#1, #3, #4) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .Investigation: The facility will investigate all injuries of unknown origin and all allegations of mistreatment, neglect or abuse. All investigations will be conducted in a timely, thorough and objective manner .Any incidents of substantiated abuse and neglect are reported and analyzed and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation dated 3/24/17 revealed the Director of Nursing (DON) had interviewed Resident #1 regarding statements of .(Licensed Practical Nurse (LPN) #3) .repositioning in bed .slammed her head . Further review of the facility investigation revealed 2 written statements, one was dated 3/31/17 signed by LPN #3 and the second was dated 4/5/17 signed by LPN #5. Interview with LPN #3 on 5/8/17 at 11:10 AM in the Social Worker's office revealed the LPN was aware of the allegations and wrote a statement of not transferring or repositioning Resident #1 on 3/24/17. Interview with the DON on 5/8/17 at 4:30 PM in the conference room revealed LPN #5 had informed the DON of the incident on 3/24/17. Interview with LPN #5 on 5/9/17 at 4:25 PM at the 1 East nursing station revealed he had been in Resident #1's room providing care and the resident repeatedly stated LPN #3 had .slammed me in the bed . and .grabbed me for no reason . Further interview revealed LPN #5 informed the DON the day of the incident. Further interview revealed LPN #5 checked the resident for any marks and found none. Further interview confirmed LPN #5 failed to document the resident's physical condition and the alleged incident on 3/24/17. Interview with the Administrator and the DON on 5/10/17 at 4:00 PM in the conference room confirmed the incident of alleged abuse occurred on 3/24/17. Further interview confirmed the facility failed to report the allegation of abuse to the State Agency. When the Administrator and DON were asked if other staff and residents were interviewed, were non-interviewable residents checked for safety, did the facility get statements on the day of the event, was Resident #1 physically and mentally checked out, did the facility complete a thorough investigation of the allegation, the Administrator stated .We steered in the wrong direction . Further interview confirmed the facility failed to complete a thorough investigation of the abuse allegation. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation included an Occurence Report signed by the DON on 4/11/17 and revealed Resident #3 was slapped by Resident #5 on 4/8/17. Continued review revealed the investigation included a statement from Licensed Practical Nurse (LPN) #1 recounting the event, and skin assessments for Residents #3 and #5 on 4/11/17. Interview with the Administrator and the DON on 5/10/17 at 4:15 PM in the conference room confirmed the facility failed to report the allegation of abuse from 4/8/17 to the State Agency for Resident #3 until 4/14/17 and therefore was not reported in the required time frame. Continued interview with the Administrator and DON revealed the facility failed to conduct additional interviews with staff and interviewable residents, and failed to check non-interviewable residents for safety on the day of the incident. Further interview with the Administrator confirmed the facility failed to thoroughly investigate the allegation for Resident #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS of 7 indicating the resident was severely cognitively impaired. Review of the facility investigation included an Occurrence Report for Resident #4 and Resident #5. Further review revealed Resident #4 was hit by Resident #5 on 4/14/17. Continued review revealed the investigation included a statement recounting the incident, a skin assessment on Resident #4 dated 4/14/17, and the record of ongoing 15 minute checks of Resident #5 dated 4/11/17 to 4/14/17. Interview with the Administrator and DON on 5/10/17 at 4:20 PM in the conference room confirmed the facility failed to report the allegation of abuse from 4/14/17 to the State Agency until 4/21/17 and therefore was not reported in the required time frame. Continued interview with the Administrator and DON revealed the facility failed to conduct additional interviews with staff and interviewable residents and failed to check non-interviewable residents for safety on the day of the incident. Further interview with the Administrator confirmed the facility failed to thoroughly investigate the allegation of abuse for Resident #4.",2020-09-01
606,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,226,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse timely to the supervisor/administrator/abuse coordinator for 1 resident (#3) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .All investigations will be conducted in a timely, thorough and objective manner . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review of the Initial Wound & Skin Record for Resident #3 dated 4/11/17 revealed .No bruises, marks or injuries noted on skin . Medical record review of a nurse's note dated 4/13/17 at 6:42 PM and written by the Director Of Nursing (DON) revealed .Late entry for 4/11/17. Resident was sitting in her room on 4/8/17 when another resident entered her room. Resident attempted to get him out of room and when she approached the resident, he slapped her in her face . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation revealed on 4/8/17 Resident #5 went into Resident #3's room and slapped Resident #3 on the face. Continued review of the facility investigation revealed an undated statement written by LPN #1 recounting the events of the incident on 4/8/17. Further review of the investigation revealed the occurrence report was not written until 4/11/17 by the DON. Interview with the Administrator and the DON on 5/10/17 at 3:55 PM in the conference room revealed they were not made aware of the incident involving Resident #5 hitting Resident #3 until 4/11/17. Further interview revealed it was the expectation of the administrator, who was also the abuse coordinator, for all allegations of abuse to be reported immediately to the supervisor and/or abuse coordinator. Continued interview revealed the Administrator confirmed LPN #1 failed to report the incident immediately to the supervisor and/or abuse coordinator.",2020-09-01
607,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,279,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, and interview, the facility failed to develop a comprehensive care plan for 1 resident (#4) of 8 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 10/2010 revealed .An individualized comprehensive care plan that included measureable objectives .to meet the resident's medical, nursing, mental and psychological needs is developed for each resident Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated 2/13/17 revealed .BEHAVIORS: (Resident #4) displays disruptive behaviors with yelling out at times . Further review revealed there was no goal for the care plan. Interview with the Minimum Data Set (MDS) Coordinator on 5/9/17 at 2:13 PM in her office revealed she did not list a goal for the Behavior Care Plan for Resident #4 because she was unsure at the time of the reason for the yelling and stated she was unsure if it was psych (psychiatric) or pain or something else. Interview with the Director of Nursing on 5/10/17 at 11:00 AM in the MDS office, with the MDS Coordinator present revealed there should have been a goal even if the reason for the behaviors was uncertain. Further interview with the DON confirmed it was inappropriate and the facility had failed to develop a comprehensive care plan for Resident #4.",2020-09-01
608,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,280,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to complete a care plan within 7 days after the completion of the comprehensive assessment and failed to revise a care plan for behaviors involving hallucinations for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 10/2010 revealed .Our facility's Care Planning/Interdisciplinary Team .develops and maintains a comprehensive care plan .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set) .Assessments of the residents are ongoing and care plans are revised as information about the resident and the resident's condition change .The Care Planning/Interdisciplinary Team is responsible for the review and updating of the care plans . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #1's Brief Interview for Mental Status was 12/15 indicating she was moderately cognitively impaired; had no mood, psychotic episodes or behaviors; she could hear adequately, and she could make herself understood and understood others. Medical record review revealed the care plan following the comprehensive MDS was dated 3/3/17, exceeding the 7 days after the assessment. Medical record review of the nursing notes revealed on 3/9/17 Resident #1 had experienced .hallucinations . Further review of nursing notes revealed the resident was seeing 1 or more children in her room or in her bed. Medical record review of the Social Service progress note dated 3/31/17 revealed .Res (Resident) continues to verbalize hallucinations according to nursing staff . Interview with the MDS Coordinator on 5/8/17 at 4:15 PM in the conference room confirmed Resident #1 had been experiencing visual hallucinations since 3/9/17 and the facility failed to revise the care plan until 4/3/17. Interview with the MDS Coordinator on 5/9/17 at 3:15 PM in the MDS office confirmed the MDS was completed on 2/8/17 and the facility failed to complete the care plan within 7 days of the MDS. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:05 PM in the Administrator's office, confirmed the facility failed to complete a care plan timely after a comprehensive assessment per facility policy. Further interview confirmed the facility failed to revise the care plan timely to address the hallucination per facility policy.",2020-09-01
609,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,281,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to obtain a physician order [REDACTED]. The findings included: Review of facility policy, Medication and Treatment Orders, revised 2/2014 revealed .Orders for medications and treatments will be consistent with principles of safe and effective order writing .shall be administered only upon the written order . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].DC (discontinue) zinc oxide cream (ointment for skin treatment) to buttock and groin q (every) shift and as needed . Further review revealed no physician signed telephone order or physician signed computerized order to initiate the the zinc oxide treatment. Medical record review of the 2/2017 and 3/2017 Treatment Administration Records revealed the zinc oxide treatment was administered from 2/15/17 to 3/13/17. Interview with Licensed Practical Nurse (LPN) #2 on 5/10/17 at 9:30 AM at 1 East nursing station confirmed she had written the 3/13/17 discontinuation of zinc oxide order. LPN #2 reviewed the telephone and computerized physician orders [REDACTED]. Interview with the Administrator on 5/10/17 at 10:45 AM in the conference room confirmed the facility failed to follow the facility policy to only administer medications and treatments after a physician order [REDACTED].",2020-09-01
610,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,323,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, facility investigation review, and interview the facility failed to prevent an altercation for 2 residents (#3, #4) of 5 residents reviewed. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .Investigation: The facility will investigate all injuries of unknown origin and all allegations of mistreatment, neglect or abuse. All investigations will be conducted in a timely, thorough and objective manner .Any incidents of substantiated abuse and neglect are reported and analyzed and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation included an Occurence Report signed by the DON on 4/11/17 and revealed Resident #3 was slapped by Resident #5 on 4/8/17. Continued review revealed the investigation included a statement from Licensed Practical Nurse (LPN) #1 recounting the event, and skin assessments for Residents #3 and #5 on 4/11/17. Interview with the Administrator and the DON on 5/10/17 at 4:15 PM in the conference room confirmed the facility failed to prevent an altercation between the two residents. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS of 7 indicating the resident was severely cognitively impaired. Review of the facility investigation included an Occurrence Report for Resident #4 and Resident #5. Further review revealed Resident #4 was hit by Resident #5 on 4/14/17. Continued review revealed the investigation included a statement recounting the incident, a skin assessment on Resident #4 dated 4/14/17, and the record of ongoing 15 minute checks of Resident #5 dated 4/11/17 to 4/14/17. Interview with the Administrator and DON on 5/10/17 at 4:20 PM in the conference room confirmed the facility failed to prevent an altercation between the two residents.",2020-09-01
611,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,356,C,1,0,DC3711,"> Based on observation and interview, the facility failed to post the nurse staffing information for 3 of 6 days. The findings included: Observation on 5/8/17 at 8:25 AM revealed the nurse staffing information form posted by the main entrance lobby area was dated 5/4/17, Thursday. Interview with the Main Entrance Receptionist on 5/8/17 at 8:45 AM by the posted nurse staffing information form in the main entrance lobby area confirmed the form was dated 5/4/17. Further interview revealed the Receptionist posted the nursing staff information form Monday through Friday. Further interview revealed the Receptionist did not receive the nurse staffing information forms in order to post them on Friday. Interview with the Staff Development Director (SDD) on 5/9/17 at 10:45 AM by the posted nurse staffing information in the main entrance area confirmed the SDD was responsible to fill out the nurse staffing information forms. Further interview revealed the SDD was to give the nurse staffing information forms to the receptionist on Thursday to post for Friday, Saturday and Sunday. Further interview confirmed the SDD failed to provide the staffing information forms to the receptionist for 5/5/17, 5/6/17, and 5/7/17 and the information was not posted.",2020-09-01
612,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,520,E,1,0,DC3711,"> Based on medical record review, facility investigation review, and interview, the facility Quality Assurance Committee failed to identify an allegation of abuse for Resident #1; failed to report allegations of abuse to the Abuse Coordinator/Administrator timely for Resident #3; failed to report allegations of abuse to the State Agency for Resident #1; failed to report allegations of abuse to the State Agency timely for Resident #3 and #4; failed to thoroughly investigate allegations of abuse for Resident #1, #3, and #4; and for failure to ensure ongoing complaince of the Plan of Correction dated 12/30/16 for F225 and F226 was maintained and monitored by the Quality Assurance Performance Improvement (QAPI) Committee. The findings included: Interview with the Administrator and the Director of Nursing (DON) on 5/10/17 beginning at 3:55 PM in the conference room revealed the (MONTH) (YEAR) QAPI Committee reviewed the (MONTH) (YEAR) concerns which included 1 allegation of abuse. Further interview confirmed the facility failed to identify the 3/24/17 incident involving Resident #1 as an allegation of abuse, failed to thoroughly investigate the allegation, and failed to report the allegation to the State Agency. Continued interview confirmed the facility failed to report the allegation of abuse on 4/8/17 to the facility administration involving Residents #3 and #5 until 4/11/17, failed to report the incident to the State Agency until 4/14/17, and failed to thoroughly investigate the allegation. Further interview confirmed the facility failed to report an allegation of abuse on 4/14/17 to the State Agency until 4/21/17 involving Residents #4 and #5, and failed to thoroughly investigate the allegation. Further interview confirmed the facility failed to ensure ongoing compliance of the Plan of Correction dated 12/30/16 for F225 and F226 was maintained and monitored by the Quality Assurance Performance Improvement Committee. Refer to F225, F226.",2020-09-01
613,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-07-11,609,D,1,0,CCNJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, it was determined the facility failed to report allegations of abuse within 2 hours for 2 of 2 (Resident #1 and #2) sampled residents reviewed for alleged abuse. The findings include: The facility's Abuse, Neglect and Exploitation policy documented, .Report allegations or suspected abuse, neglect or exploitation immediately to State Agencies . Medical record review revealed Resident #1 was admitted to facility 6/20/18 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment for decision making. Interview with Resident #1 on 7/9/19 at 11:00 AM, in the Social Service office, Resident #1 stated, He hit me in the back of the head two times so I let go of walker and his wheelchair fell backwards into the grass . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #2 scored 15 on the BIMS, which indicated no cognitive impairment for decision making. Review of the Occurrence Report dated 6/20/19 documented, .(Resident #2) was push (pushed) by another resident (#1) causing wheel (wheelchair) to go off pavement cause (causing) him (Resident #2) to fall . Interview with the Director of Nursing (DON) on 7/11/19 at 1:00 PM, in her office, the DON confirmed the date of the incident was 6/20/19 and was not reported until 6/22/19. The DON was asked if the alleged abuse was reported timely. The DON stated, Probably not.",2020-09-01
655,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,225,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, and interview, the facility failed to complete a thorough investigation following an allegation of abuse for one resident (#8) of eight residents reviewed for abuse. The findings included: Review of the facility Abuse Policy dated (MONTH) (YEAR), revealed .Investigation .the investigation shall include interviews of team members, visitors, residents/patients, volunteers .who may have knowledge of the alleged event . Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan dated 6/14/17 revealed .requires staff assistance for all ADL's (activity of daily living) .[DIAGNOSES REDACTED]. Medical record review revealed Resident #8 was unable to complete the Brief Interview for Mental Status due to a Dementia diagnosis. Review of a facility abuse investigation beginning 6/18/17, revealed Resident #8's daughter reported an allegation a staff member was mean as a snake to Resident #8 and squeezed his sore arm. The daughter alleged it occurred when the staff member positioned Resident #8 in bed on 6/17/17 on the third shift. Interview with the accused staff member on 9/12/17 at 10:40 AM, by phone, revealed she denied harming the resident and stated she no longer worked for the facility. Continued interview revealed she was not questioned about the alleged abuse and was not asked to provide a statement regarding the alleged abuse. Interview and review of the facility investigation with the Administrator and Social Worker on 9/12/17 at 10:45 AM, in the Administrator's office, confirmed the alleged perpetrator was not interviewed regarding the alleged abuse. Continued interview confirmed the facility failed to follow the facility abuse policy for investigating allegations of abuse.",2020-09-01
656,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,280,E,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to revise the care plan to include fall interventions for three residents (#6, #9, and #1), and failed to notify the responsible parties of annual care plan conferences for five residents (#6, #7, #2, #3, and #1) of six residents reviewed for care plans. The findings included: Review of the facility policy Comprehensive Care Plan dated 5/1/12, revealed .2. Social Services staff and/or designee notifies resident and responsible party prior to each care plan meeting . Review of the facility's Clinical Care System Guidelines for falls, dated (MONTH) (YEAR), revealed, Post fall, fall event and intervention is recorded on 24 hour report, patient's care plan and caregiver guide. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan with a start date of 10/14/15 revealed .at risk for impaired mobility related to [MEDICAL CONDITION] diagnosis, history of falls . Review of facility fall investigations revealed the resident had falls on 3/28/17, 4/30/17, and 8/15/17 with interventions to prevent further falls implemented after each fall. Medical record review of the current Care Plan revealed the Care Plan was not revised to reflect the newly implemented falls interventions after the falls on 3/28/17, 4/30/17, and 8/15/17. Interview with the Director of Nursing (DON) on 9/13/17 at 8:05 AM, in the conference room, confirmed the Care Plan was not revised to reflect the fall interventions. Interview and review of the Care Plan meeting book with the Social Services Director (SSD) on 9/13/17 at 9:02 AM, in the conference room, confirmed Resident #6's responsible party was not notified of the annual care plan conference held on 8/4/17, in order for the responsible party to have an opportunity to participate in care planning for Resident #6. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview and review of the Care Plan meeting book with the SSD on 9/13/17 at 9:02 AM, in the conference room, confirmed Resident #7's responsible party was not notified of the annual care plan conference held on 5/11/17, in order for the responsible party to have an opportunity to participate in care planning for Resident #7. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan with a start date of 4/23/12 revealed .is at risk for falls due to [MEDICAL CONDITION] .history of falls . Review of facility fall investigations revealed Resident #9 had falls on 6/25/17, 7/7/17, 8/5/17, and 8/26/17 with falls interventions implemented after each fall. Medical record review of the current Care Plan revealed the Care Plan was not revised to reflect the interventions implemented after the falls. Interview with the DON on 9/13/17 at 9:58 AM, in the conference room, confirmed the Care Plan was not revised to reflect the fall interventions. Medical record review revealed Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's Care Conference Summary form revealed the 5/10/17 Status Review form had been signed by various facility interdisciplinary team members but not the responsible party for the resident. Review of the Care Conference Meeting Schedule for the month of (MONTH) (YEAR), revealed Resident #2 was scheduled for an annual care conference meeting on 5/3/17 and the responsible party had not been notified. Interview with the SSD on 9/12/17 at 8:30 AM, in the conference room, confirmed Resident #2's responsible party had not been notified of the annual[NAME](YEAR) care conference meeting. Medical record review revealed Resident #3 was admitted to the facility on [DATE]. Medical record review of the resident's Care Plan Conference Summary Form: dated 4/25/17 revealed the care plan had been updated with no changes. The document had been signed by the facility's Dietary Manager, activity staff and SSD as attendees of the care plan conference. There was no indication the resident's responsible party attended the meeting. Review of the Care Conference Meeting Schedule for the month of (MONTH) (YEAR) revealed Resident #3 was scheduled for an annual care conference meeting on 4/25/17 and the responsible party had not been notified. Interview with the SSD on 9/12/17 at 8:30 AM, in the conference room, confirmed the resident's responsible party had not been notified of the annual (MONTH) (YEAR) care conference meeting. Medical record review revealed Resident #1 was admitted to the facility on [DATE]. Medical record review of Resident #1's care plan dated 10/27/15 revealed the resident was at risk for falls related to a history of falls, poor safety awareness and impaired judgment. Further review revealed the last revision to the falls interventions was on 1/24/17. Medical record review of the Nursing Note dated 4/5/47 at 4:30 PM, revealed Resident #1 was sitting on floor on buttocks with knees bent .resident unable to say how she fell . Assisted resident to wheelchair with assist of two. Medical record review of a nursing note dated 4/25/17 at 9:45 AM revealed, Technician called for help after resident had fallen in her room. Medical record review of the resident's care plan revealed the care plan was not revised to reflect new interventions implemented after the fall. Interview with the Minimum Data Set (MDS) Nurse #1 and #2 on 9/11/17 at 3:00 PM, they stated a monthly calendar was generated to indicate which residents were due for annual and quarterly conference meetings for that month. The calendar was then submitted to the Social Services Department for notification to the responsible party for the upcoming meeting. Interview with the SSD on 9/11/17 at 3:10 PM, confirmed she received the monthly care conference calendars from the MDS office. The SSD stated she then sent a letter out to the responsible party to notify them of the care conference meeting. The responsible party then called the SSD to set up the date and time of the meeting depending on their schedules. Review of the monthly calendar for the months of (MONTH) through (MONTH) (YEAR) revealed resident names had been highlighted with the letter Q next to the name. Further review revealed resident names with the letter A next to the names which had not been highlighted. Interview with the SSD on 9/11/17 at 3:10 PM, revealed the Q indicated a quarterly care conference meeting and the A indicated an annual care conference meeting. The SSD stated she had been instructed to only notify responsible parties of Quarterly meetings, and not annual care conference meetings. The SSD indicated if the name on the calendar had not been highlighted, it meant the resident was scheduled for an annual care conference meeting and the responsible party would not have been notified. Review of the Care Conference Meeting Schedule for the month of (MONTH) (YEAR), revealed Resident #1 was scheduled for an annual care conference meeting on 3/2/17 and there was no documentation the responsible party had been notified of the annual meeting. Interview with the SSD on 9/12/17 at 8:30 AM, in the conference room, confirmed the care plan for Resident #1 had not been revised to include newly implemented interventions after the falls on 4/5/17 and 4/25/17, and the responsible party had not been notified of the annual care conference meeting held on 3/2/17.",2020-09-01
657,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,309,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to monitor and evaluate the effectiveness of interventions for identified behaviors in order to attain and maintain the highest practicable psychosocial well-being for 1 (Resident# 3) of 9 sampled residents. The findings included: Medical record review revealed Resident#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/4/17, revealed Resident# 3 had a BIMS (Brief Interview for Mental Status) score of 14, indicative of intact cognitive status. Resident #3's Behavior Section of the MDS indicated [MEDICAL CONDITION] and other behavior not directed towards others. Medical record review of the plan of care developed on 3/24/08, revealed an established problem, Episodes of socially inappropriate behaviors AEB (as evidenced by) places washcloths down the front of his pants, urinates on floor and causes odor in his room, refuses care, may refuse showers at times due to his being embarrassed about his incontinence. Keeps urinal on bedside table. Interventions included: Explain the need for care trying to be provided; psych (psychiatric) eval (evaluation) and tx (treatment) as indicated; be calm in manner and approach. If resident is resistant try reproaching; encourage and then praise resident for using call light when assistance is needed; social services to visit prn (as needed); remind the resident of the need for good hygiene and odor control; Male tech if available and remove soiled linens from resident closet and bedside stand, dresser daily to eliminate odors. Medical record review of Nursing Notes, from (MONTH) and (MONTH) (YEAR) revealed on 7/18/17 at 9:07 PM Resident# 3 was noted with a history of poor hygiene habits such as pours urine at bedside. Hiding dirty laundry in closet. Medical record review of Nursing Notes dated 7/25/17 at 2:56 PM, revealed, When staff ask resident to change his clothes and to get shaved resident started yelling at staff. I'm not wet! Medical record review of Nursing Notes dated 7/31/17 at 6:32 AM, revealed, Refused x (times) 2 this morning to have brief changed which was wet, started yelling and cursing at nurse. Medical record review of Nursing Notes dated 8/8/17 at 11:15 PM, revealed, (Resident #3) was noted to like to pour urine on bedroom floor and hiding dirty laundry in closet, causing a strong smell in room and making his roommate very uncomfortable. Medical record review of the Nursing Note dated 8/16/17 at 1:13 AM, revealed, Has behavior issue such as pour urine on the floor often, hiding dirty laundry in places. Medical record review of Social Service documentation revealed no Social Services involvement regarding the identified behaviors. Interview with the Social Services Director (SSD) #1 on 9/12/17 at 8:30 AM, confirmed she had not been involved with Resident #3 and was not aware of Resident #3's inappropriate behaviors. Interview with the Director of Nursing (DON) on 9/12/17 at 10:00 AM, revealed monitoring of behaviors was documented by the nurses on the Medication Administration Record [REDACTED]. Further interview with the DON at 3:05 PM, after a review of Resident #3's MAR, confirmed the implementation of care plan approaches were not being monitored to evaluate effectiveness of interventions to further develop a systematic approach in care and services in order for Resident#3 to attain his highest practicable psychosocial well-being.",2020-09-01
658,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,514,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure an accurate medical record for one resident (#6) of nine residents reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE]. Medical record review of the resident [DIAGNOSES REDACTED]. Medical record review of the resident current Medication Administration Record [REDACTED]. Interview and review of resident [DIAGNOSES REDACTED].#6 received the [DIAGNOSES REDACTED]. Further interview confirmed the resident was not hospitalized around the time of the 11/15/16, and was not being treated for [REDACTED]. Continued interview confirmed the resident's medical record was inaccurate.",2020-09-01
659,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-03-14,565,E,1,0,2X2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Resident Council Meeting Minutes, medical record review, observations, and interviews the facility failed to ensure the residents' concerns/grievances related to staffing and call light response time were promptly acted upon for residents who attended resident council meetings, and for two (Resident #5 and #13) of six residents (Residents #1, #3, #5, #9, #12, and #13) sampled for quality of care. The findings included: Review of the resident Council Meeting Minutes for the past six months (October (YEAR) - (MONTH) (YEAR)) revealed the following: On 10/4/17 one resident stated he was not being changed at night on the second to third shift. He stated the facility needed more nurses and aides. On 11/1/17 one resident stated he was not being changed at night on the third shift. The minutes indicated, Multiple residents at the meeting complained of late night/early morning staff not answering call lights. On 12/6/17 one resident stated he was still not being changed on the second and third shift. The minutes indicated, Residents stated some staff just walks in the room and turns call light off and walks out without asking what they need. On 1/3/18 the minutes indicated, Residents stated call lights were still being turned off at times without finding out what the problem is. They also stated that if the call lights were answered it took a while to be answered. One resident stated if the call light was answered, some staff said they would be back, but did not come back or came back 1 to 2 hours later. On 2/7/18 the residents stated they felt the call lights could be answered timelier on the first and third shifts. On 3/7/18 one resident stated her call light was not being answered timely and one resident stated he was not being changed. Continued review revealed none of the Resident Council Meeting minutes included documentation of previous concerns raised by the group and what action had been taken to resolve them. Observation on 3/13/18 at 5:45 AM of the available staffing revealed the facility had a census of 76 residents; had a total of two certified nurse aides (CNA) #1 and CNA #2; and two licensed practical nurses (LPN) #1 and LPN #6 in the facility. Continued observation and interview with CNA #2 on 3/13/18 at 6:10 AM in the hallway revealed, they were supposed to have three CNAs working; however, one called in and that left just she and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides on duty. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom on time and voided on the toilet. Medical record review for Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with some ADLs. Interview with Resident #13 her room on 3/13/18 at 8:15 AM, confirmed she had been in the facility for a little over a week and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she needed to have a bowel movement (BM) and waited 10 minutes in her bed and when no one came and she could not hold it any longer she got up by herself with her walker to go to the bathroom. She stated her doctor told her not to get up without help because of her blood pressure, but she had no choice. She stated, just as she stood up she had an accident and got (BM) on the floor and in her brief. She stated once she got into the bathroom, she put the call light on because she had BM up her back and she needed help to get cleaned up. She stated she had to wait 20 more minutes while sitting on the toilet in the bathroom before staff arrived. The resident stated she found it frustrating to have to wait. Observation and interview on 3/12/18 at 3:44 PM with Resident #5 in his room revealed the facility needed more staff on the third shift. He stated, It just seems like there were no staff in the building on night shift. When asked if his call light was answered timely, he stated it took a while for it to get answered, but did not state how long. Review of Resident #5's Admission MDS assessment revealed he had a BIMs score of 14 (indicating he was cognitively intact). Interview on 3/14/18 at 9:48 AM the Director of Nursing and the Administrator in the activity room revealed the Administrator was asked about how complaints from the resident council were handled. The Administrator stated after the resident council meeting, the department heads were given the complaints about their areas and they were supposed to address them. The Administrator was asked for documentation related to the ongoing complaints about staffing and call light response from the resident council. The Administrator did not provide any documentation to demonstrate any efforts had been made by the facility to resolve the residents' grievances. The Administrator stated the staff were inserviced (educated) about answering call lights timely; however, she did not provide documentation of the inservice.",2020-09-01
660,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-03-14,600,D,1,0,2X2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, and interview the facility failed to ensure two residents (#2, #3) were free from abuse of 10 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse Protocol, dated 11/2016, revealed .Each resident has the right to be free from abuse .2. Abuse means the willful infliction of injury . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 10 indicating resident with moderately impaired cognition. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 6 of 15 indicating resident with severe cognitive impairment. Review of a facility investigation dated 12/19/17 revealed .nurse notified of an altercation .upon entering room this nurse was told by CNA on staff that she had witnessed resident in bed #2 being hit by her mother. CNA on staff had separated the altercation .resident in bed #2 stated that resident in bed #1 had hit her in the face with a closed fist more than once .Resident in bed #1 stated resident in bed #2 mother stated to daughter be good, you need to stay here and proceeded to slap daughter. Resident in bed #2 proceeded to hit her mother. Resident in bed #2 stated she couldn't stand to see resident in bed #2 slap her mother, so she went over there and slapped resident in bed #2. Resident in bed #1 stated she got me, pulled my hair and bit my hand and when she did that I slapped the hell out of her . Review of facility investigation statements and interview with the Assistant Director of Nursing (ADON) on 3/13/18 at 9:51 AM, in the activity room, confirmed resident #2 had been smacked by her mother. Continued interview revealed resident #3's hair was pulled and her hand had been bitten by resident #2.",2020-09-01
661,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-03-14,725,E,1,0,2X2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to provide adequate nursing staff to meet the needs of 2 residents ( #5, #13) of 6 residents ( #1, 3, 5, 9, 12, and 13) sampled for quality of care and residents who attended the resident council meetings. The findings included: Medical record review of Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with ADLs. Observation on 3/13/18 at 5:45 AM revealed the facility had a census of 76 residents, and there were a total of two certified nurse aides, (CNA) #1 and CNA #2, and two licensed practical nurses, (LPN) #1 and LPN #6 in the facility. On 3/13/18 at 6:10 AM CNA #2 was interviewed in the hallway. She stated they were supposed to have three CNAs working; however, one called in and that left just her and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides working. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom and voided on the toilet. Interview with Resident #13 in her room on 3/13/18 at 8:15 AM, revealed she had been in the facility for a little over a week, and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she needed to have a bowel movement (BM) and waited 10 minutes in her bed and when no one came and she could not hold it any longer she got up by herself with her walker to go to the bathroom. She stated her doctor told her not to get up without help because of her blood pressure, but she had no choice. She stated, just as she stood up she had an accident and got (BM) on the floor and in her brief. She stated once she got into the bathroom, she put the call light on because she had BM up her back and she needed help to get cleaned up. She stated she had to wait 20 more minutes while sitting on the toilet in the bathroom before staff arrived. The resident stated she found it frustrating to have to wait. Medical record review of Resident #5's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 14/15 (indicating he was cognitively intact). Continued review revealed Resident #5 required extensive assistance of 2 staff for bed mobility and transfers. Interview with Resident on 3/12/18 at 3:44 PM, in his room, revealed the facility needed more staff on the third shift. He stated, It just seems like there were no staff in the building on night shift. When asked if his call light was answered timely, he stated it took a while for it to get answered, but did not state how long. Review of the Resident Council Meeting Minutes for (MONTH) (YEAR) through (MONTH) (YEAR) revealed residents voiced concerns every month related to the facility not having adequate staff to meet their needs and/or not having care needs met timely. Cross reference F565. Interviews were conducted on 3/14/18 at 9:48 AM with the Director of Nursing (DON) and the Administrator in the activity room. The DON stated the goal was to have 3 to 4 CNAs and 2 nurses on the 11:00 PM to 7:00 AM shift. She stated a CNA called in prior to the beginning of the 3/12/18, 11:00 PM to 7:00 AM shift and she attempted to get a replacement without any luck. She stated the 11:00 PM to 7:00 AM staff called her at home after the shift started and informed her that the CNA had not come to work. Continued interview confirmed she informed them of the call off and again attempted to call in a replacement without any success. The Administrator was informed of what Resident #13 had stated about taking 30 minutes to get her light answered, and CNA #2 confirmed the resident had bowel incontinence because she (CNA #2) was unable to answer her call light in a timely manner, the Administrator stated if the resident stated it took 30 minutes then it took 30 minutes. The Administrator stated, Then we can do better. She stated they experienced high turnover and were having a hard time recruiting staff, despite advertising on the radio and on social media sources. She stated they also had a difficult time getting employees to fill in for staff who called off, despite offering pay incentives to work overtime and pick up additional shifts.",2020-09-01
671,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,580,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure the physician and resident representative were notified of the use of oxygen, antibiotic therapy, breathing treatments and a recent [DIAGNOSES REDACTED].#5 and #6) sampled residents. The findings include: 1. The facility's Change in a Resident's Condition or Status policy documented, .Our facility shall notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .e. A need to alter the resident's medical treatment significantly .Except in medical emergencies, notifications of a change occurring in the resident's medical/mental condition or status will be made . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .Monday he was wheezing .Nurse put O2 (oxygen) on him because he was winded .the RT (RT #2) on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked if the physician or family was notified of the need for oxygen. RT #2 stated, I didn't. I guess not. Medical record review revealed there was no documentation the physician or the family had been notified of the changes in Resident #5's condition or the need for the use of oxygen. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated 2/5/19 documented, .CXR (chest x-ray) due to congestion, cough, rales . Review of the Telephone Orders dated 2/6/19 documented, .[MEDICATION NAME] (an antibiotic used to treat a bacterial infection) 250 mg PO (by mouth) tab (tablet) BID (twice daily) for pneumonia For 7 days .[MEDICATION NAME] sulfate (a [MEDICATION NAME][MEDICATION NAME]) 0.083% (percent) 2-5-3 mg (milligram) INH (inhalation) Q (every) 8 hrs (hours) for 7 days . Review of a Progress Note dated 2/6/19 documented, .CHEST X-RAY RESULTS RECEIVED; LEFT LOWER LOBE PNEUMONIA FOUND . Medical record review revealed there was no documentation Resident #6's family/representative had been notified of the change in condition, the results of the chest x-ray,the new [DIAGNOSES REDACTED].",2020-09-01
672,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,677,E,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to ensure Activities for Daily Living (ADL) assistance related to incontinence care was provided for 2 of 6 (Resident #4 and #11) sampled residents reviewed of the 12 residents included in the sample. The findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 12/12/18 revealed Resident #4 scored 14 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable for decision making. Section G of the MDS documented the resident was dependent for hygiene/bathing, dressing, and eating. Review of the Comprehensive Care Plan documented, .The resident has an ADL self-care performance deficit r/t (related to) Disease Process (Stiff ma[DIAGNOSES REDACTED]) .PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on staff for personal hygiene .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t immobility, and disease process .Keep skin clean and dry . Observations on 2/27/19 at 1:40 PM in Resident #4's room revealed the resident wearing a urine soaked incontinence brief. There was a foul urine odor in the room. Interview with Resident #4 on 2/27/19 at 12:50 PM in her room, the resident stated, Nobody has been in here .I have not been changed since 5 AM .fed me breakfast and that's all . Interview with Licensed Practical Nurse (LPN) #1 on 2/27/19 at 3:47 PM at the 200 Hall nurses' Station, the LPN was asked who was responsible for providing care for Resident #4 from 7:00 AM until 3:00 PM. LPN #1 stated, I can't say that anyone did. 2. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an assessment reference date of 1/30/19 revealed Resident #11 scored 12 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable for decision making. Section G of the MDS documented the resident required extensive assistance for hygiene/bathing and dressing. Review of the Comprehensive Care Plan documented, .The resident has an ADL self-care performance deficit r/t Disease Process .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t impaired mobility and incontinence .Keep skin clean and dry .The resident has bowel and bladder incontinence .Clean peri-area with each incontinence episode . Interview with Resident #11's wife on 3/10/19 at 1:32 PM in the 100 Hall chart room, the wife stated, .I have to change him because I can't find an aide to do it. They work with only 2 or 3 aides on this hall. They don't have enough help to take care of these people. I've had to call my son to come in and help me change my husband .He has not been checked or changed since he got up for breakfast. He is wet now . Resident #11 confirmed he was wet with urine and needed incontinence care. The facility failed to provide ADL care related to incontinence care.",2020-09-01
673,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,684,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol, medical record review, and interview, the facility failed to ensure physician orders [REDACTED].#5) sampled residents. The findings include: 1. The facility's Clinical Pathways protocol documented, .[MEDICAL CONDITION]: (Chest pain) Begin oxygen 2L (liters) by nasal cannula and notify Provider .Dyspnea: Oxygen 2L by nasal cannula .Heartburn: [MEDICATION NAME] suspension (or house equivalent) 30 cc (cubic centimeters) po (by mouth) . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .the RT on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked why the O2 was administered to the resident. She stated, Because I'm an RT and he rubbed his stomach without description. It's just what I do . RT #2 was asked if Resident #5 had chest pain or shortness of breath. RT #2 stated, No. During a telephone interview with LPN #2 on 2/28/19 at 2:18 PM, LPN #2 stated, .He was in his room, rubbing his stomach, wanted something for stomach. I gave him TUMS . LPN #2 was asked if there was a physician order [REDACTED]. During an interview with the Director of Nursing (DON) ) on 2/28/19 at 2:02 PM in the conference room, the DON was asked if there was an order for [REDACTED]. TUMS is what we have as house stock . During a telephone interview with the Physician on 3/1/19 at 7:33 AM, the Physician was asked if TUMS was included in the facility's standing orders protocol. The Physician stated, There are protocols for them to give [MEDICATION NAME] . The Physician was asked if [MEDICATION NAME] and TUMS were the same drugs. The Physician stated, No. They are different drugs.",2020-09-01
674,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,697,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow physician orders [REDACTED].#12) sampled residents reviewed of the 12 residents included in the sample. The findings include: 1. Medical record review revealed Resident #12 was admitted to the facility with Hospice services on 2/12/19 at 2:00 PM with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED].[MEDICATION NAME] ER (extended release) 60 mg (milligram) tablet take one tablet po (by mouth) q (every) 12 hrs (hours) . Review of the ADMINISTRATION RECORD dated 2/12/19 revealed the [MEDICATION NAME] ER 60 mg po was not administered as ordered on [DATE] or 2/13/19. Review of the Comprehensive Care Plan documented, .has potential for pain related to [MEDICAL CONDITION] .Administer medication for pain as ordered and document effectiveness . 2. During an interview with Registered Nurse (RN) #1 on 3/5/19 at 10:45 AM in the conference room, RN #1 was asked what time Resident #12 received the [MEDICATION NAME] ER as ordered. RN #1 stated, On the 13th at 9:00 AM a prn (as needed) dose .Didn't get it ([MEDICATION NAME] ER 60 mg) on the 12th. During an interview with Licensed Practical Nurse (LPN) #3 on 3/10/19 at 3:55 PM at the 200 Hall nurses' desk, LPN #3 was asked if Resident #12 was given his pain medication as ordered when he was admitted on [DATE]. LPN #3 stated, If Hospice is bringing them we would use from Hospice. He did not come with his meds. We should have gotten a hard script for the [MEDICATION NAME] and sent to pharmacy. We would get the next day in the evening. During review of Resident #12's Administration Record with LPN #3, she was asked if the first dose of the scheduled [MEDICATION NAME] ER 60 mg was given on 2/13/19 at 6:00 PM. LPN #3 stated, Correct. During an interview with the Director of Nursing (DON) on 3/10/19 at 4:05 PM in the DON office, the DON was asked when Resident #12 received the [MEDICATION NAME] ER 60 mg tablet that was ordered every 12 hours. The DON stated, On new admits (admissions) we don't get their meds (medications) till the evening run the next day. Evening run is at 5:00 PM or later. Nurse says between 9:00 PM and 9:30 PM the next evening. We didn't have it since Hospice didn't bring it . The DON confirmed Resident #12 did not receive the scheduled [MEDICATION NAME] ER 60 mg every 12 hours as ordered on admission on 2/12/19 and 2/13/19.",2020-09-01
675,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,725,E,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Daily Staffing Sheet, medical record review, and interview, the facility failed to ensure adequate certified staff to provide care for the residents for 3 of 3 (January, February, and (MONTH) 2019) months reviewed. The findings include: 1. Review of the (MONTH) 2019 Daily Staffing Sheet revealed the facility did not have adequate staff to meet the needs of the residents 6 of 31 days: a. 1/1/19 - For a census of 146 there were 9 Certified Nursing Assistants (CNA), each providing care for 16 residents from 7:00 AM-3:00 PM. b. 1/3/19 - For a census of 144 there were 9 CNAs, each providing care for 16 residents from 7:00 AM-3:00 PM c. 1/5/19 - For a census of 148 there were 8 CNAs, each providing care for /18 residents from 3:00 PM-11:00 PM. d. 1/6/19 - For a census of 148 there were 9 CNAs, each providing care for 16 residents from 3:00 PM-11:00 PM. e. 1/13/19 - For a census of 148 there were 9 CNAs, each providing care for 16 residents from 7:00 AM-3:00 PM and 3:00 PM-11:00 PM. f. 1/14/19 - For a census of 146 there were 9 CNAs, each providing care for 16 residents from 7:00 AM-3:00 PM. Review of the (MONTH) 2019 Daily Staffing Sheet revealed the facility did not have adequate staff to meet the needs of the residents 10 of 28 days: a. 2/3/19 - For a census of 148 there were 9 CNAs, each providing care for 16 residents from 7:00 AM-3:00 PM. b. 2/6/19 - For a census of 150 there were 10 CNAs, each providing care for 15 residents from 7:00 AM-3:00 PM. c. 2/10/19 - For a census of 152 there were 9 CNAs, each providing care for 16-17 residents from 7:00 AM-3:00 PM. d. 2/14/19 - For a census of 157 there were 9 CNAs, each providing care for 17 residents from 7:00 AM-3:00 PM and 8 CNAs each providing care for 19-20 residents from 3:00 PM-11:00 PM. e. 2/16/19 - For a census of 153 there were 10 CNAs, each providing care for 15 residents from 7:00 AM-3:00 PM. f. 2/17/19 - For a census of 153 there were 10 CNAs, each providing care for 15 residents from 7:00 AM-3:00 PM. g. 2/19/19 - For a census of 155 there were 10 CNAs, each providing care for 15-16 residents from 7:00 AM-3:00 PM h. 2/24/19 - For a census of 151 there were 10 CNAs, each providing care for 15 residents from 7:00 AM-3:00 PM and 9 CNAs each providing care for 16-17 residents from 3:00 PM-11:00 PM. i. 2/25/19 - For a census of 158 there were 10 CNAs, each providing care for 15-16 residents from 7:00 AM-3:00 PM. j. 2/27/19 - For a census of 151 there were 9 CNAs, each providing care for 16-17 residents from 7:00 AM-3:00 PM. Review of the (MONTH) Daily Staffing Sheet revealed the facility did not have adequate staff to meet the needs of the residents 6 of 31 days: a. 3/1/19 - For a census of 151 there were 9 CNAs, each providing care for 16-17 residents to provide care from 7:00 AM-3:00 PM. b. 3/4/19 - For a census of 153 there were 9 CNAs, each providing care for 17 residents from 7:00 AM-3:00 PM. c. 3/5/19 - For a census of 153 there were 9 CNAs, each providing care for 17 residents from 7:00 AM-3:00 PM. d. 3/7/19 - For a census of 157 there were 10 CNAs, each providing care for 15-16 residents from 7:00 AM-3:00 PM. e. 3/9/19 - For a census of 157 there were 9 CNAs, each providing care for 17 residents from 7:00 AM-3:00 PM. f. 3/10/19 - For a census of 157 there were 8 CNAs, each providing care for 19-20 residents from 7:00 AM-3:00 PM and 10 CNAs each providing care for 15-16 residents from 3:00 PM-11:00 PM. This review revealed a total of 19 day shifts (7:00 AM-3:00 PM) and 7 evening shifts (3:00 PM-11:00 PM) that did not have sufficient staffing to meet the needs of the residents. 2. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 12/12/18 revealed Resident #4 scored 14 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable of making decisions. Section G of the MDS documented the resident was dependent for hygiene/bathing, dressing, and eating. Review of the Comprehensive Care Plan documented, .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Disease Process (Stiff ma[DIAGNOSES REDACTED]) .PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on staff for personal hygiene .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t immobility, and disease process .Keep skin clean and dry . Interview with Resident #4 on 2/27/19 at 12:50 PM in her room, the resident stated, Nobody has been in here .I have not been changed since 5 AM .fed me breakfast and that's all . Interview with Licensed Practical Nurse (LPN) #1 on 2/27/19 at 1:20 PM at the 200 Hall nurses' station, LPN #1 was asked what CNA was assigned to provide care to Resident #4. LPN #1 stated, Not sure. I've been too busy on the medication pass. I didn't know she hadn't been helped. 3. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an assessment reference date of 1/30/19 revealed Resident #11 scored 12 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable of making decisions. Section G of the MDS documented the resident required extensive assistance for hygiene/bathing and dressing. Review of the Comprehensive Care Plan documented, .The resident has an ADL self-care performance deficit r/t Disease Process .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t impaired mobility and incontinence .Keep skin clean and dry .The resident has bowel and bladder incontinence .Clean peri-area with each incontinence episode . Interview with Resident #11's wife on 3/10/19 at 1:32 PM in the 100 Hall chart room, the wife stated, .I have to change him because I can't find an aide to do it. They work with only 2 or 3 aides on this hall. They don't have enough help to take care of these people. I've had to call my son to come in and help me change my husband .He has not been checked or changed since he got up for breakfast. He is wet now . Interview with CNA #1 on 3/10/19 at 1:47 PM on the 100 Hall, CNA #1 was asked how many residents was assigned for her to provide care. CNA #1 stated, 19. CNA #1 was asked if she could provide care and meet the needs of each of the 19 residents. CNA #1 stated, No, I can't provide it all. Can't get all the ones up and out of bed today. Some will have to stay in bed. Interview with CNA #2 on 3/10/19 at 1:50 PM on the 100 Hall, CNA #2 was asked if she could provide care and meet the needs of each of the residents on her assignment. CNA #2 stated, With lunches and breakfast and get people up, I can't get to all of them. Interview with the Director of Nursing (DON) on 3/4/19 at 2:15 PM in the conference room, the DON was asked what CNA staffing was required for the day shift and evening shift to meet the care needs of the residents. The DON stated, I schedule 4 on 1st floor and usually 8 to 9 on 2nd floor. The DON was asked if that was the number that had been working recently. The DON stated, No. We had some quit and some went prn (as needed). We work with what we have . Interview with the Administrator on 3/5/19 at 4:30 PM in the Administrator's office, the Administrator stated, Staffing is a problem. We don't use agency. We work with what we have it goes up and down on staffing .",2020-09-01
676,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,760,E,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Institute for Safe Medication Practices, medical record review, and interview, the facility failed to ensure residents were free of significant medication errors when 2 of 2 (Nurse #1 and #4) nurses crushed the [MEDICATION NAME] ER (extended release) tablets and administered the crushed medications to Resident #12. The findings include: 1. Review of the Institute for Safe Medication Practices list of Oral Dosage Forms That Should Not Be Crushed list documented, .[MEDICATION NAME] Tablet Slow-release NOTE: crushing, chewing, or dissolving tablets can cause rapid release and absorption of a potentially fatal dose . Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #12 was admitted with Hospice Services. A physician's telephone order for Resident #12 dated 2/15/19 documented, .[MEDICATION NAME] ER 60 mg tablet to be one tablet po (by mouth) q (every) 8 hrs (hours) . Review of the Medication Administration Record [REDACTED]. Review of the Nurses' Note for Resident #12 dated 3/9/19 at 10:31 PM documented, .9pm .Administered medication including [MEDICATION NAME] crushed and mixed in pudding. Resident (Resident #12) took medication followed by cup of supplement w/o (without) spitting anything out. Swallowed without difficulty . Review of a Nurses' Note for Resident #12 dated 3/10/19 at 6:31 AM documented, .MEDICATIONS CRUSHED AND GIVEN RESIDENT (Resident #12) TOOK MEDS WITH NO COMPLAINTS AND WENT BACK TO SLEEP . During an interview with the Director of Nursing (DON) on 3/10/19 at 4:05 PM in the conference room, the DON was asked if [MEDICATION NAME] ER tablet should be crushed and administered. The DON stated, No. It's not to be crushed. During an interview with Nurse #1 on 3/10/19 at 4:15 PM in the conference room, Nurse #1 was asked if she crushed the [MEDICATION NAME] ER 60 mg tablet and administered the crushed medication to Resident #12. Nurse #1 confirmed she administered the crushed [MEDICATION NAME] ER 60 mg to Resident #12.",2020-09-01
677,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,842,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to provide and maintain accurate, complete medical records for 2 of 12 (Resident # 5 and 7) sampled residents. The findings include: 1. The facility's Charting and Documentation policy documented, .All observations, medications administered, services provided, etc., must be documented in the resident's clinical records .All incidents, accidents, or changes in the resident's condition must be recorded . The facility's Change in a Resident's Condition or Status policy documented, .The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . The facility's Clinical Pathways (standing orders) protocol documented, .[MEDICAL CONDITION]: (Chest pain) Begin oxygen 2L (liters) by nasal cannula and notify Provider .Dyspnea: Oxygen 2L by nasal cannula .Heartburn: [MEDICATION NAME] suspension (or house equivalent) 30 cc (cubic centimeters) po (by mouth) . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed there was no documentation of an assessment of Resident #5 on 2/16/19 or 2/17/19 and no documentation of the administration of oxygen or TUMS to the resident. During an interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .Monday he was wheezing .Nurse put O2 (oxygen) on him because he was winded .the RT on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked why the O2 was administered to the resident. She stated, Because I'm an RT and he rubbed his stomach without description. It's just what I do .I didn't document it. I should have put it in a general note . RT #2 was asked if the resident had chest pain or shortness of breath. RT #2 stated, No. During an interview with Licensed Practical Nurse (LPN) #2 on 2/28/19 at 2:18 PM at the 200 Hall nurses' station, LPN #2 stated, .He was in his room, rubbing his stomach, wanted something for stomach. I gave him TUMS . LPN #2 was asked if she documented the administration of TUMS and she stated, I wrote it on a piece of paper. I didn't document in the computer. I didn't document in his record. LPN #2 was asked if there was a physician's orders [REDACTED]. LPN #2 stated, I thought it was on standing orders. I know [MEDICATION NAME] is on it . During an interview with the Director of Nursing (DON) on 3/5/19 at 3:10 PM in the conference room, the DON was asked how staff would know the oxygen and TUMS were administered if there was no documentation. The DON stated, We don't. Should be documented. The DON was asked what the expectation was for documentation of assessments and changes in a resident's condition. The DON stated, Chart skilled assessments daily and chart every shift at times . During a telephone interview with the Physician on 3/1/19 at 7:33 AM, the Physician was asked if TUMS was on the facility's standing orders. The Physician stated, There are protocols for them to give [MEDICATION NAME] . The Physician was asked if [MEDICATION NAME] and TUMS were the same drugs. The Physician stated, No. They are different drugs. 3. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a [MEDICAL CONDITION] Note dated 2/26/19 documented, .Resident complain of SOB (shortness of breath) and requested to be on a little o2 (oxygen). RT checked his o2 sats (oxygen saturation) they were 92%, HR (heart rate) 88, rr (respiratory rate) 20. RT placed resident on 2L (liter) bnc (by nasal cannula). SPo2 (peripheral capillary oxygen saturation) came up to 98%, HR 38, rr 20. No distress noted . During a telephone interview with RT #3 on 3/5/19 at 4:22 PM, RT #3 stated, I charted that wrong. That's an error. Heart Rate was 83 . During an interview with the DON on 3/5/19 at 11:10 AM in the Administrator's office, the DON was asked if the heart rate of 38 was correct as documented. The DON looked at the [MEDICAL CONDITION] note and stated, That can't be correct .",2020-09-01
678,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-07-12,690,D,1,0,MQID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, and interview, the facility failed to ensure laboratory services were provided as ordered by the physician for 1 of 3 (Resident #5) residents reviewed for urinary tract infection. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].UA (urinalysis) & (and) Culture . Interview with the Director of Nursing (DON) on 7/5/18 at 11:37 AM, in the administrator's office, the DON was asked if the urinalysis was collected for Resident #5. The DON stated, No .we were unable to find the labs (laboratory test results) ordered by the physician on 1/31/18 . The DON was asked if it was acceptable to not follow doctor orders for labs. The DON stated, No.",2020-09-01
679,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-07-12,695,D,1,0,MQID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to provide proper [MEDICAL CONDITION] care for 1 of 3 (Resident #3) residents observed with a [MEDICAL CONDITION]. The findings included: 1. The facility's [MEDICAL CONDITION] Care policy documented, .[MEDICAL CONDITION] should be changed as ordered and as needed . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The physician's orders [REDACTED].TRACH ([MEDICAL CONDITION]) CARE Q SHIFT (every shift) . The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was assessed with [REDACTED]. Review of Medication Administration Record [REDACTED]. Review of the MARs dated (MONTH) and (MONTH) (YEAR) revealed no documentation of [MEDICAL CONDITION] care provided on either shift. Observations in Resident #3's room on 7/3/18 at 10:00 AM, revealed a large amount of thick, creamy secretions flowed from the end of the resident's [MEDICAL CONDITION] and pooled on her upper chest. Observations in Resident #3's room on 7/3/18 at 1:19 PM, revealed a small amount of thick, creamy secretions flowed from the end of the residents [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #1 on 7/3/18 at 10:00 AM, in Resident #3's room, LPN #1 was asked how often [MEDICAL CONDITION] care is performed on the resident. LPN #1 stated, .It's not due .the night shift nurse told me she did it . Interview with the Director of Nursing (DON) on 7/3/18 at 1:38 PM, in the administrator's office, the DON was asked how often [MEDICAL CONDITION] care should be performed. The DON stated, Every shift .and as needed. The DON was asked if she could tell me where the [MEDICAL CONDITION] care was documented. The DON stated, .On the MAR's . The DON was asked if it was acceptable to not perform or document [MEDICAL CONDITION] care. The DON stated, .No .it should be documented .",2020-09-01
680,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-07-30,686,D,1,0,MKNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview the facility failed to follow physician orders [REDACTED].#2 and #3) sampled residents reviewed with pressure ulcers. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Clean sacral wound c (with) NS (normal saline). Pat dry. Apply Santyl oint. (ointment) to slough. Apply collagen & (and) calcium alginate to wound bed. Cover c protective dressing. (symbol for change) QD (everyday) & PRN (as needed) Observations in Resident #2's room on 7/30/19 at 11:22 AM, revealed Treatment Nurse #1 did not apply the Collagen dressing to the wound bed during wound care. Interview with Treatment Nurse #1 on 7/30/19 at 4:40 PM, at the First Floor Nursing desk, the Treatment Nurse #1 was asked were the physician orders [REDACTED]. Treatment Nurse #1 stated, .I didn't put the Collagen, I forgot . Medical record review revealed Resident #3 was admitted to facility 3/20/19 with [DIAGNOSES REDACTED]. The physicians's order dated 7/13/19 documented, .Cleanse area to sacrum, R (right) hip c NS, pat dry, apply santyl + (and) cover drsg (dressing) (symbol for change) QD + PRN . Observations in Resident #3's room on 7/30/19 at 1:36 PM, revealed Treatment Nurse #2 applied Santyl ointment to a Calcium Alginate dressing and applied to the wound bed, and then applied the a cover dressing during wound care. Interview with Director of Nursing (DON) on 7/30/19 at 4:15 PM, at the First Floor Nursing desk, the DON was shown the physician order [REDACTED].#2 have applied Calcium Alginate to this wound. The DON stated, No .",2020-09-01
684,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2017-11-15,281,G,1,0,JVWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, page 746, facility policy, medical record review, observation, and interview, the facility failed to ensure the implementation of professional standards of practice for 2 of 3 (Resident #1 and #2) sampled residents reviewed who were receiving Percutaneous Endoscopic Gastrostomy (PEG) Tube feedings. The failure to ensure staff provided appropriate care and services for the PEG tube feeding resulted in actual harm to Resident #1 when staff failed to ensure that PEG tube feedings were appropriately administered through the PEG tube to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The Lippincott Manual of Nursing Practice, 10th Edition page 746 documented, .For continuous tube feeding .flush tubing, attach to volume control infuser according to manufacturer's instructions, attach distal end to feeding tube . 2. The facility's Enteral Tube Feeding Continuous Pump policy, documented .The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Preparation .3. Ensure that the equipment and devices are working properly .General Guidelines .3 .Check the following information: .e. Access site (PEG insertion site) .Steps in the Procedure .Verify placement of tube: .7. Auscultate: (listening for internal sounds with a stethescope) a. Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION] and bowel placement. b. Attach 60 mL (milliliters) syringe containing approximately 10 mL air. c. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing .8. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .Check gastric residual (stomach contents amount) volume (GRV): 1. Aspirate stomach contents .Reporting .1. Report complications .2. Report negative consequences of tube use .4. Report other information in accordance with facility policy and professional standards of practice . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Physicians Orders received by Registered Nurse (RN) #1 on 10/31/17 and signed by the physician on 11/3/17 documented .TUBE FEEDING FORMULA Nepro Carb Steady RATE 45 mL/hr (milliliters per hour) .H2O (water) FLUSH 60 cc (cubic centimeters) 1 (one) HOURS .ENSURE PEG DISK ROTATES EVERY SHIFT .CHECK PEG TUBE PLACEMENT FOR AUSCULTATION .CHECK RESIDUAL . Review of the Initial Care Plan dated 10/27/17 revealed .FEEDING TUBES .Observe peg tube/[DEVICE] (gastrostomy tube) site for S/S (signs and symptoms) of infection/irritation .Peg care every shift & prn (as needed) .*check Peg tube placement By auscultation .* Check residual .Renal/[MEDICAL TREATMENT] .[MEDICAL TREATMENT] as ordered .Shunt care .*Peritoneal catheter (Not in use) (Lower Lt (left) Q (quadrant)) .*[MEDICAL TREATMENT] 3 x (times) wk (week) . Review of the Admission Evaluation and Interim Care Plan Skin Condition Body Diagram dated 10/27/17 revealed, .PEG site .Peritoneal Catheter (plastic flexible tube inserted into the abdomen to allow [MEDICAL TREATMENT] fluid to enter abdominal cavity, dwell inside for a prescribed amount of time and then drain back out again) .LA (left arm) AV fistula Review of the initial Admission/Readmission Nurses Notes dated 10/27/17 at 8:20 PM revealed .Resident is currently non verbal @ (at) this time but is alert & awake .Abd. (abdomen) soft nontender/nondistended c (with) bowel sounds in all 4 quads (quadrants) Noted peritoneal [MEDICAL TREATMENT] cath. (catheter) to LL (left lower) quad of Abd. Has a PEG which is patent & intact. Receives [MEDICAL TREATMENT] x (times) 3 days wkly (weekly). AV fistula to Lt. (left) upper arm c no problems . Review of a facility incident report revealed .(Resident #1) is alert but he is nonverbal. Resident was admitted to facility on 10/27/17 at 8:20 pm for skilled services under the care of (named Medical Director) .Resident admitted with a peg tube located in his left upper abd. quadrant and a peritoneal catheter in lower left abdominal catheter (quadrant). On the evening of 10/31/2017 (named RN #1) entered resident's room. (RN #1) was unaware that resident had a peritoneal catheter. (RN #1) connected the peg tube feeding to the peritoneal catheter. (RN #1) started the tube feeding at 8:45 pm. The error was discovered by the 11-7 (11:00 pm-7:00 am) nurse (Licensed Practical Nurse (LPN #1) at 5:45 am. (LPN #1) stopped the feeding immediately .called (RN #1) and she immediately came to the facility and notified The DON (Director of Nursing). I the DON notified (Medical Director) and orders were given to transfer resident to the hospital .(RN #1) called the family and spoke with the responsible party .resident was transported via 911 ambulance . Interview with the Administrator on 11/12/17 at 6:50 PM in the conference room, the Administrator was asked about Resident #1. She stated, .he was on a continuous feed (PEG tube infusion) until he went out to [MEDICAL TREATMENT] .then it was stopped .his peritoneal tube was not in use .he had a shunt for [MEDICAL TREATMENT] (indicated her left arm) .went to (named hospital) on the 1st (11/1/17) .was in ICU (Intensive Care Unit) for 3 days, then on the 4th day he went back on the vent (ventilator) . Interview with the DON on 11/12/17 at 6:50 PM in the conference room, the DON stated RN #1 .was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN #1) wondered why they did that .took the flap off and put an adapter on it . When the DON was asked if nurses undergo a skills check-off (nursing competency skills validation) the DON stated that they do a skills check-off upon hire and annually. Telephone interview with RN #1 on 11/15/17 at 11:34 AM, RN #1 was asked about the incident with Resident #1 on 10/31/17. She stated .I went in to prepare to give him (Resident #1) his feeding .I aspirated and hooked up his feeding and that's all . When she was asked if there were any problems with his feeding, she stated, .no .a cap was on it and I had to go get a connection for it .I took the cap off and put a connection on it . She was asked if she was aware that Resident #1 had a peritoneal catheter and she stated No. She further stated that she had taken care of him one other time in the past. Telephone interview with LPN #1 on 11/15/17 at 9:50 AM, LPN #1 stated, .I can't remember his (Resident #1) name .only had him one time .I remember the Unit Manager (RN #1) was on duty that night .she was on a cart .in report she (RN #1) said, '(named LPN #1) .I had to alter his (Resident #1) feeding tube because someone took the end off .I (RN #1) spent two hours trying to get that end on' .I (LPN #1) went down there (Resident #1's room) and checked to see what she (RN #1) was talking about and everything was running okay .end looked like a PEG tube .I thought she (RN #1) said the end was off .didn't check the site .he (Resident #1) don't get no midnight meds (medications), he (Resident #1) got 6:00 meds .I went down there with the aide and I told her to change his sheets and get him ready while I was giving him his meds .as soon as she turned him over and uncovered him, I saw he was hooked up to the wrong tube .peritoneal catheter .I unhooked it immediately .went and got the night supervisor (RN #2) .she (RN #2) came down there and checked him (Resident #1) .we knew it was a peritoneal catheter, but we checked the chart just to make sure .called the Unit Manager (RN #1) .she (RN #1) said call the doctor and get a KUB (kidney, ureter, and bladder study is an X-ray study) .we called (named Medical Director and Resident #1's provider), but he said don't get a KUB send him to the ER (emergency room ) .called the family and let them know what happened .I (LPN #1) stayed with him until he left . She was then asked if she had checked on him during the night, and she stated .yes .even at the time his stomach wasn't distended .didn't grimace or anything when I pressed on it .was fine through the night . When she was asked if she was aware, prior to that night, that he had two abdominal tubes, she stated, .I knew the first night he was admitted .I had him that night .another nurse admitted him .was told in report .was also written in his chart in the nurse's notes . Review of the hospital records revealed the following: .Operative Report dated 11/1/17 at 8:35 PM- .FINDINGS: The patient had copious white fluid within the abdominal cavity .There was copious white fluid that was suctioned out. We then retrieved the peritoneal [MEDICAL TREATMENT] catheter from the abdominal cavity .After suctioning all the fluid possible, we then irrigated the abdominal cavity in all 4 quadrants in the [MEDICAL CONDITION] (area under the diaphragm) space and subhepatic (area under the liver) spaces as well as the pelvis with 7 liters of warm saline. At the end of the irrigation, the effluent (outflowing fluid) was clear .He did have some changes of [MEDICAL CONDITION] (low blood pressure) during the operation. He was taken to the intensive care unit in guarded condition (a prognosis given by the physician when the outcome of a patient's illness is in doubt) . c) Progress Note dated 11/6/17 - .Back on vent (ventilator) for stridor (high pitched breath sound) . The failure of the facility to ensure nursing staff provided professional care according to resident's care plan, facility policy, Physician order [REDACTED].#1 when the nursing staff connected a PEG tube feeding of Nepro Carb Steady and administered the feeding through his peritoneal [MEDICAL TREATMENT] catheter for approximately 9 hours. Resident #1 was sent to the hospital, had emergent surgery and remained in the hospital on mechanical ventilation at the conclusion of this survey. 3. Medical record review for Resident #2, documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED].Give Glucerna 1.2 1 (one) can ppt (per PEG Tube) tid (three times a day) . Physician's recertification orders signed 11/3/17, documented .H2O MED FLUSH 60 cc BEFORE & AFTER EACH MED PASS . Observations in Resident #2's room on 11/13/17 at 10:50 AM, revealed LPN #5 checked the tubing for the proper label as his PEG tube, checked placement per auscultation and aspiration, and then administered the bolus Glucerna 1.2. LPN #5 did not flush the PEG tube prior to administering the bolus. He stated, .I skipped a step .I'm just going to be honest .supposed to flush with 30 ccs before and after . LPN #5 flushed with 60 cc after administering the bolus of Glucerna 1.2. LPN #5 confirmed he failed to follow Physician order [REDACTED].",2020-09-01
685,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2017-11-15,322,G,1,0,JVWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility incident report review, hospital record review, observation and interview, it was determined the facility failed to ensure staff provided appropriate care and services for the Percutaneous Endoscopic Gastrostomy (PEG) Tubes for 2 of 3 (Residents #1 and #2) sampled residents reviewed with PEG tubes. The failure to ensure that PEG tube feedings were administered through the PEG tube resulted in actual harm to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The facility's Enteral Tube Feeding Continuous Pump policy, documented .The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Preparation .3. Ensure that the equipment and devices are working properly .General Guidelines .3 .Check the following information: .e. Access site (PEG insertion site) .Steps in the Procedure .Verify placement of tube: .7. Auscultate: (listening for internal sounds with a stethescope) a. Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION] and bowel placement. b. Attach 60 mL (milliliters) syringe containing approximately 10 mL air. c. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing .8. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .Check gastric residual (stomach contents amount) volume (GRV): 1. Aspirate stomach contents .Reporting .1. Report complications .2. Report negative consequences of tube use .4. Report other information in accordance with facility policy and professional standards of practice . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Physicians Orders received by Registered Nurse (RN) #1 on 10/31/17 and signed by the physician on 11/3/17, documented .TUBE FEEDING FORMULA Nepro Carb Steady RATE 45 mL/hr (milliliters per hour) .H2O (water) FLUSH 60 cc (cubic centimeters) 1 (one) HOURS .ENSURE PEG DISK ROTATES EVERY SHIFT .CHECK PEG TUBE PLACEMENT FOR AUSCULTATION .CHECK RESIDUAL . Review of the Initial Care Plan dated 10/27/17 revealed .FEEDING TUBES .Observe peg tube/[DEVICE] (gastrostomy tube) site for S/S (signs and symptoms) of infection/irritation .Peg care every shift & prn (as needed) .*check Peg tube placement By auscultation .* Check residual .Renal/[MEDICAL TREATMENT] .[MEDICAL TREATMENT] as ordered .Shunt care .*Peritoneal catheter (Not in use) (Lower Lt (left) Q (quadrant)) .*[MEDICAL TREATMENT] 3 x (times) wk (week) . Review of the Admission Evaluation and Interim Care Plan Skin Condition Body Diagram dated 10/27/17 revealed .PEG site .Peritoneal Catheter (plastic flexible tube inserted into the abdomen to allow [MEDICAL TREATMENT] fluid to enter abdominal cavity, dwell inside for a while and then drain back out again) .LA (left arm) AV fistula. Review of the initial Admission/Readmission Nurses Notes dated 10/27/17 at 8:20 PM revealed .Resident is currently non verbal @ (at) this time but is alert & awake .Abd. (abdomen) soft nontender/nondistended c (with) bowel sounds in all 4 quads (quadrants) Noted peritoneal [MEDICAL TREATMENT] cath. (catheter) to LL (left lower) quad of Abd. Has a PEG which is patent & intact. Receives [MEDICAL TREATMENT] x (times) 3 days wkly (weekly). AV fistula to Lt. (left) upper arm c no problems. Has palpable thrill and audible bruit (an indication of a well functioning [MEDICAL TREATMENT] fistula) .Requires total care with all ADLs (activities of daily living) . Review of a facility incident report revealed .(Resident #1) is alert but he is nonverbal. Resident was admitted to facility on 10/27/17 at 8:20 pm for skilled services under the care of (named Medical Director) .Resident admitted with a peg tube located in his left upper abd. quadrant and a peritoneal catheter in lower left abdominal catheter (quadrant). On the evening of 10/31/2017 (named RN #1) entered resident's room. (RN #1) was unaware that resident had a peritoneal catheter. (RN #1) connected the peg tube feeding to the peritoneal catheter. (RN #1) started the tube feeding at 8:45 pm. The error was discovered by the 11-7 (11:00 pm-7:00 am) nurse (LPN #1) at 5:45 am. (LPN #1) stopped the feeding immediately .called (RN #1) and she immediately came to the facility and notified The DON (Director of Nursing). I the DON notified (Medical Director) and orders were given to transfer resident to the hospital .(RN #1) called the family and spoke with the responsible party .resident was transported via 911 ambulance . Interview with the Administrator on 11/12/17 at 6:50 PM in the conference room, the Administrator was asked about Resident #1. She stated, .he was on a continuous feed (PEG tube infusion) until he went out to [MEDICAL TREATMENT] .then it was stopped .his peritoneal tube was not in use .he had a shunt for [MEDICAL TREATMENT] (indicated her left arm) .went to (named hospital) on the 1st (11/1/17) .was in ICU (Intensive Care Unit) for 3 days, then on the 4th day he went back on the vent (ventilator) . Interview with the DON on 11/12/17 at 6:50 PM in the conference room, the DON stated RN #1 .was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN #1) wondered why they did that .took the flap off and put an adapter on it . When the DON was asked if nurses undergo a skills check-off (nursing competency skills validation) prior to working at the facility, the DON stated that they do a skills check-off upon hire and annually. A written statement signed by RN #1 documented, .On the night of Oct (October) 31st at 845/pm I prepared to hang Nepro on (Resident #1). I checked his residual. The residual was zero. I did not know he had a peritoneal cath (catheter) & a peg tube. Resident was comfortable c no s/s (signs & symptoms) of distress. I did not provide any other services. Around 630/am I received a call from (named LPN #1) 11-7 (11:00 pm-7:00am) charge nurse. She informed me Resident (#1) had another tube higher up. I Jumped in my truck immediately & (and) came to the facility. B/P (blood pressure)153/94 (pulse)- 117 (pulse documented in medical record 119) (respirations), - 20 temp (temperature) 100.2 (degrees Fahrenheit). I called the Director (DON). Director informed me she was calling (named Medical Director). DON returned call back to facility & instructed to send out 911. 911 came to the facility immediately. Family notified. Report called to (named hospital) & spoke to a female nurse in the ER (emergency room ). Gave vital signs to nurse and informed her we were sending out due to Resident receiving tube feedings through his peritoneal cath - Informed nurse this is exactly why we are sending the Resident out. Family notified. Resident was being sent to hospital & reason for sending out. On exit Resident was easily aroused c (with) no s/s (signs and symptoms) of distress . Telephone interview with RN #1 on 11/15/17 at 11:34 AM, RN #1 was asked about the incident with Resident #1 on 10/31/17. She confirmed her written statement, and stated .I went in to prepare to give him (Resident #1) his feeding .I aspirated and hooked up his feeding and that's all . When she was asked if there were any problems with his feeding, she stated, .no .a cap was on it and I had to go get a connection for it .I took the cap off and put a connection on it . She was asked if she was aware that Resident #1 had a peritoneal catheter, and she stated No. She further stated that she had taken care of him one other time in the past. A written statement signed by Licensed Practical Nurse (LPN) #1, dated 11/1/17, documented .During shift change off going nurse (RN #1) stated she couldn't find the end of the peg tube and she had replaced it. On going nurse (LPN #1) went to the resident (Resident #1) room to observe the new pegtube. Nepro was running through the line. At 5:45 am nurse (LPN #1) return to resident (Resident #1) room to give 6AM meds. CNA (Certified Nursing Assistant #1) was already inside resident room and ask for assistance in repositioning and turning; during this time CNA (CNA #1) changed resident gown and this is when nurse (LPN #1) notice that the resident was not receiving tube feeding in the right tubing. Resident (Resident #1) was receiving feeding through his peritoneal catheter. Nurse (LPN #1) immediately disconnect the feeding and informed RN supervisor (RN #2). The charge nurse (LPN #1) and RN supervisor (RN #2) assessed the resident. The unit manager (RN #1) which was the nurse who intact (attached) the feeding was notified and she return to the facility @ 6:15am. Unit Manager (RN #1) called the DON who contact the doctor. Charge nurse (LPN #1) was getting vitals signs which was as following B/P (blood pressure) 159/94, Pulse 119 Respiration 20, Blood Glucose 159. Unit Manager (RN #1) receive orders @ (at) 6:30 am to send resident (Resident #1) to the ER (emergency room ) for further evaluation. Nurse (LPN #1) and CNA (CNA #1) stayed with resident until paramedic arrived to transport . Telephone interview with LPN #1 on 11/15/17 at 9:50 AM, LPN #1 confirmed her written statement. She stated, .I can't remember his (Resident #1) name .only had him one time .I remember the Unit Manager (RN #1) was on duty that night .she was on a cart .in report she (RN #1) said, '(named LPN #1) .I had to alter his (Resident #1) feeding tube because someone took the end off .I (RN #1) spent two hours trying to get that end on' .I (LPN #1) went down there (Resident #1's room) and checked to see what she (RN #1) was talking about and everything was running okay .end looked like a PEG tube .I thought she (RN #1) said the end was off .didn't check the site .he (Resident #1) don't get no midnight meds (medications), he (Resident #1) got 6:00 meds .I went down there with the aide and I told her to change his sheets and get him ready while I was giving him his meds (medications) .as soon as she turned him over and uncovered him, I saw he was hooked up to the wrong tube .peritoneal catheter .I unhooked it immediately .went and got the night supervisor (RN #2) .she (RN #2) came down there and checked him (Resident #1) .we knew it was a peritoneal catheter, but we checked the chart just to make sure .called the Unit Manager (RN #1) .she (RN #1) said call the doctor and get a KUB (kidney, ureter, and bladder study is an X-ray study) .we called (named Medical Director and Resident #1's provider), but he said don't get a KUB send him to the ER (emergency room ) .called the family and let them know what happened .I (LPN #1) stayed with him until he left . She was then asked if she had checked on him during the night, and she stated .yes .even at the time his stomach wasn't distended .didn't grimace or anything when I pressed on it .was fine through the night . When she was asked if she was aware, prior to that night, that he had two abdominal tubes, she stated, .I knew the first night he was admitted .I had him that night .another nurse admitted him .was told in report .was also written in his chart in the nurse's notes . Review of the hospital records revealed the following: a) Computerized [NAME]ography (CT) Scan dated 11/1/17 at 2:50 PM - .Numerous nondistended fluid-filled loops of small bowel are noted with associated bowel wall thickening and adjacent fluids .A PEG tube is noted with balloon in the stomach. Fluid is present diffusely throughout the colon with associated air-filled levels .There is a 5.8 x 4.3 cm (centimeter) irregular gas fluid collection superior to the bladder. This is concerning for abscess .A small amount of free fluid is seen within the pelvis .IMPRESSION: .2. Small amount of free intraperitoneal air. Etiology uncertain, however this is concerning for bowel perforation .4. [MEDICATION NAME] (within a tube or tubular organ) fluid throughout nondistended small bowel with associated bowel wall thickening and adjacent free fluid. [MEDICATION NAME] fluid with air- fluid levels throughout a nondistended colon. These findings are concerning for [MEDICATION NAME]. Consider infectious, [MEDICAL CONDITION] ischemic (insufficient blood flow) etiologies. 5. Small amount of free fluid in the abdomen and pelvis . b) Operative Report dated 11/1/17 at 8:35 PM- .FINDINGS: The patient had copious white fluid within the abdominal cavity .There was copious white fluid that was suctioned out. We then retrieved the peritoneal [MEDICAL TREATMENT] catheter from the abdominal cavity .After suctioning all the fluid possible, we then irrigated the abdominal cavity in all 4 quadrants in the [MEDICAL CONDITION] (area under the diaphragm) space and subhepatic (area under the liver) spaces as well as the pelvis with 7 liters of warm saline. At the end of the irrigation, the effluent (outflowing fluid) was clear .He did have some changes of [MEDICAL CONDITION] (low blood pressure) during the operation. He was taken to the intensive care unit in guarded condition . c) Progress Note dated 11/6/17 - .Back on vent (ventilator) for stridor (high pitched breath sound) . The failure of the facility to ensure that PEG tube feedings were administered appropriately through the PEG tube to Resident #1 who had Nepro Carb Steady administered through his peritoneal [MEDICAL TREATMENT] catheter for approximately 9 hours resulted in actual harm. He was sent to the hospital, had emergent surgery and remained in the hospital at the conclusion of this survey. 3. Medical record review for Resident #2, documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED].Give Glucerna 1.2 1 (one) can ppt (per PEG Tube) tid (three times a day) . Physician's recertification orders signed 11/3/17, documented .H2O MED FLUSH 60 cc BEFORE & AFTER EACH MED PASS . Observations in Resident #2's room on 11/13/17 at 10:50 AM, revealed LPN #5 checked the tubing for the proper label as his PEG tube, checked placement per auscultation and aspiration, and then administered the bolus of Glucerna 1.2. LPN #5 did not flush the PEG tube prior to administering the bolus. He stated, .I skipped a step .I'm just going to be honest .supposed to flush with 30 ccs before and after . LPN #5 flushed with 60 cc after administering the bolus of Glucerna 1.2. LPN #5 confirmed he failed to follow Physician order [REDACTED].",2020-09-01
686,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2017-11-15,520,G,1,0,JVWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented, and monitored appropriate plans of action to correct issues. The failure to ensure staff provided appropriate care and services for the Percutaneous Endoscopic Gastrostomy (PEG) Tube resulted in actual harm to Resident #1 when staff failed to ensure that PEG tube feedings were appropriately administered through the PEG tube to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The QAA Committee failed to ensure that care and services were provided appropriately to a resident with a PEG tube. The failure to provide appropriate care and services of a PEG tube feeding to a resident resulted in actual harm when Resident #1 received a feeding of Nepro Carb Steady through his peritoneal [MEDICAL TREATMENT] catheter for 9 hours. Resident #1 was sent to the hospital and had emergent surgery. Refer to F322. The deficient practice of F322 is a repeat deficient practice for failure to provide appropriate care and services to a resident with a PEG tube feeding. The facility was cited F322 on the recertification survey on 12/4/16. Interview with the Director of Nursing (DON) on 11/12/17 at 6:50 PM, in the conference room, the DON stated, Registered Nurse #1 was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN#1) wondered why they did that .took the flap off and put an adapter on it .",2020-09-01
692,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-03-01,656,D,1,0,4S6V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to develop a Comprehensive Care Plan to address the resident's issues with oral care for 1 resident (#2) of 5 residents reviewed. Findings include: Review of facility policy, Oral Hygiene, undated, revealed .Designated partners will provide care of mouth and teeth to all patients every morning and evening as needed to prevent mouth infections; prevent dental decay; prevent gum disease; and promote personal hygiene .Gently clean patient's teeth .Inspect oral cavity . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 Brief Interview for Mental Status (BIMS) scored as 3 and severely impaired cognitively. Continued review of the MDS revealed Resident #3 was dependent on 2 people for transfers; required extensive assistance of 1 person for dressing, eating; extensive assistance of 2 people for grooming; was dependent on 1 person for bathing; had functional limitations in both lower extremities; was frequently incontinent of bladder and always incontinent of bowel. Medical record review of the Activities of Daily Living (ADL) record revealed documentation Resident #3 received personal hygiene twice daily. Continued review revealed out of 40 opportunities for oral care, it was documented he received care on 24 occasions. Medical record review of a Speech Therapy evaluation dated 11/24/17 revealed Resident #3 had his natural teeth. Continued review revealed he had decreased bolus control (problems swallowing solid food). Further assessment revealed medication from earlier administration was noted in the oral cavity. Medical record review of weights revealed Resident #3 weighed 126 pounds on admission to the facility. Continued review revealed weight on 11/22/17 was 125 pounds; on 11/23/17 weight was 125 pounds. Further review revealed on 11/29/17 weight was 122 pounds and on 12/6/17 weight was 120 pounds. Continued review revealed Resident #3 refused to be weighed on 12/13/17. Medical record review of a Nutrition consult dated 12/4/17 revealed Resident #3 had poor intake, consuming Medical record review of the Care Plan dated 11/22/17 revealed Resident #3 was at risk for alteration in nutritional status/weight loss related to swallowing difficulty; age; polypharmacy; and [MEDICAL CONDITION]. Continued review revealed interventions included to adjust diet consistency as needed; mechanical soft with ground meat with gravy and high calorie diet; nutritional supplements of Ensure Clear 3 times daily with meals and House Supplement twice daily; encourage fluids between meals; adaptive equipment as needed; assist with meals; dietician assessment in progress. Medical record review revealed no documentation of any issues with oral care until 12/11/17 when nursing documented .Attempted to provide oral care on resident. Was able to get swab in mouth after coaching. As soon as swab placed in mouth pt. bit down and would not allow nurse to clean mouth. With help of therapist finally got resident to release bite on swab so it could be removed. Oral care not completed because resident refused . Medical record review of the care plan revealed no documentation of issues with oral care such as pocketing food and biting down on swabs. Medical record review of the Provider Progress Note dated 12/12/17 revealed .One of the daughters is very upset because she feels oral care has not been adequate. However, nursing staff have been very diligent to provide oral care and patient will frequently not except oral care by clenching teeth and biting sponges. Speech Therapy has really worked with patient on this and will be teaching family how to perform oral care as well so patient may respond to a more familiar person. Registered dietitian reports he is still only receiving around 20 bites of food an hour. Patient frequently pockets food in this puts him at great risk for aspiration pneumonia. Labs showed he was maintaining renal function okay, no dehydration notes. Failure to thrive - patient's prognosis is poor and not likely to make meaningful recovery . Medical record review of a Provider Progress Note dated 12/19/17 revealed .Diligent oral care has been attempted but patient will frequently clench and bite sponges which make cleaning difficult for nursing staff. Patient also pockets food in this puts him at great risk for aspiration pneumonia. Unfortunately he is experiencing failure to thrive. Patient's daughter is not accepting of this diagnosis . Interview with the Director of Nursing (DON) on 2/14/18 at 11:55 AM in the conference room revealed staff had tried to perform oral care for Resident #2 but he clamped down on the swab or anything placed in his mouth. Continued interview with the DON confirmed the care plan did not include the fact Resident #2 pocketed his food and also he clamped down on the swab. Further interview confirmed there were no interventions for addressing these issues.",2020-09-01
693,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-03-01,689,D,1,0,4S6V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure residents had adequate supervision to prevent falls for 1 resident (#1) of 3 residents reviewed for falls. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was scored 99 on BIMS ( Brief Interview for Mental score ) of 99 indicating severely impaired cognitively. Continued review of the MDS revealed Resident #1 required extensive assistance of 1 person for transfers, ambulation, dressing, eating, grooming, and bathing; was occasionally incontinent of bowel and bladder; and had functional limitation of 1 upper extremity. Medical record review of the Hospital Discharge summary dated [DATE] revealed Resident #1 was admitted with a [MEDICAL CONDITION], left humerus and ulna fractures. Continued review revealed the injury was non-operative and would be conservatively managed. Further review revealed Resident #1 had a small right convexity subdural hematoma (collection of blood in the brain on the top right side of the head) and a large left superior convexity subdural hematoma. Medical record review of the care plan dated [DATE] revealed a problem of being at risk for complications related to behavior - refuses care, combative, agitated, disorganized thoughts. Continued review of the care plan revealed Resident #1 had a problem of being at risk for orthopedic complications related to fall with fracture, refusal to wear C-collar (cervical collar), non-compliant with weight-bearing status from the humerus and ulna fracture. Further review revealed interventions included assess for signs/symptoms of infection at surgical site; notify physician of signs/symptoms of complications; Occupational Therapy screen; observe for signs/symptoms of [MEDICAL CONDITION]. Medical record review of a Provider Progress Note dated [DATE] revealed .Patient has been very lethargic and vomited x2 today. Patient's medications have been titrated due to agitation from dementia. Patient had recent titration up on [MEDICATION NAME] to 2 times daily. She also had [MEDICATION NAME] 2 times daily. [MEDICATION NAME] as needed. Nausea with vomiting - new problem. Patient did not have any recent falls. Will go ahead and initiate neuro checks as she does have history of recent new subdural hematoma. Medical record review of a Post Fall Initial Note dated [DATE] revealed on [DATE] at 5:15 PM Resident #1 was found lying on the floor in fetal position in the activities room. Continued review revealed she had been walking in the room unassisted. Further review of the note revealed the following questions: 1. Did the patient have pain after the fall? Yes 2. Description of injury: Right fracture femur 3. First aid treatment administered: X-ray sent to ER (emergency room ) for evaluation 4. Right hip range of motion: Unable to perform Review of facility investigation revealed a written statement from Certified Nurse Aide (CNA) #5 dated [DATE] at 5:30 PM, which stated .I was doing rounds and observed patient on the floor. I called for a nurse. The nurse checked her and I ran vitals, and safely assisted resident to wheelchair . Review of facility investigation revealed a statement from Registered Nurse (RN) #1 dated [DATE] which stated .Patient did not appear uncomfortable on [DATE] or [DATE]. When the tech went to get patient OOB (out of bed) patient called out in discomfort. Patient was left in bed and nurse practitioner notified on morning of [DATE] . Review of facility investigation revealed a statement from CNA #1, dated [DATE] which stated .While providing daily care during AM shift (6A - 2P) on 24th and 25th I noted no increased pain in (named resident) when getting her cleaned and up to the chair. On morning of ,[DATE] I went to get her up and saw her frown like she may be in pain so I left her in bed and went to tell nurses who came to check on patient when I told them . Review of facility investigation revealed a statement from Licensed Practical Nurse (LPN) #2 dated [DATE] which stated .At time of fall patient was assessed, no c/o (complaint of ) pain, and no apparent injuries notes. Scheduled Tylenol given as ordered as patient had been getting this prior to fall. Review of facility investigation revealed a statement from RN #3 dated ,[DATE] 18 who stated .I took care of the patient approximately 24 hours post fall on a Saturday evening shift. The patient was not in increased pain and did not otherwise show any signs of change of function during my shift. I decided to put the patient in bed and perform neurological checks per post-fall protocol. The patient was comfortable in bed and all vital signs were stable during the shift . Review of facility investigation of an undated statement from LPN #3, revealed .I worked Saturday 23rd. (named resident #1) was resting in bed most of that double shift. I did not notice any acute distress or discomfort that weekend . Medical record review of a Change in Condition report dated [DATE] revealed .Pt crying with complaints of pain upon getting up, or also lifting her left leg .she did fall on Fridat evening this past week . Medical record review of a Provider Progress Note dated [DATE] revealed .night shift nurse reports patient complains of pain to right LE (lower extremity), cries out with transfers and care, report fell on Friday. Pt very confused with dementia, unable to answer ROS (review of symptoms) question. She does however cry out and grimace in pain with passive ROM (range of motion) of right LE, at hip and knee. X-ray ordered. NWB (non weightbearing) until resulted. Highly suspect fracture d/t (due to) pt response to movement and her overall withdrawn mood today. Pt usually restless and trying to ambulate, mildly agitated and constantly busy; staff frequently engaged in distracting and occupying pt with conversation, folding linens, drawing, etc. Today she is very quiet and withdrawn, no attempts to get out of WC (wheelchair) observed . Medical record review of a Provider Progress Note dated [DATE] revealed .Patient seen for abnormal x-ray. Patient fell over the weekend Patient originally was not found to have any injury. However, she became progressively more in pain when trying x-ray of the hip was done and showed acute fracture. Patient sent to hospital for further evaluation by orthopedics . Review of facility investigation of a statement from Nurse Practitioner (NP) #1, revealed .I was called to see the patient (Resident #1) on [DATE] related to lethargy and vomiting. I ordered abdominal x-ray, blood work, and neuro checks because she did have a recent history of a SDH (subdural hematoma) I felt the most likely rationale for her symptoms was slight oversedation from [MEDICATION NAME] plus [MEDICATION NAME]/[MEDICATION NAME]. The abdominal film and blood work were within normal limits. She then had a fall on [DATE] and was not immediately found to have any injuries from nursing staff. On the night of the 25th/morning of the 26th nursing notes she was having pain and difficulty turning so this prompted an x-ray. This did reveal an assumed acute fracture on the right hip. Her family was notified and agreed to send to the ER for prompt evaluation by orthopedics . Review of facility investigation of an undated statement by NP #2, revealed .(Resident #1) had several falls prior to admission and her dementia was made worse by [MEDICAL CONDITION] related to a pretty severe non-operative cerebral hemorrhage which occurred prior to admission. During her stay she was continually confused and disoriented, frequently agitated and trying to rise from the wheelchair, bed, or chair without any awareness of personal safety and fall risk . On (MONTH) 26th I was notified at the beginning of my work day by the outgoing night shift nurse the patient was crying out in pain with transfers and personal care, especially when the right lower extremity was moved. On examination I found the patient sitting in a wheelchair but not her usual active, agitated self. She denied pain verbally but called out and grimaced with passive ROM exam of her lower extremities, more so on the right side. Because the patient was constitutionally changed with flat affect, withdrawn, refusing offer of drink, my suspicion of a possible [MEDICAL CONDITION] was heightened. The nurse reported she had fallen several days earlier but no visible injury or change in behavior or ROM was noted at the time of the fall. The pain in the right lower extremity seemed, from verbal reports by staff, to be a concern early that morning (26th). I ordered an x-ray of the right hip and knee. The results were give to my colleague who followed up with an exam of the patient and sent her out to the hospital for further evaluation and treatment . Review of facility investigation revealed Resident #1 was transferred from the hospital to Hospice where she expired on [DATE]. Review of the Death Certificate from the Medical Examiner revealed the cause of death was acute right femur fracture; the contributing cause was acute on chronic left subdural hematoma; and the death was accidental. Interview with the Director of Nursing (DON) on [DATE] at 11:55 AM in the conference room revealed Resident #1 had a fall on [DATE]; the nurse assessed her; and Resident #1 was determined to have no injury. Continued interview revealed Resident #1 was assisted to bed without problem. Further interview revealed on [DATE] the night nurse discovered Resident #1 was in increased pain which was reported to the NP and an x-ray was ordered. Continued interview revealed the DON talked to all staff who cared for Resident #1 from [DATE] - [DATE]. Further interview revealed Resident #1 complained of nausea and vomiting on [DATE] and the NP assessed her, concerned the subdural hematoma was extending. Continued interview revealed the NP ordered labs and neuro checks to assess any changes. Further interview revealed Resident #1 received Tylenol Arthritis three times daily and did not required any additional pain medication from [DATE] - [DATE]. Continued interview revealed Resident #1 had [MEDICAL CONDITION] and the NP questioned whether the resident sustained [REDACTED]. Further interview the DON confirmed Resident #1 was not supervised adequately to prevent a fall.",2020-09-01
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
739,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-02-28,600,D,1,0,VR3611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility investigation, and interview the facility failed to intervene and protect from abuse 1 (#2) of 4 sampled residents. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 1/19/18 Quarterly Minimum Data Set (MDS) revealed Resident #1 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 of 15. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact with a BIMS score of 15 of 15. Review of the facility investigation revealed on 1/28/18 Resident #1 and Resident #2 were together outside of the Bedford Corner dining room. Continued review revealed staff heard Resident #2 state loudly Resident #1 was going to hit (Resident #2). Continued review revealed three staff, including Certified Nurse Assistant (CNA) #1 rushed to reach Resident #1 and Resident #2 to separate them. Further review revealed Resident #1 struck Resident #2 in the chest/upper arm area 3 times before the staff reached Resident #1 and #2. Continued review revealed Resident #1 and Resident #2 were examined for injury and Resident #2 was found to have a hand print mark on her right breast. Interview with CNA #1 on 2/27/18 at 5:05 PM at Nurse Station 1 revealed she had witnessed the altercation between Resident #1 and Resident #2 on 1/28/18. Continued interview revealed CNA #1, just prior to the altercation, had walked through the Bedford Corner dining room and observed and heard Resident #1 and Resident #2 bickering. Continued interview revealed CNA #1 had told Resident #1 and Resident #2 to stop bickering and to separate from one another. Continued interview revealed she left Resident #1 and Resident #2 before ensuring they had separated and she continued down the hallway. Continued interview revealed she heard Resident #2 state Resident #1 was trying to hit (Resident #2). Continued interview revealed she turned and saw Resident #1 strike Resident #2 three times before staff could separate the two residents. Interview with the Director of Nursing (DON) on 2/28/18 at 8:45 AM in the conference room revealed the staff was expected to immediately separate residents who were engaged in any type of altercation. Continued interview confirmed CNA #1 failed to separate Resident #1 and Resident #2 when she witnessed the two residents arguing. Continued interview revealed the facility's failure to separate Resident #1 and Resident #2 resulted in failure to protect Resident #2 from physical abuse from Resident #1.",2020-09-01
740,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-06-26,726,D,1,0,UMZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, narcotic log review, and interview the facility failed to show nursing competency in medication administration documentation for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.",2020-09-01
741,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-06-26,755,D,1,0,UMZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, narcotic log review, and interview the facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for controlled substances for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Telephone interview with the Pharmacist on 6/25/19 at 10:23 AM confirmed an audit done by the Pharmacist, the DON, and the ADON revealed some nurses were sporadic in making entries appropriately and timely to the MAR. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.",2020-09-01
742,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-09-25,609,D,1,0,YCKB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to report a suspicion/allegation of abuse to the administrator for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .Abuse Reporting .This facility will not tolerate abuse .by anyone, including staff members .All alleged violations involving .abuse .MUST be reported to the Administrator and Director of Nursing. The Administrator is the Abuse Coordinator .the person(s) observing the incident of resident abuse or suspected resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Identification .Employees are required to report any incident, allegation or suspicion of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .Supervisors will immediately inform the Administrator or in absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations or suspicion of potential mistreatment. Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed staff had written statements or responses to questionnaires regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of the facility documentation included the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the facility documentation included the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the facility documentation included thestatement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with the Administrator on 9/25/8 at 11:15 AM in the conference room when asked if (RN #2) was to report the allegation/suspicion of abuse alleged involving Resident #1 on 9/16/18 to the Administrator or designee, the Administrator stated .should have been reported to me the morning of 9/16/18 .",2020-09-01
743,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-09-25,610,D,1,0,YCKB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to thoroughly investigate a suspicion/allegation of abuse to the Administrator or designee for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Medical record review of the Physician Orders revealed the following: From 6/23/18 to the present [MEDICATION NAME] HCL ER ([MEDICATION NAME]-antidepressant) 150 milligrams by mouth 1 time a day for depression. On 8/13/18 [MEDICATION NAME] ([MEDICATION NAME]-antianxiety) 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Discontinue [MEDICATION NAME] 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Restore [MEDICATION NAME] back to 1 milligram by mouth three times daily, note in chart GDR (Gradual Dose Reduction) failure. On 8/20/18 [MEDICATION NAME] 1 milligram by mouth three times a day related to anxiety disorder. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records revealed the medications noted above were administered as ordered. Behavior monitoring for the antianxiety mediation was done every shift with no documentation of a behavior during (MONTH) and (MONTH) (YEAR). Medical record review of the physician orders dated 9/12/18 revealed .Check UA (urinalysis) . Medical record review of the Urinalysis, Culture and Sensitivity laboratory results dated [DATE] the UA revealed .SL (slightly) cloudy .Many Bacteria . indicating possible urinary tract infection. Further review revealed on 9/15/18 the Culture and Sensitively result .Escherichia Coli (EColi) and Extended Spectrum B-Lactamase (ESBL) . indication the resident had a urinary tract infection requiring contact isolation. Medical record review of the physician orders dated 9/13/18 revealed .Contact Isolation for ESBL until antibiotics complete . Further review of the physician orders dated 9/16/18 revealed [MEDICATION NAME] (antibiotic) 100 milligrams by mouth two times daily times 10 days for Urinary Tract Infection. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The facility reported an allegation of abuse occurring on 9/15/18 at 1:00 AM involving Resident #1 and a staff member. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed Resident #1 had responded to a questionnaire regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of facility documentation of the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the undated staff questionnaire completed by CNA #1 after the 9/16/18 event asking Do you know of any abuse? had NO. Review of facility documentation included the email dated 9/18/18 from CNA #2 to the facility revealed On Saturday the 15th of (MONTH) as I was giving care to (Resident #1) she was very agitated and aggressive, cursing and smaking (sic) at me refusing care and knocking her bedside table over all on table stuff was in floor (Resident #1) had been digging and playing in her bm (bowel movement) was trying to get out. Of bed I went immediately to the charge nurse (RN #2) and told her what was going on and ask the other tech (CNA #1) could she help me attend to (Resident #1) she agreed then the nurse asked us to switch patient and I did so. Further review revealed no interview with CNA #2. Review of facility documentation of the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the staff questionnaire completed by RN #2 dated 9/18/18 asking Do you know of any abuse? had NO. Review of facility documentation of the statement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Review of facility documentation of the undated staff questionnaire completed after the 9/16/18 event by CNA #3, #4, #6, and LPN #1 asking Do you know of any abuse? had NO. Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with Resident #1's daughter on 9/24/18 at 3:23 PM in the conference room revealed Resident #1 .complained of lady for past couple of weeks. Said 'she (Resident #1) didn't like her (CNA #2), (CNA #2) was rough with me, argues with me, I might have wanted something and press the call light and lady (CNA #2) comes in argues with me and turns call light off and leaves.' (Resident #1) said one night the CNA (#2) stuck her head in the door and said 'I heard you were talking about me, you need to stop talking about me.' I told Mom they don't need to be arguing with you and you not argue with them. She has dementia. This went on for a couple of weeks, then she calmed down for a week. Sunday I was here and she said '(CNA #2) slapped her and was rough with me last night . I told her 'Mom, tell me the truth, are you sure? Why would she slap you?' Mom said 'she was rough with me, I told her to stop and she slapped me. She's rough with me when she changes me and I don't like it.' I told her to tell me the truth and she said the same thing again. I told her it was Sunday and I can't do anything today. I checked her skin and there were no marks on her face. I checked her skin the next day but she bruises all the time anyway. I couldn't go by that .Mom told me was a heavy set red head .I ran into RN #1 up front .When I said a red head to RN #1 she didn't know that person name either. RN #1 said she would take care of it right now. RN #1 went to the Administrator and came back to me and the Administrator and ADON (Assistant Director of Nursing) .talked . Review of the facility documentation regarding the allegation of abuse on 9/16/18 revealed no evidence the UA was considered, the [MEDICAL CONDITION] medications adjusted in 8/2018 were considered, failed to have interview with staff on duty on 9/16/18 at 1:00 AM to 3:00 AM addressing the allegation, failed to have an interview with the alleged perpetrator and residents in the vicinity of the Resident #1, failed to have documentation of Resident #1's multiple interviews with different information, failed to have an interview with the family member reporting the allegation on 9/17/18 and clarifying the details, and failed to clarify why RN #2, CNA #1 and #2 answered No to the employee questionnaire asking Do you know of any abuse? Interview with the Administrator on 9/25/8 at 1:15 PM in the conference room when asked if the facility had the multiple interviews with the resident with different versions of the event, he stated No; if they had the staff interviews of all on duty and clarification of discrepancies, he stated No, but see where should have; if there was an interview with the reporting family member for clarification of information, he stated No; if there were interviews with residents in the vicinity of the event for information, he said No; for there was a medication review considering [MEDICAL CONDITION] medication had recently been changed, he said NO; and if the laboratory results of urinary tract infection was considered to contribute, he said NO.",2020-09-01
757,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,580,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the Resident's Representative of a fall for 1 resident (Resident #3) of 3 residents reviewed for falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed .the responsible party should be notified . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING [MEDICAL CONDITION], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, and MAJOR [MEDICAL CONDITION]. Medical record review of the Face Sheet for Resident #3 revealed Family Member #3 was listed as the Contact/Emergency Contact #1. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. Medical record review revealed the following: On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5, revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (patient - (Resident #3) lying face down on the floor. there was a fair amount of blood on floor .pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek . On 1/10/2020, of the Post Fall Review, written by LPN #5, revealed Resident #3 had an unwitnessed fall on 1/9/2020 at 12:50 PM. Further review revealed the .Family/Responsible Party was notified on 1/9/2020 at 2:00 PM and named the specific family member. Further review revealed the specified family member notified was not Family Member #3. Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room. The form revealed the resident's family member, specifying the relationship to the resident, was notified on 1/9/2020 at 1:15 PM. Further review revealed the family member notified was not family Member #3. Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN stated she went to the nursing station and was checking the resident's chart to initiate the notifications when the nursing station telephone rang. The LPN answered the telephone and Resident #3's relative was asking to speak to the resident. The LPN stated she noticed this family members name was listed as an emergency contact and proceeded to inform the individual of the fall and then took the telephone to the resident for the family member to talk with the resident. The LPN stated she saw the name on the list and did not recall if there was a designation of which to notify first. The LPN stated several hours later, (Named Family Member #3) called the facility and 'was yelling at me why didn't I notify her first.' The LPN stated she tried to apologize and explained what had happened regarding the telephone ringing right when she was ready to call and it was Resident #3's family on the telephone and on the emergency contact list. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed to notify the appropriate Family Member, #3. Further interview revealed the Face Sheet used at the time of the 1/9/2020 fall included the name of the the family member which called the facility but there was no evidence of the information in the current medical record or in the fall investigation documentation.",2020-09-01
758,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,641,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to accurately assess the fall on the Minimum Data Set for 1 (Resident #1) resident of 5 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS, [MEDICAL CONDITIONS] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named Certified Nurse Aide (CNA) #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. Further review revealed the resident's head hurt, and she had 2 hematomas to the head and was bleeding. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed Resident #1 had an unwitnessed fall with a significant injury while in another resident's room. Further review revealed the resident sustained [REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed the MDS did not address the fall with injury which occurred on 12/4/2019. Interview with the Registered Nurse MDS Coordinator on 2/5/2020 at 9:20 AM in the conference room confirmed the MDS dated [DATE] failed to include the fall of 12/4/2019 by Resident #1.",2020-09-01
759,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,689,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to conduct a thorough investigation of falls for 2 (Resident #1 and #3) residents of 3 residents reviewed with falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed the corporation strived to maintain a hazard free environment, mitigate fall risk factors and the implementation of preventative measures. The definition of a fall was considered to be .an unintentional coming to rest on the ground, floor, or the lower level, but not as a result of an overwhelming external force .when a resident is found on the floor, a fall is considered to have occurred . The Procedure included the fall risk assessment as part of the admission, quarterly and when a fall occurred, the identified risk factors should have been evaluated for the contribution they may have to the resident's likelihood of falling and the care plan interventions should have been implemented that addressed the resident's risk factors. Further review revealed if the event the resident fell .the attending nurse shall complete a post fall assessment .includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and the appropriateness of the interventions .nursing staff will observe and document continued resident response and effectiveness of interventions for 72 hours . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had adequate hearing and vision with no devices; had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She did not have a change in mental status and exhibited no [MEDICAL CONDITION] or behaviors during the review period. She did exhibit inattentiveness which did fluctuate. She exhibited alteration in sleep and depression/feeling down for 12 - 14 days of the review period. She exhibited a change in energy for 7 - 12 days of the review period. She exhibited a change in appetite and concentration for 2 - 6 days of the review period. She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the care plan updated in 10/28/2019, revealed Resident #1 was at risk for falls related to she required assistance with ADLs at times, received [MEDICAL CONDITION] medication, and had Actual Falls. The interventions included .Encourage resident to request assistance in ambulating, Fall Intervention: Keep personal items within reach, activities that minimize the potential for falls while providing diversion and distraction upon her visitors departure, Make sure shower chair is locked on both sides, Provide non-skid footwear as tolerated, and Therapy to provide resident with a reacher device (long handled device with pinchers on one end to grasp items) . Medical record review of the Morse Fall Scale form dated 10/29/2019, revealed Resident #1 was at a moderate risk for falls with a score of 40. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named CNA #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side, pressure was applied with a cold towel, the other nurse called for an ambulance, which arrived and transported the resident to (named hospital) . Review of the facility investigation of the undated, Staffs 10 Questions at the Time of a Resident Fall, written by LPN #1, revealed Resident #1's head hurt, .What were you trying to do when you fell ? Walking .Position of resident when they fell ? Near wheelchair. How far from surface where they? Next to surface. What were position of their arms and legs? Arms in lap, legs in front of her .Apparel resident was wearing? Night gown .Shoes, Socks (non-skid) . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. She possibly fell from the wheelchair, unknown. The resident's head hurt, and she had 2 hematomas to the head and was bleeding. The Immediate Intervention was to apply pressure to the wounds. The resident had not had a previous fall. CNA #1 found the resident. The resident was sent to the emergency room and neurological checks were started after the resident returned from the hospital. The physician and family were notified. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed the physician and family were notified. The assigned staff to Resident #1 were CNA #1 and LPN #1. The resident had an unwitnessed fall with a significant injury while in another resident's room and was found on the floor. The circumstances were unknown. The resident sustained [REDACTED]. Review of the POS [REDACTED]. Vital Signs were - Temperature 98.4; Pulse 71; Respiration 16; and Blood Pressure 147/99. The resident was found on the floor of another resident's room and she didn't know what happened, says 'I just fell .' Fall review location: in another resident's room; location prior to fall: wheelchair; Activity at time of the fall? Unknown. Footwear/device at time of fall: shoes. There were no environmental factors identified. The immediate prevention put in place was to encourage resident to ask for assistance with ADL's. Medical record review for the Morse Fall Scale form revealed there was no form for the fall on 12/4/2019 for Resident #1. Review of the undated written statement by CNA # 1 revealed .Went down 300 hall to start my round I saw (named Resident #1) on the floor with blood around her. I immediately called for help. (Named LPN #6) and (named LPN #1) came down and we grabbed towels and applied pressure. (Named LPN #6) went and called 911 and got all the paperwork together. We took her vitals and assessed her. The paramedics showed up and picked her up . Medical record review of the potential resident witnesses to the fall of Resident #1 on 12/4/2019, revealed Resident #4's Quarterly MDS dated [DATE], showed she had a BIMS of 9, indicating she was moderately cognitively impaired (moderately range 8 - 12). She had minimal difficulty hearing, adequate vision, had clear speech and could usually make herself understood and usually understood others. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Medical record review of potential resident witness to the fall of Resident #1 on 12/4/2019, revealed Resident #5's Annual MDS dated [DATE], showed she had a BIMS of 12, indicating she was moderately cognitively impaired. She had adequate hearing and vision, clear speech, and could make herself understood and understood others. Resident #5 had another MDS dated [DATE], which showed her BIMS was 13, indicating she was cognitively intact (intact range 13 - 15) and the other data was the same as the 9/15/2019 MDS. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Further review of the investigation revealed the failure to identify the room where the fall took place, failure to identify the 2 residents in the room of the fall, and failure to obtain an interview from the residents potentially witnessing the fall, if feasible, or have data to show the 2 residents where not capable of providing information. The investigation did not include a diagram of the room layout and the resident's position at the time of the fall. The investigation included 1 witness statement, by CNA #1, who named another staff member, (named LPN #6) was present in the room. There was no statement in the investigation from LPN #6. The investigation did not include a root cause. Interview with the Interim Director of Nursing (IDON) on 2/4/2020 at 8:00 AM, in the conference room stated some areas of the Post Fall Review form addressed the fall risks assessment addressed in the Falls Management Program Guidelines policy. The IDON read the Post Fall Review dated 12/4/2019 and confirmed it did not include the fall risk assessment. Further interview at 9:10 AM confirmed the investigation did not include the statement by the staff named (LPN #6) in CNA #1's statement, did not indicate when Resident #1 was last seen by staff and what she was doing, did not include how Resident #1 got into room of the fall, did not specify the room where the fall occurred, and did not identify the 2 residents who were potential witnesses and if the 2 residents were capable of providing a statement. The IDON confirmed the investigation was not complete. The IDON confirmed the Fall Risk Assessment should have been completed as part of the investigation. Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, HYPERTENSION, CHRONIC PAIN, [MEDICAL CONDITION], TYPE 2 DIABETES MELLITUS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING AND ATROPHY, RETENTION OF URINE, [MEDICAL CONDITIONS], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, MAJOR [MEDICAL CONDITION], and ANXIETY DISORDER . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. She had no changes in mental status, no [MEDICAL CONDITION], no [MEDICAL CONDITION] or any behaviors during the review period. The resident exhibited feeling down/depressed and a change in appetite over the past 12-14 days; a change in energy for 7-11 days, and a change in sleep and feeling bad about herself/let others down over the past 2-6 days of the review period. The resident required total 1 person assistance for bathing; extensive 2 plus (+) person assistance with bed mobility; extensive 1 person assistance with transferring, dressing, hygiene, and with toilet use. She required supervision of 1 person with locomotion on and off the unit. She resident was always incontinent of bowel and bladder. The resident had not had falls after the last MDS. Medical record review revealed the following: On 1/8/2020, of the Morse Fall Scale revealed Resident #3 score 55, indicating the resident was at high risk for falls. On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5 revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (Resident #3) lying face down on the floor. there was a fair amount of blood on floor with pt's glasses on floor in front of her. called another nurse into room, assessed pt then turned her over on her back, pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek. Pt was A&O x (alert and oriented times) 4, able to tell us what happened, denied any pain at this time. Picked her up and placed her back into her wheelchair. pt stated I was sitting on side of my bed, bent over to plug in my cell phone, and fell over. v/s (vital signs) (Blood Pressure (BP)) 134/78, (Respiration (R)) 18, (Pulse (P)) 80, O2 97% (percent) on room air. at this time bleeding to her head had stopped, contacted wound care nurse to asses for treatment, spoke to (named Nurse Practitioner). Had pt apply ice to right side of face/eye area. Will continue to monitor, continue on neuro checks per protocol. Call light within reach . Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room while bending forward trying to plug cell phone in. The roommate found the resident. The resident had an injury of a laceration above the right eye, was not sent to the emergency room , neurochecks were initiated and the physician and resident's (family member) were notified. The facility intervention was to attach the phone cord to the bedrail for easy access and the intervention was placed on the care plan. Review of the facility investigation included the undated Staff's 10 Questions at the Time of a Resident Fall form which revealed the resident stated she was 'Okay', that she was face down next to a surface and the environment was clean, dry, had no spills and the area was uncluttered. The resident was wearing pants, shirt, shoes and socks. The assistive device used was a wheelchair and she was wearing her glasses. Review of the facility investigation included the Resident Event Report Worksheet form dated 1/9/2020, written by LPN #5, revealed the date and time of the unwitnessed fall by Resident #3 was 1/9/2020 at 12:50 PM, which had occurred in Resident #3's room. The resident sustained [REDACTED]. The resident had a laceration to the right eyebrow/temple area and a red cheek. The factors related to the fall was she was reaching. The resident had no pain and the physician and family were notified. Medical record review of Resident #3's roommate, at the time of the 1/9/2020 fall, Quarterly MDS dated [DATE], revealed a BIMS score of 11, indicating she was (upper range) moderately cognitively impaired (Moderate range: 8 - 12). She had moderate difficulty with hearing, she had adequate vision and wore lenses. Medical record review of the Neurological Record form dated 1/9/2020 at 1:00 PM through 9:30 PM, and on 1/10/2020 at 1:30 AM through 5:30 AM, revealed Resident #3's results were within normal range. Medical record review of the Health Status Note dated 1/10/2020 at 9:00 AM, revealed .Nurse was called to room by (named Family Member #3). (Named Family Member #3) insisted on resident being sent to hospital for a CT (Computerized [NAME]ography) Scan due to S/P (status [REDACTED]. Noted to have bruise to right shoulder. Skin tear above right eye. No bleeding or swelling noted to site. (Named) NP (Nurse Practitioner) was called, received new orders to transport to (named hospital) for CT scan. Will continue to monitor . Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN called for help from other nurse. The LPN could not recall the name of the nurse helping her. The LPN reviewed her written report and confirmed she failed to write the name of the nurse on the report. The LPN stated once the other nurse was available, they assessed the resident. The LPN stated she notified the NP who was in the facility and the LPN recalled the NP went to assess the resident. The NP saw the resident, the vital signs and neurochecks were normal, the resident had complained of a sore head, but not pain, and the NP did not order a discharge to the hospital. Interview with the NP on 2/5/2020 at 9:35 AM, in the conference room revealed the NP had seen Resident #3 earlier in the day, prior to the fall on 1/9/2020. The NP stated she was notified of the fall, went to assess the resident, noted the neurocheck was normal so far, and the resident was not complaining of pain. The NP stated her intent was to continue monitoring the vital signs and neurochecks and to assess the resident for abnormalities. The NP stated the resident returned to the facility on [DATE] and she then wrote her note dated on 1/13/2020. Further review of the investigation revealed no written statements from the staff involved in the response, LPN #5, another unnamed nurse, the assigned CNA, the NP; failed to include what the resident was doing and last known location, prior to the fall; no statement from the resident; no statement from the roommate alerting staff of the fall; no diagram of the resident's room and the of the resident as found at the time of the fall, a complete set of the neurochecks, and no root cause analysis. Medical record review revealed the following: On 1/14/2020 at 10:48 AM, of the Infection Note revealed .Review of (Resident #3's) S/Sx (signs/symptoms) of infection completed using McGeer's Criteria. diagnosed infection: uti (urinary tract infection) Medication Order: [MEDICATION NAME]. Care plan revised as indicated . On 1/20/2020 at 3:20 PM, of the Health Status Note, written by LPN #3, revealed .Nurse was called to resident's room by therapy. Resident was sitting in floor on her bottom at the foot of her bed, with her back leaned up against heater. When asked resident what she was doing she said, I stood up and I was trying to reach my cell phone and I fell over. No complaints of pain voiced. No injuries noted. Intervention: Signage to be used to remind resident to ask for assistance. (Named NP) was notified. (Named Family Member #3) was notified .(Named Director of Nursing) was notified. Will continue to monitor . On 1/21/2020 at 8:53 AM, of the Health Status Note revealed the .IDT met to discuss resident's fall from (1/20/2020). Resident fell while in her room. Intervention is to provide resident with a sign to ask for staff assist . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #3, dated 1/20/2020, revealed Resident #3 fell on Monday, 1/20/2020 at 2:30 PM, in her room when she stood up from the wheelchair and was reaching for the cell phone and fell out of the wheelchair. The therapist found the resident on the floor. The resident had no injuries or complaint of pain. The facility's immediate intervention was to assist the resident up from the floor, with 2 staff assisting, back into the wheelchair. The recent had had recent falls and the facility started neurochecks. The physician and (Family Member #3) were notified. The intervention was signage. Review of the facility investigation included the undated, Staff's 10 Questions at the Time of a Resident Fall form, written by LPN #3, revealed Resident #3 stated she was okay, and had stood up to reach for her cell phone. The resident's position after the fall was described as sitting on her bottom with her back against the heater with her legs straight out and her arms in her lap. The environment was described as clean, dry, and uncluttered with good visibility. The resident was wearing shoes and socks with proper fitting clothing. There was no one in the area when the resident fell . Review of the facility investigation included the Resident Event Report Worksheet form, written by LPN #3, dated 1/20/2020, which revealed Resident #3 had a fall in her room while reaching which resulted in no significant injury. Further review revealed LPN #2 and CNA #2 were assigned to the resident. Interview with CNA #2 on 2/4/2020 at 1:07 PM, in the conference room revealed the CNA had been assigned to the resident but she had not witnessed the fall on 1/20/2020. CNA #2 stated she had been informed of the fall by a therapist. The therapist was working with another resident in the hallway and had walked past Resident #3's room when she saw Resident #3 on the floor. The CNA stated when she entered the room the resident was seated on her bottom with her back to the heater/air conditioner, her left side was next to the window wall, her right side was on the bed side, and her legs were straight out in front of her. The CNA asked the resident to wait to get a nurse to check her over. The CNA stated LPN #4 came to the room because LPN #2, assigned to the resident, was not available. LPN #4 assessed the resident and no injury was noted and 'we got the resident into the wheelchair.' Interview with LPN #3 on 2/4/2020 at 1:34 PM, in the conference room revealed the assigned nurse, LPN #2, had gone to lunch and she had responded to CNA #2's request to help with Resident #3. The LPN did not recall a therapist being involved. LPN #3 stated LPN #4 helped her get the resident off the floor. LPN #3 stated she called the NP and Family Member #3 regarding the fall. Interview with LPN #4 on 2/4/2020 at 1:57 PM, in the conference room revealed a therapist had walked down the hall and had said something to LPN #3, then .LPN #3 yelled for me . When LPN #4 got into Resident #3's room the resident was seated on the floor with her back to the heater/air conditioner. LPN #4 stated she and LPN #3 assessed the resident, got her up into her wheelchair, and obtained vital signs. Interview with LPN #2 on 2/4/2020 at 2:55 PM, in the conference room revealed the LPN was assigned to Resident #3 on 1/20/2020. The LPN stated .a therapist got LPN #3 in the hall, then LPN #3 or CNA #2, or someone, got me. The resident was on her buttocks with her back to the heater/air conditioner and her legs were in front of her . when the LPN got into the room. The LPN stated the resident was assessed for pain and injury, while she was on the floor, and she was okay. LPN #2 stated LPN #3 was in the room with LPN #2 but LPN #2 had no recall of LPN #4 being present. LPN #2 stated this LPN notified the NP and Family Member #3 of the fall. Further review of the investigation revealed no written statements by CNA #2, LPN #2, LPN #3, LPN #4, the NP, or the therapist seeing Resident #3 on the floor. The investigation provided failed to identify all the staff involved and failed to identify the therapist. There was no diagram of the resident's room and of the resident as found at the time of the fall, and no root cause analysis. The investigation did not include the potential of the UTI contributing to the fall. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed .to obtain interviews from staff, the therapist, anyone involved with the fall. I understand what you're saying. The information isn't there and the investigation isn't complete .",2020-09-01
760,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2018-03-07,602,D,1,0,V5FH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect a resident's right to be free from misappropriation of property for 1 resident (#3) of 10 residents reviewed. The findings included: Review of facility policy, Drug Diversion, POL 602.23, revised 11/28/17, revealed .Oncoming and off-going nurses complete a shift to shift count on medication cards or containers containing controlled substance medication; controlled substance medication sheets; controlled substance medications in Emergency Kits when the kit had been opened .Nurses report any discrepancies in controlled substance medication counts to the Director of Nursing Service immediately .Facility management should investigate and make every reasonable effort to reconcile reported discrepancies .Investigation includes but may not be limited to interviews, medical record review, observation of facility practices related to handling of controlled substances, evaluation if loss is associated or attributed to specific individual(s), time period, unique situation or random, and identify any potential negative impact on resident's condition or safety .If potential criminal activity is suspected notify the Administrator, pharmacy manager, and consultant pharmacist at once .Educate staff on current procedures and implement interventions if needed .Document corrective action taken .Analyze findings from any discrepancy events or substantiated thefts or diversions as part of Performance Improvement . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's admission orders [REDACTED]. Continued review revealed Resident #3 brought a bottle of [MEDICATION NAME] from home. Facility investigation review revealed on 1/30/18 it was discovered 5 pills were missing from the bottle the resident brought in from home. Continued review revealed an investigation was conducted including staff interviews as well as police involvement. Further review revealed one nurse confessed she had taken the pills. Continued review revealed the nurse was terminated and the resident was reimbursed for the missing pills. Review of facility investigation revealed an interview with Registered Nurse (RN) #1 on 1/30/18 who stated she was speaking with the off-going Supervisor about the new admission (Resident #3). Continued review revealed RN #1 stated Resident #3 came in with 20 [MEDICATION NAME] pills but the Supervisor stated the resident had come in with 25 pills because she had counted them. Further review revealed both nurses went to the Narcotic box; counted the pills in the bottle; and arrived at a count of 20 pills. Continued review revealed RN #1 reviewed the narcotic sheet and it was labeled with 20 pills so she called the Administrator. Review of facility investigation revealed an interview with Licensed Practical Nurse (LPN) #2 on 1/30/18 revealed she was asked if she was the one who inventoried the pills of Resident #3 he brought from home and she said she was. Continued investigation revealed LPN #2 stated she counted 20 pills and stated LPN #1 had counted with her. Further investigation revealed LPN #2 was told the pills were counted previously and there were 25 pills but LPN #2 did not know how that was possible. Review of facility investigation revealed an interview with RN #2 who stated she counted 25 pills of [MEDICATION NAME] 10/325 mg which belonged to Resident #3. Review of facility investigation revealed an interview with LPN #1 on 2/1/18, who stated LPN #2 walked over to her chair at the nurses' station and said they had to count narcotics for the new admission. Continued review revealed LPN #1 was in the process of putting the new admission medications into the computer so pharmacy would deliver them. Further interview revealed LPN #1 saw LPN #2 with the bottle of pills but never actually saw her pour them out or physically see her count them but heard her count to 20 twice. Continued interview revealed LPN #1 never touched the pills nor did she physically see the pills. Further review revealed at this point both nurses were suspended pending the outcome of the investigation. Review of facility investigation revealed on 2/1/18 the police called the Administrator to say LPN #2 was requesting to speak with her at the police station. Continued interview revealed LPN #2 said she had done it and when asked what she had done she responded I took those pills and I'm sorry. What happens from here? Further review revealed the Administrator told LPN #2 was terminated and she would be reported to the Board of Nursing. Continued interview revealed LPN #2 was asked if she had taken any other pills and she responded This was the only time I've ever done that; I don't know what I was thinking. Review of facility investigation revealed Resident #3's personal physician as well as the Medical Director were informed of the diversion. Continued review revealed Resident #3 was informed of the situation and the facility reimbursed him for the medication. Facility investigation revealed all nurses were re-educated on narcotic counts with both nurses observing the medications and the count sheets when doing change of shift counts as well as both nurses observing and counting together when a resident brings medications from home. Interview with the DON and Administrator on 3/7/18 at 1:15 PM in the conference room revealed neither was in the facility when the diversion occurred. Review of the employee records of LPN #1 and LPN #2 revealed no previous disciplinary action for either of them.",2020-09-01
765,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,224,D,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of law enforcement arrest report, facility policy, medical record review, facility investigation and interview, the facility failed to ensure 1 resident (#15) of 15 reviewed was free from misappropriation of property. The findings included: Review of facility policy, Abuse, dated 10/20/16 revealed .misappropriation of patient property are strictly prohibited . Medical record review revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE]. Further review of the Minimum (MDS) data set [DATE] revealed Resident #15 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Review of a facility investigation dated 10/14/17 revealed Resident #15 reported a missing $60 gift card. Further review of a written statement by Licensed Practical Nurse (LPN) #6 dated 10/15/17 revealed .(Resident #15) stated that she had a $60.00 gift card stolen from her pink wristlet change purse .(Resident #15) also stated that tech (certified nurse aide) who took the card came to her room on the night of 10/14/17 after hearing that she reported a gift card stolen and tech stated 'Really (Resident #15), you borrow money off of me for weeks and then pay me back with a gift card and then report it stolen.' (Resident #15) stated she never borrowed money from the tech and she would never borrow money from a tech . Continued review of a written statement by Resident #15's sister on 10/16/17 revealed a $50 gift card was purchased on 9/19/17 and given to the resident on the same day. The resident's sister also reported the gift card had been used twice on 10/12/17 at a local store. Review of a law enforcement arrest report dated 10/14/17 revealed .We proceeded to speak with (Resident #15) who advised that she had a visa gift card missing from her change purse and presumed it had been stolen. She further advised the gift card was valued at $60.00. (Resident #15's sister) checked with the visa customer service and found that the card had been used .visa had records indicating that a total of 49.47 had been spent .A check of (local store) video footage .shows a white female making a purchase with the card number provided .A good photo (photograph) was printed and taken to the charge nurse .who recognized the lady as one of the night shift nurses .she (Certified Nurse Assistant (CNA) #7) has admitted to using the card as witnessed on video but claims she paid (Resident #15) cash for the card. To verify this statement I called (Resident #15) and she absolutely denies this ever happened .(CNA #7) showed obvious intent to deprive the owner of certain property without her effective consent. (CNA #7) was placed under arrest . Review of a written statement given to law enforcement by CNA #7 dated 10/14/17 revealed .I (CNA #7) worked on Wednesday night 10/11/12 - 10/12/12 on (the) 700 hall. (Resident #15) asked me if I would give her cash for her prepaid debit card bc (because) it wasn't a cash back card and no one would take her card and get anything for her. I told her I only had sixty dollars and she said it had fifty something on there so I gave her three twenty dollar bills and she gave me the card . Interview with the Administrator on 10/24/17 at 2:20 PM in the conference room revealed the facility investigation was neither substantiated nor unsubstantiated because she was unable to get a statement from CNA #7 and Resident #15 was reluctant to give a detailed statement. The Administrator confirmed CNA #7 was terminated due to the misappropriation of property.",2020-09-01
766,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,280,G,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to update the Care Plan with interventions for 3 residents (#7, #6, #4) of 7 residents reviewed. The facility's failure to identify risk and update the care plan with approporiate interventions resulted in falls with injuries (HARM) for resident #7,#6, #4. The findings included: Review of facility policy, Accidents and Supervision to Prevent Accidents (dated: 4/28/2011), revealed .The center provides an environment that is free from accident hazards .Implementation of interventions to reduce hazard(s) and risk(s) .Monitors to verify interventions are in place .Evaluates interventions at designated interval for effectiveness .Modifies and/or replaces ineffective interventions when necessary . Medical record review revealed Resident #7 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #7 had a Brief Interview Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with transfers and Activities of Daily Living (ADL) and had no impairment of the upper and lower extremities. The resident was occasionally incontinent of the bowel and bladder. Medical record review of a Progress Note dated 9/5/17 revealed Resident #7 had a fall with no injury to occur on 9/5/17 and 9/9/17. Review of the Care Plan initiated on 8/7/17 for Resident #7 revealed it was not updated after the fall occurred on 9/5/17, 9/9/17, 9/17/17, and only revised on 10/24/17. Medical record review of a Post Fall Investigation dated 9/17/17 revealed the resident was .heard resident yelling .went to room and the resident was sitting on the floor on the L (left) side of the bed .was sitting on her botttom with her leg bent at the knee under her. When the resident tried to straighten it out she yelled and there was a popping noise . Continued review revealed the resident was transferred to the hospital and admitted for a Nondisplaced Midcervical Fracture of Right Femur. Interview with LPN #9 on 10/26/17 at 9:20 AM in the conference room revealed the nurse was to update the Care Plan with interventions after each fall. LPN #9 confirmed she failed to update the Care Plan after Resident #7 fell on [DATE] and another fall occurred on 9/17/17. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plans were to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #7 had a fall with injury (HARM) on 9/17/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30-day Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had severe cognitive impairment with short and long term memory problems. The resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene, eating and toileting and required total dependence for bathing. Continued review revealed Resident #6 was always incontinent of bowel and bladder, had bilateral impairment of both upper and lower extremities and utilized a wheelchair for mobility. Upon admission pt (patient) was identified as falls risk as evidenced by admission Care Plan. Medical record review of Progress Notes dated 8/27/17 and 9/6/17 revealed Resident #6 had falls to occur on these dates. Further review revealed Resident #6 received an injury as a result of the 9/6/17 fall when found on floor. Continued review of a Progress Note dated 9/7/17 revealed .family says he's been c/o (complaining of) left side discomfort . Medical record review of a Radiology Report dated 9/7/17 revealed .Conclusion: Acute right lateral ninth rib fracture . Medical record review of the Care Plan for Resident #6 revealed it was not updated or revised with new interventions after the falls occurred on 8/27/17 and 9/6/17. Interview with Licensed Practical Nurse (LPN) #9 on 10/26/17 at 9:20 AM in the conference room revealed after each fall the nurse was required to update the Care Plan with interventions. LPN #9 confirmed she failed to update the Care Plan with an appropriate intervention after Resident #6 fell on [DATE]. Interview with Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plan was to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #6 had falls to occur on 8/27/17 and 9/6/17. Medical record review of the Care Plan for Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quartely MDS dated [DATE] revealed the resident has a BMS score of 7 (severe impairment). The Resident was extensive assist with 1 person for transfer, extensive assist with 1 person for transfer, dressing and personal hygeine, independent with ambulationwith wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The residnet had impairment on one side for upper and lower extremities and frequesntly incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of a Progress Note dated 9/18/17 revealed the Physician ordered a Tibia/Fibula x-ray. Review of the results of the x-ray dated 9/19/17 revealed an abnormal x-ray and orders to consult with an Orthopedic Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall. Interview on 10/26/17 with the Administrator at 9:33 AM in her office revealed the facility failed to update the Care Plan after the 9/17/17 fall. The Administrator confirmed the facility failed to update the Care Plan with interventions after falls. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 7 (severe impairment). The resident required extensive assistance with 1 person for transfer, dressing and personal hygiene, independent with ambulation with wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The resident had unilateral impairment on one side of upper and lower extremities and frequently incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of Progress Notes dated 9/18/17 revealed the resident with a Tibula/Fibula fracture and placement of a cast. Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall. Interview with the Administrator on 10/26/17 at 9:33 AM in her office confirmed the facility failed to update the Care Plan after the 9/17/17 fall.",2020-09-01
767,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,323,G,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to maintain an environment free from accidents for 3 residents (#7,#6, #4) of 7 residents reviewed. The facility's failure to recognize fall risk and identify interventions for three residents (#7, #6, #4) resulted in falls with injury (HARM). The findings included: Review of facility policy, Accidents and Supervision to Prevent Accidents, dated 4/28/2011 revealed .The center provides an environment that is free from accidents hazards .Implementation of interventions to reduce hazard(s) and risk(s) .Monitors to verify interventions are in place .Evaluates interventions at designated interval for effectiveness .Modifies and/or replaces ineffective interventions when necessary . Medical record review revealed Resident #7 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS (Minimum Data Set) dated 10/10/17 revealed Resident #7 had a Brief Interview Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with transfers and Activities of Daily Living (ADL) and had no impairment of the upper and lower extremities. The resident was occasionally incontinent of the bowel and bladder. Medical record review of a Progress Note dated 9/5/17 revealed Resident #7 had a fall with no injury to occur on 9/5/17 and 9/9/17. Review of the Care Plan initiated on 8/7/17 for Resident #7 revealed it was not updated after the fall occurred on 9/5/17, 9/9/17, 9/17/17, and only revised on 10/24/17. Medical record review of a Post Fall Investigation dated 9/17/17 revealed .heard resident yelling .went to room and the resident was sitting on the floor on the L (left) side of the bed .was sitting on her botttom with her leg bent at the knee under her. When the resident tried to straighten it out she yelled and there was a popping noise . Continued review revealed the resident was transferred to the hospital and admitted for a Nondisplaced Midcervical Fracture of Right Femur. Interview with LPN (Licensed Practical Nurse) #9 on 10/26/17 at 9:20 AM in the conference room revealed the nurse was to update the Care Plan with interventions after each fall. LPN #9 confirmed she failed to update the Care Plan after Resident #7 fell on [DATE] and another fall occurred on 9/17/17. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plans were to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #7 had a fall with injury (HARM) on 9/17/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30-day MDS dated [DATE] revealed Resident #6 had severe cognitive impairment with short and long term memory problems. The resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene, eating and toileting and required total dependence for bathing. Continued review revealed Resident #6 was always incontinent of bowel and bladder, had bilateral impairment of both upper and lower extremities and utilized a wheelchair for mobility. Medical record review revealed Resident #6 had falls to occur on 8/11/17, 8/12/17, 8/13/17 and 8/14/17. Continued review revealed the following interventions were put in place after the falls occurred: .encourage to participate in activities .Strips to be placed to floor on each side of bed .encourage resident to toilet upon rising, before meals and after meals, and before bed .assist resident to common area .apply dysum pad to w/c (wheelchair) when arising to w/c . Medical record review of a Progress Note dated 8/27/17 revealed Resident #6 had a witnessed fall to occur as he was attempting to get up from the wheelchair. Review of the Care Plan revealed no intervention was put in place after the fall occurred on 8/27/17. Medical record review of a Progress Note dated 9/6/17 revealed Resident #6 had an unwitnessed fall to occur. Resident #6 was found by staff .sitting on his bottom beside of the end of the bed with his legs outstretched and his hands to his side. The residents pants were slightly pulled down as if the resident was trying to go to the restroom and his diaper was wet . Continued review of a Progress Note dated 9/7/17 revealed .MD (Medical Doctor) notified that Pt (patient) is now c/o (complaining of) discomfort in the left ribcage area. Pt grimaces with pain when area is palpated. Received order for x-ray . Medical record review of a Radiology Report dated 9/7/17 revealed .Conclusion: Acute right lateral ninth rib fracture . Review of the Care Plan revealed no intervention was put in place after the fall occurred on 8/27/17. Interview with LPN #9 on 10/26/17 at 9:20 AM in the conference room revealed after each fall the nurse was required to update the Care Plan with interventions. LPN #9 confirmed she failed to update the Care Plan with an appropriate intervention after Resident #6 fell on [DATE]. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plan was to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to maintain an environment free from accidents for Resident #6 who had a fall to occur on 9/6/17 which resulted in a fracture of the rib (HARM). Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quartely MDS dated [DATE] revealed the resident has a BIMS score of 7 (severe impairment). The Resident was extensive assist with 1 person for transfer, extensive assist with 1 person for transfer, dressing and personal hygeine, independent with ambulationwith wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The residnet had impairment on one side for upper and lower extremities and frequesntly incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of a Progress Note dated 9/18/17 revealed Called mobile with x-ray order. Review of the Progress Notes dated 9/20/17 revealed .Received resident Tibia/Fibula x-ray report on 9/19/17 at 1800 (6:00 PM). Noted abnormal x-ray .Notified NP (Nurse Practitioner) via phone .of x-ray results. Received the following new MD (Medical Doctor) orders. 1. consult with (orthopedic) . Review of a Progress Note dated 9/21/17 revealed MD applied cast at this time to right lower extremeity. MD wants to follow up with an x-ray on Monday 9/25/17 to check placement with new cast. MD wants to follow up in four weeks to change cast on 11/19/17. Family made aware . Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall and place new interventions in place to prevent falls. Interview on 10/26/17 with the Administrator at 9:33 AM in her office revealed the facility failed to update the Care Plan after the 9/17/17 fall.",2020-09-01
768,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,333,D,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, resident observation and interview, the facility failed to ensure residents are free of any significant medication errors for 1 resident (#12) of 13 reviewed for medications with parameters. The findings included: Review of facility policy (undated), Suggested Medication Administration, Assistance or Observation Procedures, revealed .Resident Right's and Dignity must be preserved during medication administration/observation . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order Sheet (POS) revealed an order dated 3/7/17 .[MEDICATION NAME] (Antihypertensive) 100 mg (milligram) give 1 tablet by mouth 1 time a day at 7:00 AM [MEDICAL CONDITION](Hypertension). Hold if pulse is 60 or below . Continued review of the POS revealed a second order for [MEDICATION NAME] 200 mg, give 1 tablet 1 time a day at 8:00pm for HTN, re written on 5/24/17 to include, hold if pulse is 60 or below . Medical record review of the Medication Administration Record (MAR) revealed Resident #12 received [MEDICATION NAME] 100 mg 7:AM dose and 200mg PM dose on the following dates with the pulse documented at 60 or below. 4/2/17 pulse 54, medication documented as administered. 4/9/17 pulse 60, medication documented as administered. 4/28/17 pulse 60, medication documented as administered. 6/8/17 pulse 60, medication documented as administered. 6/24/17 pulse 60, medication documented as administered. 7/22/17 pulse 60, medication documented as administered. 7/26/17 pulse 60, medication documented as administered. 7/31/17 pulse 60, medication documented as administered. 8/1/17 pulse 56, medication documented as administered. 8/2/17 pulse 60, medication documented as administered. 8/15/17 pulse 56, medication documented as administered. 8/16/17 pulse 60, medication documented as administered. 9/17/17 pulse 60, medication documented as administered. 10/15/17 pulse 60, medication documented as administered. Resident observation on 10/23/17 at 12:35 PM revealed Resident #12 sitting at bedside, call light in reach, well-groomed and dressed appropriately, conversing with roommate. Further observation on 10/23/17 at 7:45 PM revealed Resident #12 sitting at bedside conversing on the telephone. Interview with Licensed Practical Nurse #2 on 10/23/17 at 7:45 PM on the 700 hall revealed .when the pulse check of Resident #12 is 60 or below the nurse was to hold the medication . Interview with the Nurse Practitioner on 10/24/17 at 11:30 AM in the conference room revealed she .expected the nurses to follow the parameters .and was .concerned .the resident had received [MEDICATION NAME] with heart rate 60 or below .The Nurse Practitioner reviewed the MAR and confirmed the medication was given with a pulse check of 60 and below . Interview with the Medical Director on 10/24/17 at 11:10 AM on the 800 hallway revealed that he .expects the nurses to follow parameters and not to administer [MEDICATION NAME] to (Resident #12) if pulse is 60 or below. Interview with the Director of Nursing (DON) on 10/25/17 at 3:15 PM in her office confirmed .the [MEDICATION NAME] was given to (Resident #12) with pulse documented at 60 and below . The DON confirmed the facility failed to prevent a significant medication error for Resident #12.",2020-09-01
769,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,431,D,1,0,KCFU11,"> Based on review of facility policy, observation, and interview, the facility failed to properly label, date, and/or discard 3 multi-dose vials of insulin according to facility policy on 1 of 4 medication carts reviewed. The findings included: Review of facility policy dated 8/31/12, Medication package insert, Medication Storage, Storage and Expiration Dating of Medications, Biologicals, Syringes and needles, revealed .facility should ensure that medications and biologicals (1) have an expired date on the label; (2) have been retained longer than manufacturers guidelines; or,(3) have been contaminated or deteriorated , are stored separate from other medications until destroyed or returned to the pharmacy .Facility should destroy or return all discontinued, outdated/expired medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law . Review of package insert for Novolin R insulin storage revealed instructions to .throw away the vial 42 days after it is taken out of the refrigerator if it is unopened . Observation of Licensed Practical Nurse (LPN) #2 during medication pass on 10/23/17 at 7:30 PM on the 700 Hall revealed 1 vial of Novolin R Insulin multi-dose vial, date opened 8/31/17. Continued observation revealed LPN #2 drew up 2 units of Insulin for Resident #16 from the vial to be administered and placed the syringe on the top of the medication cart. The surveyor advised LPN #2 the vial was expired and LPN #2 immediately discarded the syringe. Further observation of the medication cart revealed a bottle of novolin R insulin multi dose- vial opened, half full, and undated, received from the pharmacy 9/16/17, 1 vial of novalin N insulin multi-dose vial opened, undated and received from the pharmacy on 10/04/17. Interview with LPN #2 accompanied by the Director of Nursing (DON) on 10/23/17 at 8:00 PM at the 700 hall medication cart confirmed .the vial of R Insulin was expired .and the 1 vial of novolin N insulin and 1 vial of novolin R insulin were opened and undated . Interview with the DON on 10/25/17 at 3:15 PM in her office revealed the nurses are expected to label and date insulin medications when opened, discard expired medication, and check for expiration dates before administering medications. The DON confirmed the facility failed to properly label, discard and/or store medication.",2020-09-01
770,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,441,D,1,0,KCFU11,"> Based on facility policy, observation, and interview, the facility failed to follow infection control protocol for glucometer cleaning on 1 of 4 observations and facility failed to prevent cross contamination of medications, and medication cup on 1 of 25 opportunities observed. The findings included: Review of the facility policy dated 8/31/12, Cleaning Diagnostic Equipment In-Between Patients, revealed the procedure is to .clean outside of patient equipment .If no manufacturer's instructions clean with a 10% (percent) bleach solution moistened wipes in-between each patient and as needed .Allow contact with bleach solution for 1 minute .Follow with a cloth dampened with water to remove residual bleach . Further review of facility policy, General Dose Preparation and Medication Administration, Assistance or Observation revealed .The community staff should not touch the medication when opening a bottle or unit dose package . Observation of Licensed Practical Nurse (LPN) #2 on 10/23/17 at 7:40 PM on the 700 Hall at the medication cart revealed LPN #2 cleaning the glucometer without gloves and using an alcohol prep pad. LPN #2 had not used glucometer to check blood glucose level, and when asked by the surveyor how she should clean the glucometer stated .she would find out .and not use the glucometer until she found out how to clean it. Interview with LPN #2 on 10/23/17 at 7:45 PM on the 700 Hall at the medication cart revealed when asked if she knew the policy for cleaning the glucometers she said .No I don't . Interview with the Director of Nursing (DON) on 10/23/17 at 8:00 PM on the 700 Hall at the medication cart confirmed the facility failed to follow infection control protocol and cleaning of the glucometer. Observation of the Medication Pass on 10/25/17 at 7:30 AM on the 500 Hall revealed LPN #3 with 2 capsules and 1 tablet lying on top of medication cart surface. LPN #3 picked up the tablet with her ungloved hand and placed the tablet in the medication pouch to be crushed.Further observation revealed LPN #3 then picked up the 2 capsules with her ungloved hand off the medication cart, opened them and placed the contents into the medication pouch to be crushed. Observation of the Medication Pass on 10/25/17 at 7:30 AM on the 500 Hall revealed LPN #3 placed her ungloved finger into the top of the medication cup, then placed the medication into the cup. Interview with LPN #3 on 10/25/17 at 7:30 AM on 500 Hall confirmed .she should not touch medications with her ungloved hands, let medications come into contact with uncleaned surfaces, or touch other objects with gloved hands and then touch medication . Interview with the Director of Nursing (DON) on 10/25/17 at 3:15 PM in her office confirmed .nursing should not touch medication or the inside of medication cups with their hands or with gloves which have been used to touch other surfaces . The DON confirmed the facility failed to follow facility policy for infection control protocol.",2020-09-01
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
793,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,622,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility record review and interview, the facility failed to ensure resident wasn't discharged during the appeal process, for an involuntary discharge of 1 resident (#123), of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's, Notice of Involuntary Discharge, revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Nurse's Note dated 1/20/18 revealed, .Voices needs without diff (difficulty). Forgetful @ (at) times . independent c (with) transfers and ADLs (activities of daily living). Propels self about facility in w/c (wheel chair). Continent of B&B (bowel and bladder), toilets self. Feeds self .sets up own tray . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Review of the Nurse Practitioner's (NP) #1 Progress Note dated 2/9/18 revealed, .I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 filed an appeal on 1/3/18 related to the Involuntary Discharge notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Resident #123 was discharged on [DATE] to a hotel via the facility's van. Continued interview with the SSD on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview with the SSD on 3/7/18 at 10:50 AM, in the Social Services office, confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident. Further interview confirmed the SSD and Licensed Practical Nurse (LPN) #4 had taken some of the prescribed medications that remained at the nursing home to the resident's hotel room on 2/13/18. Continued interview confirmed the resident had been visited at the Long Term Care Facility and assessed by the TennCare Choices (part of the state Medicaid program) Transition Coordinator and a representative from a local group living home. Further interview confirmed the Choices Transition Coordinator had not been informed of the resident's impending discharge on 2/9/18. Interview with the Interim Administrator on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed the Interim Administrator began working at the facility on 1/29/18. Interview continued and in response to why the documented every 15 minute checks on Resident #123 began on 1/21/18, had ended on 1/30/18, the Interim Administrator responded, First I have heard of every 15 minute checks . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy. I don't know if I would have discharged him but he refused to give me the matches or lighter and he refused to give them to either of us (reference to the SSD) .were not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview continued and the Interim Administrator responded to the question of why the Commissioner's Designee was not informed of the impending discharge, I am not required to contact them . Refer to F623, F624",2020-09-01
794,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,623,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility records, and interview, the facility failed to notify the Long Term Care Ombudsman of 1 resident (#123) who had an ongoing appeal of a 30 day Involuntary Discharge Notice, of 3 residents reviewed for discharge. The facility's failure to provide advance notice as well as a plan resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of the Nurse Practitioner's (NP #1, employed by the resident's attending physician) progress note dated 2/9/18 revealed, I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Medical record review of a NP order dated 2/9/18 revealed .DC (discharge) patient (Resident #123) .today (to hotel) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the social services office, confirmed Resident #123 filed an appeal for the Involuntary Discharge on 1/3/18. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Tennessee Department of Finance and Administration Commissioner's Designee, and the presiding Administrative Law judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the social services office, confirmed a previous Administrator had not provided documentation of notification to the Long Term Care Ombudsman of the Notice of Involuntary Discharge issued to Resident #123 on 12/21/17. Continued interview confirmed the current IA and the SSD had not notified the Ombudsman of the Notice of Involuntary Discharge, the pending appeal, or of the resident's discharge on 2/9/18 to a hotel room. Interview with Resident #123's NP #1 on 3/20/18 at 9:30 AM, in room [ROOM NUMBER], confirmed the NP cared for the resident on behalf of his attending physician. Continued interview revealed, .the physician on call, not sure if it was (name of the resident's attending physician) was called and notified that day . Further interview confirmed the notification was after the resident had been discharged to a hotel. Interview by telephone with the Ombudsman for the East Tennessee Region, District 1, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not aware Resident #123 was discharged on [DATE] and revealed, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them (the nursing home) he didn't have his meds when I was there (at the nursing home ) .there about 9:00 AM .the sister paid for another night at the hotel .After I got back (to her office) I called the State Director of the Ombudsman Program . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy . were not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview confirmed the facility's Ombudsman had not been notified prior to the discharge of Resident #123 to a hotel room on 2/9/18. Interview continued and the IA responded to the question of why the Commissioner's Designee was not informed of the impending discharge, I am not required to contact them . Refer to F622, F624",2020-09-01
795,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,624,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility records, medical record review and interview, the facility failed to ensure a safe and orderly discharge for 1 resident (#123) of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was admitted following an acute care hospital stay due to a Traumatic Subdural Hemorrhage that required surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating he was assessed as cognitively intact. Review of Resident #123's Admission MDS dated [DATE] revealed, .Problem .does have cognitive deficit . Continued review revealed the Quarterly MDS assessment dated [DATE] revealed a problem, .potential for skin breakdown r/t (related to) cognition and decreased safety awareness. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Medical record review of the facility Attending Physician's History and Physical dated 1/5/18 revealed, .he (Resident #123) has been followed by psych (psychiatric services) and requires [MEDICATION NAME] (antipsychotic medication) to try to prevent mood swings .he continues to smoke. He has been caught smoking in his room twice and he was given a 30 day notice of discharge about 2 weeks ago due to this issue . Review of a Nurse's Note dated 1/20/18 revealed, .Voices needs without diff (difficulty). Forgetful @ (at) times . independent c (with) transfers and ADLs (activities of daily living). Propels self about facility in w/c (wheel chair). Continent of B&B (bowel and bladder), toilets self. Feeds self .sets up own tray . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Medical record review of Resident #123's Physician order [REDACTED]. Review of a Social Progress Note by the Social Services Director (SSD) dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator-State Medicaid program) for update. He (Transition Coordinator) said he would set up transportation for resident to look at house and meet roommates next week. Medical record review of Nurse Practitioner's (NP) #1 progress note dated 2/9/18 revealed, .I am seeing pt (patient) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Medical record review of the NP orders written 2/9/18, revealed the orders for Resident #123 at discharge included: Diet-NAS (no added salt); Activity as tolerated; Resident to follow up with his primary physician on 2/27/18; Social Service to arrange Home Health services to include skilled nursing, physical and occupational therapy; Discharge meds-see discharge Medication Administration Record; DME (durable medical equipment) O2 concentrator with tubing; O2 at 2Lpm (oxygen at 2 liters per minute) - continuous; Overnight pulse ox test (used to measure oxygen levels in the bloodstream during the hours of sleeping); Review of the medication list prepared for the discharge revealed the following medications checked to be included on the discharge list: multivitamin/mineral tablet 1 daily (vitamin replacement); [MEDICATION NAME] HCL 20 milligrams (mg) 1 tablet every morning (for [MEDICAL CONDITION]); [MEDICATION NAME] 100 mg (vitamin replacement); [MEDICATION NAME] 10 Grams per 15 milliliters (ml) solution 30 ml twice a day (reduces blood ammonia level); [MEDICATION NAME] 500 mg 1 tablet twice a day (for [MEDICAL CONDITION]); [MEDICATION NAME] 5 percent patch apply 1 patch per day (for pain); [MEDICATION NAME] 25 mg 1 tablet twice per day (for lowering blood pressure); [MEDICATION NAME] Extended Release 1200 mg 1 tablet twice per day (for congestion); [MEDICATION NAME] 150 mg tablet 1 tablet twice per day (for reflux disorder); [MEDICATION NAME] inhaler 2 puffs by mouth twice per day; [MEDICATION NAME] 10 mg capsule 1 three times per day (for anxiety disorder); [MEDICATION NAME] 100 mg 1 tablet at bedtime (antipsychotic medication); [MEDICATION NAME] 2.25 inhale contents of one vial by mouth per nebulizer every 4 hours as needed for breathing; [MEDICATION NAME] 2.5-0.5 mg per 3 ml one vial by mouth per nebulizer every 6 hours as needed for wheezing and [MEDICATION NAME] HFA 90 micrograms inhale 1-2 puffs by mouth as needed for wheezing. Review of a document signed by Licensed Practical Nurse (LPN) #4 and Resident #123, dated 2/13/18 at 11:00 AM, revealed the resident acknowledged the receipt of the following medications, at the hotel, from the facility: [MEDICATION NAME] 10 Gm per 15 ml-1 whole bottle, and 1/2 bottle; iprat-albut nebs-1 box (to be used for respiratory treatments with nebulizer); asthmanefrin inhale-1 box (to be used for respiratory treatments with nebulizer); [MEDICATION NAME] 500 mg-27 tablets and [MEDICATION NAME]-12 patches. Interview with NP #1 on 3/7/18 at 9:50 AM, in the conference room, confirmed she wrote the 2/9/18 discharge orders for Resident #123. Continued interview revealed his order for oxygen was PRN (as needed) in the nursing home. Interview continued and revealed the order she wrote on 2/9/18 for an overnight pulse ox test was to evaluate the resident's oxygen levels and see if he would qualify for oxygen. Interview with the Interim Administrator and the SSD on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 had filed an appeal on 1/3/18 of the Involuntary Discharge Notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview with the Interim Administrator and the SSD on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM, after the resident's discharge, .I gave her his hotel room number . Interview continued and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed on 2/12/18 the SSD became aware the medications had not been delivered to the resident. Continued interview confirmed the SSD and LPN #4 had delivered some of Resident #123's prescribed medications remaining at the Long Term Care facility to the resident at his hotel room on 2/13/18. Interview with the van driver on 3/19/18 at 12:10 PM, in room [ROOM NUMBER], confirmed he transported Resident #123 to the hotel on 2/9/18. Continued interview revealed he transported him .in the 2 o'clock (2:00 PM) hour .helped him put his stuff in the room .he stayed in the his wheelchair the whole time .he (the resident) asked me what was going to happen to him .when I got off work, I took him a (name of fast food) meal .I knew if I had been in that situation I would appreciate it . Interview with LPN #5 on 3/19/18 at 5:50 PM, in room [ROOM NUMBER], revealed, .Me and him (Resident #123) got along quite well .He could do everything for himself .he said often to me that he was forgetful .sometimes he would come to me for his meds (medications) after he had forgotten his meds had been taken . Continued interview revealed LPN #5 answered No to the question of whether Resident #123 could manage his medications on his own. Interview with LPN #6 on 3/19/18 at 6:30 PM, in room [ROOM NUMBER], revealed, .Always complained of not being able to breathe .would forget when he had his inhalers . Continued interview revealed LPN #6 answered No to the question of whether Resident #123 could manage his own medications. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not made aware Resident #123 was being discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds on Monday when I was there (at the Long Term Care facility .I was there about 9:00 AM .the sister paid for another night at the hotel . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18) .I just started 1/29/18. Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Telephone interview with the Choices Transition Coordinator on 3/20/18 at 1:30 PM revealed the Coordinator learned Monday evening (3/12/18) from an Ombudsman about Resident #123's discharge and stated, I called him Tuesday morning (3/13/18) at the hotel and he (Resident #123) told me, 'in contact with .state legal people' .he told me his last meal was Friday evening .and that he didn't have his meds .he was anxious about what would happen next . Interview with Resident #123's attending physician on 3/20/18 at 5:00 PM, in room [ROOM NUMBER], revealed she was aware of an ongoing plan for (Resident #123) to be discharged to a local area group home in the near future. Continued interview revealed she was not consulted prior to the discharge to the hotel on 2/9/18, but was notified later. Further interview revealed the resident had impulse control problems and failed a gradual dose reduction of [MEDICATION NAME] . Continued interview revealed he needed the psychoactive medications to help him maintain control. (Note: The resident did not have prescribed psychoactive medications of [MEDICATION NAME] at bedtime (from the evening of 2/9/18-2/13/18, [MEDICATION NAME] 3 times a day (from the evening of 2/9/18-2/13/18), or [MEDICATION NAME] each morning (from 2/10/18-2/13/18). Telephone interview with Resident #123 on 3/20/18 at 8:10 PM revealed he had difficulty maintaining focus on the immediate events before and after his discharge on 2/9/18 to the hotel room. At the beginning of the interview, he stated, I have difficulty with days of the week and dates .ever since they put three holes in my head for surgery. Continued interview revealed, They told me get your stuff ready .you will be leaving here .they already had my stuff packed .I thought my meds were packed up .they didn't ask me about a pharmacy, I would have used (name of his previous pharmacy) .at the hotel I went twice to the main office and asked for a phone and didn't get one . Further interview related to food revealed Resident #123 stated he had 1 meal on Friday night and 2 boxes of peanut butter crackers and some candy to eat for the following 3 days. Further interview included a question of whether he went to the breakfast the hotel provided and he responded, .that continental breakfast .stale rolls, I didn't go back . Continued interview revealed, Don't know how the people knew to come and get me (referring to group home personnel). Further interview confirmed he did not have his medications after he was discharged to the hotel and revealed, .my thinking was off. Interview with LPN #4 on 3/21/18 at 8:10 AM, in front of the 200 hall nursing station, confirmed the medications for Resident #123's nebulizer treatments were not provided to him before 2/13/18 when she and the SSD took the medications remaining at the facility to his hotel room, which included 2 medications for respiratory treatments with a nebulizer, an anti-[MEDICAL CONDITION] medication, a medication to lower ammonia level in bloodstream, and [MEDICATION NAME]es for back pain. Interview with LPN #3 on 3/21/18 at 9:45 AM, in room [ROOM NUMBER], revealed, .I guess between 9 and 10 (9:00 AM to 10:00 AM) when (SSD) came to me and asked me to find a PCP and pharmacy for him (Resident #123) .I did try to find a pharmacy that would deliver .Honestly, (SSD) came up with (name of pharmacy) .I went over his meds with him .he came back and asked me to go over his meds with him a second time .he did get forgetful .about whether or not he had taken his meds (medications) and I would jog his memory. Telephone interview by phone with the Advanced Practice Nurse (APN) on 3/21/18 at 11:37 AM revealed the APN stated the psychologist in her practice co-treated Resident #123. Further interview revealed, .he had a negative thought process .impatient .he instigated, argued .I can remember at some points thinking he could be at home and at other times thinking not so much .impulsiveness .didn't think about consequences . Telephone interview with the durable medical equipment (DME) oxygen supplier on 3/21/18 at 11:48 AM revealed, .provided him (Resident #123) with a nebulizer on 2/9/18 .didn't run an O2 sat (saturation) overnight, did not receive an order for [REDACTED]. Telephone interview with the Legal Aid Attorney on 3/21/18 at 5:05 PM, .first actual contact was on 2/12/18 when I heard the voice mail his (Resident #123's) sister had left me on Friday (2/9/18) .she said the facility called her around 4:00 PM after the resident had already been discharged to the hotel .I went to the hotel on Monday morning (2/12/18) and he didn't have a good memory and seemed extremely distressed, especially about what was going to happen to him and about not having his medications . In summary, Resident #123 had an involuntary discharge from the nursing facility, planned and executed on the day of 2/9/18. The attending Physician and Medical Director were not consulted prior to the discharge. The facility paid for 3 nights at the hotel over the weekend (Friday, Saturday, Sunday). By the time the family was notified, Resident #123 had already been discharged to the hotel and plans for more appropriate living arrangements could not be pursued prior to the opening of business on Monday, 2/12/18 . The facility had not ensured the resident received his medications. The facility had not made any arrangements for meals, and did not know if the resident had funds to purchase meals. The facility failed to ensure the resident had a working phone. The facility Interim Administrator and SSD had not contacted anyone in the Choices program who was able to pursue alternative living arrangements. The facility was not aware of the resident not having a working phone and not receiving his medications from the pharmacy until the Ombudsman's visit to the facility on [DATE] at 9:00 AM. The facility had made no plans to check on the resident's wellbeing and did not visited the resident until 2/13/18, when the SSD and LPN #4 delivered some medications to the resident. Refer to F622, F623",2020-09-01
796,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,745,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility record review, and interview, the facility failed to ensure the Social Services Director fulfilled their duties and responsibilities when a resident was discharged , during the appeal process for an involuntary discharge of 1 resident (#123), of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in the discharge of Resident #123 to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The facility was cited F 745 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Social Progress Note by the SSD dated 12/29/17 revealed, Received phone call from Choices (State Medicaid program) case manager asking why (Resident #123) had been issued 30 day notice. I told her it was rule violation (smoking). She stated she was getting ready to call (Resident #123's) sister .Spoke with her again later and was advised (sister) is going to start hunting place . Review of a Social Progress Note by the SSD dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator) for update. He said he would set up transportation for resident to look at house and meet roommates next week. Interview with the Interim Administrator and the SSD (Social Services Director) on 3/7/18 at 10:50 AM, in the Social Services office, revealed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge issued 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM of the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party. Continued interview revealed the facility paid for 3 nights in a hotel (Friday, Saturday, and Sunday from 2/9/18-2/11/18). Further interview revealed .the hotel provided a phone and complimentary breakfast meal. Continued interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Further interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident and the SSD had not known this prior to the Ombudsman's visit on 2/12/18. Further interview confirmed the Choices Transition Coordinator (State Medicaid Care Coordinator) had not been contacted on 2/9/18 with information of the resident's impending discharge. Continued interview revealed the facility had not made a plan to check on the resident's wellbeing and did not visit the resident until 2/13/18, when the SSD and LPN #4 delivered some medications to the resident. Interview with the SSD on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed she had been in her position at the facility for [AGE] years. Continued interview confirmed she had not made contacts with other facilities in an effort to seek placement for Resident #123 after the 30 day notice was issued and revealed, .it was up to Choices . Interview continued and the question of why Choices was not contacted on 2/9/18, was asked and revealed, .something that didn't even come to mind. Refer to F622, F624",2020-09-01
797,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,835,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of facility records, medical record review and interview, the Administrator failed to provide adequate oversight for 1 resident (#123) discharged during an appeal process of an involuntary discharge of 3 residents reviewed for discharge. The Administrator's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Review of the Nurse Practitioner's progress note dated 2/9/18 revealed, .I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident had been discharged , and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident. Further interview confirmed the SSD and Licensed Practical Nurse (LPN) #4 had taken some of the prescribed medications that remained at the Long Term Care facility to the resident's hotel room on 2/13/18. Further interview confirmed the Choices (part of the state medicaid program) Transition Coordinator had not been contacted on 2/9/18 with information of the resident's impending discharge. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed the prior Administrator had not provided documentation of notification to the Long Term Care Ombudsman of the Notice of Involuntary Discharge issued to Resident #123 on 12/21/17. Continued interview confirmed the current Interim Administrator and the SSD had not notified the Ombudsman of the Notice of Involuntary Discharge, the pending appeal, or of the resident's discharge on 2/9/18 to a hotel room. Interview with the Interim Administrator on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed she began working at the facility on 1/29/18. Interview continued and in response to why the documented every 15 minute checks on Resident #123 began on 1/21/18, had ended on 1/30/18, she responded, First I have heard of every 15 minute checks . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy. I don't know if I would have discharged him but he refused to give me the matches or lighter and he refused to give them to either of us (reference to the SSD) .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview continued and the Interim Administrator responded to the question of why the Commissioner's Designee was not informed of the impending discharge, she replied, I am not required to contact them . Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-837 (J), and F-867 (J).",2020-09-01
798,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,837,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility records and interview, the Governing Body failed to ensure the facility followed the discharge policy to develop a safe and orderly discharge for 1 resident (#123) of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Interview with the Interim Administrator and the Social Services Director (SSD) in the Social Services office on 3/7/18 at 10:50 AM, revealed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge issued 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party. Continued interview revealed the facility paid for 3 nights in a hotel (Friday, Saturday, and Sunday from 2/9/18-2/11/18). Further interview revealed .the hotel provided a phone and complimentary breakfast meal. Continued interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed the medications had not been delivered to the resident, and the facility did not know this prior to the Ombudsman's visit on 2/12/18. Continued interview revealed the facility had not made a plan to check on the resident's wellbeing. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not aware Resident #123 was discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to (the facility's proper name) .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds . Interview with the Supervisor Administrator on 3/21/18 at 3:00 PM, in room [ROOM NUMBER], revealed the Supervisor Administrator provided oversight of the facility as needed. Continued interview with concurrent review of the organizational chart revealed the Supervisor Administrator reported directly to the President of the Governing Body. Further interview revealed the Supervisor Administrator was not onsite on 2/9/18 and did not have full knowledge of the circumstances of Resident #123's discharge, and stated .I didn't know he didn't have his medications . In summary, Resident #123 had a discharge from the nursing facility planned and executed on the day of 2/9/18. The attending physician and Medical Director were not consulted prior to Resident #123's discharge to a hotel room. The facility paid for 3 nights over the weekend (Friday, Saturday, Sunday). By the time the family was notified, Resident #123 had already been discharged to the hotel and plans for more appropriate living arrangements could not be pursued prior to the opening of business on Monday, 2/12/18 . The facility had not ensured the resident received his medications. The facility had not made any arrangements for meals, and did not know if the resident had funds to purchase meals. The facility failed to ensure the resident had a working phone. The facility Interim Administrator and SSD had not contacted anyone in the Choices program who was able to pursue alternative living arrangements. The facility did not become aware of the resident not having a working phone and not receiving his medications from the pharmacy until the Ombudsman's visit to the facility on [DATE] at 9:00 AM. The facility had made no plans to check on the resident's wellbeing and had not visited the resident until 2/13/18, when the SSD and Licensed Practical Nurse (LPN) #4 delivered some medications to the resident at the hotel. Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-835 (J) and F-867 (J).",2020-09-01
799,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,867,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility's profile, facility's policy, review of the Quality Assurance Performance Improvement (QAPI) committee monthly meetings, and interview, the QAPI committee failed to ensure sustained compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities by identifying issues and implementing a corrective action plan with monitors to ensure the adverse event of an Involuntary Discharge Notice, issued 12/21/17, was appropriate and acceptable as a safe discharge. The QAPI committee failed to identify the untoward outcomes and take corrective action related to the unplanned discharge, which took place during the appeals process, and resulted in an unsafe discharge for 1 resident (#123) of 3 residents reviewed for discharge. The failure of the QAPI committee to ensure a safe and orderly discharge resulted in Resident #123's discharge to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of the facility profile revealed the facility had a Federal recertification survey on 12/7/16 and was cited Immediate Jeopardy for the following: 483.10 - Notification of Changes for failure to notify the Physician of the presence of 2 pressure ulcers; 483.12 - Freedom from Abuse, Neglect, and Exploitation for failure to prevent abuse, neglect, report allegations, and complete thorough investigations of allegations. 483.21 - Comprehensive Resident Centered Care Plans for failure to revise the care plan. 483.25 - Quality of Care for failure to provide wound assessment and treatment for [REDACTED]. 483.24 - Quality of Life for failure to provide timely incontinence care. 483.35 - Nursing Services for failure to ensure adequate staffing to provide necessary personal care assistance and incontinence care in a timely manner. 483.70 - Administration, Governing Body, and Medical Director for failure to provide oversight of the facility in a manner to ensure residents attain the highest practicable well-being possible. 483.75 - Quality Assurance and Performance Improvement (QAPI) for failure to ensure the QAPI committee identified issues, implemented corrective action plans when needed, monitored and enforced facility policy. The facility was entered into the Special Focus Facility Program on 3/20/17. Review of the facility's policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Review of the QAPI committee monthly meetings from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the Administrator, the Medical Director, and the Social Services Director were all members of the committee and present at the meetings. Further review revealed the last meeting of the committee submitted for review by the survey team was 12/12/17. Review of the facility's document, Notice of Involuntary Discharge, revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Medical record review of the Attending Physician's History and Physical dated 1/5/18 revealed, .he (Resident #123) has been followed by psych (psychiatric services) and requires [MEDICATION NAME] (antipsychotic medication) to try to prevent mood swings .he continues to smoke. He has been caught smoking in his room twice, and he was given a 30 day notice of discharge about 2 weeks ago due to this issue . Review of a Social Progress Note by the SSD dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator-State Medicaid program) for update. He (Transition Coordinator) said he would set up transportation for resident to look at house and meet roommates next week. Medical record review of the Nurse Practitioner's (NP) progress note dated 2/9/18 revealed, .I am seeing pt (patient) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Interview with the Interim Administrator and the Social Services Director (SSD) in the Social Services office on 3/7/18 at 10:50 AM, confirmed Resident #123 filed an appeal on 1/3/18 of the Involuntary Discharge Notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he (Resident #23) would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview on 3/7/18 at 10:50 AM, in the Social Services office revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM, after the resident's discharge, .I gave her his hotel room number . Interview continued and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed on 2/12/18 the SSD became aware the medications had not been delivered to the resident. Continued interview confirmed the SSD and Licensed Practical Nurse #4 had delivered some of Resident #123's prescribed medications remaining at the Long Term Care facility to the resident at his hotel room on 2/13/18. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not made aware Resident #123 was being discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds on Monday when I was there (at the nursing home) .I was there about 9:00 AM .the sister paid for another night at the hotel . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18) .I just started 1/29/18. Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview with the Medical Director on 3/20/18 at 4:00 PM, in room [ROOM NUMBER], revealed he did not know of the 2/9/18 discharge prior to Resident #123's being discharged to a hotel room, I wasn't called .I knew there was a dust up or whatever because of smoking. Continued interview revealed he did not know until 3/20/18 the resident did not have his meds at discharge, I didn't know he didn't have his meds for those days. Continued interview revealed, I didn't know about Choices planning a transfer. Continued interview revealed the involuntary discharge notice of 12/21/17 had not been addressed by the QAPI committee as an adverse event. The QAPI committee did not convene to identify the cause and take corrective action when the facility failed to ensure a safe and orderly discharge for Resident #123 resulting in Immediate Jeopardy. Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-835 (J) and F-837 (J).",2020-09-01
814,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-02-23,656,D,1,0,42HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to develop a plan of care to address moods for 1 of 7 samples residents (Resident #6). Findings include: Review of the undated facility policy MDS/Care Plans revealed .The facility must develop a comprehensive care plan to meet a resident's .needs . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; Brief Interview for Mental Status (BIMS) was 13/15, indicating he was cognitively intact, and exhibited little interest, feeling down/depressed, tired, and change of appetite for 2-6 days of the review period. Medical review of the Quarterly MDS dated [DATE] revealed the BIMS score of 14/15; and exhibited feeling down/depressed for 2-6 days of the review period. Medical record review of the care plan with completion date of 11/30/17 and revised in 1/19/18 revealed feeling down/depressed and tired were not addressed. Interview with the Registered Nurse (RN) #1/ MDS Coordinator on 2/21/18 at 8:45 AM in the conference room confirmed the care plan with completion date of 11/30/17 failed to address the resident was down/depressed and tired. Further interview confirmed the care plan with the completion date of 1/19/18 failed to address feeling down/depressed.",2020-09-01
815,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-02-23,657,D,1,0,42HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to timely revise a plan of care to address manipulative behaviors for 1 of 7 samples residents (Resident #6). Findings include: Review of the undated facility policy MDS/Care Plans revealed .The facility must develop a comprehensive care plan to meet a resident's .needs .are reviewed and/or revised . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; Brief Interview for Mental Status (BIMS) was 13/15, indicating he was cognitively intact; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited little interest, feeling down/depressed, tired, change appetite for 2-6 days of the review period. Medical review of the Quarterly MDS dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; BIMS score of 14/15; exhibited feeling down/depressed for 2-6 days of the review period; and exhibited no [MEDICAL CONDITIONS], or behaviors. Medical record review of facility documentation dated 1/31/18 revealed Resident #6 informed Certified Nurse Aide (CNA) #3 of CNA #1 got in bed with Resident #6 on 1/30/18. Further facility documentation review revealed the resident had made a false accusation. Medical record review of the care plan dated 2/12/18 revealed on a problem was initiated addressing the resident .exhibiting behavior symptoms as making false accusations toward staff while providing care and being manipulative toward staff when providing care . The approaches dated 2/12/18 included .Acknowledge resident feelings & (and) try to negotiate an agreement to stay until all concerned parties can be brought together to satisfactorily strategize the resident's needs; Document behaviors. Attempt to identify pattern to target interventions; Staff will enter (resident's) room with two people to provide care due to making false allegations . The approach dated 2/16/18 revealed .Will be refer to psych (psychiatric) for evaluation . Interview with the Registered Nurse (RN) #1/MDS Coordinator on 2/21/18 at 8:45 AM in the conference room revealed the comprehensive care plan and the Certified Nurse Aide (CNA) Bedside Care Plans, addressing resident care and needs, were updated with any new concerns or interventions. Further interview confirmed the facility failed to timely revise the care plan after the false allegation and manipulation of staff was reported on 1/31/18. Interview with the Social Worker (SW) on 2/21/18 at 9:32 AM in the conference room confirmed the SW was responsible to address behaviors on the MDS and the care plan. Further interview confirmed the facility failed to timely revise the care plan after the resident's false allegation and manipulation of staff was reported on 1/31/18. Interview with the Administrator on 2/21/18 at 10:52 AM in the conference room confirmed the facility failed to revise the care plan timely after the event was reported on 1/31/18.",2020-09-01
839,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,550,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility video footage review, and interview the facility failed to ensure 1 resident (Resident #2) of 3 residents reviewed was treated with respect, dignity, and quality of life when restrained with a gait belt to his wheelchair. The findings include: Review of the facility policy, Abuse, Neglect and Exploitation of Residents, undated, revealed .It is the policy of the facility that the acts of abuse directed against residents are absolutely prohibited .unlawful restraint is intentionally or knowingly using a physical or chemical restraint . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Medical record review of Resident #2's (MONTH) 2019 Order Summary Reports revealed no order for a restraint. Review of the facility's video footage on 5/2/19 and interview with the Administrator on 6/11/19 at 11:52 AM in the conference room confirmed the Alleged Perpretrator (AP) restrained Resident #2 to his wheelchair by putting a gait belt around his chest and fastening the gait belt to the back of the wheelchair, restraining Resident #2 in his wheelchair. Interview with the Administrator revealed the AP, Certified Nursing Assistant (CNA) #3 and CNA #4 were identified by the Administrator on the video footage. Further review of the facility's video footage revealed CNA #4 was standing at the nurses station facing the AP and Resident #2 and it appeared that CNA #3, wearing a pink shirt, was in the sideline of the camera then CNA #3 walked by the AP and Resident #2 after the gait belt was applied. Further review revealed the facility's video footage did not show removal of the gait belt. Interview with the Administrator revealed the video footage containing conversation between the Respiratory Therapist (RT) and Resident #2 was unavailable due to the system rolls over video footage after 14 days, and some video footage is self-erased. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed the DON was informed of the abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continued interview revealed by the time the DON informed the Administrator, the Respiratory Therapist (RT) had already reported it to the Administrator. Continued interview revealed when asked when staff were to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was notified on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being restrained in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed she stated, RT (#1) reported to me that (Resident #2 ) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured to the wheelchair; I went immediately and assessed Resident #2 and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 stated, I reported to the Director of Nursing around 8:30 AM the RT witnessed Resident #2 being in a wheelchair with a gait belt around his chest, secured (restrained) to the wheelchair. Interview with RT #1 on 6/11/19 at 1:15 PM in the conference room revealed on arrival to the facility on [DATE] around 5:30 AM she observed Resident #2 sitting in a wheelchair yelling come here. and look what that [***] did to me. RT #1 stated the resident had a gait belt around the upper part of the chest, attached to the wheelchair, and fitted snugly against the resident's chest. Continued interview revealed RT #1 reported what she saw to the Administrator around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told (LPN #5) as soon as she got here. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident on 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was completed and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
840,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,604,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of the facility investigation, medical record review, facility video footage review and interview the facility failed to ensure 1 resident (Resident #2) of 3 residents was free from the use of restraints related to Resident #2 being restrained with a gait belt to his wheelchair. The findings include: Review of the facility policy, Use of Restraints, undated, revealed .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted . Review of facility policy, Gait Belts, undated, revealed .Gait belts must be used by all Therapy Rehabilitation staff during balance activities, transfers, and gait training of patients to promote safety during therapeutic activities, unless contraindicated . Review of the facility investigation revealed an investigation was started on 5/2/19 related to allegation of abuse by the alleged perpertrator (AP) to Resident #2. Continued review revealed initial written statements were obtained from the Respiratory Therapist (RT #1) Certified Nurse Aide (CNA) #3 and CNA #4. Further review revealed RT #1's initial written statement revealed I walked over to 2A's nsg (nursing) station at approximately 04:45 to discuss this [MEDICAL CONDITION] Care. As I arrived in the common area, I saw the Resident (#2) sitting in his wheelchair. He was secured (restrained) to the chair with a pink and grey gait belt. The belt was wrapped around the Resident (#2's) chest and the wheelchair. I talked briefly with him. He said the word [***] and motioned his hand as he pointed to the nurses station. When I looked at the nursing station the AP was the only person sitting there. The gait belt was obviously tightly secured because he could not lift his back off of the back of the wheelchair. Continued review of CNA #4's statement revealed I would like to see the video footage because I don't remember seeing any resident being abused while I was working 2A on 5/2/19. Further review revealed CNA #3's statement revealed I don't know really when I came out (of) the room (Resident #2) was already in the chair strapped in. Continued review revealed the initial statement for the AP dated 5/6/19 revealed .there was no intent of abuse .it was placed for his safety . Further review revealed the AP received abuse training upon employment with the facility on 8/22/18. Continued review revealed the AP's employment was terminated on 5/6/19. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Medical record review of Resident #2's Order Summary Report dated (MONTH) 2019 revealed no order for a restraint. Review of the facility's video footage on 5/2/19 with the Administrator on 6/11/19 at 11:52 AM in the conference room confirmed the AP restrained Resident #2 to his wheelchair at approximately 4:39 AM by putting a gait belt around his chest and fastening the gait belt to the back of the wheelchair, restraining Resident #2 in his wheelchair. Interview with the Administrator revealed the AP, CNA #3 and CNA #4 were identified by the Administrator on the video footage. Further review of the facility's video footage revealed CNA #4 was standing at the nurses station facing the AP and Resident #2 and it appeared that CNA #3, wearing a pink shirt, was in the sideline of the camera then CNA #3 walked by the AP and Resident #2 after the gait belt was applied. Further review revealed video footage did not show removal of the gait belt. Interview with the Administrator revealed the video footage containing conversation between RT #1 and Resident #2 was unavailable due to the system rolls over video footage after 14 days, and some video footage is self-erased. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed she was informed of the alleged abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continue interview revealed by the time the DON informed the Administrator, RT #1 had already reported it to the Administrator. Continued interview when asked when staff were to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was informed on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being restrained in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed, she stated, the RT (#1) reported to me that (Resident #2) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured to the wheelchair; I went immediately and assessed Resident #2 and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 revealed I reported to the DON around 8:30 AM RT #1 witnessed (Resident #2) being in a wheelchair with a gait belt around his chest, secured to the wheelchair. Interview with the RT #1 on 6/11/19 at 1:15 PM in the conference room revealed she reported for work on 5/2/19 around 5:30 AM to educate the night shift nurses on [MEDICAL CONDITION] care. Continued interview revealed when she went to station 2A around 5:45 AM and she observed Resident #2 sitting in a wheelchair with his back facing the nurses station. Resident #2 hollered (yelled) come here and motioned for RT #1 to come over to him. RT #1 went over to Resident #2 and he pointed at a gait belt that was around his chest, and said look what that [***] did to me, pointing toward the nurses station where the AP was sitting. Further interview revealed, when asked how was the gait belt placed on Resident #2 she confirmed the gait belt was around the upper part of Resident #2's chest snugly, and attached to the wheelchair. When asked to explain snuggly, RT #1 replied, he could not raise his back off the back of the wheelchair. Continued interview revealed RT #1 went inside the nurses station and spoke to the AP related to the training she was doing and the AP spoke hatefully saying, I don't have time to do the training. RT #1 left nurses station 2A and went to the 400 hall. Further interview revealed RT #1 reported her observation of Resident #2 with a gait belt around his chest restraining Resident #2 to his wheelchair to LPN #5 (Unit Manager for 200 Hall) when she (LPN #5) arrived at the facility at 7:30 AM. Continued interview revealed RT #1 reported her observation of Resident #2 in his wheelchair with a gait belt around his chest to the Administrator during the morning stand up meeting around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told ( LPN #5) as soon as she got here. Telephone interview with CNA #3 on 6/12/19 at 7:25 AM revealed she has been employed with the facility since (MONTH) (YEAR) and usually worked station 2A, the secured unit. Continued interview revealed CNA #3 was trained on abuse upon hire and quarterly. Further interview revealed CNA #3 named the types of abuse and had never suspected or witnessed abuse and would report suspected or witnessed abuse immediately to the supervisor and the DON. Continued interview when asked if she ever witnessed abuse, stated No I've never witnessed abuse, when they (Administrator and DON) called me and asked me about the (AP) securing (restraining) (Resident #2), I told them that I didn't know what they were talking about and I never seen anything, I even wrote a statement saying I never seen nothing. Further interview revealed CNA #3 was again questioned about observing abusive behavior toward residents, CNA #3 stated, I have never seen nobody being abused when I've worked. Telephone interview with CNA #4 on 6/12/19 at 8:17 AM revealed she has been employed with the facility for one year and usually worked on station 2A, the secured unit. Continued interview revealed CNA #4 received training on abuse upon hire during orientation and every month. CNA #4 named the types of abuse and would report suspected or witnessed abuse immediately to the supervisor. Further interview revealed CNA #4 had never observed any resident being abused while working at the facility. CNA #4 stated she had worked with the AP and had never observed her abuse any resident. Continued interview when asked if she recalled Resident #2 being restrained by the AP she stated I never saw him (Resident #2) with a gait belt on him, I only saw him sitting in the wheelchair. Further interview revealed CNA #4 was again questioned about observing abusive behavior toward residents with same answer given as stated above. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident of 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. The disciplinary action was completed on 5/6/19. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was done and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
841,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,609,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, employee files and interviews the facility failed to follow the facility policy related to reporting abuse immediately to the supervisor. The findings include: Review of the facility policy, Abuse, Neglect and Exploitation of Residents, undated, revealed .It is the policy of the facility that acts of abuse directed against residents are absolutely prohibited .All personnel (including volunteers) in all departments will be alert to indicators of suspected or actual abuse, neglect and exploitation. The resident is assisted to safety and is protected against (further) harm, and if abuse is suspected, personnel will report their observations to their supervisor immediately and without delay . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Review of the facility investigation and a Respiratory Therapist (RT #1) initial written statement dated 5/2/19 revealed I walked over to 2A's nsg (nursing) station at approximately 4:45 AM to discuss this [MEDICAL CONDITION] Care. As I arrived in the common area, I saw (Resident #2) sitting in his wheelchair. He was secured (restrained) to the chair with a pink and grey gait belt. The belt was wrapped around (Resident #2's) chest and the wheelchair. I talked briefly with him. He said the word '[***] ' and motioned his hand as to point to the nurses station. When I looked at the nsg station the (AP) was the only person sitting there. The gait belt was obviously tightly secured because he could not lift his back off of the back of the wheel chair. Review of the RT #1's employee file on 6/12/19 revealed RT #1 received training on abuse and reporting abuse upon hire in (MONTH) 2019. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed the DON was informed of the alleged abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continued interview revealed by the time the DON informed the Administrator, the RT #1 had already reported it to the Administrator. Continued interview when asked when staff are to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was informed on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being secured (restrained) in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview with the RT #1 on 6/11/19 at 1:15 PM in the conference room revealed she reported for work on 5/2/19 around 5:30 AM to educate the night shift nurses on [MEDICAL CONDITION] care. Continued interview revealed when she went to station 2A around 5:45 AM and she observed Resident #2 sitting in a wheelchair with his back facing the nurses station. Resident #2 hollered (yelled) come here and motioned for the RT (#1) to come over to him. RT #1 went over to Resident #2 and he pointed at a gait belt that was around his chest, and said look what that [***] did to me, pointing toward the nurses station where the (AP) was sitting. Further interview, when asked how was the gait belt placed on Resident #2 she confirmed the gait belt was around the upper part of Resident #2's chest snuggly, and attached to the wheelchair. When asked to explain snugly, RT #1 replied, he could not raise his back off the back of the wheelchair. Continued interview revealed RT #1 went inside the nurses station and spoke to the AP related to the training she was doing and the AP spoke hatefully saying, I don't have time to do the training. The RT left nurses station 2A and went to the 400 hall. Further interview revealed the RT reported her observation of Resident #2 with a gait belt around his chest securing (restraining) Resident #2 to his wheelchair to LPN #5 (Unit Manager for 200 Hall) when she (LPN #5) arrived at the facility at 7:30 AM. Continued interview revealed RT #1 reported her observation of Resident #2 in his wheelchair with a gait belt around his chest to the Administrator during the morning stand up meeting around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told (LPN #5) as soon as she got here. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed she stated, the (RT #1) reported to me that (Resident #2) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured (restrained) to the wheelchair; I went immediately and assessed (Resident #2) and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 revealed I reported to the DON around 8:30 AM (RT #1) witnessed (Resident #2) being in a wheelchair with a gait belt around his chest, secured to the wheelchair. Validation of the IJ removal plan to remove the IJ was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident of 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was done and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
842,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,689,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview the facility failed to prevent elopement from the facility to the facility parking lot for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of facility policy, Elopements, revealed .when a departing individual returns to the facility the Director of Nursing Services or Charge Nurse shall .complete and file Report of Incident /Accident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an annual Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 8 indicating moderate cognitive impairment. Medical record review of an elopement risk evaluation dated 4/22/19 revealed a score of 9 (9 or greater indicated a risk of elopement). Continued medical record review of an elopement risk evaluation dated 5/18/19 revealed a score of 21. Further review of the medical record revealed Resident #1 was care planned for wandering and exit seeking. Interview with the Director of Nursing (DON) on 6/11/19 at 8:40 AM in the conference room revealed video footage of Resident #1's elopement on 5/17/19 was reviewed. Continued interview confirmed the DON stated the video showed the resident pushing open the door (key pad coded) and self-propelling from inside the facility to outside the facility. Further interview revealed the video footage was no longer available due to the facility video system auto-erasing every 14 days. The DON confirmed an investigation was not done for Resident #1's elopement on 5/17/19. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/19 at 12:10 PM in the Unit Manager's office revealed Resident #1 self-propelled from the resident's room to the rehabilitation (rehab) unit as he desired. Continued interview with LPN #1 revealed the resident had a pattern of going to the rehab unit most everyday. Further interview with the LPN revealed when the station 3 nursing staff could not locate the resident they would look in the rehab unit. LPN #1 confirmed the resident had exit seeking behaviors. Interview with LPN #3 on 6/11/19 at 4:35 PM in the conference room revealed as she was leaving the facility on 5/17/19 at approximately 7:00 PM she observed an empty wheelchair with a person sitting by a truck, on his butt, on the asphalt and touching the truck. Continued interview revealed she observed the person as was Resident #1. Further interview revealed the resident stated he was working on this truck; I've been meaning to get to it all day. LPN #3 did a quick assessment of Resident #1 for injuries as she used her cellular phone to call the nursing staff for assistance with the resident. Continued interview revealed LPN #3 was told by Resident #1 he was unsure how he got outside. Interview with the Administrator on 6/12/19 at 9:05 AM in the conference room revealed the video footage from 5/17/19 was auto-erased by the video program system. Continued interview revealed the Administrator gave a description of the video to this surveyor. Further interview revealed the Administrator stated Resident #1 was seen rounding the corner of the hall into the area in front of the door #13 (key pad coded). The Administrator confirmed the resident was seen on the video to push open the door and self-propel himself outside. Continued interview confirmed Resident #1 was unable to be seen on the video in the parking lot. Further interview confirmed the video monitor for the facility was not watched 24/7. The Administrator confirmed the time frame Resident #1 was out of the building was unknown. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Resident #1 was returned to the facility and the facility policy for elopement appropriately followed as evidenced by nursing progress notes, event notes and staff interviews. The resident was checked every hour by physician's orders [REDACTED]. 2. In-service education was provided 5/20/19 for wandering and elopement as evidenced from sign-in rosters and staff interviews. Daily door audits were initiated 5/20/19 and performed by the department heads. Audits were ongoing every shift for 2 weeks then weekly for 3 months. Key pad coded doors (4) in the rehab unit were scheduled for installation of alarms the week of 6/17/19. 3. Resident assessments were checked for current status to match condition on 6/12/19 and performed by the DON and nursing staff. The maintenance director will continue daily door audits for proper operation for an additional 2 weeks and then resume daily audits. 4. Presentation of all audits by the DON and maintenance director to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
845,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-09-13,226,E,1,0,DOIC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview, the facility staff failed to report bruises, injury of unknown origin, to the administrative staff for 2 residents (#1, #2) of 3 residents reviewed with bruising. The findings included: Review of facility policy, Accidents and Incidents, revised (MONTH) 2011 revealed .All accidents or incidents involving residents .occurring on our premises shall be invested and reported to the Administration .The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident .The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] and 8/17/17 revealed Resident #1 had moderate difficulty with hearing, clear speech, could make self understood and usually understood others; was moderately cognitively impaired, had no [MEDICAL CONDITION], mood, [MEDICAL CONDITION] or behaviors; required extensive 1 person assistance with bed mobility, transfers, walking in the room, dressing, toileting, personal hygiene; balance was not steady and required staff to stabilize and had no issue with range of motion in upper and lower extremities. Medical record review of the Physician order [REDACTED].#1 received Aspirin (anti-coagulant) 81 milligrams (mg) by mouth once a day. Medical record review of the care plan initiated 11/29/16, and updated on 2/17/17, 5/25/17, and 8/24/17, revealed .Problem .Requires staff assist with toileting needs for safety and hygiene purposes, communicates needs for toileting, is at risk for skin alteration r/t (related to) presence of frail/fragile skin .Interventions .Assess skin daily during routine care for redness, shearing, blisters, or open areas . Further review revealed the .Problem .Potential for abnormal bleeding/bruising, clotting r/t medication therapy. Receives ASA (Aspirin) .Interventions .Observe, document, and report to MD/NP (Medical Doctor/Nurse Practitioner) PRN (as needed) any .bruising .Protect from injury as able . Observation and interview with Resident #1 on 9/12/17 at 12:43 PM revealed Resident #1 in her room fully reclined with feet extended in a recliner with 2 reddish purple bruises to the top of the right hand. When the resident was asked how the bruises to the right hand occurred the resident pointed to the left side of the over bed table in front of her and stated I hit it right there. Further interview revealed the resident was not sure when the bruise occurred and that she .takes Aspirin every day and bruises real easy . Interview with Registered Nurse (RN) #2 on 9/12/17 at 12:50 PM at the 100 hall nursing station, confirmed she was assigned to Resident #1 and had been on duty 1 hour due to Licensed Practical Nurse (LPN) #8, assigned to Resident #1, leaving the facility ill. Further interview revealed the RN was not aware of the bruise to the right hand. Interview with LPN #6 on 9/12/17 at 12:54 PM in the conference room revealed the LPN was the Unit Manager for Resident #1 and was not aware of the bruise on the right hand. Interview with Certified Nurse Aide (CNA) #8 on 9/12/17 at 1:05 PM outside room [ROOM NUMBER] confirmed the CNA was assigned to Resident #1. Further interview revealed the CNA was aware of the bruise at 10:30 AM on 9/12/17 when she took the resident to the bathroom. Further interview revealed she went to inform the Charge Nurse, LPN #8, but could not find him and the CNA continued with her duties. Further interview confirmed the CNA failed to report the bruise to any person in administrative capacity. Interview with Resident #1's daughter on 9/13/17 beginning at 7:55 AM in the resident's room revealed the daughter was asked regarding the right hand bruise observed on 9/12/17 when the Resident stated .I hit it there . as she pointed to the left corner of the over bed table and the daughter stated That's what she told me too but my brother saw it happen and it was in the bathroom at the sink . Interview with the Director of Nursing (DON) and the Assistant DON (ADON) on 9/13/17 at 6:00 PM in the conference room confirmed the facility staff failed to report the right hand bruise to the administrative staff timely. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #2 was highly impaired with hearing; had clear speech, sometimes could make self understood, and sometimes could understand others; had short and long term memory impairment with moderately impaired cognitive skills for daily decision making; no [MEDICAL CONDITION]; was feeling down/depressed/hopeless and tired/little energy for 2-6 days; and was physically abusive 1-3 days during the review period. Further review revealed the resident required extensive 1 person assistance with bed mobility, dressing, eating, hygiene, and extensive 2 person assistance with transfers, and toilet use. Medical record review of the care plan dated 8/11/17 revealed .Problem .Potential for abnormal bleeding or clotting r/t (related to) medication therapy, anticoagulant .Interventions .Observe, document, and report to MD/NP (Medical Doctor/Nurse Practitioner) PRN (as needed) any .bruising .Protect from injury as able . Observation on 9/12/17 at 11:58 AM revealed Resident #2 in the Memory Unit dining room in a speciality chair with a tray attached and the resident's arms, torso, head and legs were in continuous motion. Further observation revealed the left hand had a dark purple bruise on the wrist bone and another bruise on the top of the hand. Further observation revealed the right hand had a bruise at the wrist and another at the thumb joint. Further observation at 5:38 PM, with the Administrator present, revealed Resident #2 in the specialty chair on the Memory Unit by the nursing station. Interview with the Administrator on 9/12/17 at 5:38 PM on the Memory Unit by the nursing station confirmed Resident #2 had 2 bruises on each hand. Interview with LPN #3 on 9/12/17 at 5:40 PM on the Memory Unit by the nursing station confirmed Resident #2's medical record, binder with Skin Reports, and Nurse's Notes did not have documentation addressing the 4 bruise sites observed on 9/12/17. Interview with the Director of Nursing on 9/13/17 at 6:15 PM in the conference room confirmed the facility staff failed to report the 4 bruises for Resident #2 timely to the administrative staff.",2020-09-01
846,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-09-25,626,D,1,0,GEY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to document its inability to meet the resident's needs for 1 (#5) of 7 residents reviewed for Admission/Transfer/Discharge criteria. The findings include: Review of facility policy, Transfer Agreement, revised 3/2017, revealed .Our facility has a transfer agreement in place with a designated hospital should our residents need care that is beyond the scope of our available care and services .The agreement ensures that residents are transferred from the facility to the hospital and admitted in a timely manner in an emergency situation by another practitioner .The agreement specifies restrictions with respect to the types of services available and types of residents or health conditions that will not be accepted by the hospital or the facility .Inquiries related to the transfer agreement should be referred to the Administrator . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored 15 on the Brief Interview for Mental Status (BIMS) indicating he was alert, oriented, and able to make his needs known. Continued review of the MDS revealed Resident #5 was dependent on 2 people for transfers and bathing; required extensive assistance of 2 people with bed mobility, dressing, toileting, and grooming; and was frequently incontinent of bowel and bladder. Medical record review revealed multiple episodes of refusing care; yelling and cursing at staff; family trying to use a mechanical lift to transfer him without staff being present; and family bringing in medications and other materials not associated with his care. Medical record review revealed Resident #5 was sent to the hospital with unresponsiveness and the facility refused to allow him to return due to inability to meet his needs. Medical record review revealed no documentation the Ombudsman was notified of the Residents discharge. Medical record review revealed no documentation in the record of the specific needs which could not be met at the facility; attempts made by the facility to meet those needs, or the services another facility could provide. This failure of documentation was confirmed by the Administrator on 9/25/19 at 4:40 PM in the conference room.",2020-09-01
847,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,609,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record, and interview the facility failed to report an investigation for 1 resident ( #24) of 24 residents reviewed to the state agency. The findings include: Review of the facility policy revised 7/2017 Abuse Investigation and Reporting revealed .All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his /her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . Review of the facility policy dated 7/2017 Abuse Investigation and Reporting revealed .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of findings of the investigationb within 5 working days of occcureence of the incident . Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of the facility investigation dated 10/18/18 revealed there not an investigation completed. Interview with the Administrator on 11/21/18 at 3:52 PM in his office revealed Resident #24 reported an allegation of abuse. Further interview when asked why the allegation was not reported to the state agency the Administrator responded .Resident #24 told us in conversation that nurse was rough with her and then she retracted her statement . Further interview confirmed .we proceeded as an informal investigation .",2020-09-01
848,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,610,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record, and interview the facility failed to do a completed investigation for 1 resident (#24) of 24 residents reviewed for abuse. The finidings include: Review of the facility policy dated 7/2017 Abuse Investigation and Reporting revealed .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of findings of the investigationb within 5 working days of occcureence of the incident . Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Interview with the Director Of Nursing on 11/27/18 at 12:22 PM in the conference room revealed completed an informal investigation. Further interview confirmed she did not complete a formal interview because the resident retracted her statement.",2020-09-01
849,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,690,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview revealed the facility failed to have a [DIAGNOSES REDACTED].#24) of 6 with Foley catheters. The findings include: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Medical record review of the physician orders [REDACTED].Foley-insert for diuresis . Observation on 11/21/18 and 11/26/18 Resident #24 had a Foley Catheter in place. Interview Resident #24 on 11/21/18 at 3:01 PM in her room revealed she had requested for a Foley Catheter. Interview with Nurse Practitioner (NP) on 11/21/18 at 1:24 PM in the conference room revealed Resident #24 never had urine retention, and could void. Further interview confirmed it was for her comfort that is the reason for the catheter. She does not have it for [MEDICAL CONDITION] nor does she need it. It was never intended for long term use, only for a short amount of time.",2020-09-01
850,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,580,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician services of the failure to administer an as needed diuretic as ordered after a weight gain as ordered; the failure to obtain daily weights as ordered; the failure to obtain laboratory tests as ordered; and the failure to administer a daily diuretic as ordered for 1 resident (#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligrams (mg) 1 tab by po (by mouth) once every day as needed (PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling ([MEDICAL CONDITION]), or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN (every day as needed) r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in 5 days. 2. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BNP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 days was administered on 11/13/17 and 11/14/17. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight, in pounds, documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Medical record review revealed no laboratory test results for 10/10/17 as ordered for the CBC, BMP and BNP. Review of the Admission Nursing Note dated 11/2/17 revealed Resident #1 had 1+ [MEDICAL CONDITION] on bilateral lower extremities. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 Physician order [REDACTED]. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR and failed to administer the mediation as ordered. Further interview revealed if the medication was not administered the DON expected the reason to be documented on the back of the MAR. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident and failed to administer the PRN 40 mg [MEDICATION NAME] on 11/4/17 after a weight gain. Further interview confirmed the facility failed to obtain the 10/10/17 laboratory tests as ordered and failed to notify the physician. Interview with the Nurse Practitioner (NP) #1 on 12/18/17 at 2:30 PM in the conference room confirmed the NP had not been notified the daily weights had not been obtained, the PRN [MEDICATION NAME] had not been administered after the weight gain on 11/4/17, the 10/10/17 laboratory tests were not obtained and the [MEDICATION NAME] 20 mg daily order had not been transcribed or administered.",2020-09-01
851,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,607,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, video review, facility investigation review, and interview, the facility staff failed to report an allegation of abuse to the facility administration per policy for 1 resident (#2) of 9 residents reviewed. The findings included: Review of the undated facility policy, Abuse, Neglect and Exploitation of Residents, revealed .Responsibilities .All personnel .if abuse is suspected, personnel will report their observations to their supervisor immediately and without delay .will .report any signs of suspected abuse, neglect and exploitation . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged as a 911 at 5:24 PM to the emergency room following the event. Review of the video dated 9/19/17 from 4:07:45 PM to 4:07:55 PM revealed Certified Nurse Aide (CNA) #1 leaning against the hallway wall when Resident #2 aggressively and with fisted hands attempting to strike the second employee. Further review of the 2 views of the video revealed these were the only 2 employees in the area at the time of the event. Review of the facility investigation included CNA #1's interview on 10/24/17 revealed the CNA was asked why she did not report the event when it occurred the CNA .stated due to all the staff being there that the event was reported . Interview with the Administrator on 12/12/17 at 9:30 AM in the conference room revealed the event which occurred on 9/19/17 was reported on 10/24/17 when the agency CNA #1 involved informed the shift supervisor. The shift supervisor then called the Administrator to report the allegation and the investigation was started. Further interview confirmed the facility staff failed to report the allegation to the facility administration immediately per policy.",2020-09-01
852,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,684,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow physician orders [REDACTED].#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligram (mg) 1 tab by po (by mouth) once every day (Q D) as needed ( PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling, or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in 5 days. 2. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BMP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 days was administered on 11/13/17 and 11/14/17. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 order for [MEDICATION NAME] 20 mg and failed to transcribe the order on the MAR. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR and failed to administer the mediation as ordered. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident and failed to administer the PRN 40 mg [MEDICATION NAME] on 11/4/17 after a weight gain. Further interview confirmed the facility failed to obtain the 10/10/17 laboratory tests as ordered and failed to notify the physician.",2020-09-01
853,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,732,C,1,0,RPNN11,"> Based on observation and interview, the facility failed to post the current daily staffing for 1 of 5 days of the survey. The findings included: Observation on 12/12/17 at 7:15 AM in the main lobby and hall area, with various informational postings for families and residents, revealed the posted staffing and census form was dated 11/20/17. Interview with Licensed Practical Nurse #11 on 12/12/17 at 7:30 AM in the conference room, after reviewing the posted staffing form, confirmed the posted staffing and census was dated 11/20/17. Interview with the Director of Nursing at 8:35 AM in the conference room confirmed the posted staffing form dated 11/20/17 was not current.",2020-09-01
854,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,842,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligram (mg) 1 tab by po once every day (Q D) as needed (PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling, or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. 2. [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] a [MEDICATION NAME][MEDICATION NAME]) 0.5 mg-2.5mg/3 milliliters (ml) 3 ml inhalation 4 times daily (QID). Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in days. 2. [MEDICATION NAME] 0.5-2.5mg/3 ml inhalation QID (4 times a day) 3. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BNP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 D was administered on 11/13/17 and 11/14/17. 2. [MEDICATION NAME] 0.5-2.5mg/3 ml inhalation QID at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Of the 50 opportunities for administration 16 treatments were not administered with no supporting documentation for 14 administrations. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 order for [MEDICATION NAME] 20 mg and failed to transcribe the order on the MAR. Further interview revealed the LPN was not aware she was to document the reason for not administering a medication on the back of the MAR. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR. Further interview revealed if the medication was not administered the DON expected the reason to be documented on the back of the MAR and the facility failed to do so. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident. The facility failed to maintain a complete and accurate medical record.",2020-09-01
873,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,225,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure a complete, thorough, and timely investigation was conducted for resident to resident altercations for 2 of 4 (Resident #3 and 6) sampled residents. The findings included: 1. The facility's Abuse, Neglect, Misappropriation of Resident Funds policy documented .Reporting of abuse, Neglect, or Misappropriation/Procedure 1. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the administrator or Director of Nursing (DON) .The names of any witnesses to the incident .7. Upon receiving information concerning a report of abuse, neglect, misappropriation, the Administrator or designee will investigate, obtain statements, and ensure the residents are safe and receive quality care . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an incident documented, On 2/19 (2/19/17 at 10:40 AM) resident (Resident #3) was witnessed by other residents in the dining room running into the chair of resident (Resident #6). During this event resident (Resident #6)attempted to hit resident (Resident #3) causing a small scratch on lip. Residents were separated and monitored throughout the day. Mobile Crisis notified as was the DON (Director of Nursing) and Administrator . Review of the POS [REDACTED].Immediate Post-Incident Action: CNAs (Certified Nursing Assistant) informed to keep the 2 separated for today and to be [MEDICAL CONDITION] .Immediate actions Taken: Assessed for injuries, separated the 2 involved to different rooms, vital signs taken, asked him about what happened . 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED].Narrative of incident: When in dining room, elder was hit in the face by another elder. No employees were present. 3 other elders were able to report the incident. Immediate Post-Incident action: Try to keep elders involved separated in the dining area. Assessed for injuries and separate to different rooms . Interview with the Assistant Director of Nursing (ADON) on 5/23/17 at 2:38 PM, in the DON's office, the ADON was asked to describe the incident between Resident #3 and Resident #6. The ADON stated, I do not know who the other 3 residents were that witnessed it and the nurse that filed the report is no longer here . Interview with the Administrator on 5/23/17 at 2:43 PM, in the DON's office, the Administrator was asked to describe the incident between Resident #38 and Resident #6, the investigation, and who were the 3 other residents that witnessed the incident. The Administrator stated, .I don't have a witness statement in there (looking through the investigation report) .I sure thought the statements were in there .I have had some renovation done to my office and they moved my desk around and may have slipped out of the file .I first put down that she was hit in the mouth but actually that was a growth on her lip area. She did not get hit in the mouth .the second altercation is when he hit her and I kept him in my office until the paramedics could come and get him out .when we have someone that has an altercation like that we separate them .make sure everyone is ok .get statements .monitor them .redirect them . Interview with the Administrator on 5/23/17 at 3:58 PM, in the DON's office, the Administrator was asked if he had statements from the witnesses. The Administrator stated, No .that is my fault for not following up on it .(the witnesses) they would have been able to tell you what happened right then but the next day they couldn't have told you . The facility failed to complete a thorough investigation of the incident that occurred between Resident #38 and 6.",2020-09-01
874,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,280,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to revise the care plan to reflect current status for 3 of 20 (Resident #38, 6, and 42) sampled residents reviewed of the 33 residents included in stage 2. The findings included: 1. Review of the facility's CARE PLANS - COMPREHENSIVE policy documented, .Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly and upon change of condition . 2. Review of an incident documented, .On 2/19 (2/19/17 at 10:40 AM) resident #3289 (Resident #38) was witnessed by other residents in dining room running into chair of resident (Resident #6). During this event resident (Resident #38) attempted to hit resident (Resident #6) causing a small scratch on lip. Residents were separated and monitored throughout the day. Mobile Crisis notified as was the DON(Director of Nursing) and Administrator . 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's care plan dated 5/12/16 revealed no documentation of the altercation with Resident #6 that occurred on 2/19/17. 4. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's care plan for behaviors dated 2/3/15 revealed no documentation of the altercation with Resident #3 that occurred on 2/19/17. Interview with the Interim Director of Nursing (IDON) on 5/23/17 at 4:53 PM, in the DON's office, the IDON was asked if she would expect the care plans to be updated to reflect the altercation that occurred on 5/9/17. The IDON stated, Yes. The IDON was asked if the care plans for Resident #38 and 6 had been updated to reflect the altercation that occurred on 2/19/17. The IDON stated, No. 5. Medical record review revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #42 had a fall on 5/19/17 at 9:51 AM while attempting to cross the threshold of the front entrance foyer when his wheelchair tipped over backwards resulting in a skin tear to his left forearm and the intervention included weights to be placed on the front of Resident #42's wheelchair and the furniture in front entrance foyer rearranged. Review of Resident #42's care plan dated 11/8/16 revealed no documentation of Resident #42's risk for falls or the fall that occurred on 5/19/17. Interview with the Minimum Data Set (MDS) Coordinator on 5/24/17 at 1:39 PM, in the Social Service's Office, the MDS Coordinator was asked if a resident who had a [DIAGNOSES REDACTED]. The MDS Coordinator stated, Yes. The MDS Coordinator was then asked if Resident #42 had a fall on 5/19/17 should the care plan have been updated to reflect that fall and the interventions that were put into place. The MDS Coordinator stated, Yes, it should .",2020-09-01
875,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,309,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow the physician's orders for laboratory tests for 1 of 20 (Resident #71) sampled residents reviewed of the 33 included in stage 2. The findings included: Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone orders dated 10/7/16 documented, CBC (complete blood count), with Diff (differential), CMP (Comprehensive Metabolic Panel) D-Dimer, PT ([MEDICATION NAME] Time) /INR (International Normalized Ratio) (on) 10/11/16 . There were no laboratory results dated [DATE] for the CBC with Diff, CMP, D-Dimer, PT/INR found in the medical record. Interview with the Interim Director of Nursing (IDON) on 5/23/17 at 10:10 AM, in the hallway outside her office, the IDON stated she could not locate the laboratory results.",2020-09-01
900,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-03-21,609,D,1,0,ZD9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review and interviews, the facility failed to report to the state agency allegations of abuse to include an injury of unknown origin for one resident (#4) of five sampled residents reviewed for allegations of abuse. The findings included: Review of the facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 12/4/2017, revealed allegations of abuse are to be reported to the Administrator, State Agency, law enforcement, the physician, and the resident and/or Power of Attorney. Review of the medical record revealed the facility admitted Resident #4 on 5/3/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #4 had a chest x-ray on 1/2/2018 due to a cough. Review of the medical record revealed KUB (Kidney, Ureters, and Bladder) x-rays were done on 1/29/18, 1/30/18, and 2/1/18. These x-rays reported a metallic screw over the right upper quadrant of the abdomen. Review of the medical record revealed the physician was notified of the KUB x-ray results on 1/29/18, 1/30/18 and 2/1/18. Review of the nurse's note dated 2/1/18 revealed the POA agreed with the doctor for Resident #4 to be admitted to the hospital on [DATE] for evaluation of the screw in the abdomen. Review of the Op Note (surgical note) dated 2/1/18 revealed the screw was removed from the resident's duodenum (upper part of the small intestine) with a scope inserted down the resident's throat. Resident #4 tolerated the procedure well and returned to the facility on [DATE]. Interview with Resident #4 was attempted on 3/19/18 at 1:00 PM, on in the 300-500-unit dining room, and Resident #4 was unable to answer any questions. Interview with the Medical Director, who was also the attending physician, on 3/20/18 at 1:30 PM, at the nurses' station on the 300-500 units, revealed, Later when I looked at the chest x-ray films, I thought I saw a foreign body on the films even though the chest x-ray report did not mention it so I ordered the KUB x-ray. I have no idea where the screw came from. The screw showed up on a chest x-ray so I ordered a KUB (x-ray of the abdomen) three times to verify that this was a screw and not an artifact. The resident had no pain or vomiting or change in bowel habits. Once I verified that it was a screw I admitted her to the hospital under the care of a [MEDICATION NAME]. The screw was removed without any adverse effect to the resident. The Medical Director stated Resident #4 had no prior history of putting non-food items in her mouth. Interview with the Director of Nursing (DON) on 3/20/18 at 11:30 AM, in the DON's office, revealed the incident of Resident #4 having a screw in her abdomen was not reported. The DON stated a screw in the abdomen is an unusual finding and we should have reported it. Since she (Resident #4) didn't have any outcome we just didn't think to report it.",2020-09-01
901,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-03-21,610,D,1,0,ZD9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to investigate an injury of unknown origin for one resident (#4) of five sampled residents reviewed for abuse. The findings included: Review of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 12/4/2017, revealed allegations of abuse are to be investigated. Review of the medical record revealed the facility admitted Resident #4 on 5/3/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #4 had a chest x-ray on 1/2/2018 due to a cough. Review of the medical record revealed KUB (Kidney, Ureters, and Bladder) x-rays were done on 1/29/18, 1/30/18, and 2/1/18. These x-rays reported a metallic screw over the right upper quadrant of the abdomen. Review of the medical record revealed the physician was notified of the KUB x-ray results on 1/29/18, 1/30/18 and 2/1/18. Review of the nurse's note dated 2/1/18 revealed the POA agreed with the doctor for Resident #4 to be admitted to the hospital on [DATE] for evaluation of the screw in the abdomen. Review of the Op Note (surgical note) dated 2/1/18 revealed the screw was removed from the resident's duodenum (upper part of the small intestine) with a scope inserted down the resident's throat. Resident #4 tolerated the procedure well and returned to the facility on [DATE]. Interview with Resident #4 was attempted on 3/19/18 at 1:00 PM, on in the 300-500-unit dining room, and Resident #4 was unable to answer any questions. Interview with the Director of Nursing (DON) on 3/20/18 at 11:30 AM, in the DON's office, revealed no formal investigation had been done or documented. The DON stated the family was interviewed about Resident #4 possibly swallowing a screw prior to admission to the facility, staff were interviewed if Resident #4 had displayed any behavior of putting non-food items in her mouth, and the physician was interviewed. The DON stated the resident had no change in condition related to swallowing, pain or bowel movements. It (the screw) was discovered as a fluke on an x-ray. Interview with the Medical Director on 3/20/18 at 1:30 PM, at the nurses' station on the 300-500 units, revealed he had no idea where the screw came from. The screw showed up on a chest x-ray so I ordered a KUB three times to verify that this was a screw and not an artifact. Once verified, I admitted the resident to the hospital under a [MEDICATION NAME] (physician specializing in the throat, stomach, and intestinal tract). The screw was removed without adverse effect to the resident. I had the staff check the resident's room and wheel chair for missing screws. None were found. Interview with the DON on 3/21/18 at 9:45 AM, in the conference room, confirmed, We did not write up an investigation.",2020-09-01
950,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,221,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation, and interview, the facility failed to ensure 1 resident (#4) of 11 residents reviewed was free of a physical restraint unless it was needed to treat an assessed medical symptom. Resident #4 was restrained in bed through the use of 4 side rails. The restraint was used without assessment for its need, without less restrictive measures attempted prior to its use, without a medical symptom justifying the use of the restraint, and without a physician's orders [REDACTED]. The findings included: Review of facility policy, Restraint Management, revealed Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff conveniences or for the prevention of falls. Physical restraints include, but are not limited to .side rails. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: Using side rails that keep a resident from voluntarily getting out of bed. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. Treat the medical symptom; b. Protect the resident's safety; and c. Help the resident attain the highest level of his/her physical or psychological well being. Prior to applying a restraint, one must have an order for [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the MDS revealed Resident #4 required extensive assistance from staff with bed mobility, transfers, and locomotion, and had no restraints. Review of the medical record revealed no evidence of Physician Orders, Assessment, or Consent for the use of a restraint. Continued review revealed no evidence of an assessment for the use of side rails. Review of the current care plan, with a goal date of 10/17/17, revealed conflicting information about the use of side rails. Review of the Care Plan revealed Self Care Deficit, with approaches including, 7/4/17 .1/4 (one quarter) length side rails up times 2 when in bed to enable participation with bed mobility. However, review of the Care Plan for Fall Risk revealed an approach dated 7/26/17 Staff to ensure placement and raising of lower bedrail to amputation side of the bed in order to assist with safety during sleep. Note: (Resident #4) will still be able to get OOB (out of bed) to her strong side. Observation on 9/18/17 at 8:35 AM and 1:49 PM revealed Resident #4 was asleep in bed. She had 2 one half side rails raised on each side of the bed. The use of these 4 partial rails resulted in the effect of 2 full side rails which blocked normal egress from the bed. Interview on 9/18/17 at 1:52 PM with Certified Nurse Aide (CNA) #3, in the hallway outside the resident's room, confirmed the resident had 4 side rails up while she was asleep in bed. CNA #3 stated she always used all 4 side rails when Resident #4 was in bed. She stated the resident had a leg amputation earlier this year, and After she came back from the hospital, we was (were) told to use all 4 side rails with her because she's a fall risk. Further interview with CNA #3 revealed the use of the 4 side rails restricted the resident's normal movement of exit/entry from the bed, as she stated, Just last week, I found her sliding out the end of the bed when all 4 side rails were raised. Interview on 9/18/17 at 1:55 PM with Licensed Practical Nurse (LPN) #1, in the hallway outside the resident's room, revealed staff were only supposed to use 2 side rails, because if they used all 4 side rails, It would be a restraint. CNA #3, who was present during this interview, confirmed all 4 side rails would constitute a restraint, saying, That's right. However, CNA #3 added, I was told to use all 4 because she's a fall risk. Interview with the Director of Nursing (DON) on 9/18/17 at 2:10 PM, in the first floor administrative wing confirmed, We have not historically done any assessment for side rails. She stated the facility was in the process of adding this to the admission packet, but confirmed no side rail or restraint assessments had been completed for Resident #4. The DON stated 4 side rails constituted a restraint for Resident #4, based on her physical condition. Further interview with the DON revealed she was unaware staff were using all 4 side rails when the resident was in bed, and the resident had no medical symptom to justify the use of a restraint.",2020-09-01
951,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,223,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, observation, review of a Tek-Care Report and interview, the facility failed to prevent Verbal Abuse for 1 resident (#5) and Neglect for 1 resident (#6) of 7 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention, revised 4/1/17 revealed, .Abuse .will not be tolerated by anyone, including staff .Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure the care is provided as needed for the resident .Verbal Abuse: The use of oral .language that willfully includes disparaging and derogatory terms to the residents .or within hearing distance . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact, bed bound, and required extensive assistance from 2 or more people for bed mobility; extensive assistance from 1 person for dressing, eating, and hygiene; was totally dependent with 2 or more people needed for bathing and toileting. Continued review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Review of a facility investigation dated 6/27/17 at 2:45 PM revealed Certified Nurse Aide (CNA) #6 was providing incontinence care to Resident #5 when 2 Licensed Practical Nurses (LPNs) and another CNA entered the resident's room and CNA #6 told them she was not catering to her ass, the resident got on her nerves, and she had been on the call light all day. Continued review of a handwritten statement from LPN #5 dated 6/27/17 revealed, .walked into (Resident #5's) room and (CNA #6) was changing her. I overheard her say to (Resident #5) .she doesn't have time for this[***]and I'm not catering to her ass. She gets on my nerves, she's been on the call light all day .(CNA #6) said 'f*** this[***] packed up the dirty linen and left .(Resident #5) was in tears . Continued review revealed handwritten statements from LPN #6 and CNA #8 dated 6/27/17 corroborated the same details. Further review of a statement from Resident #5 taken by the Director of Nursing (DON) on 6/28/17 revealed the resident stated, .(CNA #6) kept yelling at her and saying she cannot keep coming in there and change her .when other staff named (LPN #6, LPN #5, and CNA #8) were in the room that (CNA #6) stated she didn't have time to cater to her ass . Observation and interview of Resident #5 on 9/19/17 at 8:55 AM in the resident's room revealed the resident was awake, alert, oriented, on the ventilator and unable to speak out loud. Continued observation revealed the resident was able to nod yes or no and mouthed words when spoken to. Interview with the resident revealed she was able to confirm the facts were the same as written by LPN #5. Interview with LPN #5 on 9/18/17 at 10:30 AM in the conference room revealed, .(Resident #5) was crying and (CNA #6) was cleaning her up and telling her she wasn't catering to her ass .asked her (CNA #6) to leave because she was being aggressive and she said 'F*** this[***] and left .(Resident #5) was still crying and pointed to the door and mouthed 'I don't want her back in my room . Continued interview confirmed the interaction between the resident and CNA #6 was reported immediately to the DON and LPN #5 wrote a statement of the event. Interview with the DON on 9/19/17 at 10:50 AM in the conference room confirmed allegations of verbal abuse to Resident #5 from CNA #6 were substantiated by the facility and CNA #6 was terminated. Continued interview revealed the DON confirmed the facility failed to prevent verbal abuse to Resident #5. Medical record review revealed Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 30 day MDS dated [DATE] revealed Resident #6 was cognitively intact with modified independence, and altered level of consciousness that fluctuated; was bed bound and was dependent with assistance of 1 person required for bed mobility, dressing, eating, hygiene, bathing and toileting. Continued review revealed the resident had bilateral upper extremity impairments and received services from Respiratory Therapy for oxygen, suctioning, [MEDICAL CONDITION] care and ventilator care. Review of a facility investigation dated 7/26/17 revealed Resident #6 pushed his call light between 8:00 AM and 8:30 AM and told CNA #5 he needed Respiratory Therapy. The CNA told Respiratory Therapist (RT) #1 the resident requested him and he said OK. The resident pushed his call light a 2nd time and CNA #8 answered the call light and was told he needed respiratory because he couldn't breathe. The CNA informed RT #1 and he said OK, thanks. Approximately 5 minutes later the call light went off a 3rd time and CNA #8 answered it and the resident again stated he needed respiratory and he couldn't breathe. The CNA asked if RT #1 had made it in yet and the resident said No. The CNA said she would let him know again and found RT #1 sitting at a table in the hallway charting. CNA #8 told him Resident #6 still needed him because he said he couldn't breathe, and the RT smiled and said OK, thanks. The resident pushed his call light a 4th time and CNA #5 and LPN #7 entered the resident's room and he asked to be transferred out of the facility because he didn't feel safe. Review of handwritten statements in the facility investigation from CNA #5, and CNA #8 dated 7/26/17 corroborated the allegations above. Continued review of LPN #7's written statement revealed, .Resident requested to be 'sent out' .asked what was going on Resident stated, 'I don't feel safe here' .asked why he felt unsafe and who made him feel unsafe .(RT #1) .made him feel uneasy .Resident stated, 'I couldn't breathe and the alarm was going off.' The tech entered the room and resident asked for (RT #1) and he never came. A 2nd tech came and resident requested to see (RT #1) and he finally came. Resident stated, '(RT #1) chewed me out. He told me it was the same people everyday and he wasn't dealing with this crap today.' He turned off the alarm and walked out.' The resident stated, 'I'd rather die than feel the way he makes me feel' . Interview with the RT Director on 9/20/17 at 1:20 PM in the 2nd floor dining room stated she took over RT #1's assignment the morning of 7/26/17. Continued interview revealed the Nurse Practitioner asked her to assess Resident #6's respiratory status as she had heard wheezes in his lungs. Continued interview confirmed the resident had coarse wheezes and the RT Director gave him a PRN (as needed) breathing treatment per the physician's orders [REDACTED].#6 to be believable, she stated, Yes, I do with this situation. Interview with CNA #5 on 9/20/17 at 1:35 PM in the 2nd floor dining room confirmed she had answered the call light of Resident #6 on 7/26/17 between 8:00 AM and 8:30 AM the first time and told RT #1 the resident needed him. Continued review revealed CNA #5 and CNA #8 were working together in another resident's room and CNA #5 was able to confirm CNA #8 answered the resident's call light 2 more times and reported to RT #1 the resident needed him both times. Further interview revealed when the resident's call light went off a 4th time both she and LPN #7 entered the resident's room together and the CNA heard the resident say I want to be moved out, I don't feel safe here. Continued interview revealed LPN #7 asked the resident what was the problem, and the resident said (RT #1) said I'm not dealing with this crap today and turned off my alarms and left. Review of a Tek-Care Report dated 7/31/17 revealed the ventilator alarm for Resident #6 went off on 7/26/17 at 8:49:42 AM and alarmed for 5 minutes, 18 seconds. Continued review revealed the oxygen saturation alarm went off on 7/26/17 at 8:49:53 AM and alarmed for 3 minutes, 44 seconds. Interview with the DON on 9/20/17 at 3:36 PM in the conference room revealed RT #1 was terminated. Continued interview confirmed the DON found the written statements dated 7/26/17 by facility staff regarding events occurring to Resident #6 to be truthful. Continued interview confirmed the facility failed to respond to ventilator and oxygen saturation alarms timely, and failed to provide care and assistance to Resident #6 as requested resulting in neglect to the resident.",2020-09-01
952,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,225,E,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigation, and interview, the facility failed to report timely, thoroughly investigate, and/or report investigative findings within 5 working days to the State Agency for an injury of unknown origin for 2 residents (#4, #7) and allegations of abuse for 1 resident (#5) of 7 residents reviewed for abuse. The findings included: Medical record review revealed Resident #4's Admission notes revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review admission Minimum Data Set (MDS), dated [DATE] revealed the resident was cognitively impaired, and required limited assistance with bed mobility, transfers and walking in her room. The resident had no functional limitations to range of motion, but was not steady in transfers, and was only able to stabilize herself during transfers with staff assistance. She was assessed as at risk for falls. Review of Resident #4's Progress Notes dated 5/14/17 revealed the resident complained of pain to her left leg. No falls were documented in the record, and the Progress Notes included there was no visible injury. Continued review of the Progress Notes dated 5/15/17 revealed the resident was sent out to the hospital for evaluation when the pain worsened. She returned from the hospital the same day with changes to her [MEDICATION NAME] order and a [DIAGNOSES REDACTED]. Review of Resident #4's Progress Notes dated 5/18/17 revealed on 5/17/17 the resident continued to have pain in the left leg. The nurse Noted visual quivering of thigh muscle left. Pt (patient) reports increased pain with muscle spasms. Review of Resident #4's Progress Notes dated 5/19/17 revealed, the resident was sent to the ER (emergency room ) for eval (evaluation) and TX (treatment) r/t (related to) recent x-ray of the left hip. Review of the x-ray report dated 5/19/17 revealed the resident had increased pain, decreased mobility, and the x-ray showed an acute [MEDICAL CONDITION] femoral neck. Review of the Progress Notes the resident was hospitalized from [DATE] - 5/24/17 when she was readmitted to the facility with new [DIAGNOSES REDACTED]. Review of Resident #4's clinical record revealed no evidence as to how the left [MEDICAL CONDITION] occurred. Review of the facility's investigation revealed an investigation was started on 5/19/17 when the x-ray indicated a [MEDICAL CONDITION] and there was no known etiology. The allegation of injury of unknown origin was not reported to the State Survey Agency (SSA) until 3 days later, on 5/22/17. Further review of the facility investigation by the survey team on 9/18/17 revealed no evidence the investigation was completed or that the facility had made a determination as to abuse/neglect which was not reported to the SSA within 5 working days. The investigation was not thorough and did not provide sufficient information to make a determination as to whether abuse/neglect occurred. The investigation contained no evidence of any interviews with staff to determine if they might have knowledge of how the fracture happened. The only interview documented was with the resident. There was no evidence the facility came to a conclusion about the injury of unknown origin, reported the results to the SSA or took action to prevent the potential for further abuse/neglect of the resident. Interview with the Director of Nursing (DON) on 9/18/17 at 2:27 PM verified the packet of information provided to the survey team was the complete investigation into Resident #4's injury of unknown origin. The DON stated the facility became aware of the injury of unknown origin on 5/19/17; however, it was not reported to the SSA until 5/22/17. When asked why the allegation of injury of unknown origin was not immediately reported to the SSA, the DON stated, I think I was trying to figure out what happened. The DON stated, at the time of Resident #4's injury, My understanding was that we had 24 hours (to report). The DON stated she believed the regulation is going to 2 hours in (MONTH) (2018), so we're doing that now. Further interview with the DON revealed she was unaware the changes regarding time frames for reporting had been in effect since (MONTH) 8, (YEAR), and the allegation of injury of unknown origin resulted in serious harm was required to be reported within 2 hours. The DON stated the facility was currently only submitting a follow-up to the SSA within 5 working days if the initial allegation included a named perpetrator of abuse or neglect. She stated she was unaware the 5-day follow-up report was required for all allegations, including injuries of unknown origin, that were reported to the SS[NAME] Further interview with the DON revealed staff should have been interviewed and witness statements should have been completed as part of a thorough investigation. She confirmed there were none present in the investigation file, and stated she could not explain why these were not done. The DON, who stated she was the abuse coordinator, stated, That's my frustration, I've not been shown how to complete an investigation. Interview with the DON on 9/18/17 at 2:35 PM revealed she had additional information about why the allegation of injury of unknown origin had not been reported timely. She stated staff learned of the fracture of unknown source on 5/19/17, which was a Friday. The DON stated the nurse who received the x-ray did not report the fracture to her, and she was unaware of the incident until she returned to work on Monday, 5/22/17. The DON stated when the nurse received the x-ray results indicating a fracture with no known origin, she should have called the DON, Quality Assurance (QA) Nurse, Administrator, or Social Worker. The DON stated any of these 4 staff could have reported the allegation to the SS[NAME] However, No one called and the administrative staff were not aware until the following Monday, when they then reported the allegation to the SS[NAME] Review of facility policy, Abuse Prevention, revised 4/1/17 revealed it did not include correct time frames for reporting abuse. This policy indicated, Any alleged incident of abuse or neglect will be reported immediately to the Administrator/Assistant Administrator and to other officials in accordance with State Law within 5 working days of the event. Further review of this policy revealed Any patient event that is reported to any staff .will be considered as possible abuse if it meets any of the following criteria .Any indication of possible willful infliction of injury to include unexplained bruising. Any partner having any knowledge .is required to report either verbally or in writing to their supervisor, to the facility social worker, the Director of Nursing/ADON (Assistant Director of Nursing) or the Administrator/Assistant Administrator. On 9/19/17 at 10:00 AM, the DON provided a second policy, titled, Abuse, Neglect, Misappropriation Protocol, revised 2/17. Interview with the DON revealed this was the correct abuse policy for the facility, and the policy dated 4/1/17 had been provided in error. Review of the second policy provided by the facility revealed To help with recognition of incidents of abuse, the following definitions of abuse are provided .Injury of unknown source is defined as an injury that meets both following conditions: a. source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: i. the extent of the injury; or ii. the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma. The first policy provided time frames for the reporting of reasonable suspicion of a crime, depending on the seriousness of the event that leads to the reasonable suspicion, review of the second policy revealed it did not address time frames for reporting allegations of abuse and neglect to the SS[NAME] Further review of the second policy revealed, The individual conducting the investigation will, as a minimum .Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors .Witness reports will be reduced to writing, Witnesses will be required to sign and date such reports. Note: A copy of such reports must be attached to the Resident Abuse Investigation Report .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, and the local police department, if necessary, and other as may be required within five (5) working days of the reported incident. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated 6/27/17 at 2:45 PM revealed Certified Nurse Aide (CNA) #6 was providing incontinence care to Resident #5 when 2 Licensed Practical Nurses (LPN's) and another CNA entered the resident's room and CNA #6 told them she was not catering to her ass, the resident got on her nerves, and she had been on the call light all day. Continued review of a handwritten statement from LPN #5 dated 6/27/17 revealed, .walked into (Resident #5's) room and (CNA #6) was changing her. I overheard her say to (Resident #5) .she doesn't have time for this[***]and I'm not catering to her ass. She gets on my nerves, she's been on the call light all day .(CNA #6) said 'f*** this[***] packed up the dirty linen and left .(Resident #5) was in tears . Continued review revealed handwritten statements from LPN #6 and CNA #8 dated 6/27/17 corroborated the same details. Further review of a statement from Resident #5 taken by the DON on 6/28/17 revealed the resident stated, .(CNA #6) kept yelling at her and saying she cannot keep coming in there and change her .when other staff named (LPN #6, LPN #5, and CNA #8) were in the room that (CNA #6) stated she didn't have time to cater to her ass . Interview with the DON on 9/20/17 at 3:36 PM in the conference room when asked what time the above allegation of abuse was reported to the State Agency, the DON stated, I reported it on 6/27/17 at 6:29 PM. Continued interview confirmed the facility failed to timely report allegations of abuse for Resident #5. Medical record review revealed Resident #7's [DIAGNOSES REDACTED]. Review of the resident's most recent quarterly assessment, dated 8/23/17, revealed the resident was moderately cognitively impaired and totally dependent on staff for transfers and required extensive staff assistance for bed mobility. Medical record review of the Progress Notes revealed on 8/5/17, the resident was noted to have a large brised (bruised) area to right upper chest that was dark in coloration. Unknown etiology, patient is unable to recall. On 8/6/17, the Progress Notes indicated the bruise to the Rt (right) shoulder, upper arm and chest area has gotten worse. The Physician was contacted and ordered x-rays D/T (due to) bruising and [MEDICAL CONDITION] (swelling) and pain. Review of the Progress Notes on 8/7/17 revealed the x-rays were negative for fractures; however, the bruising continues to spread down her rt arm and side. Staff continued to monitor and document the bruising was still present as of 9/18/17. Further review of Resident #7's medical record revealed no evidence the origin of this injury had been identified. Review of the facility investigation revealed no evidence this injury of unknown origin was immediately reported to the SSA when the bruising was identified on 8/4/17 at 7:30 PM. In addition to the failure to immediately make the initial notification of an injury of unknown origin to the SSA as required, the facility also failed to complete and report the findings of an investigation to the SSA within 5 days. Review of the facility's investigation revealed it was not completed within 5 days of its initiation. There was no evidence of any investigative activity after 9/3/17 until 9/18/17 (after intervention by the survey team) when a handwritten note was added to the investigation form that read ecchymosis (discoloration of the skin resulting frombleeding underneath typically caused by bruising) discussed with nursing director - not related to abuse/neglect by facility. Further review of the investigation revealed it was not thorough. Review of Progress Notes dated 8/16/17 indicated the bruising was s/p (status [REDACTED]. The investigation form was marked Yes to indicate Employee statements completed and reviewed. However, review of the investigation reports provided by the facility revealed there were no employee statements documented. Interview with the DON on 9/18/17 at 1:13 PM revealed she was the facility's abuse coordinator. When asked about Resident #7's injury of unknown origin, she stated, It didn't ring a bell and she would have to investigate further. She confirmed she had provided all investigations completed and reported to the SSA since the last standard survey in (MONTH) (YEAR), and Resident #7's injury of unknown origin was not included in them. Additional interview with the DON on 9/18/17 at 2:50 PM confirmed the injury of unknown origin had never been reported to the SSA, and there had been no investigation into the cause of the bruising to Resident #7's chest. At 2:52 PM, the DON then provided different information, by stating the facility's QA Nurse had an open investigation into the injury of unknown origin, and That's why it wasn't reported. At this time, she provided the investigation report. Additional interview with the DON on 9/18/17 at 3:00 PM confirmed the investigation was not thorough or complete. She stated the QA nurse did not have witness statements, saying, She just talked to staff. Further interview with the DON revealed the facility had not reported the allegation because it was still open, there was no evidence of any action being taken to investigate the injury of unknown origin from 9/3/17 until 9/18/17, when the survey team asked for the record. Observation during an assessment on 9/18/17 at 3:00 PM revealed Resident #7 had bruising across her chest. The resident, who had a right [PR[NAME]EDURE], had purple-grey bruising across this area and the tissue was very firm. The bruising then extended from the right breast area, across the midline to the areola of the left breast. From the sternum to the left breast, the area was yellow-green (indicative of old bruising) that was soft-feeling. In addition, there was one dime-sized area by the areola that was dark purple in color. A Nurse Practitioner (NP), who was present during this assessment, palpated the area and stated it felt like there had been a hematoma (a solid swelling of clotted blood within the tissue) that had bled and was now healing. An attempt was made to interview the resident during the assessment; however, she answered nonsensical words to various questions which were asked and could not tell how the bruising had occurred. An additional attempt to interview the resident on 9/18/17 at 5:06 PM was also unsuccessful, as the resident mumbled inaudible words in response to questions. Interview with the QA Nurse on 9/18/17 at 3:05 PM revealed whenever a resident had a bruise, skin tear or other injury, the nurse on the unit would start the investigation paperwork. It would then be reviewed by the Unit Manager, who would, in turn, send it to the QA nurse and Then I look at it. If the nurse can determine what caused them, then I don't have to do an investigation. However, she continued, Resident #7 was completely different. She stated the bruise just showed up out of nowhere and We didn't know how it happened. She stated the facility knew the bruise was not related to a fall because the resident could not get up off the floor without staff assistance and no falls had been reported. The QA Nurse stated she had not documented any interviews with staff. When asked why, she stated if the resident had said someone had been mean, I would have gotten written statements. But I didn't think it was abuse so I didn't. I just get it (written statements) when there is abuse. Further interview with the QA nurse revealed she did not know how the injury occurred and stated, Maybe when they (staff) were turning her - she is prone to bruising. Further interview with the QA Nurse on 9/18/17 at 3:05 PM confirmed she had never reported the injury of unknown origin to the SS[NAME] When asked why, she stated, I hadn't concluded my investigation so it had not yet been reported. The QA Nurse could not provide an explanation as to why the investigation had not been completed in the 46 days since the bruising was first identified. The QA Nurse could also provide no rationale as to why, if it was still being investigated, there had been no action taken from 9/03 - 9/18/17. During this interview, the QA nurse stated, I'll be honest - I did not know what the time frame was for reporting when the investigation was initiated. She added, I do now - we have 2 hours to report. I found that out about 2 weeks ago.",2020-09-01
953,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,226,D,1,0,SMVC11,"> Based on facility policy review and interview, the facility failed to develop a current Abuse Policy containing accurate information related to 2 components, Reporting and Training, of the 7 mandatory requirements maintained in an Abuse Policy, and failed to include and define Exploitation in the facility Abuse Policy. The findings included: Review of facility policy, Abuse Prevention, with an effective date of 11/1/10 and a revised dated of 4/1/17, provided by the Director of Nursing (DON) on 9/18/17 at 9:05 AM revealed, .Any alleged incident of abuse or neglect will be reported immediately to the Administrator .and to other officials in accordance with State Law within 5 working days of the event . Interview with the DON on 9/18/17 at 6:00 PM in the conference room revealed she did not know the 7 components required in the facility Abuse Policy, but would have to check. Continued interview confirmed the DON was the Abuse Coordinator. Further interview revealed the DON and the Social Services Director were responsible for drafting facility policy's with the Administrator signing off on them. Review of facility policy, Abuse, Neglect, Misappropriation Protocol, with an effective date of 1/17/2001 and revised 2/2017 provided by the DON on 9/19/17 at 10:00 AM revealed, .Elder Abuse Act .crime has occurred against a resident .from this facility, he/she MUST notify BOTH .The State Survey Agency (SSA) .A Local Law Enforcement Entity .The facility has identified the .(named city) Police Department to notify if abuse occurs .Reporting of Abuse, Neglect, or Misappropriation/Protection .Reports must be within 24 hours (if there is not serious bodily injury) after forming your reasonable suspicion. Within 2 hours (if there is serious bodily injury) .Serious Bodily Injury - 2 Hour Limit: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the facility shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .All Others - Within 24 Hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the facility shall report the suspicion not later than 24 hours after forming the suspicion .Training .All new employees will be trained as part of General Orientation, departmental Orientation, and ongoing training sessions to include .Definition of abuse, neglect, involuntary seclusion and misappropriation of resident property . Continued review of the Abuse, Neglect, Misappropriation Protocol policy revealed the local Police Department identified to notify if abuse occurred was not a local Police Department, not located in the same county as the facility, and was 100 miles away from the facility. Continued review revealed it did not include allegations of abuse in the 2 hour time frame for reporting to the State Agency. Further review revealed the training component did not include annual training for abuse. Further review revealed neither policy included exploitation as a form of resident abuse. Interview with the DON on 9/19/17 at 9:50 AM in the conference room confirmed the Abuse Prevention Policy was not up to date with current federal guidelines for reporting allegations of Abuse within 2 hours. Further interview confirmed the Abuse, Neglect, Misappropriation Protocol did not contain accurate information, and did not accurately reflect the Reporting and Training components required. The DON confirmed the facility failed to maintain an updated Abuse Policy.",2020-09-01
954,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,279,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, review of facility policy,and interview, the facility failed to revise the care plan to reflect the resident's current status for 2 residents (#4, #7) of 11 residents reviewed. The facility failed to update care plans for 2 residents (#4, #7) when previous approaches were no longer appropriate and/or new interventions were needed to prevent accidents. The findings included: Review of the facility's undated policy, Care Plans Comprehensive, revealed: The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of Care Plans: When there has been a significant change in the resident's condition .At least quarterly. Observation on 9/18/17 at 11:40 AM revealed Resident #4 was sitting in a wheelchair. The resident was observed to have an amputation of the left leg below the knee and was using a stabilizer to hold the stump of her leg in place. Review of Resident #4's clinical record revealed the resident was readmitted to the facility on [DATE], after a [MEDICAL CONDITION] (BKA) of the left leg due to a gangrenous toe. Review of a comprehensive assessment, dated 7/10/17, was completed based on the changes in the resident's condition due to the amputation. Review of her Comprehensive Care Plan revealed the last care conference was held on 7/19/17 and the Care Plan showed a goal date of 10/17/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. For example, the Care Plan noted the resident was at risk for infection r/t Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The Care Plan also noted the resident is a fall risk r/t S/P (Status/Post) BK[NAME] Approaches to meet the goal of no avoidable falls included Therapy states that she is able to ambulate herself to and from the bathroom. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed with 4 side rails raised. The bed was not in a low position. No fall mats were in use on either side of the bed. Additional observation on 9/18/17 at 1:49 PM. revealed the resident was asleep in bed. Although the bed was now in a low position, no fall mats were in use and all 4 side rails were raised. Review of Resident #4's Physician order [REDACTED]. Further review of Resident #4's Comprehensive Care Plan revealed, although the Care Plan identified the resident was at risk for falls, neither of these Physician ordered interventions had been added to the Care Plan. Interview on 9/19/17 at 9:12 AM with Minimum Data Set (MDS) Coordinator #1, in the first floor administrative wing, revealed the facility currently had a Care Plan Nurse. He stated, although the facility's system was changing in (MONTH) (YEAR), the Care Plan Nurse was currently responsible for developing Care Plans from required assessments, as well as making any needed revisions, including new approaches identified during falls meeting. Interview on 9/19/17 at 9:30 AM with the Care Plan Nurse, in his office revealed it depended on the type of Care Plan revision as to who was responsible for updating the Care Plan. He stated if the resident had a fall, the floor nurse should update both the comprehensive Care Plan and the summarized Care Plan used by direct staff with new interventions to prevent further accidents. The Care Plan Nurse stated he then completed the Care Plan reviews that were required after each quarterly or comprehensive MDS. He stated, When I review, I try to make sure what's in Matrix (the facility's electronic health system used for comprehensive care plans) jibes with what's in the closet (where the summary care plans used by direct care staff are stored.) The Care Plan Nurse confirmed the resident's Care Plan should have been updated, saying, The obvious answer is yes. He stated the approaches of shoes and walking to the bathroom were no longer appropriate for Resident #4, and the Care Plan should have been revised, as the resident had completely different needs after the amputation of her leg. Further interview with the Care Plan Nurse revealed he did not know the reason for the delay in revising the Care Plan with new interventions. He stated he was not alerted when every new order was received, and the nurse on the unit who was aware of the order should have revised the Care Plan if needed. Medical record review of Resident #7's revealed [DIAGNOSES REDACTED]. Medical record review of Resident #7's Comprehensive Care Plan with a review date of 9/7/17, revealed the resident was an elopement risk r/t (related to) dementia. Review of the approaches for this problem revealed they included, Apply wander alert safety bracelet to resident, if ambulatory, and w/c (wheelchair) if chair bound. Observation on 9/18/17 at 5:06 PM revealed the resident was seated in a wheelchair in her room. Additional observations on 9/19/17 at 8:10 AM and 3:15 PM, revealed the resident was seated in her wheelchair in the third floor dining/day room. No wander alert bracelet was applied to the wheelchair and none was visible on the resident during any of these observations. Interview on 9/19/17 at 8:10 AM with Certified Nursing Assistant (CNA) #1, in the third floor dining/day room, confirmed the resident did not have a wander alert bracelet on either her body or her wheelchair. Interview on 9/19/17 at 3:15 PM with Licensed Practical Nurse (LPN) #1, in the third floor dining/day room, confirmed the resident did not currently use a wander alert bracelet. Interview on 9/19/17 at 3:22 PM with Unit Manager (UM) #1, in his office, revealed Resident #7 doesn't need or use a wander alert bracelet anymore. He stated the facility had used one when the resident was ambulatory, but it was no longer needed because she was no longer at risk for elopement and used a wheelchair for locomotion. Interview with UM #2, who was also present during the interview on 9/19/17 at 3:22 PM, confirmed Resident #7 had not used a wander alert bracelet since at least (YEAR). Interview with UM #1 revealed the care plan should have been revised when the wander alert bracelet was discontinued. He stated any nurse in the building could update Care Plans, and the need for revision could have also been identified when required quarterly care plan reviews were completed.",2020-09-01
955,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,280,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observation, medical record review, and interview, the facility failed to revise the Care Plan to reflect the resident's current status for 3 of 11 sampled residents (#4, #5, #7). The facility failed to update Care Plans for Resident #4 and Resident #7 when previous approaches were no longer appropriate and/or new interventions were needed to prevent accidents. The facility failed to update the Care Plan for Resident #4 to reflect a new intervention for a skin tear. The findings included: Review of facility policy, Care Plans - Comprehensive, undated revealed The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: When there has been a significant change in the resident's condition .At least quarterly. Medical record review revealed Resident #4's clinical record revealed the resident was admitted on [DATE] and readmitted to the facility on [DATE], after a [MEDICAL CONDITION] (BKA) of the left leg due to a gangrenous toe. A comprehensive assessment dated [DATE], was completed, based on the changes in the resident's condition due to the amputation. Review of her Comprehensive Care Plan revealed the last care conference was held on 7/19/17 and the Care Plan showed a goal date of 10/17/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. Medical record review revealed the Care Plan noted the resident was at risk for infection r/t (related to) Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The care plan also noted the resident is a fall risk r/t S/P (Status/Post) BK[NAME] Approaches to meet the goal of no avoidable falls included Therapy states that she is able to ambulate herself to and from the bathroom. Review of Resident #4's Physician order [REDACTED]. Further review of Resident #4's Comprehensive Care Plan revealed although the Care Plan identified the resident was at risk for falls, neither of these Physician Ordered interventions had been added to the Care Plan. Observation on 9/18/17 at 11:40 AM revealed Resident #4 was sitting in a wheelchair. The resident was observed to have an amputation of the left leg below the knee and was using a stabilizer to hold the stump of her leg in place. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed with 4 side rails raised. The bed was not in a low position. No fall mats were in use on either side of the bed. Additional observation on 9/18/17 at 1:49 PM revealed the resident was asleep in bed. Although the bed was now in a low position, no fall mats were in use and all 4 side rails were raised. Interview on 9/19/17 at 9:12 AM with the Minimum Data Set (MDS) Coordinator #1 revealed the facility currently had a Care Plan Nurse. He stated, although the facility's system was changing in (MONTH) (YEAR), the Care Plan Nurse was currently responsible for developing Care Plans from required assessments, as well as making any needed revisions, including new approaches identified during falls meeting. Interview on 9/19/17 at 9:30 AM with the Care Plan Nurse revealed that it depended on the type of Care Plan revision as to who was responsible for updating the Care Plan. He stated if the resident had a fall, the floor nurse should update both the comprehensive Care Plan and the summarized Care Plan used by direct staff with new interventions to prevent further accidents. The Care Plan Nurse stated he then completed the Care Plan reviews that were required after each quarterly or Comprehensive MDS. He stated, When I review, I try to make sure what's in Matrix (the facility's electronic health system used for comprehensive Care Plans) jibes with what's in the closet (where the summary Care Plans used by direct care staff are stored.) The Care Plan Nurse confirmed the resident's Care Plan should have been updated, saying, The obvious answer is yes. He stated the approaches of shoes and walking to the bathroom were no longer appropriate for Resident #4, and the Care Plan should have been revised, as the resident had completely different needs after the amputation of her leg. Further interview with the Care Plan Nurse revealed he did not know the reason for the delay in revising the Care Plan with new interventions. He stated he was not alerted when every new order was received, and the nurse on the unit who was aware of the order should have revised the Care Plan if needed. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a facility Event Report dated 6/18/17 revealed Resident #5 was found with a skin tear to her right inner thigh as a result from scratching herself. Continued review revealed new orders related to the incident was a referral to the Wound Care Nurse. Continued review documented the Care Plan was updated on 6/18/17 at 7:42 PM. Medical record review of the Comprehensive Care Plan dated 2/23/17 revealed a problem of impaired skin integrity. Continued review revealed the approaches were dated 2/23/17 and no new approaches related to the skin tear were present. Interview with the Director of Nursing (DON) on 9/20/17 at 3:36 PM in the Conference Room confirmed the facility failed to revise Resident #5's Care Plan to reflect approaches related to a skin tear on 6/18/17. Medical record review revealed Resident #7's [DIAGNOSES REDACTED]. Review of Resident #7's Comprehensive Care Plan, review date of 9/7/17, revealed the resident was an elopement risk r/t dementia. Review of the approaches for this problem revealed they included, Apply wander alert safety bracelet to resident, if ambulatory, and w/c (wheelchair) if chair bound. Observation on 9/18/17 at 5:06 PM, and 9/19/17 at 8:10 AM and 3:15 PM, revealed the resident was seated in her wheelchair. No wander alert bracelet was applied to the wheelchair and none was visible on the resident. Interview on 9/19/17 at 8:10 AM with Certified Nurse Aide (CNA) #1 confirmed the resident did not have a wander alert bracelet on either her body or her wheelchair. Interview on 9/19/17 at 3:15 PM with Licensed Practical Nurse (LPN) #1 confirmed the resident did not currently use a wander alert bracelet. Interview on 9/19/17 at 3:22 with Unit Manager (UM) #1 revealed Resident #7 doesn't need or use a wander alert bracelet anymore. He stated the facility had used one when the resident was ambulatory, but it was no longer needed because she was no longer at risk for elopement and used a wheelchair for locomotion. Interview with UM #2, who was also present during the interview on 9/19/17 at 3:22 PM, confirmed Resident #7 had not used a wander alert bracelet since at least (YEAR). Interview with UM #1 revealed the Care Plan should have been revised when the wander alert bracelet was discontinued. He stated any nurse in the building could update Care Plans, and the need for revision could have also been identified when required quarterly Care Plan reviews were completed.",2020-09-01
956,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,282,G,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of Event Report, interview, and observation, the facility failed to ensure Care Plans were followed for 5 residents (#2, #6, #7, #8, #9) of 11 residents reviewed. Resident #2 sustained HARM (laceration to head which required stitches) during a fall when staff failed to follow his Care Plan for using 2 staff to provide care. In addition, the facility failed to follow other Care Plan interventions designed to prevent accidents, such as low bed, fall mats, and call light in reach for Resident #8; failed to provide respiratory care for Resident #6 and #9; and failed to use geri-sleeves to prevent skin tears for Resident #7. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE]. The resident had a [MEDICAL CONDITION] and was dependent on supplemental oxygen. The resident's [DIAGNOSES REDACTED]. Review of an Event Report dated 1/1/16 revealed the resident was lowered to floor. Review of the investigation notes revealed, while she was giving him a bed bath, resident coughed violently multiple times that had him leaning off bed. For safety, resident was lowered to floor to keep from falling off bed .Care Plan to reflect x2 (2 staff) assist for all care. Continued review revealed the staff were educated to use x2 assist for Activities of Daily Living (ADLs) and turning. Review of the 11/16/16 Minimum Data Set (MDS) revealed Resident #2 continued to require total assistance of 2 staff for ADLs, as noted on his Care Plan, which indicated the resident was at risk for falls r/t (related to) impaired mobility, need for 2 staff members with ADL assistance. Review of an Event Report dated 12/4/16 revealed at 6:00 AM, Resident #2 sustained a fall when staff failed to follow the Care Plan and provided only 1 staff during ADL care. Per the resident, the 1 Certified Nurse Aide (CNA) had resident turned twards (towards) herself as she was providing incontinent (incontinence) care. Resident began to forcefully cough multiple times. Resident's body came off the bed and (staff) was unable to stop him from falling due to weight. The Event Report noted the resident had a 2-inch gash above the right eye. The resident was transferred to the hospital, where stitches were applied to the laceration above the resident's eye. In addition, review of the hospital report revealed a computerized tomography (CT) scan of the resident's head was conducted and found a small amount of new intraventricular hemorrhage within the atria of both lateral ventricles, greatest on the left. Interview with the Quality Assurance (QA) Nurse on 9/19/17 at 11:04 AM on the first floor administration wing revealed she had been responsible for the investigation of the incident. She stated the fall with injury occurred when the resident's Care Plan was not followed. The QA Nurse confirmed the Care Plan called for 2 staff to be present whenever ADL care was given; however, only one staff was present to give care when the fall occurred. The QA Nurse stated the CNA, who no longer worked at the facility, was aware of the resident's Care Plan, stating the CNA knew that there were supposed to be 2 people in the room, but she was in a hurry. She made a big mistake resulting in a fall from the bed requiring stitches to a laceration on the forehead (Harm). Medical record review revealed Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 30 day MDS dated [DATE] revealed the resident was cognitively intact with modified independence, and altered level of consciousness that fluctuated; was bed bound and was dependent with assistance of 1 person for bed mobility, dressing, eating, hygiene, bathing and toileting. Continued review revealed the resident had bilateral upper extremity impairments and received services from Respiratory Therapy for oxygen, suctioning, [MEDICAL CONDITION] care and ventilator care. Review of a facility investigation dated 7/26/17 revealed Resident #6 pushed his call light between 8:00 AM and 8:30 AM and told CNA #5 he needed respiratory therapy. The CNA told Respiratory Therapist (RT) #1 the resident requested him and he said OK. The RT was caring for another resident at that time. The resident pushed his call light a 2nd time and CNA #8 answered the call light and was told he needed respiratory because he couldn't breathe. The CNA informed RT #1 who was caring for another resident, stated OK, thanks. Approximately 5 minutes later the call light went off a 3rd time and CNA #8 answered it and the resident again stated he needed respiratory and he couldn't breathe. The CNA asked if RT #1 had made it in yet and the resident said No. The CNA said she would let him know again and found RT #1 sitting at a table in the hallway charting. CNA #8 told him Resident #6 still needed him because he said he couldn't breathe, and the RT smiled and said OK, thanks. The resident pushed his call light a 4th time and CNA #5 and Licensed Practical Nurse (LPN #7) entered the resident's room and he asked to be transferred out of the facility because he didn't feel safe. Medical record review of the Comprehensive Care Plan dated 6/2/17 revealed a problem of Impaired Gas Exchange-Ventilation with approaches to Perform Ventilator Checks every 4 hours and as needed.; a problem of Impaired Gas Exchange-Oxygenation with an approach to initiate SP02 (peripheral capillary oxygen saturation - an amount of oxygen in the blood) monitoring; a problem of Airway Patency and [MEDICAL CONDITION] Hygiene with approaches to Administer [MEDICATION NAME][MEDICATION NAME] via Nebulizer per orders, Tracheal Suctioning as needed. Review of a Tek-Care Report dated 7/31/17 revealed the ventilator alarm for Resident #6 went off on 7/26/17 at 8:49:42 AM and alarmed for 5 minutes, 18 seconds. Continued review revealed the oxygen saturation alarm went off on 7/26/17 at 8:49:53 AM and alarmed for 3 minutes, 44 seconds. Medical record review of the Respiratory Treatment Flo Administration History dated 7/1/17-7/31/17 revealed End Tidal Capnography every 4 hours (checks carbon [MEDICATION NAME] level) was scheduled to be checked at 8:00 AM on 7/26/17. RT #1 documented it was checked at 9:50 AM. Continued review revealed Resident #6 received his breathing treatment scheduled at 8:00 AM and 9:50 AM by RT #1. Continued review revealed Resident #6 was suctioned by RT #1 at 9:50 AM on 7/26/17 and received a moderate amount of thick pale yellow secretions. Interview with the Director of Nursing (DON) on 9/20/17 at 3:36 PM in the conference room confirmed the facility failed to respond to ventilator and oxygen saturation alarms timely, failed to provide care and assistance to Resident #6 timely, and failed to follow the Comprehensive Care Plan. Medical record review revealed Resident #7 was admitted with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE], revealed the resident was moderately cognitively impaired, totally dependent on staff for transfer, and required extensive assistance with bed mobility. The resident did not walk and required either supervision or limited assistance from staff with locomotion in her wheelchair. Review of Resident #7's Progress Notes revealed the resident had a history of [REDACTED]. Review of Resident #7's Comprehensive Care Plan, dated 9/7/17, revealed the resident has impaired/potential for impaired skin integrity r/t impaired mobility, incontinence of bowel and bladder, age related skin changes, ASA (aspirin) in use. [MEDICAL CONDITION], chronic [MEDICAL CONDITION]. Approaches to help the resident meet the goal of avoidable skin breakdown included 8/21/16 - Geri-sleeves to be in place. Review of the Safety Care Plan used by direct care staff and posted in the resident's closet also revealed the instructions: Geri-sleeves to be in place at all times d/t (due to) frequent STs (skin tears) - 8/21/16. Observation of Resident #7 on 9/18/17 at 8:48 AM, 3:00 PM., 5:06 PM., and on 9/19/17 at 8:10 AM., 8:26 AM, and 3:15 PM, revealed the resident was not wearing geri-sleeves. Bruising was noted on the resident's right hand, which extended from the index finger to the thumb, across the back of the hand. Interview on 9/19/17 at 8:26 AM with CNA #1 in the third floor dining/dayroom confirmed the resident was not wearing geri-sleeves at that time, and her arms were bare from below her elbow. CNA #1 stated, No, she doesn't use them. Interview with CNA #1 revealed she used the Care Plans posted in each resident's closet to know what care needed to be provided. After a review of the Care Plan posted in Resident #7's closet, CNA #1 confirmed it called for the use of geri-sleeves at all times, and she stated she had not known this intervention was listed on the Care Plan. Interview on 9/19/17 at 3:15 PM with LPN #1 in the third floor dining/dayroom, confirmed Resident #7 was not wearing geri sleeves. She stated the facility had geri-sleeves available, and they should be in place if the Care Plan called for their use. Interview on 9/19/17 at 3:22 PM with Unit Manager (UM) #1 in his office also confirmed the facility had geri-sleeves available for the resident's use and stated, If it's on the Care Plan, they should have been used. Review of Resident #8's Comprehensive Care Plan, initiated 11/10/16, was reviewed on 9/18/17. The Care Plan indicated the resident is at risk for falls r/t dependent on staff for ADLs, limited mobility, antihypertensive and [MEDICAL CONDITION] medications in use. To meet the goal of no avoidable falls, interventions since 12/20/16 included Floor mats at bedside. Interview on 9/18/17 at 1:52 PM with CNA #3 on the third floor hallway revealed the facility posted Care Plans in each resident's closet so direct care staff knew what care the resident needed. She stated the Care Plans included the amount of ADL assistance the resident needed, as well as any special devices or equipment that were to be used. Observation on 9/18/17 at 5:34 PM revealed Resident #8 was in his bed, which was in a high position. A fall mat was observed on the left side of the bed. However, no fall mat was present on the right side of the bed. Observation in Resident #8's closet revealed there was no Care Plan posted to provide information on the resident-specific approaches to be implemented. Review of Resident #9's Admission MDS, dated [DATE], revealed the resident was moderately cognitively impaired, was bedfast, had a [MEDICAL CONDITION], and was totally dependent on staff for all care, including transfers and bed mobility. Review of an Event Report revealed, on 9/17/17 at 2:20 AM, the resident had a fall from the bed and was found on the floor between the two beds in the room. The Event Report noted injuries from the fall, as the resident was decannulated ([MEDICAL CONDITION] came out), complained of pain after the fall, and had to have a [MEDICAL CONDITION]. In response to this fall, Resident #9's Care Plan for fall risk, initiated 8/23/17, was revised on 9/17/17 to include a Low bed when unattended. Observation on 9/18/17 at 5:24 PM, revealed the resident was asleep in bed, with his [MEDICAL CONDITION] in place, and nutrition infusing via gastrostomy tube. No staff were present in the room. The resident's bed was not in a low position and was higher than that of his roommate in the next bed. Interview on 9/19/17 at 3:22 PM with UM #1 in his office revealed if an intervention was listed on the Care Plan, it should have been used.",2020-09-01
957,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,323,G,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of Event Report, review of hospital record, interview, and observation, the facility failed to provide an environment free of accident hazards and the supervision needed to prevent accidents for 5 residents (#2, #4, #7, #8, #9) of 11 residents reviewed. Resident #2 sustained HARM (laceration to head which required stitches) during a fall when the facility failed to follow his care plan by using 2 staff to provide care. In addition, the facility failed to provide assistive devices such as low beds, fall mats, and call lights in reach to prevent falls for 4 residents (#4, #7, #8, #9). The facility failed to ensure devices to prevent accidents, such as geri-sleeves to prevent skin tears, were provided for Resident #7. The facility failed to ensure interventions resulting from an investigation were acted upon for 4 residents (#2, #4, #7, #9). The facility failed to ensure the environment was free of accident hazards such as side rails for which there was no assessment and were a factor in Resident #4's fall from the bed. The findings included: Review of facility policy, Fall Risk Reduction and Management, revised 9/16 revealed .A 'fall' is when a resident comes to rest unintentionally on the floor. An intercepted fall is a fall. A fall without injury is a fall. When a resident is found on the floor, the conclusion is that a fall has occurred. If a resident rolls or 'scoots' off a bed or mattress on the floor, this is a fall .Complete side rail assessment at time of admission, quarterly, at time of significant change Interventions appropriate to individual resident and their risk for falls will be implemented based on recognized standards of practice .MDS (Minimum Data Set)/Care Plan Coordinator is responsible for updating care plan related to fall risks, interventions and/or injury related to falls .Interdisciplinary staff will make suggestions for appropriate interventions to decrease likelihood of recurrent fall/fall with injury .The MDS/Care Plan Coordinator will be responsible for making sure that the care plan is updated accordingly .If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Review of a facility policy, Incident/Accident, revised 9/10/16, revealed .Incidents, accidents, or injury of unknown origin will be investigated and appropriate interventions taken as needed .Residents are assessed through the routine assessment and care planning process for factors that may place them at risk for incidents or accidents. Interventions will be implemented based on the assessment findings .The facility will investigate the incident, accident or injury to identify potential contributing factors .Based on investigative findings, the care plan will be reviewed and revised to include preventative interventions to decrease potential for recurrence . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident had a tracheostomy and was dependent on supplemental oxygen. Review of an Event Report dated 1/1/16 revealed the resident was lowered to floor. Review of the facility investigation revealed staff stated while she was giving him a bed bath, resident coughed violently multiple times that had him leaning off bed. For safety, resident was lowered to floor to keep from falling off bed .Care Plan to reflect x2 (2 person) assist for all care. Continued review of the note, staff were educated to use x2 assist for ADLs (Activities of Daily Living) and turning. Review of hospital records dated 11/2/16, revealed the resident was admitted to the hospital with [REDACTED]. Review of Progress Notes revealed the resident was readmitted to the facility on [DATE]. Review of an admission Fall Risk assessment completed on 11/9/16 revealed the resident was at risk for falls based on factors including decreased muscular coordination, impaired mobility, continent, medication use, length of stay, and his neuromuscular/functional status. Review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 continued to require total assistance of 2 staff for ADLs including bed mobility, transfer, dressing and toilet use. Continued review of the assessment revealed the resident was bedfast, severely cognitively impaired, and had no recent falls. Review of Resident #2's fall risk Care Plan last updated on 12/4/16, revealed upon his return to the facility, the documentation remained the resident at risk for falls r/t (related to) impaired mobility, need for 2 staff members with ADL assistance. Review of an Event Report dated 12/4/16 revealed at 6:00 AM staff had resident turned twards (towards) herself as she was providing incontinent (incontinence) care. Resident began to forcefully cough multiple times. Resident's body came off the bed and (staff) was unable to stop him from falling due to weight. The Event Report noted the resident had a 2-inch gash above the right eye. Review of the Progress Notes attached to the facility investigation revealed swelling was present to the area and neurochecks were started due to suspected head trauma. Review of the fall investigation revealed the resident was transferred to the hospital at approximately 9:15 AM, at the sister's request. Review of the 12/4/16 hospital record revealed the resident had stitches applied to the laceration above his right eye. Continued review of a computerized tomography (CT) scan of the resident's head revealed there was a small amount of new intraventricular hemorrhage within the atria of both lateral ventricles, greatest on the left. Review of the 12/4/16 Progress Notes dated 12/4/16 revealed the resident returned from the Emergency Department at approximately 2:30 PM. Review of Progress Notes on 12/5/16, revealed the resident continues to have edema (swelling) to right side of face and eye (the same side of the head as the craniectomy). Continued review of the Progress Notes revealed the Resident is noted to have blood present in trachea and is present when being suctioned, that was initially noted after returning from hospital. Review of a CNA (Certified Nurse Aide) Observation form dated 12/4/16 and a witness statement from the CNA that was present at the time of the fall revealed, I was turning (Resident #2) towards the window .to reposition him and change him. (Resident) coughed and coughed very hard two - 3 times. He threw himself out of the bed and I was unable to catch him. He fell out and had hurt himself. Review of her statement revealed that she had marked Yes to the question, Were all intervention(s) in place? Interview with the Director of Nursing (DON) on 9/19/17 at 10:48 AM on the first floor administrative wing revealed the Quality Assurance (QA) Nurse completed the investigation of this fall with injury, and she would be able to answer questions about it. The DON related the CNA involved in the incident had been disciplined for failing to follow the resident's Care Plan a second time in (MONTH) (YEAR), and no longer worked at the facility. Interview with the QA Nurse on 9/19/17 at 11:04 AM revealed the CNA's witness statement was not accurate. She stated all interventions were not in place, as the Care Plan called for 2 staff to be present whenever ADL care was given. The QA Nurse confirmed There were supposed to be 2 staff present at the time of the fall. She stated the CNA was aware of the resident's Care Plan and knew that there were supposed to be 2 people in the room but she was in a hurry. She made a big mistake. Medical record review revealed Resident #4's was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed the resident was cognitively impaired and required limited assistance with bed mobility, transfers and walking in her room. Continued review revealed the resident had no functional limitations to range of motion, but was not steady in transfers and was only able to stabilize herself during transfers with staff assistance. She was assessed as at risk for falls and the problem was Care Planned. Review of Resident #4's clinical record revealed no Physician Orders for any type of restraints, including side rails. Review of x-ray results dated 5/19/17 revealed Resident #4 was diagnosed with [REDACTED]. Review of Progress Notes dated 5/19/17 revealed the resident required hospitalization and a hip replacement. Review of the facility investigation revealed the facility was unable to determine the etiology of this fracture. Resident #4 returned to the facility on [DATE] and remained at risk for falls and the problem continued to be Care Planned. Fall 1 - Review of an Event Report dated 6/20/17 revealed at 11:00 PM the resident had an unwitnessed fall, and was found sitting next to bed on floor. Patient still had blankets on. Continued review of the Event Report revealed bilateral hip and sacral x-rays were ordered on [DATE] due to the resident's increased pain after the fall; however, no new fractures were found. The Probable Cause of the fall was listed as resident attempted to ambulate without assistance. Review of the Event Report revealed the Care Plan was updated; however, review of the Care Plan, initiated on 4/19/17, revealed no interventions were added to the Care Plan. Review of hospital records revealed the resident was hospitalized from [DATE] - 7/3/17, when she required a below the knee amputation (BKA) of her left leg due to a gangrenous great toe. Resident #4 returned to the facility on [DATE]. The resident's Comprehensive Care Plan continued to indicate she was at risk for falls. Medical record review of a comprehensive assessment dated [DATE], was completed for a significant change in the resident's condition. After the amputation, the resident no longer walked, and needed extensive staff assistance with bed mobility and transfers. After completion of the Comprehensive Assessment, the resident's Comprehensive Care Plan was updated and a Care Conference was held on 7/19/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. Review of the Care Plan revealed the resident was at risk for infection r/t Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The care plan also noted the resident is a fall risk r/t S/P (status [REDACTED]. Both of these approaches had previously been on the resident's Care Plan and were not revised/deleted after the amputation of the resident's leg. Fall 2 - Review of an Event Report dated 7/13/17 revealed the resident's next fall occurred on 7/13/17 at 1:35 AM. The resident was found by staff Sitting on floor at bedside with legs extended in front of her. Resident stated she slid out of bed once her leg went over the side. Medical record review of a x-ray Report of the resident's left hip (which was previously fractured and replaced) revealed no new fractures. Review of Physician Orders attached to the Event Report revealed, on 7/13/17, the Physician gave new orders for Fall mats beside pt's (patient's) bed. Bed in lowest position at ALL times. Continued review of the Event Report revealed the resident's Care Plan was updated in response to the fall on 7/13/17. Further review of the Care Plan revealed the approach of the bed in the lowest position was not added to the Care Plan until 8/1/17. Continued review of the Care Plan revealed, as of 9/18/17, the approach of fall mats at the bedside had never been added to Resident #4's Care Plan. Fall 3 - Review of an Event Report dated 8/1/17 revealed, at approximately 4:30 PM, the resident was found sitting on the floor .When asked what happened, the resident stated, I just wanted to get in the chair. Continued review of the Event Report revealed the Probable cause of the fall was the Resident has intermittent confusion, is a fall risk, and doesn't always remember to use call light. Although the investigation identified the resident's [DIAGNOSES REDACTED]. Fall 4 - Review of an Event Report dated 8/25/17 revealed at 4:15 PM, the resident attempted to transfer herself from the chair to the bed without assistance and fell , did not call and ask for help. The root cause was described as transferring without assistance, not using call light. The Care Plan was updated on 8/25/17 with an intervention for, Remind resident to use the call light for assistance. Continued review revealed there was no evidence of identification that the use of the call light was already on the Care Plan and was not successful in preventing this fall. Further review revealed there was no evidence of an investigation as to why the previous intervention of the call light was not successful, and the facility did not assess factors such as whether the call light was out of reach, or if the resident could not remember to use it due to cognitive function. Fall 5 - Review of an Event Report dated 9/11/17 revealed at 11:20 AM, staff walked into resident's room to find resident at the end of bed with legs hanging off bed touching floor. Resident began to slide, (staff) assisted resident to floor. Review of the Probable Cause was listed as resident scooted to foot of bed and lost her balance and fell off bed. Continued review revealed there was no evidence the facility assessed the root cause of why the resident scooted to the foot of the bed. Medical record review of the resident's Care Plan revealed, since 7/26/17, the resident was to have a lower bedrail raised on the amputation side (left side) of the bed. Further review of the Care Plan revealed with the use of the one lower side rail, the resident will still be able to get OOB (out of bed) to her strong side. Review revealed there was no evidence the facility investigated whether one (or more) side rails were in use at the time of this fall and whether their use restricted normal exit from the bed, forcing the resident to scoot to the end to try and get out of bed. Although the Event Report indicated there were no injuries noted from this fall, review of the facility investigation revealed the resident complained of pain to the left leg stump on 9/12/17 and 9/13/17, as well as knee pain on 9/14/17. Fall 6 - Review of Progress Notes dated 9/17/17 revealed at approximately 5:30 AM the resident was found sitting on floor on knee/stump, claims she forgot she only has one leg. Medical record review revealed the resident's stump was bleeding and she had a small bruise to the right knee. Continued medical record review revealed at 7:16 PM, the resident was complaining of pain in her right ankle from the fall and the nurse observed bruising across the top of the ankle. X-rays were obtained on 9/18/17, and no fracture was identified. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed. The resident's Physician Orders for fall mats and the bed to be in the lowest position were not followed. Observation revealed the resident's bed was not lowered and the fall mats were not in use. The resident's Care Plan called for one lower side rail to be up when the resident was in bed. However,observation revealed all 4 one-half side rails were raised, creating the effect of 2 full side rails which restrained the resident in bed. Although the Care Plan called for the resident to use her call light to prevent falls, observation revealed the call light cord was looped through the middle bar of the top side rail, and was dangling under the bed, out of the resident's reach. Further observation on 9/18/17 at 1:49 PM revealed the resident was asleep in bed with the bed in the lowest position closest to the floor with no fall mats in use and the 4 side rails raised. Observation on 9/19/17 at 8:08 AM revealed Resident #4's right foot was bruised and purple-grey in color. The bruising extended over the top of the resident's foot from the ankle to the toe and around the back and side of the ankle. The resident was moaning, and when Licensed Practical Nurse (LPN) #1 asked Resident #4 if her foot hurt, she responded, Yes. Interview with CNA #3 on 9/18/17 at 1:52 PM, confirmed all 4 side rails were raised, and there were no fall mats in place. CNA #3 stated, She doesn't use any fall mats; not that I know of. CNA #3 stated the bed was always supposed to be in the lowest position; however, it had to be raised for meals to get the over-bed table in place. When told of the observation on 9/18/17 at 8:08 AM, she stated staff, may have forgotten to lower the bed after the resident's meal was finished. During the interview on 9/18/17 at 1:52 PM, CNA #3 stated she always used all 4 side rails for the resident when she was in bed. She stated the resident had a leg amputation earlier this year, and After she came back from the hospital, we was (were) told to use all 4 side rails with her because she's a fall risk. Further interview with CNA #3 revealed the resident doesn't try to climb over - she goes out the end (of the bed) instead. CNA #3 stated she was the staff who witnessed Fall #5 on 9/11/17, saying, Just last week, I found her sliding out the end of the bed when she could not exit the bed in a normal fashion because all 4 side rails were raised. Further interview with CNA #3 revealed each resident had a Care Plan posted in their closet and this information was used to know what type of assistance and devices were needed. She went to Resident #4's closet and showed there was a Care Plan posted on the left door of the resident's closet. Review of the documents which CNA #3 referred to revealed the Safety care plan included only one intervention - Mattress stops in place to prevent mattress from sliding down. CNA #3 reviewed the Safety Care Plan and confirmed it did not show the need for fall mats, low bed, and only 1 side rail to the lower left side of the bed. Interview with the DON about Resident #4 on 9/18/17 at 2:10 PM, the DON stated, She's fallen more times than you can count. When informed the Safety Care Plan provided by CNA #3 did not include multiple interventions which had been identified to prevent falls, the DON provided another document titled Safety Careplan and stated this was also posted in the resident's closet (on the right door of the closet.) Review of this Safety Careplan revealed the resident was supposed to have: Bed in lowest position at all times. Fall mats. Remind her to use call light. Raise Lower Bedrail on bed to help with safe sleep. Further interview with the DON at this same time revealed she was unaware staff were not consistently using a low bed and were not using fall mats when the resident was in bed. The DON stated historically the facility did not assess for the use of side rails. She stated, although the facility was in the process of adding side rail assessments to the admission packet, Resident #4 did not have a side rail assessment completed. The DON stated she had no evidence the facility had conducted a thorough assessment of the safety of this equipment relative to the resident's condition. Continued interview with the DON revealed after the fall in (MONTH) (YEAR), the fall team decided the resident should only have 1 side rail (lower left) raised when she was in bed. She stated she was unaware staff were using all 4 side rails when the resident was in bed. The DON added she was unaware all 4 side rails were in use at the time of the 9/11/17 fall, and confirmed the investigation should have addressed this as a possible root cause and determined if the fall from the end of the bed occurred because all 4 side rails were raised and Resident #4 could not get out of bed in a routine manner. The DON was interviewed about other interventions listed on the investigations and care plans to prevent further accidents. She stated the repeated addition of the call light was not appropriate, based on the resident's cognition, which she stated had declined since admission. Interview with the Care Plan Coordinator on 9/19/17 at 9:50 AM revealed if the call light was already listed on the Care Plan, the Care Plan should have been revised with a different intervention - Not one that was already on there. Further interview with the Care Plan Coordinator on 9/19/17 at 4:35 PM revealed Anyone can update the Care Plan when the falls team meets. He could provide no explanation as to why Care Plan approaches were not updated per the Event Report documentation, and stated, It should have been done. Medical record review revealed Resident #7's with [DIAGNOSES REDACTED]. Review of the resident's most recent assessment, a Quarterly MDS dated [DATE], revealed the resident was moderately cognitively impaired, was totally dependent on staff for transfer, and required extensive assistance with bed mobility. The resident did not walk and required either supervision or limited assistance from staff with locomotion in her wheelchair. Medical record review revealed Resident #7 had a history of [REDACTED]. -11/10/16 skin tear to left lower extremity during transfer to wheelchair by staff -1/3/17 skin tear to back of right calf during transfer by staff -2/18/17 skin tear to right thigh -3/23/17 skin tear to left forearm -4/30/17 skin tear to right hand -6/22/17 skin tear to left upper extremity (x2) -7/19/17 skin tear to left lower extremity -7/19/17 skin tear to right lower extremity -8/6/17 skin tear to left wrist -8/21/17 skin tear to second knuckle of right hand Review of Resident #7's Comprehensive Care Plan, dated 9/7/17, revealed that since 11/30/15, the resident has impaired/potential for impaired skin integrity r/t impaired mobility, incontinence of bowel and bladder, age related skin changes, ASA (aspirin) in use. Venous insufficiency, chronic edema. Approaches to help the resident meet the goal of avoidable skin breakdown included 8/21/16 - Geri-sleeves to be in place. Review of the Safety Care Plan used by direct care staff and posted in the resident's closet also revealed the instructions: Geri-sleeves to be in place at all times d/t (due to) frequent STs (skin tears) - 8/21/16. Observation of Resident #7 on 9/18/17 at 8:48 AM, 3:00 PM, 5:06 PM, and 9/19/17 at 8:10 AM, 8:26 AM, and 3:15 PM revealed the resident was not wearing geri-sleeves. Bruising was noted on the resident's right hand, which extended from the index finger to the thumb, across the back of the hand. Interview on 9/19/17 at 8:26 AM with CNA #1 confirmed the resident was not wearing geri-sleeves at that time, and her arms were bare from below her elbow. CNA #1 stated, No, she doesn't use them. Interview with CNA #1 revealed she was unaware that the resident's Care Plan called for the use of geri-sleeves at all times. Interviews on 9/19/17 at 3:15 PM with LPN #1 and on 9/19/17 at 3:22 PM with UM #1 both confirmed that the facility had geri-sleeves available for use. Each confirmed that this assistance device to prevent injuries should have been used per Resident #7's care plan. Review of Resident #8's most recent Comprehensive Assessment (admission MDS of 11/17/16) revealed the resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident was bedfast and totally dependent on staff for all ADLs, including bed mobility and turning/repositioning. Review of a readmission History and Physical, dated 5/17/17 revealed the resident had a tracheostomy, and was ventilator and dialysis dependent. Demographic information revealed the resident also had [DIAGNOSES REDACTED]. Review of the most recent Fall Risk assessment form, completed 8/31/17, revealed the resident was at risk for falls based on intermittent confusion/poor recall/judgement/safety awareness, decreased muscular coordinator, incontinence, medication use, and neuromuscular//functional status. Resident #8's Comprehensive Care Plan, initiated 11/10/16, was reviewed on 9/18/17. The Care Plan stated the resident is at risk for falls r/t dependent on staff for ADLs, limited mobility, antihypertensive and psychotropic medications in use. To meet the goal of no avoidable falls, interventions since 12/20/16 included Floor mats at bedside. Observation on 9/18/17 at 5:34 PM revealed Resident #7 was in his bed, which was in a high position. A fall mat was observed on the left side of the bed. However, no fall mat was present on the right side of the bed. A fall mat was noted on the floor in the bathroom, underneath a reclining chair in storage. Additional observations on 9/19/17 at 8:30 AM and 10:04 AM also revealed, while the resident was in bed, there was no fall mat on the right side of the bed, which was in a high position. Interview on 9/19/17 at 10:04 AM with CNA #2 confirmed there was no fall mat on the right side of the resident's bed. She stated, I think it's family preference that there was no mat on one side of the bed. She stated if a Care Plan intervention was not being used, it should be reported to the nurse; however, she had not done so. CNA #2 was also asked about the height of Resident #7's bed, which increased the potential for injury, should a fall occur. She stated, Oh, he wants it that way. You can ask him. When interviewed at this time, Resident #7 responded No, he did not want his bed to be in a high position. When asked if he wanted his bed lower, he replied, Yes. CNA #2 then stated, Oh, well and did not lower the resident's bed before she left the room. Further review of Resident #8's Care Plan on 9/19/17 revealed the intervention of fall mats, which had been in effect since (YEAR), was no longer on the Care Plan. Review of the Care Plan History revealed the intervention of fall mats was deleted on 9/18/17 after surveyor intervention. The reason for the discontinuation of the mats on the Care Plan was listed as prior admit. Interview with the Care Plan Coordinator on 9/19/17 at 4:45 PM revealed he had deleted the intervention of fall mats after the survey team left the faciity on [DATE] because, I was just trying to make the Care Plans right and the fall mats had been in place on the Care Plan since the resident's last admission. He confirmed that each of the other interventions listed on the Care Plan were also in place since the last admission, and could provide no explanation as to why he had discontinued the one intervention on the Care Plan which the survey team identified was not being implemented by staff. Interview with a corporate representative who was present during this interview revealed the Care Plan approach of fall mats should not have been removed without an assessment of the resident's current needs and ongoing fall risk. Review of Resident #9's Admission Notes dated 8/7/17 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. The admission note documented the resident's right side was flaccid, but he could move his left arm within the functional limitation. Demographic information revealed additional [DIAGNOSES REDACTED]. An Admission Fall Risk assessment completed 8/7/17 revealed the resident was at risk for falls, based on his incontinence, use of multiple medications, neuromuscular/functional status, and length of stay in the facility. Resident #9's admission MDS, dated [DATE] revealed the resident was moderately cognitively impaired, was bedfast, and was totally dependent on staff for all care, including transfers and bed mobility. Review of Resident #9's Comprehensive Care Plan revealed it was initiated on 8/23/17. The Care Plan noted the resident was at risk for falls r/t weakness S/P CVA (cerebrovascular accident - stroke). In response, 4 standard nursing interventions were listed as interventions - administer medications per orders, anticipate needs proactively, get assistance with ADLS to ensure safety as needed and observe for unsafe actions - intervene immediately. Review of Resident #9's Progress Notes revealed on 9/2/17, Nursing staff have had to assist resident back into proper position multiple times this shift. Resident has been found with legs out of bed. Progress Notes on both 9/8/17 and 9/9/17 documented the resident was in a low bed with call light in reach. Progress Notes on 9/15/17 documented the resident was noted with more activity, movement in legs, reaching, turning self from side to side .Bed currently in low position for patient safety. However, review of the Care Plan revealed it was not revised to reflect the fall risk related to the resident being found with portions of his body out of bed, his increased mobility and movement in legs, or the need for a low bed and call light that was identified by staff. Review of an Event Report revealed on 9/17/17 at 2:20 AM, a staff was walking hallway, noted resident OOB (out of bed) and yelled for assistance. Upon entering room, resident noted on R (right) side on floor between A and B bed. The report noted injuries from the fall, as the resident was decannulated (tracheostomy tube came out), complained of pain after the fall and had to have a .new trach placed . Per the Event Report, the facility was unable to determine the root cause of the fall, noting the resident was non-verbal/clean and dry. In response to this fall, the Care Plan was updated for a .Low bed when unattended . Observation on 9/18/17 at 5:24 PM revealed the resident was asleep in bed, with his tracheostomy in place, and nutrition infusing via gastrostomy tube. No staff were present in the room. The resident's bed was not in a low position. Interview on 9/18/17 at 5:29 PM with LPN #3 revealed, although he was aware Resident #9 had fallen from bed the previous day, he did not know the resident had been injured or required trach placement in response to the fall. He stated, He's been trying to get out of bed again today, especially this morning. LPN #3 stated, although the resident was totally dependent on staff for turning and repositioning, the resident had limited use of one arm and one foot, which he was using to wriggle himself across the bed. LPN #3 stated We put some pillows in to help keep the resident's position in the center of the bed to prevent further falls. Further observations of Resident #9 in bed on 9/18/17 at 5:33 PM, and on 9/19/17 at 8:33 AM and 2:03 PM revealed there were no pillows being used to",2020-09-01
993,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2017-05-02,371,F,1,0,5GRM11,"> Based on review of facility policy, observation, and interview, the facility failed to maintain sanitary conditions in the dietary department and failed to maintain proper food temperatures in 1 of 1 observations made. The findings included: Review of facility policy Food Preparation and Service, last revised 2014, revealed .maintain clean food storage areas at all times .mechanically altered hot foods .must stay above 135 degrees .during preparation . Observation and interview with the Dietary Manager on 5/2/17 from 10:59 AM to 11:05 AM, during tour of the dietary department, revealed debris including paper clutter, a tray top, and a coffee cup on the floor behind and beneath the clean dish rack. Continued observations of the dry storage area revealed a 6 pound 9 ounce can of tomato sauce, two 111 ounce cans of northern beans, and a 6 pound can of mandarin oranges stored dented and ready for use. Further observations of the walk in refrigerator revealed five 2 pound bags of shredded coconut with an expiration date of 8/15/2015 and 67 pints of milk with an expiration date of 4/30/17. Continued observation of food temperatures during tray line preparation revealed the pureed spaghetti sauce was 116.2 degrees Fahrenheit (low) and the pureed carrots were 79 degrees Fahrenheit (low). Interview with the Dietary Manager confirmed the facility failed to maintain sanitary conditions in the kitchen, failed to ensure expired foods and dented cans of food were not available for resident use, and failed to ensure prepared foods were served at the appropriate temperature.",2020-09-01
994,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2017-05-02,465,F,1,0,5GRM11,"> Based on observation and interview, the facility failed to maintain the function and the sanitary conditions in 2 shower rooms (east wing and west wing) of 3 shower rooms observed. The findings included: Observation during initial tour of the east wing shower room toilet facilities on 5/1/17 at 12:12 PM revealed the following: 1. 2 candy wrappers, 3 previously used vinyl gloves, 2 candy sucker sticks, previously used alcohol prep pads, and plastic wrappers lying on the floor; 2. 1 overfilled 50 gallon trash can with numerous soiled adult briefs and pads, within it; 3. Brown colored debris on the floor near the shower drain; 4. Brown colored debris on the flooring in front of and near the toilet; 5. Yellow colored stains in front the toilet; 6. The commode was clogged with dark black and brown debris and was unable to be flushed; 7. Brown colored debris on the toilet bowl and a bariatric chair situated above the commode; 8. The shower had an overwhelming odor of urine and feces; 9. 1 pair of soiled adult briefs atop the faucet handles of the handwashing sink; 10. Clean adult briefs stored next to the center of the shower room floor, between the trash cans and the shower stalls. 11. Shower chairs located in two of the shower stalls were stored wet and had brown stains on the seats; 12. The hand held shower heads were stained and were dripping water. Observation of the west wing shower room on 5/1/17 at 1:40 PM, revealed the following: 1. The commode was clogged with a large amount of dark black and brown debris and was unable to be flushed; 2. Dark brown and black debris was smeared on the inner commode rim; 3. The floor in front of the toilet was soiled with dark brown and yellow colored debris; 4. A small trash can was overfilled with soiled adult briefs and other assorted trash; 5. The shower room had an overwhelming odor of urine and feces; 6. The shower heads were stained. Continued observation revealed 3 staff members entered the west wing shower room, removed the trash can filled with soiled briefs, replaced the barrel with an empty receptacle, and exited the shower room without any further cleanup of the shower room. Interview with the Director of Nursing (DON) on 5/1/17 at 2:30 PM, in the DON's office, confirmed the facility failed to maintain sanitary conditions in the shower rooms and failed to ensure the commodes functioned and were available for resident use.",2020-09-01
995,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-09-20,584,E,1,0,4QHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of facility maintenance records, the facility failed to maintain clean, comfortable and home like conditions on 3 of 4 resident units observed for physical environment. The findings include: Observations of facility dining area and front lobby during initial tour revealed it was closed due to renovations in progress. Observations during the initial tour revealed the front lobby, front hallway, dining area and common seating areas adjacent to the lobby were cordoned off by a black, vinyl curtain with a zipper and sign that informed viewers that section of the facility was closed due to renovation. Continued observation revealed the dining room appeared to be renovated with new flooring, wall coverings and carpet. Rolls of new flooring materials were in the floor near the wall adjacent to the kitchen door of the dining room and the dining room appeared to have been unused for a substantial period of time as evidenced by dust on a few of the tables near the rear of the dining room adjacent to the kitchen. Staff offices in the construction area were in use, including the medical records department, admissions office, conference room and Administrator's Office. Interview with the Director of Nursing (DON) and construction foreman during the initial tour revealed the dining area and a major portion of the West Wing had been under renovation since (MONTH) (YEAR), and residents had been required to dine in their rooms or on the unit hallways since then. Observations of the East Wing, H Wing Hallway and portions of the West Wing still in use, with the DON, on 9/18/18, from 2:39 PM to 3:30 PM revealed the following: East Wing 1. A pervasive odor of urine was present in the hallway, attributed to the carpet, between rooms 205-212. room [ROOM NUMBER] was closed for renovations and was reported to have a pervasive odor prior to renovation due to odors absorbed by the wall coverings. 2. Crusty matter which appeared to be dried food particles were present ground into the carpet in front of the East Wing Nursing Station between rooms [ROOM NUMBERS]. 3. There was a pervasive odor of urine at the distal end of the East Wing again attributed to carpeting in the hallway in the vicinity of room [ROOM NUMBER], which extended to the exit door at the end of the unit. 4. Observations of the carpeting revealed the carpet was worn with multiple bare spots near the carpet edges, and heavy black staining throughout the East Unit. 5. The tile floors of rooms, 203-209, 223, 226, 230 and 231, were heavily scuffed with black marks, and appeared heavily worn, dirty and dull. 6. The wall covering near the door in room [ROOM NUMBER] was visibly stained and dirty. The wall covering around the air condition unit in room [ROOM NUMBER] was in a state disrepair, scuffed and dirty. 7. Observations of the East Wing Shower room revealed the metal box which contained the thermostat was hanging open. A single used vinyl glove was inside the lid of the box which hung by the hinges below the box. The plastic thermostat cover was lying in the hanging portion of the box. The thermostat mechanism itself with single red and white wires visible, was exposed to open air. A paper clip was noted to be present protruding from the lock mechanism on the upper front portion of the box which was inoperable. The box could not be closed by the DON who attempted secure it and it would fall open when attempts to close it were made. Continued observations of the H Hallway (between the East and West Units) revealed the following: 1. The H Hallway carpet was heavily worn and stained with a black stain that appeared water like in pattern, throughout the entire length of the hallway. A pervasive, musty odor was present the length of the hallway between the East and West units. There was dirt and debris ground into the carpet near the nursing stations at either end of the hallway. 2. Observations of the flooring in the H Hallway shower room revealed it to be in a state of disrepair. Sections of the flooring were loose and appeared to have become detached from the sub flooring beneath. The DON reported the shower had been out of use for several months due to the flooring issues and the owners of the facility had ordered it closed in lieu of repair, due to planned renovation. The DON reported at the time, the facility used the 2 remaining shower rooms (East wing shower at the other end of the H Hallway, and another shower room on the main hall entrance to the East Wing) for all 65 residents who remained in the facility. Observations of the West Wing revealed the following: 1. The carpet on the unit from the nursing station to the end of the unit was heavily worn and soiled with black stains similar to those noted on both the East and H Hallways. 2. A pervasive musty odor was present at the far end of the West Hallway. 3. The tile floors in the resident rooms were noted to be heavily scuffed, dirty and worn in rooms 122, 123, 125 and 131. The threshold of room [ROOM NUMBER] was noted to be covered with gray duct tape, which was torn at the edge adjacent to the door frame, wood fragments were noted to be in the floor atop the duct tape, which appeared to have flaked off the finish of the room door. Interview with the interim Housekeeping Supervisor (HS) revealed she had been in the position for 2 weeks. The HS reported the facility did not own a floor cleaner or tile buffer and the tile floors had not been cleaned other than routine mopping. The HS reported the facility did not own a carpet cleaner as well and staff attempted to keep the carpets clean via sweeping it or vacuuming it after meals. The HS confirmed for several months residents had taken meals in the hallways or their rooms as the dining hall had been closed due to renovations. The HS reported her predecessor had advised her and other members of the housekeeping staff, the facility owners did not wish to spend money on carpet or floor cleaning equipment or commercial carpeting cleaning services, due to the costs of ongoing renovations and plans to change the flooring. The HS reported the facility carpets had not been deep cleaned since before the last annual survey sometime in (YEAR). Review of the facility carpet cleaning receipts revealed the facility had not contracted for carpet cleaning since (MONTH) of (YEAR). There were no receipts for tile floor cleaning. Interview with the DON on 9/18/18 at 5:00 PM, in the conference room confirmed the facility did not own a tile floor buffer or carpet cleaner other than a standard vacuum cleaner, and confirmed the facility had not contracted for cleaning services for the floors since (MONTH) (YEAR) per the receipts. The DON confirmed the facility dining hall had been closed for 10 consecutive months due to renovations and confirmed the facility failed to maintain a clean, comfortable and homelike environment on the East Wing, H Hallway and West Wings as identified during observations.",2020-09-01
996,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-09-25,600,D,1,0,ZR0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent abuse for 1 resident (#2) of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse Neglect, Mistreatment and Misappropriation of Resident Property, last revised 10/2017, revealed .it is the policy of this facility to prevent abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pair or mental anguish .Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Review of a facility investigation dated 7/27/19 revealed on 7/27/19 at approximately 11:00 AM Resident #6 entered Resident #2's room. Further review a nurse entered Resident #2's room after hearing the residents cursing loudly. Continued review revealed as the nurse was removing Resident #6 from Resident #2's room; Resident #6 reached over and hit Resident #2 on the foot. Further review revealed the nurse grabbed Resident #6's arm and placed it close to his body, but Resident #6 quickly reached back and hit Resident #2's foot again. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not completed due to .resident is rarely/never understood . Review of a Staff Assessment for mental status revealed the resident's short and long memory was good. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and discharged [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #6's Annual MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. Observation and interview with Resident #2 and Licensed Practical Nurse (LPN) #1 on 9/23/19 at 10:20 AM, in the hallway outside the resident's room, revealed the resident was seated in a wheelchair, was well groomed, and had no anxious or fearful behaviors. Interview with Resident #2 revealed .(Resident #6) hit my foot (translated by LPN #1) . Telephone interview with LPN #2 on 9/23/19 at 1:40 PM revealed .He (Resident #6) was in (Resident #2's) room visiting her roommate .(Resident #2) was yelling so I went in the room and was rolling him (Resident #6) out. When we passed the foot of her (Resident #2's) bed he (Resident #6) reached out .hit her (Resident #2's) foot .before I could get (Resident #6's) arms he hit (Resident #2's) foot again .he meant to hit her . Interview with the Director of Nursing on 9/25/19 at 11:18 AM, in the conference room, confirmed Resident #6 deliberately hit Resident #2 on her foot twice. In summary, the facility failed to prevent abuse to Resident #2.",2020-09-01
997,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2017-10-18,465,F,1,0,RWX011,"> Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment on 2 of 2 units observed. The findings included: Observations on 10/18/17 from 10:30 AM to 10:55 AM revealed the carpet on the East and West Wing hallways had large dark brown to black stains. Continued observation on the West Wing hallway revealed the carpeting at the nursing station was loose from the floor and an elevated ridge had formed. Further observation revealed the West Wing nursing station dry wall was unfinished and unpainted. Continued observation revealed the West Wing fire doors located between the entrance to the unit and the central hallway had rough and small irregular chunks missing from the door edges and the wood beneath the finish was exposed. Further observation revealed the threshold in room 214 was cracked and there were 2 large fist sized holes located above bed B. Continued observation revealed the paint was chipped from the wall around the sink and soap dispenser located in room 214. Interview with the Administrator on 10/18/17 at 11:00 AM, in the conference room, confirmed the facility failed to maintain a clean, comfortable, and homelike environment on both the East and West Wings.",2020-09-01
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
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
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
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
1021,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-12-14,761,D,1,0,DJ7L11,"> Based on review of facility policy, observation, and interviews, the facility failed to follow established procedures for narcotic drug reconciliation counts on 1 medication cart (#1) of 5 medication carts reviewed on 1 hallway (#400) of 5 hallways reviewed. The findings included: Review of the facility policy Controlled Medication and Drug Diversion, undated, revealed .At each shift change or when keys are rendered, a physical inventory of all controlled medications is conducted by two staff: licensed nurse .or per state regulation and is documented .this is completed as follows .the nurse .surrendering the keys will read from the controlled substance accountability book the name of resident and the medication to be accounted .oncoming nurse .will locate medication .in the narcotic drawer .count remaining medication and report to nurse the amount of the medication remaining .the nurse in charge of the accountability book will verify correct or incorrect .medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage and disposal .in accordance with federal, state and other applicable laws and regulations . Observation of a narcotic drug reconciliation on 12/17/18 at 5:32 AM, on the 400 hallway with Licensed Practical Nurse (LPN) #16 and LPN # 17 revealed LPN #16 and LPN #17 failed to name the resident listed on each narcotic inventory sheet, failed to name each drug counted, and failed to verified the number of remaining narcotic tablets matched the number on the narcotic control logs for each resident during the narcotic drug reconciliation. Interview with the Director of Nursing and Administrator on 12/17/18 at 7:30 AM, in the conference room, confirmed the facility failed to follow procedures for medication reconciliation and 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
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
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
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
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
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
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
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
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
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
1068,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-09-25,745,D,1,0,X6BC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the facility policy review, Social Service Job Description review, medical record review, and interview the facility failed to have Social Services follow up with 2 residents (#4 and #5) of 5 residents reviewed for abuse following a physical altercation between Residents #4 and #5. The findings include: Review of the facility's abuse policy, Abuse Prevention Policy and Procedure, revised 2/26/18 revealed .REPORTING/INVESTIGATION/RESPONSE POLICY .Facility Social Worker is to provide counseling and support to the resident and possibly the family involved .The counseling is to be provided as long as necessary .the psychosocial intervention is to be documented in the resident's clinical record . Review of the Social Service Job description, Social Services, revised 6/2006 revealed General Purpose .Identify and provide for each resident's social, emotional and psychological needs .Essential Job Functions .Provide timely and accurate completion of Social Services .Progress Notes as well as Social Service Assessment .and other forms as required by the Administrator in order to comply with federal and state regulations and facility policies and procedures .Maintain progress notes for each resident as required by company policy and state and federal regulations .Progress notes must reflect progress made regarding problems identified in the Plan of Care . 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 of Resident #4's General Notes revealed no Social Service documentation from 9/17/18-9/24/19 following a physical altercation related to abuse which occurred on 9/17/19 between Residents #4 and #5. Medical record review revealed Resident #5 was admitted 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 . Continued review revealed the residents care plan was updated on 9/17/19 and a new intervention was initiated. Further review revealed .9/17/19 RESIDENT TO RESIDENT CONTACT .RESIDENT EDUCATED ON ASKING FOR HELP FROM STAFF IF HAVING DIFFICULTY WITH ANOTHER RESIDENT INSTEAD OF ENGAGING IN PHYSICAL CONTACT . 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 . Medical record review of Resident #4's General Notes revealed no Social Service documentation from 9/17/18-9/24/19 following a physical altercation related to abuse which occurred on 9/17/19 between Residents #4 and #5. Interview with the Social Worker (SW) on 9/24/19 at 11:18 AM, in the conference room, confirmed the SW failed to conduct any follow up services with Resident #4 and #5 after an incident of resident to resident abuse on 9/17/19. Continued interview confirmed the SW was unaware she was responsible for providing counseling and support to Resident #4 and #5 after any allegation or suspicion of resident abuse occurred. Further interview confirmed .I didn't know then but I know now . Interview with the Director of Nursing (DON) on 9/24/19 at 2:37 PM, in the conference room, confirmed there was physical contact between Resident #4 and #5. Further interview confirmed physical abuse had occurred between Residents #4 and #5. Continued interview confirmed the facility failed to have Social Services follow up with Residents #4 and #5 as required by the facility's policy. Further interview confirmed Social Services failed to provide counseling and support to Residents #4 and #5 after the abuse allegation.",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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
1258,SIGNATURE HEALTHCARE OF MEMPHIS,445241,1150 DOVECREST RD,MEMPHIS,TN,38134,2019-07-22,921,E,1,0,CW6W11,"> Based on policy review, observation and interview, the facility failed to ensure 3 of 4 shower chairs in 2 of 2 (North and South Shower Rooms) shower rooms were clean and sanitary. The findings include: 1. The facility's Cleaning and Disinfection of Resident-Care Items and Equipment documented, .Durable medical equipment must be cleaned and disinfected before use by another resident . 2. Observations in the North Shower room on 7/22/19 at 11:08 AM and at 11:40 AM revealed a dried brown substance on the seat of 1 shower chair. Interview with Certified Nursing Assistant (CNA) #1 on 7/22/19 at 11:05 AM in the North Shower room, CNA #1 was asked if the shower chair had been cleaned after resident use. CNA #1 stated, .I'll wipe it down. Looks like something is on it. CNA #1 confirmed the shower chair had been used earlier this day. Interview with the Director of Nursing (DON) on 7/22/19 at 11:40 AM in the North Shower room, the DON was asked if the shower chairs should be cleaned between each resident use. The DON stated, Yes . When the DON was asked what was the brown substance on the seat of the shower chair, she stated, Looks like BM (bowel movement). When asked if the shower chair had been cleaned, the DON stated, No ma'am, doesn't appear to have been. 3.Observations in the South Shower room on 7/22/19 at 11:10 AM and 11:48 AM revealed a brown substance on the seat and frame of 2 shower chairs. Interview with the DON on 7/22/19 at 11:48 AM in the South Shower room, the DON was asked what was the brown substance on the seat and frame of the shower chairs. The DON stated, Dirt, soiled. Needs cleaning .",2020-09-01
1259,SIGNATURE HEALTHCARE OF MEMPHIS,445241,1150 DOVECREST RD,MEMPHIS,TN,38134,2017-08-23,225,D,1,0,2Z9411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 922 Based on policy review, facility investigation review, medical record review, and interview, the facility failed to immediately suspend an employee after an allegation of abuse for 1 of 4 (Residents #2) sampled residents reviewed for abuse. The findings included: 1. The facility's Abuse, Neglect . policy documented, .C. Abuse Prevention and Protection .5. If the suspected perpetrator is a Stakeholder (employee), the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated . 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 had no cognitive impairment and required extensive assistance with personal hygiene. The facility's COMPLAINT/GRIEVANCE REPORT dated and signed on 6/10/17, (Incorrect date) by Registered Nurse (RN) #1 documented, Resident stated that last week (July 5th), a tall CNA (Certified Nursing Assistant) .slapped me on my bottom while changing me . The facility's investigation revealed a written statement by CNA #1 dated 7/12/17, documented, Wednesday (MONTH) 5 I took care of (Named Resident #2) as I proceeded to do personal care on her I had to move her over a little because she is very heavy around her bottom and she is deaf. I did not hit her . The facility's incident investigation revealed a typed statement by the Director of Nursing (DON), dated 7/5/17, documented, .Resident could not give this nurse any information about a CAN (CNA) hitting her on her bottom. The facility's investigation revealed a written statement by Licensed Practical Nurse (LPN) #1 undated documented, On 7-10-17 during my med pass (Named Resident #2) told me that while receiving care on 11 (PM)-7 (AM) the night before, someone had slapped her. She could not tell me who or describe them. I went and got the DON, who then went with me to try to speak to her again. (Named Resident #2) would not say anything about being slapped . Review of CNA #1's personnel file revealed no documentation of suspension during the alleged abuse investigation. A progress note dated 7/11/17 by the Social Worker (SW) #1 documented, This morning I received a complaint/grievance report indicating that the resident had stated that last Wednesday (July 5th) a tall CNA .slapped me on my bottom while changing me .I asked her where did she slap you and she replied on my behind. I asked her When and she replied last week, either Tuesday or Wednesday .I asked her why she thought she slapped her and she replied because I can't roll over so good, I am slow .This information has been shared verbally with (Named DON), Administrator and South Assistant Director of Nursing (ADON) . Interview with Resident #2 on 8/21/17 at 9:35 AM, in Resident #2's room, she was asked if anyone had slapped her. She stated that a CNA did, but she couldn't remember her name. She stated that the CNA was in her room and was rolling her over toward the wall and slapped her on the behind. She stated she is deaf but she is not stupid and she doesn't trust people here because they don't believe her. Interview with CNA #1 on 8/22/17 at 2:37 PM in the conference room, she was asked about the incident regarding Resident #2. CNA #1 stated, (Named ADON) came and got me. She asked me if I had her (Resident #2) on (MONTH) 5th. I told her yes. When I roll her over, I pat her and that lets her know to roll that way. That is her que to know which way to roll. We do that because she is deaf. I never got suspended. I am still assigned to her and I still take care of her. I am assigned to her today. I use my fingers to tap. She has had no complaints about me. Interview with the DON on 8/22/17 at 3:20 PM, in the conference room, she was asked if the date on her statement was the date of the alleged incident or the date she typed the statement. The DON stated, It was the date of the incident. I didn't know about it until (Named SW) told me a week later . Interview with the Administrator on 8/23/17 at 6:35 PM, in the conference room, she was asked the abuse prohibition questions and communicated appropriate answers. She was asked if she was aware that CNA #1 had not been suspended during the investigation. She confirmed she was aware the CNA had not been suspended. Interview with SW #1 on 8/23/17 at 2:42 PM, she was asked about the alleged abuse allegation by Resident #2. The SW stated, I received the information from a grievance form that was placed on my door. I found it that morning (7/11/17) and I went to follow up with (Named Resident #2). The SW confirmed Resident #2 thought it was because she didn't turn over quick enough and slapped her. Interview with RN #1 on 8/23/17 at 5:04 PM, in the conference room, he was asked how he knew about the incident with Resident #2. He stated, (Named LPN #2) told me on 3-11 shift on 7/10/17. I filled out an incident report. He was asked who he reported it to and was the CNA suspended. He stated, I let either (Named ADON, or Named DON) know from my report. I did not suspend her; I felt it was a communication issue.",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
1301,JEFFERSON CITY HEALTH AND REHAB CENTER,445246,283 W BROADWAY BLVD,JEFFERSON CITY,TN,37760,2018-04-04,584,D,1,0,M5V611,"> Based on observation and interviews, the facility failed to ensure over the bed tables were clean in 3 resident rooms (#109, #402, and #519) and failed to ensure bathroom nightlight covers were clean in 7 resident rooms (#109, #113, #207, #209, #210, #402, and #409) of 20 resident rooms observed for cleanliness. The findings included: Observation and interview with the Director of Nursing (DON) on 4/4/18 from 7:00 AM to 8:30 AM, during tour of resident's rooms, revealed the over the bed tables in rooms #109, #402, and #519 were sticky to the touch and had a buildup of dust and grime. Continued observation revealed the bathroom nightlight covers in rooms #109, #113, #207, #209, #210, #402, and #409 had a buildup of dust and brown colored grime. Interview with the DON confirmed the facility failed to thoroughly clean the over the bed tables and the bathroom nightlight covers in the residents' rooms. Further interview confirmed .(rooms) .need to be cleaned .",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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
1359,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2019-09-19,728,K,1,0,2T6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of job description, interview, facility investigation documentation review, facility staffing documentation review and employee record review, the facility failed to ensure full-time employees working as Nurse Aides (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) were either in a State approved training and competency evaluation program or had recently successfully completed such a program for 11 NA employees (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12) of 11 NA hired by the facility. This failure had the potential to result in negative outcomes for the 44 residents residing in the facility at the time of the survey, including 6 residents (#1, #2, #5, #8, #10, #13) of 13 residents reviewed. The facility's noncompliance for Resident #1 resulted in a fall and a laceration to the head requiring 10 sutures. The facility's noncompliance for Resident #2 resulted in a fall and a [MEDICAL CONDITION]. The facility's noncompliance for Resident #5 resulted in abuse by facility staff. The facility's noncompliance for Residents #8, #9, #10 and #13 resulted in falls. The facility's 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 facility's failure placed Resident #5 in Actual Harm for Abuse. 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 job description for the Job Position/Description Nursing Assistant (NA) revealed .Major Duties and Responsibilities .Assist residents with dental and mouth care .Assist with .feeding of resident .Perform after meal care as required (i.e. cleaning resident's hands, face, clothing, etc.) .Assist in preparing residents for meal (i.e. taking to/from dining room .assisting with feeding .supervision in dining rooms, etc.) .bathe residents as assigned and in accordance with our established nursing care procedures .Dress residents neatly .Assist residents in dressing as necessary .Comb and brush resident's hair daily and as needed. Shampoo as instructed .Qualifications .must obtain State certification within 120 days of being employed . Review of the 11 NA employee records for hire date, date began working as a NA, first date providing direct resident care and nursing aide job description verification revealed the following: NA #1 was hired as a NA on 6/8/19 and began providing direct resident care on 6/8/19. The job description was signed by the NA on 6/9/19. Resident #2's fall resulted in a fracture on 7/14/19 with NA #1 and Licensed Practical Nurse (LPN) #1 assigned to the resident. LPN #1, NA #1 and Registered Nurse (RN) #1 all left the resident unattended in the bathroom on 3 separate occasions on 7/14/19. Refer to F 689. NA #2 was hired as a NA on 3/26/19 and began providing direct resident care on 3/27/19. The NA's employee record did not contain a job description. Resident #1 fell on [DATE] at 9:00 PM and was assigned to NA #2 who transferred the resident into the bed. The bed pad alarm was not working properly at the time of the fall. LPN #6 was assigned to the resident at the time of the fall with NA #6 in orientation on the unit on 6/3/19. Resident #1 fell on [DATE] resulted in a laceration requiring 10 sutures was assigned to NA #2. The NA transferred the resident into the bed and the bed pad alarm was not working properly at the time of the fall. RN #1 and NA #7 were also on the unit with a total of 26 residents. Refer to F689. Resident #5's psychosocial abuse occurred on 6/13/19 by NA #3, with NA #2 and CNA #6 present and witnessing NA #3 splashing water in the resident's face purposely. NA #2 and CNA #6 left NA #3 alone with the resident. Refer to F600. Resident #10 fell on [DATE] and was assigned to NA #2 and LPN #7. NA #12 was also on the unit with a total of 25 residents. Refer to F689. NA #3 was hired as a NA on 6/22/18 and signed the job description on 6/22/18. NA #3 was terminated on 6/13/19. Resident #5's psychosocial abuse occurred on 6/13/19 by NA #3 who purposely splashed water into the resident's face. NA #2 and CNA #6 were present to witness NA #3's actions. NA #2 and CNA #6 left NA #3 alone with the resident. Refer to F600. NA #4 was hired as a NA on 12/4/18 and signed the job description on 12/7/18. NA #4 was terminated on 6/12/19. NA #6 was hired as a NA on 5/28/19 and signed the job description on 5/29/19. NA #6 was terminated in (MONTH) 2019. Resident #1 fell on [DATE] at 9:00 PM and was assigned to NA #2 and LPN #6. NA #6 was in orientation on 6/3/19 and worked alone with LPN #3 from 3:00 PM - 6:00 PM with a total of 26 residents. Refer to F689. NA #7 was hired as a NA and began providing direct resident care on 6/4/19. The employee record did not contain a job description. Resident #1 fell on [DATE] resulted in a laceration requiring 10 sutures and was assigned to NA #2 and RN #1. NA #7 was also on the unit with a total of 26 residents. Refer to F689. Resident #8 fell on [DATE] and was assigned to NA #12 and RN #2. NA #7 was also on the unit with a total of 24 residents. RN #1 was alone on the unit from 3:00 PM - 4:30 PM. Refer to F689. NA #8 was hired as a NA and began providing direct resident care on 6/8/19. The job description was signed on 6/8/19. NA #9 began working as a NA on 7/8/19 and began providing direct resident care on 7/8/19. The NA job description was not signed. Resident #13 fell on [DATE] with NA #9, in orientation, on the unit with 25 residents with CNA #9 and LPN #2. Refer to F689. NA #10 began working as a NA on 7/29/19 and began providing direct resident care on 7/29/19. The employee record did not contain a NA job description. NA #11 was hired on 7/3/19 and began working as a NA on 7/7/19. NA #7 began providing direct resident care 7/7/19. The job description was signed on 7/3/19. NA #12 began working as a NA on 6/8/18 and signed the job description on 6/8/18. Resident #8 fell on [DATE] and was assigned to NA #12 and RN #2. NA #7 was also on the unit with a total of 24 residents. RN #2 was alone on the unit from 3:00 PM - 4:30 PM. Refer to F689. Further review of the employee records revealed no competencies were conducted for the NAs. Interview with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) 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 . When asked if the NAs were reviewed for competency the DON revealed .would need to check . Interview with Certified Nurse Aide (CNA) #8 on 8/12/19 at 4:40 PM in the conference room when asked if the CNA was aware if the NAs provided residents bathing, showering, incontinence care, transferring, and/or feeding assistance without supervision, the CNA revealed .Yes, I'm aware it happened at times . Telephone interview with NA #2 on 8/12/19 at 5:28 PM and on 8/13/19 at 11:06 AM revealed .Since I was hired I did all the care, sometimes a nurse or CNA was there but I've been on a hall by myself and did the entire patient care by myself . Telephone interview with NA #8 on 9/12/19 at 9:57 AM revealed the NA had repositioned, fed and provided incontinence care to residents without any other staff present. Telephone interview with NA #9 on 8/13/19 at 10:03 AM when asked what the facility told the NA of the duties and responsibilities the NA was to perform, the NA revealed .bathing, changing the resident (incontinence care), walking them, feeding them, dressing them . because we're so understaffed .facility had told us to ask for help and I had asked for help and sometimes they could help me, but I had to do it on my own too . Interview with the DON on 8/13/19 at 4:18 PM in the conference room confirmed the NAs did not have competency verification. Interview with the Administrator, DON, ADON, and Business Office Manager on 8/14/19 at 5:05 PM in the conference room, when asked why the job descriptions in the NAs file included direct patient care responsibilities, the DON, ADON, and Administrator did not respond. 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 F728 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
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
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
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
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
1401,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2017-09-05,520,D,1,0,9YDY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of prior survey results, medical record review, review of facility investigation, and interview, the facility failed to maintain sustained compliance with prior plans of correction related to the timely reporting and investigation of abuse allegations for 1 resident (Resident #1) of 12 residents reviewed for abuse or neglect, on 1 of 3 units. 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 . Review of the facility's prior survey results revealed the facility was cited at F-225, Scope/Severity D, related to the timely reporting of abuse allegations during the annual Recertification survey completed on 3/8/17. The facility submitted a plan of correction, with a date of compliance of 3/31/17, which included facility-wide education for staff on requirements for abuse reporting and a monitoring plan to ensure compliance with the policy. The monitoring plan included daily rounds to ensure compliance by staff and reporting to the Quality Assurance committee. 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. Review of the facility investigation and witness statements dated 4/27/17 (Thursday), revealed Registered Nurse (RN) #2) reported allegations of abuse 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 did not immediately report the allegations to the facility Administrator, Director of Nursing (DON), or Charge Nurse. Continued review of the facility investigation revealed RN #2 completed her shift on 4/26/17 at 7:00 AM, and 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, revealed the Administrator confirmed RN #2 failed to report allegations of abuse to the facility Administration immediately when they were allegedly observed. The Administrator confirmed the facility was not informed of the allegations until 36 hours after the alleged incident had occurred and confirmed the facility had failed to maintain sustained compliance with the prior plan of correction. Refer to F-225",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
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
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
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
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
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
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
1409,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2020-02-12,609,D,1,0,7H4S11,"> Based on facility policy review, review of a facility investigation, and interview, the facility failed to report allegations of abuse to the State Survey Agency within 2 hours for 1 resident (Resident #5) of 5 residents reviewed for abuse. The findings included: Review of the facility's policy titled, Abuse Prevention Program, dated 12/2016, showed .Investigate and report any allegations of abuse within timeframes as required by federal requirements. Review of a facility investigation dated 1/14/2020 showed Resident #5 was hit by Resident #2 on 1/14/2020. Further review showed the incident was not reported to the State Survey Agency within 2 hours. During an interview on 2/12/2020 at 1:15 PM, the Assistant Administrator stated the facility failed to report the incident to the State Survey Agency. Refer to F-[AGE]0.",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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
1527,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,223,J,1,0,EO0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the facility policy review, medical record review, observation, and interview, the facility failed to prevent and protect 2 residents (#2, #16) from abuse of 23 residents reviewed. This failure resulted in harm to Residents #2 and #16. The findings included: Review of facility policy, Abuse and Neglect Prohibition, revised date ,[DATE], .each resident has the right to be free from abuse .the facility Administrator is the Abuse Prevention Coordinator . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record reveiw of an quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively intact with no moods but delusional behaviors exhibited. Further medical record review of the quarterly MDS revealed the resident is independent with set-up for Activities of Daily Living (ADL's). Medical record review of an Incident/Accident Report dated [DATE] revealed Resident #2 was assualted twice by Resident #22. Continued review revealed .Patient was yelling this nurse went into her room. She states (Resident #2) that he (Resident #22) was trying to kill her, she states that he grabbed her left arm, and she has a bruise on her left arm . Medical record review of a Nurses Note of the Resident dated [DATE] 11:17 AM revealed .Resident stay(ed) at (in) dining room pt (patient) stated that 'still I have anxiety' r/t (related to) release fire extinguisher pt has bruises on arm . Medical record review of the Nurses Note dated [DATE] 9:10 AM revealed Licensed Practical Nurse #2 .pt(Patient) reported that she was hit on her left upper arm and left forearm, side of face. Bruising noted to left arm and slight swelling to left side of face. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record review of an admission MDS dated [DATE] revealed the resident was moderately cognitively intact and extensive assistance with help of 1 staff person for all ADL's except bathing requiring total assistance of 1 staff person. Further medical record review of admission MDS dated [DATE] revealed moderately cognitively intact and extensive assistance with help of 1 staff person for all ADL's except bathing requiring total assistance of 1 staff person. Medical record review of a note dated [DATE] at 3:38 AM Situation, Background, Assessment, Recommendation, (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 Nursing Technician). We were unable to get the extinguisher from him. MD (Medical Doctor) was notified and gave order to send resident out (to the hospital) for further evaluation . Observation and interview of Resident #2 on [DATE] at 9:00 AM in the 3rd floor dining room revealed the resident stated .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 left forearm and on outer forearm. Resident touched the left side of her face showing, .he hit me here and it hurts in here (showing the inside of her mouth) . Interview with Registered Nurse (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 Resident #2's room. Continued interview revealed she was informed of the incident verbally by Licensed Practical Nurse (LPN) #3 in morning report. Further interview confirmed RN #5 did not report the incident to the Abuse Coordinator (Administrator). Interview with Director of Nursing (DON) on [DATE] at 1:50 PM in the conference room confirmed that she was made aware of the incident between Resident #2 and Resident #22. 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. Further interview confirmed the DON failed to start an investigation of abuse. Continued interview with the DON confirmed the facility failed to prevent, protect, investigate and report physical abuse of Resident #2. Medical record review, observation, and interview, revealed the facility failed to protect Resident #2 from abuse by Resident #22. Further investigation revealed the facility failed to report previous abuse, on [DATE], of Resident #2 by Resident #22. 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 (#16) has a habit (holding others {wheelchair} or clothes) (patient) grasp fistful of (Resident #20's clothing) so (Resident #20) upset and smacking her face . Medical record review of a SBAR Summary 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. 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 hit Resident #16. Continued interview revealed RN #2 was unable to remember who reported the incident to her. Continued interview confirmed RN #2 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 on 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 she thought it was abuse, RN #2 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 Summary so they know. No. I did not notify the Administrator . Interview with the DON on [DATE] at 6:40 PM in the conference room confirmed the facility failed to prevent and protect Resident #16 from abuse. Medical record review revealed Resident #20 was admitted to the facility on [DATE], readmitted on [DATE] and [DATE], and was discharged to a psychiatric facility on [DATE] 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 a SBAR Summary dated [DATE] 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 [DATE] revealed, .Resident returned from hospital on [DATE] as (with) same problems .lunch time she opened door and suddenly throw (threw) the food toward staff .when staff trying to control her behavior she hit, scratched staff and yelling out. After closed door she throw (threw) the food tray on the floor . Medical record review of a Behavior Note dated [DATE] revealed, .increasing agitation this pm. combative .(continues) back and forth between room & nurses station . Medical record review of Behavior Note dated [DATE] revealed, .wandering hallway sometimes .entering other resident's room, (patient) has agitation. At 6 PM .in room [ROOM NUMBER] 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 [DATE] revealed, .Resident has been having psychiatric behavior recently pt (patient) increased agitation, self harming and others harming behavior, wandering, kicking toward staff, verbally aggressive, restlessness noted . Medical record review of a Behavior Note dated [DATE] revealed, .Resident returned from hospital still pt has confusion, wandering, agitation observed pt trying to use elevator for (to) get out of here and lay (laid) down in front of elevator . Medical record review of a SBAR Summary dated [DATE] 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 [DATE] revealed, .Pt rolling around day room in (wheelchair) rolling up to pt, striking at another pt. Pt rolling around reaching and try to hit at other residents. Interview with the DON on [DATE] at 6:40 PM in the conference room confirmed the facility failed to prevent the behaviors of Resident #20 from escalating to causing harm to Resident #2 and #16.",2020-09-01
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
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
1530,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,226,L,1,0,EO0911,"> Based on facility policy review and interview, the facility failed to implement Abuse and Neglect Prohibition Policy and to provide training to facility and agency staff on abuse recognition, abuse prevention and abuse reporting. This failure resulted in Harm to the residents for prevention of abuse and failure to provide protection from abuse. The findings included: Review of facility policy, Abuse and Neglect Prohibition, revised 8/17, revealed . the facility will train each employee on this policy during orientation, annually, and more often as determined by the facility .The facility will provide training regarding related policies and procedures . Interview with the Director of Nursing (DON) in the conference room on 10/30/17 at 9:30 AM revealed the facility trained 29 of 239 employees in (YEAR) on Abuse and Neglect prevention as evidenced by document titled .Training Attendance . Continued review revealed the training dates listed were 1/13/17 and 07/31/17. No additional documentation of Abuse and Neglect training were provided for calendar year (YEAR). Further interview with the DON confirmed the Agency staff were not included in the facility abuse and neglect prevention training. The DON stated .I was told the individual agencies do their own training . Interview with Registered Nurse (RN) #6 on 10/25/2017 at 3:40 PM revealed .Agency staff are not included in Greenhills Rehab orientation or training . Interview with RN #1 revealed .No, I did not get any orientation, I am agency . Interview with the DON on 10/30/17 at 6:10 PM in the conference room confirmed the facility failed to provide training for facility staff and agency staff on abuse and neglect prevention.",2020-09-01
1531,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,252,E,1,0,EO0911,"> Based on observation and interview, the facility failed to maintain cleanliness for 1 of 26 resident rooms on the 3rd floor, failed to provide a water pitcher for 1 resident (#7) of 11 residents, and failed to maintan cleanliness for 9 of 9 tables in the 3rd floor dining area. The findings included: Observation of Resident #7's room on 10/23/17 at 9:40 AM revealed 1 canvas shoe, dirty toilet paper with what appeared to be brown colored matter and 1 adult brief with brown colored matter with fecal odor present in the restroom. Continued observation revealed the bed sheets were wrinkled and disheveled with part of the top sheet partially laying on the floor. No water pitcher was present in the room. Observation of Resident #7's room on 10/24/17 at 8:25 AM revealed the restroom floor contained a folded adult brief, 1 flat slip-on shoe and used toilet paper. Continued observation revealed no water pitcher was present in the room. Observation of Resident #7's room on 10/25/17 at 8:35 AM revealed no water pitcher was present in the room. Continued observation revealed the restroom floor contained 1 flat, slip-on shoe and used toilet paper. Continued observation revealed the resident's fitted sheet was soiled with a moderate amount of brown debris. Futher observation revealed no water pitcher was present. Interview with Certified Nurse Aide (CNA) #3 on 10/25/17 at 9:20 AM on the 3rd floor secured unit revealed housekeeping was to look in the resident rooms and clean as needed every day. Continued interview revealed the CNA confirmed the resident did not have a water pitcher. Interview with Housekeeper #3 on 10/25/17 at 10:55 AM at the 3rd floor nurses station confirmed the housekeeping staff assigned to the floor was responsible to look in each resident's room and spot clean if needed. Continued interview confirmed the items located on the restroom floor should have been removed by the housekeeping staff. Continued interview confirmed the facility failed to provide and maintain a homelike (clean and comfortable) environment for the residents. Observation on 10/25/17 at 8:00 AM in the 3rd floor dining room revealed 9 of 9 tables, accomodating 4 residents each, were soiled with dried and sticky debris on the tabletops. Continued observation revealed the residents were being seated for the morning meal at the tables and were observed to be touching and scraping at the dried and sticky debris. Interview with CNA #9 on 10/24/17 at 6:15 PM in the 3rd floor dining room revealed the tabletops were supposed to be cleaned by housekeeping staff after each meal. Interview with CNA #3 on 10/25/17 at 8:00 AM in the 3rd floor dining room revealed the tabletops were covered with dried and sticky debris. Continued interview confirmed the CNA noticed the residents touching the soiled tabletops and stated it appeared the tables had not been cleaned after the evening meal the night before. Interview with HK #3 on 10/25/17 at 10:55 AM at the 3rd floor nurses station confirmed the 9 of 9 tabletops in the 3rd floor dining room were soiled and not cleaned and kept in a homelike manner by housekeeping following the previous evening meal. Continued interviewed confirmed the facility failed to provide and maintain a homelike (clean and comfortable) environment.",2020-09-01
1532,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,254,E,1,0,EO0911,"> Based on review of the Daily Linen Inventory, observation, and interview, the facility failed to make available a sufficient amount of linens (towels and washcloths) for the residents on the 2nd and 3rd floors. The findings included: Review of the Daily Linen Inventory for 9/3/17 to 10/21/17 documented the linen items being delivered to the floors and linen items being returned to the laundry to be laundered. Continued review revealed the amounts of each type of clean linen (towels, washcloths, flat sheets, fitted sheets, etc) were designated by a formula of 3 pieces per resident for each type of linen (towels, washcloths, flat sheets, fitted sheets, etc.). For example, the required amount of towels for a census of 120 residents would be obtained by multiplying 120 by 3 and would equal 360 indicating 360 towels, 360 washcloths, etc. would be the minimum of linen needed for residents in the facility. Continued review revealed 36 of 49 days the facility had fewer than the required amounts of towels and washcloths. Further review revealed 42 of 49 days the facility had fewer washcloths than the minimum amount required for residents in the facility. Observation on 10/23/17 at 9:50 AM of the 2nd floor linen cart revealed 15 washcloths and 10 towels were available for resident use on the 2nd floor with a census of 46. Observation on 10/23/17 at 10:15 AM of the 3rd floor linen room revealed 10 washcloths and 7 towels were available for resident use on the 3rd floor with a census of 45. Interview with Housekeeper (HK) #3 on 10/24/17 at 8:15 AM in the 1st floor hall outside Central Supply revealed current laundry services were contracted with an outside provider. Continued interview with HK #3 revealed housekeeping was to collect dirty linen from the dirty linen carts on all floors, transport to laundry, process (wash/dry/fold) the linens and deliver the linens to each floor the next day. Continued interview revealed all linen was delivered and there was no excess linen anywhere else in the facility. Further interview confirmed the facility had difficulty keeping enough washcloths and towels stocked for resident use. Observation on 10/24/17 at 10:20 AM of the 2nd floor linen cart revealed 18 washcloths and 16 towels were available for resident use on the 2nd floor with a census of 43. Observation on 10/24/17 at 11:15 AM of the 3rd floor linen room revealed 15 washcloths and 14 towels were available for resident use on the 3rd floor with a census of 46. Interview with Resident #23 on 10/24/17 at 10:35 AM in the resident's room revealed the resident stated many days there were not enough washcloths and towels. Continued interview revealed she stated she was requested to wait for clean linen to be delivered until she could provide resident care and stated this has happened the past couple of months. Interview with Resident #25 on 10/24/17 at 10:40 AM in the resident's room revealed there have not been enough washcloths and towels for the past couple of months. Continued interview revealed the resident stated the CNAs (Certified Nursing Assistant) will ask if he minded waiting for his shower until the clean linen was delivered. Interview with Residents #24 and #26 on 10/24/17 at 10:45 AM in the residents's room revealed both residents stated there were frequently not enough washcloths. Continued interview revealed Resident #26 stated the CNAs had only been able to offer wet paper towels to clean hands and faces before meals. Interview with CNA #7 on 10/24/17 at 5:55 PM at the 2nd floor nurses station revealed for the past couple of months there have not been enough clean washcloths. Interview with CNA #3 on 10/25/17 at 7:55 AM on the 2nd floor, east hall revealed there had not been enough washcloths for 2 months. Continued interview revealed the CNA had used wet paper towels for the residents until the clean linen was delivered. Interview with CNA #1 on 10/25/17 at 8:45 AM on the 3rd floor, south hall revealed for the past 2 months, the staff had to wait for clean linen to be delivered. Continued interview revealed the CNA stated, she resorted to giving some residents moistened paper towels to wipe hands and faces before meals. Interview with CNA #2 on 10/25/17 at 8:55 AM on the 3rd floor, north hall revealed she had postponed giving showers until clean linen was delivered and confirmed there was not enough clean washcloths and towels. Interview with HK #3 on 10/25/17 at 10:55 AM at the 3rd floor nurses station confirmed there was not enough washcloths and towels for resident use. Continued interview confirmed facility staff had called down requesting clean linen, before laundry was able to complete processing and delivery. Continued interview confirmed the facility did not have adequate inventory of towels and washcloths available for resident use.",2020-09-01
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
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
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
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
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
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
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
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
1541,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,490,L,1,0,EO0911,"> Based on facility staffing records, medical record review, facility policy review, observation, and interview, the Administrator failed to maintain safe, trained, and oriented staffing which contributed to neglect, falls, and/or abuse for 10 of 18 residents residing on the 3rd floor of the facility. The Administrator'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 the residents. 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 multiple falls resulting in injury to residents assessed as high risk for falls without interventions to prevent falls from time of admission. Continued review revealed falls were not investigated to determine a cause per facility policy. Further review revealed resident to resident altercations were not reported to the facility Abuse Coordinator, the state, or investigated per facility policy. Observations revealed residents were wearing soiled clothing, wearing the same clothes for consecutive days and were not provided baths/showers, and personal hygiene regularly. Interview with the Administrator with the DON present on 10/24/17 at 6:55 PM in the conference room confirmed the facility had difficulties with staffing and used 6 different agencies to staff the facility with nurses and Certified Nurse Aides (CNA's). Continued interview revealed the Administrator stated when she began working at the facility in September, 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 any recent resident to resident altercations on the 3rd floor and there were no current investigations related to abuse in the facility. Interview with Registered Nurse (RN) #5 on 10/30/17 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 10/4/17. 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 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. Further interview confirmed the facility failed to prevent, protect, report and investigate allegations of abuse and the Administrator's failure to prevent, protect, report and investigate the allegations of abuse resulted in harm to the residents. Refer to F-224 K Refer to F-309 K Refer to F-323 K Refer to F-353 K",2020-09-01
1542,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,501,L,1,0,EO0911,"> Based on medical record review and interview, the Medical Director failed in his role/function related to a fall prevention program, protocol or interventions, abuse investigations, and a behavioral monitoring program. 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 residents of the facility. 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 multiple falls resulting in injury to residents assessed as high risk for falls without interventions to prevent falls from time of admission. Continued review revealed falls were not investigated to determine a cause per facility policy. Further review revealed resident to resident altercations were not reported to the facility Abuse Coordinator, the State Agency, or investigated per facility policy. Interview with Registered Nurse (RN) #5 on 10/30/17 at 3:03 PM in the conference room confirmed she was the Unit Manager on the 3rd floor and the secured unit. Continued interview confirmed several residents in the secured unit had behaviors of wandering, anxiety, agitation, combativeness, and intrusion into other residents rooms. Further interview confirmed the facility did not have a behavioral management program in place and utilized the services of a Psychiatric Nurse Practitioner twice a week. Telephone interview with the Medical Director (MD) on 10/30/17 at 2:25 PM stated he was aware the facility used multiple agencies to staff the facility and stated, It's a problem in every facility in[NAME]on County. Continued review revealed the MD was unaware the facility did not have a fall prevention program or protocol or a behavioral health program in place. Further interview revealed the MD stated, I would expect a higher incidents of falls on the secure unit. Maybe it's a little higher than most, and maybe it does have to do with staffing, I don't know. Continued interview confirmed the Medical Director did not make any recommendations to the facility to lessen the incident of falls, or behavioral concerns and stated, It's up to the facility to determine the interventions. Further review revealed the MD was not aware the Care Plans were not individualized to each resident and failed to contain pertinent interventions. He stated, Whatever we're not doing, we will fix it. Continued interview confirmed the Medical Director failed to prevent possible servious injury or harm for the residents by not ensuring protocols for fall prevention, abuse investigations and behavioral monitoring. Refer to F-224 K SQC Refer to F-309 K SQC Refer to F323 K SQC Refer to F327 K SQC Refer to F353 K SQC Refer to F490",2020-09-01
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
1544,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,520,L,1,0,EO0911,"> Based on facility policy review, medical record review, observation, and interview, the facility's QAPI (Quality Assurance and Performance Improvement) committee failed to recognize inadequate staffing; failed to prevent neglect of residents; failed to prevent abuse of residents; failed to prevent accidents; failed to identify escalating behaviors; and failed to implement an appropriate plan of action to correct the deficient practice. 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 residents in the facility. 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, Quality Assurance & Performance Improvement Committee (QAPI), undated revealed, .The QAPI process enables us to better serve our customers through routine, systematic performance evaluation, monitoring, and follow-through. The QAPI process will help .Prioritize high risk, high volume, problem-prone opportunities .Improve/fix opportunities using a Performance Improvement Plan . Review of an Identification of Others at Risk form dated 8/8/17 revealed, .19 residents have been identified that are present in the facility that have had a fall since 6/20/17 .Fall Prevention System not fully implemented . Interview with the Administrator with the Director of Nursing (DON) present 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 (CNA's). Further interview revealed the facility was trying to hire their own staff but could not compete with agency pay, flexibility of scheduling, and agency staff being paid in advance or daily. 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, or behavioral management program. Further interview confirmed the QAPI Committee failed to prevent neglect, and failed to protect, prevent, report and investigate allegations of abuse. 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 F490 K Refer to F501 K Refer to F-511 K",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
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
1548,"LEBANON CENTER FOR REHABILITATION AND HEALING, LLC",445268,731 CASTLE HEIGHTS COURT,LEBANON,TN,37087,2018-04-10,730,D,1,0,P4UJ11,"> Based on record review and interview, the facility failed to conduct yearly performance evaluations for one of one Certified Nurse Aide (CNA #1) personnel file reviewed. Findings include: Review of CNA #1's personnel file, on 4/10/18 at 11:30 AM, revealed CNA #1's date of hire was 6/23/08. The file contained a document titled, Resident Care Specialist Skill Inventory Checklist (Certified Nursing Assistant# 1), dated (YEAR). The document was incomplete in that the Skills, Demonstrated, Observed, Explained portion of the evaluation was not all evaluated. The document indicated that only 17 of the 39 check off boxes were dated as Met and contained the evaluator's initials. During the review of CNA #1's employee record, the only performance evaluation found in the file was dated 2010. This document was completed and signed by the employee and evaluator. Review of CNA #1's personnel file, on 4/10/18 at 11:30 AM, revealed CNA #1's date of hire was 6/23/08. The file contained a document titled, Resident Care Specialist Skill Inventory Checklist (Certified Nursing Assistant 1), dated (YEAR). The document was incomplete in that the Skills, Demonstrated, Observed, Explained portion of the evaluation was not all evaluated. The document indicated that only 17 of the 39 check off boxes were dated as Met and contained the evaluator's initials. During the review of CNA #1's employee record, the only performance evaluation found in the file was dated 2010. This document was completed and signed by the employee and evaluator. During an interview on 4/10/18 at 11:30 AM in the facility conference room, the Administrator confirmed that CNA #1 personnel file only completed annual performance evaluation was dated 2010. The Administrator, Director of Nursing and Area Staff Development Coordinator confirmed the (YEAR) performance evaluation was incomplete and the Employee and the Evaluator had not signed the document. During the interview on 4/10/18 at 11:30 AM in the facility's conference room, the Administrator stated that he has been the Administrator for the facility approximately one and a half years and that during this time he was aware that annual employee performance evaluations for all staff of the facility was not completed. The Administrator stated that he has not received an annual performance evaluation.",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
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
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
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
1567,MABRY HEALTH CARE,445272,1340 N GRUNDY QUARLES HWY P O BOX 7,GAINESBORO,TN,38562,2019-01-29,727,D,1,0,8TUT11,"> Based on review of the facility's Payroll-Based Journal Worksheet the facility failed to provide the services of a Registered Nurse (RN) for the minimum requirement of 8 hours per day on 40 days (between the period of 4/1/18 and 1/14/19) of 289 days reviewed. The findings included: Review of a Payroll-Based Journal Worksheet dated 4/1/18 through 1/14/19 revealed no RN services were provided on 4/14-15/18, 4/28-29/18, 5/26-27/18, 6/9/18, 6/23-24/18, 7/7-8/18, 7/15/18, 7/21-22/18, 8/4-5/18, 8/18-19/18, 9/2/18, 9/16/18, 9/29/18, 10/13-14/18, 10/15-20/18, 10/27-28/18, 11/11/18, 11/24/18, 12/8-9/18, 12/22-23/18, 1/6/19, and 1/12/19. Continued review revealed RN coverage was only provided for 5.5 hours on 4/22/18. Interview with the Director of Nursing on 1/29/19 at 2:55 PM, in the conference room, confirmed the facility failed to meet the minimum requirement of 8 hours of RN coverage per day on 40 days between the period of 4/1/18 and 1/14/19.",2020-09-01
1579,MABRY HEALTH CARE,445272,1340 N GRUNDY QUARLES HWY P O BOX 7,GAINESBORO,TN,38562,2018-11-07,607,E,1,0,129T11,"> Based on review of facility policy, review of personnel files, and interviews, the facility failed to revise their abuse policy to meet federally required standards for screening potential employees, failed to complete Criminal Background Checks prior to employees providing direct patient care, and failed to obtain and document reference checks, in 8 of 8 personnel files reviewed. The findings included: Review of the facility policy Resident Abuse dated 4/18, revealed .Screening of new hires will include: A) A check of the licensing registry for reports of previous abuse. B) A reference check of previous employment will be completed . Review of the facility personnel files revealed the following: 1). Licensed Practical Nurse (LPN) #3 was hired on 8/9/18, Criminal Background Check was completed on 8/15/18. 2). Certified Nursing Assistant (CNA) #1 was hired on 10/15/18, Criminal Background Check was completed on 10/17/18. 3). CNA #6 was hired on 8/31/18, Criminal Background Check was completed on 10/1/18. 4). CNA #7 was hired on 8/31/18, Criminal Background Check was completed on 9/5/18. 5). CNA #8 was hired on 10/23/18, Criminal Background Check was completed on 11/2/18. 6). CNA #9 was hired on 10/8/18, Criminal Background Check was completed on 10/16/18. 7). CNA #10 was hired on 10/4/18, Criminal Background Check was completed on 10/15/18. 8). CNA #11 was hired on 10/4/18, Criminal Background Check was completed on 10/12/18. Continued review of personnel files, revealed no documentation references checks were obtained by the facility. Interview with the Assistant Director of Nursing on 11/6/18 at 2:40 PM, in the conference room, confirmed we initiate the Criminal Background Checks within 7 days of employment, the background checks are not completed prior to the employee providing direct patient care. Continued interview confirmed the facility had not revised their abuse policy to meet Federal Regulations for the screening process of potential employees. Interview with the Administrative Assistant/Chief Financial Officer, on 11/6/18 at 3:00 PM, in the conference room, confirmed the facility had no written documentation reference checks had been completed. Further interview confirmed Criminal Background Checks were not completed before employees were permitted to provide direct patient care. Interview with the Administrator on 11/7/18 at 11:30 AM, in the conference room, confirmed he was unaware Federal Regulations had been revised in regards to the screening process of potential employees. Continued interview confirmed the facility had not revised their abuse policy to meet federally required standards for screening potential employees, resulting in Criminal Background Check not being completed by the facility prior to employees providing direct patient care, and the facility had no documentation references checks had been obtained.",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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
1643,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2017-07-20,441,E,1,0,4V9N11,"> Based on policy review, observation and interview, the facility failed to ensure practices were followed to prevent the potential spread of infection when 2 of 2 (Certified Nurses Aide (CNA) #1, and Licensed Practical Nurses (LPN) #5) staff members failed to perform appropriate hand hygiene during perineal care and wound care. The findings included: 1. 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 . 2. 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 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 pick up a marker, label the brief, and move the peri-wash spray. 3. 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 then used the same gloved hands to pick up the package of wipes, a tube of barrier cream, and a spray bottle of peri-wash. CNA #1 then changed gloves without performing hand hygiene, removed the soiled incontinence pad from underneath Resident #6, pulled up Resident #6 in bed using the draw sheet, picked up Resident #6's purse, and then pushed the privacy curtain back, all using the same soiled gloves. Interview with the Director of Nursing (DON) on 7/18/17 at 5:37 PM, in the conference room, the DON was asked whether it was acceptable for staff to throw a soiled washed cloth on the floor during pericare. The DON stated, That happened, right? The DON was asked if it was acceptable. The DON stated, No. The DON was asked whether it was acceptable for staff to use the same gloves to perform bowel incontinence care and to touch items in the environment, such as barrier cream, a peri-wash spray bottle, or the resident's purse. The DON stated, No .don't move things around in room until after you're done. 4. Observations in Resident #8's room on 7/18/17 at 3:50 PM, Licensed Practical Nurse (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. 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 washed her hands and changed her gloves after removing the dirty dressing. LPN #5 stated, Yes, I should have. Interview with the 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. The DON stated, No, they should clean their hands and put on clean gloves and then put the new dressing on.",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
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
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
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
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
1679,WILLOW RIDGE CENTER,445284,215 RICHARDSON WAY,MAYNARDVILLE,TN,37807,2020-01-30,609,D,1,0,6AOE11,"> Based on facility policy review, facility investigation file review, and interview, the facility failed to report an allegation of abuse to all the required agencies for 1 resident (#1) of 3 residents reviewed for abuse. The findings include: Review of the facility's policy, Abuse Prohibition, revised 7/1/2019, showed, .7.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required .Refer to: .State Specific Abuse Reporting Forms/Tools. Review of the facility's investigation file for the self-reported allegation of abuse, dated 12/13/2019, revealed Resident #1 reported to an evening Certified Nurse Aide (CNA) that a night shift CNA was mean to her the previous night during incontinence care. The reporting CNA stated Resident #1 said the night shift CNA rolled her hard, talked mean to her, and then smacked her. Review of the facility's investigation file did not indicate Adult Protective Services or the Ombudsman had been contacted for Resident #1's allegation of abuse, dated 12/13/2019. During an interview with the Director of Nurses, on 1/29/2020 at 9:35 AM, confirmed the facility failed to contact Adult Protective Services or the Ombudsman with Resident #1's allegation of abuse and the facility policy was not followed.",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
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
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
1694,WILLOW RIDGE CENTER,445284,215 RICHARDSON WAY,MAYNARDVILLE,TN,37807,2018-11-20,867,D,1,0,PGOW11,"> Based on review of the facility policy, review of the Quality Assurance Performance Improvement (QAPI) monthly meeting minutes, review of facility abuse investigations, and interview, revealed the facility failed to review allegations of abuse for 2 residents (#4 and #3) of 9 residents reviewed for abuse. The findings included: Review of facility policy Abuse Prohibition, last revised 7/1/18, revealed .9. At the monthly QAPI meeting, review all allegations of abuse that were reported to the state to: 9.1 Analyze occurrences to determine what changes are needed, if any, to prevent further occurrences . Review of a facility investigation dated 9/27/18 revealed Resident #4 alleged she was beaten up but did not know when it happened. 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. Review of the QAPI monthly meeting minutes dated 10/26/18 revealed the allegations of abuse were not discussed during the meeting. Interview with the Administrator on 11/20/18 at 3:30 PM, in her office, confirmed the alleged events involving abuse for Resident #3 and #4 were not reviewed or analyzed during the QAPI Committee meeting held on 10/26/18. Refer to F610.",2020-09-01
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
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
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
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
1744,BEECH TREE HEALTH AND REHABILITATION,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2018-03-07,609,E,1,0,1FZ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility incidents, and interview, the facility failed to ensure all alleged violations involving abuse were reported to Adult Protective Services (APS) in accordance with state law, and were reported to the ombudsman in accordance with facility policy for 8 residents (#1, #2, #3, #4, #5, #7, #9, and #11) of 11 residents reviewed. The findings included: Review of the facility's 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]. Review of the facility's policy Abuse Investigation and Reporting dated (MONTH) (YEAR), revealed, The investigator will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process .If the ombudsman declines the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. Review of the facility's policy Abuse Investigation and Reporting dated (MONTH) (YEAR), revealed the local/State Ombudsman and Adult Protective Services would be notified of, 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/his designee Review of a facility incident with a date of occurrence of 12/7/17 at 9:18 PM revealed, According to video surveillance, at 9:18 p.m. on 12/7/2017, (Resident #8), who was standing across the hallway from (Resident #1), is noted to be verbalizing something to (Resident #1), her body language demonstrates that she is upset. She is noted to be pointing her finger at (Resident #1) and then proceeds to cross the hallway to where (Resident #1) is standing, drinking a soda. (Resident #1) does not appear to provoke nor retaliate against (Resident #8). At 9:19:06 p.m. (Resident #8) swings her opened right hand and strikes (Resident #1) in the general torso area, (Resident #1) is wearing a coat and does not appear to be hurt by the blow, she does not flinch or try to move away from (Resident #8). At 9:19:09 p.m. (Resident #8) strikes (Resident #1) a second time, again with her right, open hand, this time hitting (Resident #1) on the face. (Resident #1) puts her hand to her face where she has just been hit. At 9:19:09 p.m. (Resident #8) retreats to her side of the hallway. At 9:19:42 (Resident #1) walks away from the general location. At 9:20:44 p.m. an LPN (licensed practical nurse) arrives but is not made aware of the incident. On the morning of 12/8/2017, (Resident #12) reported to a therapy professional that (Resident #8) was bragging that she had hit (Resident #1) while waiting to go to the late smoke break yesterday evening. Upon investigation, the above video surveillance was discovered. (Resident #1) was assessed head to toe with no apparent injury and appears to be doing well. (Resident #1) does not appear to be in any emotional distress, she is eating, smoking and socializing within normal limits .She has a BIMS (Brief Interview for Mental Status) of 05 (severe cognitive impairment) .(Resident #8) has [DIAGNOSES REDACTED]. The majority of her behaviors have involved being territorial toward a male friend when other female residents talk to him. (Resident #8's) BIMS is 10 (moderate cognitive impairment) . Interview with the Social Worker (SW) on 3/7/18 at 11:08 AM, in the SW office, revealed she was the assigned investigator for some of the abuse investigations conducted. The SW stated the Administrator or Director of Nursing (DON) were the assigned investigators for the remaining investigations. The SW was asked who notified the Ombudsman and Adult Protective Services (APS) of abuse allegations and she stated, I do, (Administrator), or (DON) notifies APS and the ombudsman. The SW stated, For any type of abuse, we contact the ombudsman and APS. Interview and review of the investigative file and progress notes for the residents in this incident confirmed there was no evidence of notifying or participation by either the ombudsman or APS. Review of a facility incident with a date of occurrence of 12/12/17 at 10:00 AM, revealed, On (MONTH) 12, (YEAR), at 10:00 a.m. (Resident #5) asked if certified nursing assistants employee #2000 and employee #836 were going to hurt her when they came to take her for a shower. The CNAs (Certified Nursing Assistants) stated no and asked if someone has hurt her. (Resident #5) responded with a yes and the CNAs told her if you see this person in the shower room to let them know with a point or nod. As (Resident #5) was being pushed into the shower room she pointed at (NA (Nurse Aide) #3) per CNAs statements. Administrator and DON spoke with (Resident #5) Resident stated someone has pulled her hair and pinched her, tried to turn over her w/c (wheelchair) when she is in it, grabs her arm and will not let go, and slapped her in the back of the head. Resident stated she had seen her in the bathroom today but did not know her name. Resident stated it was a crazy woman, she lives on either side of my room, stated the medicine we give her makes her high. DON asked (Resident #5) if this someone was a resident or an employee. Resident stated she is a patient here. Investigated and asked which resident was with the employee (NA #3) that r (Resident #5) pointed at in the shower room and it was (Resident #11) which lives in the next room to (Resident #5). We had the social worker interview (Resident #5) along with other Residents to see if anyone had witnessed or been subject to any abuse. While the Social Worker was interviewing (Resident #5), the resident stated, right there she is pointing to (Resident #9). Social Worker did not find anyone who witnessed or was subject to abuse through her interviews. (Resident #9) wanders aimlessly around the unit and will occasionally try to gently push resident' (sic) wheelchairs and hold their hands or grab their arms. (Resident #9) is a gentle woman with severe dementia. Investigation Conclusion: Investigation revealed possible altercation between two residents with dementia that resulted in no physical harm to either party. (Resident #5) has a [DIAGNOSES REDACTED]. She curses and refused care and known to be combative with other residents. Resident appears to have a vindictive attitude toward other residents at times. We believe (Resident #5) was agitated with (Resident #9) due to her wandering and possibly touching wheelchair or resident . Interview with the SW on 3/7/18 at 11:19 AM, in the SW office, and review of the progress notes and investigative file, confirmed there was no documentation that APS or the Ombudsman had been notified of the incident. Interview with the DON and Administrator on 3/7/18 at 2:23 PM, in the SW office, confirmed there was no documentation to indicate APS or the Ombudsman had been notified of the incident. 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]. Interview with the SW on 3/7/18 at 11:19 AM, in the SW office, and review of the progress notes and investigative file, confirmed there was no documentation that APS or the ombudsman had been notified of the incident. Interview with the DON and Administrator on 3/7/18 at 2:23 PM, in the SW office. confirmed there was no documentation to indicate APS or the Ombudsman had been notified of the incident. Review of a facility incident with a date of occurrence of 12/26/17 at 4:45 PM revealed, On (MONTH) 26, (YEAR), at 4:45 p.m. (Resident #4) reported to a Licensed Practical Nurse that a man with glasses touched her breasts. The Licensed Practical Nurse asked which man and she pointed to (Resident #2). (Resident #2) has a BIMS of 11 (moderate cognitive impairment) and (Resident #4) has a BIMS of 1 (severe cognitive impairment). Social Worker was made aware of the incident and interviewed (Resident #4) asked if she had any concerns or problems over the past few days. Resident stated everybody has been good to her. The Social Worker asked if anybody had touched her inappropriately and she stated no. Social Worker asked her why she had reported that someone had touched and she said yes, he touched my boobs. Social Worker asked if he touched in a pointing touch or caressing her, and (Resident #4) stated, he just touched my boobs. Social Worker asked if he had touched her before or after this, and she said no. (Resident #4) does not appear to be in any distress physically or psychologically. Social Worker interviewed (Resident #2) and asked him if he was talking to (Resident #4) and he said yes. She asked him if he touched her in any way and he said no. Resident told Social Worker that (Resident #4) is sometimes ok and sometimes she yells out and that he just tries to stay away from her. Video surveillance was reviewed and does not capture the area this allegedly happened. However, it does capture (Resident #2) leaving the area and (Resident #4) leaving the area a few seconds later. Both residents were seen in the hallway a few seconds later. Both residents were seen in the hallway passing each other with no contact as if nothing had occurred while (Resident #4) made her way to the nurse's station to possibly report the alleged incident. Social Worker interviewed 2 other residents with no report or complaints of inappropriate behavior. Two other employees were seen in the video passing by the area and were interviewed. One employee stated she had seen them sitting opposite of each other with no contact and the other employee stated that (Resident #2) was sleeping in the chair and (Resident #4) was sitting in her wheelchair across the hallway . Interview with the SW on 3/7/18 at 11:19 AM, in the SW office, and review of the progress notes and investigative file, confirmed there was no documentation that APS or the Ombudsman had been notified of the incident. Interview with the DON and Administrator on 3/7/18 at 2:23 PM, in the SW office, confirmed there was no documentation to indicate APS or the ombudsman had been notified of the incident. Interview with the Ombudsman by phone on 3/6/18 at 4:30 PM, revealed the Ombudsman was supposed to be and expected to be notified of all abuse allegations. He stated APS also notified him. He stated this was a trigger for pertinent agencies/personnel to get involved or investigate as their jurisdictions dictated. The Ombudsman was asked if he was notified of the 4 incidents. The Ombudsman stated none of the incidents sounded familiar and he had no record of having been notified of these incidents. The Ombudsman stated he had not received a on any of the incidents from APS either. Interview with the supervisor at Adult Protective Services on 3/7/18 at 10:19 AM by phone revealed Tennessee was a mandatory reporting state, which meant nursing homes were required to report allegations of abuse to them. The APS supervisor reviewed each incident and stated APS had not been notified of any of the 4 incidents. The APS supervisor stated, Certain incidents are required to be reported. Any type of abuse or neglect. That does not mean we would assign a case. With resident to resident abuse, we look at it. We would investigate any type of sexual abuse .If it is in a nursing home, we always send everything to law enforcement (except self-neglect). They can decide to investigate if it meets their criteria. For Nursing Homes, we send to ombudsman, and the Department of Health. Interview with the Administrator and DON on 3/7/18 at 2:12 PM, in the SW office, confirmed there was no system in place to ensure the Ombudsman and APS were notified of abuse allegations. The Administrator stated he relied on the SW for notification, but there was no designated individual that had been doing this.",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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
1819,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2019-07-22,812,F,1,0,FO4U11,"> Based on review of facility policies, observation, and interviews, the facility failed to maintain a sanitary environment in 1 of 1 dish rooms; failed to ensure the dish machine was in proper working order in 1 of 1 dish rooms; and failed to maintain a sanitary environment in 1 of 1 dry food stock rooms, in 1 of 1 kitchens, in 1 of 1 walk in coolers, and in 1 of 1 walk in freezers observed; affecting 93 of 98 residents. The findings included: Review of facility policy Sanitation Inspection, not dated, revealed .All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects . Review of facility policy Food Safety Requirements, not dated, revealed .Food safety practices shall be followed throughout the facility's entire food handling process .Storage of food in a manner that helps prevent deterioration or contamination of the food .Dry food storage-keep foods/beverages in a clean, dry area .Refrigerated storage-foods that require refrigeration shall be refrigerated immediately upon receipt .Practices to maintain safe refrigerated storage include .Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by-date .keep foods covered or in tight containers .All equipment used in the handling of food shall be cleaned and sanitized .Staff shall follow facility procedures for dishwashing . Review of facility policy Monitoring of Cooler/Freezer Temperature, not dated, revealed .All food items will be stored at least 6 inches off the ground .Foods will never be stored directly above or in contact with ice .Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date . Review of facility policy Dishwasher Temperature, not dated, revealed .Manufacturer's instruction shall be followed for machine washing and sanitizing .The wash temperature shall be 120 degrees Fahrenheit .The sanitizing solution shall be 50 ppm (parts per million) .chlorine on dish surface in final rinse . Observation and interview with the Assistant Dietary Services Manager (ADSM) on 7/8/19 at 7:50 AM, of the dish room in the kitchen, revealed the following: *1 brown insect crawling up the back wall; identified by the ADSM as a roach *2 glasses, 3 bowls, various pieces of paper lying on the floor under the dish machine *buildup of food like debris on the floor and baseboard under the dish machine *4 dead insects on the floor under the dish machine; identified by the ADSM as roaches *buildup of a dark dusty type debris with particles loosely hanging down from the ceiling vent and blowing downward into the dish room *1 knife and 1 fork with visible dried debris stored on top of the dish machine Interview with the ADSM confirmed the dish room was not maintained in a sanitary manner. Observation and interview with the Dietary Manager (DM) on 7/8/19 at 8:00 AM, in the dish room, revealed the dish machine was in use and an empty 5 gallon bucket of sanitizer was connected to the dish machine. Further observation revealed the DM tested the concentration of the sanitizer in the dish machine. Interview with the DM confirmed no sanitizer was detected on the test strip and the facility failed to ensure dishes were sanitized. Observation and interview with the ADSM on 7/8/19 at 8:10 AM, of the dry food stock room in the kitchen, revealed the following: *1 brown insect crawling on the floor; identified by the ADMS as a roach *multiple dead brown insects on the floor behind the dry stock room door and under the dry food storage racks; identified by the ADSM as roaches *multiple packages of mustard, mayonnaise, and artificial sweeteners, and jelly, on the floor under the dry storage racks *8 bowl lids, 3 pieces of plastic, and a glass under the dry food storage racks *17 individual jelly packets with a sticky substance on the outside of the packet; stored on a shelf of the dry food storage racks *small dark brown elongated pellet type debris on 15 of 15 food storage rack shelves; identified by the ADSM as .mice turds . *a 10 pound bag of pasta approximately 1/3 full stored opened on a shelf Interview with the ADSM confirmed the dry food stock room was not maintained in a sanitary manner. Observation with the ADSM on 7/8/19 at 8:25 AM, in the kitchen, revealed the following: *multiple pieces of paper, dried food like debris, and a thick sticky debris on the kitchen floor *thick sticky substances on the floor, drain pipes, and wall under the 3 compartment sink *thick dark brown sticky debris on the back of the stove and on 2 of 2 power source boxes and the stove motor *dried debris and loose food-like particles on the bottom of the 3 sleeve plate warmer; which contained clean plates. *dark dusty type debris with particles loosely hanging down from the ceiling vent over the tray line *1 air conditioner with condensation dripping onto the floor beside the tray line *a utility cart which contained a 1 pound package of instant pudding approximately 1/2 full, 2 one pound bags of gravy mix each approximately 1/2 full, a 1 pound bag of brown sugar approximately 3/4 full, a 1 pound package of cheese sauce mix approximately 1/2 full; all stored opened to air, not labeled with a use by date (UBD) Interview with the ADSM confirmed the kitchen was not maintained in a sanitary manner Observation with the ADSM on 7/8/19 at 8:50 AM, of a walk in cooler in the kitchen, revealed the following food items were stored opened to air and not labeled with a UBD: *1 1/2 pound pack of provolone cheese approximately 1/2 full *2 1/2 pound packs of sliced turkey approximately 3/4 full *1 pound package of bologna approximately 1/2 full *12 quart open container containing a 5 pound package of sliced cheese approximately 3/4 full *3 large blocks of cheese *a 1 gallon container of applesauce approximately 1/2 full *a 1 pound tub of pimento cheese approximately 3/4 full *a 1 gallon container of pudding approximately 1/2 full *a 1 gallon container of a ground meat mixture approximately 1/2 full Continued observation revealed a 10 pound box of ground beef was stored on the floor in the walk in cooler. Interview with the ADSM confirmed the food items were not labeled and confirmed the ground beef was stored on the floor. Observation with the ADSM on 7/8/19 at 9:05 AM, of a walk in freezer in the kitchen, revealed 2 of 2 fans covered in a buildup of thick ice with ice cycles hanging downward and incasing a 3 gallon container of ice cream. Interview with the ADSM confirmed the walk in freezer had a buildup of ice. Observation and interview with the ADSM on 7/8/19 at 9:20 AM, of the kitchen, revealed 1 broom, 1 dust pan, and 1 mop stored in an alcove in the kitchen. Interview with the ADSM confirmed the mop head was dirty and the mop head was to be removed from the mop and stored outside of the kitchen. Continued interview confirmed brooms, dustpans, and mop handles were to be hung on wall pegs and stored off of the floor. Interview with the Housekeeping Supervisor on 7/8/19 at 9:40 AM, in the conference room, revealed .I was made aware of a mouse on the 300 hall and the 200 hall .we have caught 4 small mice .have out glue traps .every time the Dietary Manager reports any issues as far as mice in the kitchen I call pest control .we have a bait station outside of the kitchen door, at the receiving door, and at the end of the 200 hall . Interview with the Director of Nursing on 7/8/19 at 10:20 AM, in the conference room, revealed .last week there was a small mouse caught on a glue trap on the 200 hall .I was unaware of any concerns in the dietary department related to rodents . Interview with the ADSM on 7/8/19 at 12:45 AM, in the kitchen, confirmed the facility failed to maintain the kitchen, the dish room, the dry stock room, and food service equipment in a clean and sanitary manner and failed to provide a pest free environment. Interview with the ADSM on 7/22/19 at 6:40 AM, in the kitchen, confirmed .there is no logical explanation for us being out of sanitizer .",2020-09-01
1845,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2019-05-21,609,D,1,0,YL5411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, facility investigation review, observation, and interview, the facility staff failed to report an allegation of abuse to administrative staff timely involving 1 (#3) resident of 6 reviewed for abuse. 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 to the hospital 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 Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had a 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; and received antidepressant, and opioid medication during last 7 days of review period. Medical record review of Resident #3's (MONTH) 2019 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 Resident #3's (MONTH) 2019 Medication Administration Record [REDACTED]. 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. Review of facility investigation documentation by Certified Nurse Aide (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 . Observation 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 with 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 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 . 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 (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 . Interview with the Administrator on [DATE] at 5:15 PM in her office was informed CNA #2 was aware of the allegation at about 8:40 PM and failed to report it to a nursing supervisor at the request of the Resident #3, who stated the (resident) would report it to LPN #1. The CNA further stated the CNA was aware the resident informed the nurse about 2 hours after telling the CN[NAME] When asked if the CNA failed to report the allegation timely, the Administrator state .The CNA should have reported it to her nurse right away . 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 .",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
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
1848,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,226,D,1,0,DUCD11,"> Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to follow the abuse policy and procedure related to investigation, and failed to follow up in response to incidents of resident to resident abuse, for 5 residents, (#10, #11, #12, #13, #15); allegations of sexual abuse for 1 resident (#6); and allegations of misappropriation of resident property (narcotics) for 1 resident (#9) out of 18 residents reviewed for abuse. 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, .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 Director of Nursing (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 of the facility's policy revealed .Investigation Guidelines .the investigation should include interviews of persons who may have knowledge of the alleged incident .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 . 1. Review of a facility investigation dated 11/25/16, revealed Resident #10 was involved as the aggressor in a witnessed resident to resident altercation with Resident #13 on 11/25/16. Further review revealed no written witness statements were included with the investigation per the facility policy. Review of the facility investigation dated 11/25/16, revealed the interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #10 and Resident #13 Medical record review revealed Resident #10 did not have a psychiatric consult until 2/19/17, almost 3 months after the event, with no intervention put in place to protect other residents during the interim period. Further review revealed no Social Service note, or visit to Resident #10 or Resident #13 after the incident and no Chaplain referral was made for the two residents. 2. Review a facility investigation dated 11/28/16, revealed Resident #11 was involved as the aggressor in a witnessed resident to resident altercation with Resident #13 on 11/28/16. Further review revealed no written witness statements were included with the investigation per the facility policy. Review of the facility investigation dated 11/28/16, revealed the interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #11 and Resident #13. Further review revealed the facility failed to implement the interventions noted on the investigation to prevent further resident to resident encounters per the facility policy. There was no Social Service note, or visit to Resident #11 or Resident #13 after the incident. Furthermore, there was no Chaplain referral made. 3. Review of the record of Resident #12 revealed a facility investigation document dated 4/8/17, revealed Resident #12 was the victim in a witnessed resident to resident altercation with Resident #13 on 4/7/17. Further review revealed no written witness statements were included with the investigation as required per the facility policy. Review of the facility investigation dated 4/8/17, for the incident which occurred on 4/7/18 at 8:00 PM, revealed the interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #12 and Resident #13. Medical record review revealed no Social Service note, or visit to Resident #11 or Resident #13 after the incident, and no Chaplain referral was made. The facility failed to follow their policy. No interventions were put in place to protect the residents from further abuse. 4. Review of a facility investigation dated 4/8/17, revealed the resident was involved, as the aggressor in a witnessed resident to resident altercation with Resident #12 on 4/7/17. Further review revealed no written witness statements were included with the investigation as required per the facility policy. Review of the facility investigation dated 4/8/17, revealed the interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #12 and Resident #13. Medical record review revealed no Social Service note, or visit to Resident #13 after the incident, and no Chaplain referral was made. No interventions were put in place to protect residents from further abuse as directed in the facility policy. Review of a 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, Resident #15, on 4/18/17. Review of the facility investigation dated 4/18/17, revealed Resident #13 was .immediately removed from the area and placed on 1:1 (one to one) . Further review revealed no documentation could be found in the record of Resident #13 to evidence the one to one intervention was provided by the facility as directed on the investigation report. Further interventions to be implemented were, referral to social services, psychiatric services and the chaplain for Resident #13 and Resident #15. Services were not provided per the facility policy to follow interventions as noted on the investigation report of an incident. 5. Review of the record of Resident #15 revealed a facility investigation document dated 4/18/17. Review of the document indicated Resident #15 was the victim in a witnessed resident to resident altercation with Resident #13, on 4/18/17. Per the facility investigation, dated 4/18/17, 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 (Quality Assurance Performance Improvement) committee for resolution. Medical record review revealed no social service note, or visit to Resident #15 after the incident or a Chaplain referral made per the indicated intervention to prevent further incidents per the facility Abuse, Neglect, Exploitation and Misappropriation of Property policy. None of the 5 resident-to-resident incidents, which involved Resident #10, Resident #11, Resident #12, Resident #13 and Resident #15 had any determination, or reasonable explanation, as to the cause of the incident, as directed in the facility policy. Additionally, interventions of referrals to social services, psychiatric services, and the chaplain were not provided by the facility as noted in each investigation. Interview with the DON, on 9/20/17 at 2:20 PM, in the facility 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 the facility tracked, or monitored, resident-to-resident altercations. She could not state how they determined the correct interventions were implemented to prevent further abuse. The DON further stated they .take reportable to their QAPI meeting to determine root causes . Interview with the Administrator, and review of the facility investigations which involved Resident #10, Resident #11, Resident #12, Resident #13 and Resident #15, on 9/20/17 at 4:00 PM, in the conference room, revealed the Administrator would not be able to .conclusively . determine, per policy, outcomes of the resident-to-resident incidents based on the information in the facility investigation documentation. Additionally, he stated .The details are not here . 6. Review of Resident #6's facility investigation document dated 2/21/17 submitted by the DON revealed on 2/20/17 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 the DON on 9/18/17 at 2:45 PM in the DON's office, revealed Certified Nurse Aide (CNA) #7 worked on contract and was identified based on the resident's vague descriptions. There was no evidence that the facility had interviewed CNA #7 or any of the other male staff. Interview with the Administrator on 9/20/17 at 4:00 PM in the conference room confirmed the investigation did not include a written statement from CNA #7 and that the facility failed to follow their policy regarding how to conduct a thorough investigation. 7 . Review of the hand-written Resident Investigation Tool for Allegation of Abuse, Neglect, Misappropriation of Resident Property form dated 8/21/17 revealed the form had been completed by the DON. The form revealed Licensed Practical Nurse (LPN) #2 reported misappropriation of Resident #9's narcotics by LPN #6 on 8/19/17. Review of CNA #1's witness statement dated 8/19/17 revealed .(Resident #21) stated that nurse right their (there) in the glasses has been taking dope all night . There was no documentation in the facility's investigative file of a 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 8/9/17 through 8/22/17 revealed no entry regarding his verbal report of witnessing a nurse taking medications off the medication cart. All 5 instances took place on the secure unit where a total of 13 residents resided. In none of these 5 instances, was a thorough investigation completed or sufficient interventions implemented to prevent recurrence, resulting in the potential for further resident to resident altercations or harm. In an interview in the DON's office on 9/18/17 at 2:45 PM the DON confirmed Resident #21 should have been interviewed and that the facility had failed to follow their Abuse policy. The facility further failed to thoroughly investigate, and determine appropriate interventions, for 5 instances of resident to resident altercations by Resident #10, #11, #12, #13 and #15.",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
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
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
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
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
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
1855,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,323,D,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, review of Event Report and review of Fall Investigation forms, observation, and interview, the facility failed to ensure falls had been thoroughly and completely investigated to ensure interventions were put in place and monitored to minimize repeat falls for 2 residents (#9, #14) of 3 sampled residents with falls. The findings included: 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 .Document assessment, pertinent facts and incident in Event Manager .Interdisciplinary Team (IDT) to determine root cause of fall if possible .Update care plan .Falls will be a standing agenda item for facility QAPI (Quality Assurance Performance Improvement) Committee .DON or designee will review tracking/trending of incidence of falls for the month at the monthly QAPI meeting .The committee will determine course of action based on trends .Actions taken will be reviewed and revised as needed . Individual falls root cause analysis and intervention monitoring had not been included in the falls policy. Review of facility policy, Care Plans-Comprehensive, updated, revealed .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 resident status . 1. Medical record review of Resident #9's Admission Record Face Sheet revealed she had been admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #9's Fall Risk Evaluation dated 6/22/17 revealed she was at risk for falls. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #9's mental status was a 3, indicating severe cognitive impaired. Resident #9 required supervision (oversight, encouragement, or cueing) with set up help only walking in her room, walking in the corridor, and for locomotion in the unit Review of the facility's Event Reports revealed Resident #9 had falls on 6/23/17, 8/5/17, and 9/17/17. Review of her 6/23/17 Fall Investigation and Nursing Assessment revealed she had been observed tripping over a leg rest of another resident's wheelchair and falling on her bottom in the dining room doorway. There had been no interventions in place at the time of the fall. The new intervention, documented in the resident's 6/23/17 Fall Investigation, was keep footwear on Resident when OOB (out of bed) at all times. The Fall Narrative section of the electronic Fall Investigation form was left blank. That section included analysis of what factors could have contributed to the fall. There was a section on the form for staff to mark if they had been made aware of new interventions. That section was left blank. There was also no documentation in Resident #9's medical record that the new intervention had been followed up or monitored for effectiveness. The Fall Investigation had stated her fall would be monitored through the Quality Assurance Performance Improvement (QAPI) committee. Review of Resident #9's most recent Care Plan, updated 9/17/17, revealed the intervention, .keep footwear on Resident ., was been added to the Care Plan after the 6/23/17 fall. Review of Resident #9's 8/5/17 Fall Investigation and Nursing Assessment revealed she had an unwitnessed fall and had been found on the floor in her room on her hands and knees and a chair was tipped over. She sustained a hematoma to her forehead. New interventions put in place were to wear nonskid socks at all times. The Fall Narrative section had been left blank. There was no documentation in her medical record the new interventions had been followed up on or monitored for effectiveness. The Fall Investigation had stated her fall would be monitored through the QAPI committee. Review of her 9/17/17 Fall Investigation and Nursing Assessment revealed she had been walking behind a Certified Nurse Aide (CNA) and lost her footing and fell to the floor. For interventions in place during the fall, not answered had been entered. The Fall Narrative section had been left blank. The Nursing Interventions section had been marked as yes for new interventions implemented, but the rest of the section describing the new interventions was left blank. Nonskid footwear had been mentioned in the Investigative summary and should have already been in place in the Care Plan. There was no documentation in her medical record the interventions had been followed up on or monitored for effectiveness. The Fall Investigation stated her fall would be monitored through the QAPI committee. Resident #9's current Care Plan, updated 9/17/17, revealed nonskid footwear had been added to theapproach for her At risk for fall related injury section twice; after her fall on 8/5/17 and after the fall on 9/17/17. Observation in the secure unit, on 9/18/17 at 5:33 PM, CNA #9 and CNA #3 were removing dinner trays from an insulated food delivery cart and delivering the trays to resident rooms. Resident #9 walked out of room 134 (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 continued to walk into the living room and dining room area unobserved by staff. Interview with Licensed Practical Nurse (LPN) #2 on 9/20/17 at 10:32 AM in the conference room, revealed Resident #9 was a fall risk, and they must keep her in their 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 line of sight all the time, but they try. Interview with the Director of Nursing (DON) on 9/20/17 at 3:15 PM in the DON's office, revealed the DON's expectation was that 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 that there was usually a nurse present too. Interview with the DON on 9/21/17 at 10:15 AM in her office revealed when the same interventions were put in place after multiple falls (nonskid socks/footwear on Resident #9's Care Plan twice), that usually meant the interventions had not been followed since originally implemented. Those interventions should have been followed from the time, they should have been, added on the Care Plans. 2. Medical record review of Resident #14's Admission Record Face Sheet revealed she had been admitted on [DATE] with [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 her Nursing Progress Notes revealed she had a fall and a behavior incident on 8/16/17. It had not been included on the Event Reports. Review of Resident #14's 7/21/17 Fall Investigation and Nursing Assessment, revealed she had an unwitnessed fall and had been found on the floor with no injury. New Nursing Interventions put into place, as noted in the resident's Fall Investigation, was fall mat at bedside. According to the Nursing Assessment, her Brief Interview for Mental Status (BIMS) score at that time had been a 3, indicating severe cognitive impairment. The Fall Narrative section of that Fall Investigation had been left blank. There was no documentation in her medical record the new interventions had been followed up on or monitored for effectiveness. The Fall Investigation had stated her fall would be monitored through the QAPI committee. Review of Resident #14's 8/16/17 incident Investigation revealed she had an unwitnessed fall and was observed on the floor in room at bedside. Resident had no injuries noted. Interventions implemented included .allow elder to crawl on the floor and ensure free path ways . The care plan had been documented as reviewed/revised at that time. There was no Fall Narrative section on that investigation. There was no documentation in her medical record the new interventions had been followed up on or monitored for effectiveness. The Investigation had stated her fall would be monitored through the QAPI committee. Resident #14's 8/23/17 Fall Investigation revealed she had an unwitnessed fall and was found laying in front of couch sitting area. She sustained no injuries. New Nursing Interventions put into place were fall mats. There were no interventions in place at the time of the fall. The Fall Narrative section of the investigation had been left blank. There was no documentation in her medical record the new interventions had been followed up on or monitored for effectiveness. The Fall Investigation had stated her fall would be monitored through the QAPI committee. Review of Resident 14's Nursing Progress Notes revealed a note from LPN #9 on 8/22/17, .Elder (resident) is post day (8/21/17) one fall . Another note on 8/23/17 stated Resident had another fall today and previous fall was post fall day 2/3. There had been no documentation in her complete medical record or in any fall investigations for a fall on 8/21/17. Review of Resident #14's 9/11/17 Fall Investigation and Nursing Assessment revealed she had a witnessed fall. She .attempted to sit in a chair and the chair tilted and she fell to the ground . in the hallway. There had not been any interventions in place at the time of her fall. The Fall Narrative section of the investigation had been left blank. New interventions put in place had been .nonskid socks applied . There was no documentation in her medical record the new interventions had been followed up on or monitored for effectiveness. The Fall Investigation stated her fall would be monitored through the QAPI committee. Review of her current Care Plan, revised 9/16/17, revealed a .Problem .of at risk for fall related injury .dx (diagnosis) of Dementia and her safety awareness is poor . Fall mats had not been included on her Care Plan. An approach or intervention dated 8/8/17 was .Address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity Observation on 9/18/17 at 6:00 PM revealed Resident #14 was propelling herself in a wheelchair around the unit and into the dining room. Resident #14 then came walking out of the dining room without her wheelchair and no staff was present walking with her. Observation on 9/19/17 at 7:35 AM revealed Resident #14 was in her room in the 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 LPN #9 on 9/20/17 at 11:45 AM in the DON's office revealed any interventions listed in the fall investigations should have been on Resident #14's Care Plan. The DON had not been aware her Care Plan had not included all interventions. Further interview revealed the DON had not been aware of the fall on 8/21/17 and had no further documentation or investigation for that fall. According to the DON, the intervention of walking with Resident #14 to address her wandering behavior should have been removed from her Care Plan because Resident #14 had become more independent. The DON stated Resident #14 should have had a fall mat laying out next to her bed while she was in bed at all times. It should not have been folded up as was observed on 9/19/17. 3. Interview with the DON in her office, on 9/21/17 at 10:15 AM, revealed when the same interventions were put in place over multiple falls (Resident #14 had fall mats asnew interventions for her falls on 7/21/17 and 8/23/17) that meant the interventions had not been being followed since originally implemented. Those interventions should have been followed from the time they should have been added on the Care Plans. Further interview with the DON, regarding fall investigations, revealed root cause analysis of individual falls was not documented. Staff talked about recent falls in daily stand-up meetings, but did not document anything. 4. Interview with the Administrator in the conference room, on 9/21/17 at 11:30 AM regarding fall monitoring during QAPI meetings, revealed the committee went over root cause analysis of falls as a whole to look for patterns so they can determine facility-wide interventions. They did not analyze each individual fall during QAPI for root cause and intervention monitoring for effectiveness. The computer program used to document data for falls had the ability to be used to look at falls individually, but it was used for more general data as indicated above.",2020-09-01
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
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
1858,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,371,D,1,0,DUCD11,"> Based on observation and interview, the facility dietary department failed to serve cold food at or less than 41 degrees Fahrenheit (F) on 1 of 2 meal observations. The findings included: Observation on 9/18/17 at 12:12 PM to 12:30 PM in the main dining room, with the facility Registered Dietitian present, revealed the resident mid-day meal tray line was in progress and 3 hall carts had been delivered to the units. Further observation revealed a rack with 2 trays containing 18 portions of individually wrapped slices of lemon cream pies and a bin containing 2 layers (approximately 36) of individual milk cartons with ice under the bottom layer of milk cartons. Further observation revealed the cook obtaining the temperatures of the lemon pie at 57.7 degrees F and the milk was 42 degrees F. Further observation revealed the items were served to the residents in the dining room. Interview with the Registered Dietitian on 9/18/17 at 12:30 PM in the main dining room by the tray line confirmed the facility failed to maintain cold food at or below 41 degrees F.",2020-09-01
1859,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,490,E,1,0,DUCD11,"> Based on facility policy review, medical record review, review of facility investigations, review of event and fall forms, interviews and observations, the Administer failed to ensure adequate staffing to ensure residents were shaved and bathed as scheduled and/or per preference for 6 residents (#3, #4, #5, #6, #22, #23) of 24 reviewed for dignity, honoring preference and/or needing assistance; failed to administer the facility to ensure falls/accidents were thoroughly investigated and care plans were updated for 2 residents (#9, #14) of 3 residents reviewed with falls; and failed to administer the facility to ensure all alleged violations were thoroughly investigated and care plan was updated 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: 1. Residents #3, #4, #5, #6, #22, #23 failed to receive a shave and/or shower as scheduled or per resident preference from 12/2016 to the present. Refer to F241, F242, F312, F353. Interview with the Director of Nursing (DON ) on 9/19/17 at 3:15 PM in the DON's office, on 9/20/17 at 2:35 PM in the conference room, on 9/21/17 at 7:30 AM in the DON's office and on 9/21/17 at 2:25 PM in the conference room, confirmed the facility failed to ensure adequate staff to provide/assist residents with a shave and/or shower per resident preference and/or per the bathing schedule to maintain the residents dignity. 2. Resident #9 had falls on 6/23/17, 8/5/17, and 9/17/17; the facility failed to have documentation completed after her falls; and failed to have root cause analysis, intervention monitoring, or follow-up for intervention effectiveness. Refer to F323. Resident #14 had falls on 7/21/17, 8/16/17, 8/21/17, 8/23/17, and 9/11/17; the facility failed to have documentation regarding her falls on 7/21/17, 8/16/17, 8/23/17, and 9/11/17 had been completed; failed to have root cause analysis, intervention monitoring, or follow-up for intervention effectiveness. Her fall on 8/21/17 had not been investigated. The Care Plan was not updated with new interventions after the falls. Refer to F279, F323. Interview with the DON on 9/20/17 at 2:20 PM in the conference room and on 9/21/17 at 10:15 AM in her office, 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 . Interview with the Administrator in the conference room on 9/21/17 at 11:30 AM, regarding fall monitoring revealed the facility did not analyze each individual fall for root cause and intervention monitoring for effectiveness. 3. Review of the records 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 revealed the facility failed to thoroughly investigate the allegations/altercations to determine the root cause, per facility policy, and failed to update the Care Plan interventions after the allegation/altercations. Refer to F225, F226, F279, F514. Interview with the DON on 9/20/17 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, after review of the facility investigations on 9/20/17 at 4:00 PM, in the conference room, revealed the Administrator would not be able to .conclusively . determine outcomes of the .incidents based on the information in the facility investigation documentation. Additionally, he stated .The details are not here .",2020-09-01
1860,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,514,E,1,0,DUCD11,"> Based on facility policy review, interview, review of facility event and fall documentation, and medical record review, the facility failed to maintain complete and accurate medical records, failed to provide surveyors computer access to review data, and failed to provide data in a timely manner for 7 residents (#9, #10, #11, #12, #13, #14, #15) of 11 self reported investigations reviewed. The findings included: Review of facility policy, Falls, dated 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 . Document assessment, pertinent facts and incident in Event Manager .Interdisciplinary Team (IDT) to determine root cause of fall if possible .Update care plan .Falls will be a standing agenda item for facility QAPI Committee .DON or designee will review tracking/trending of incidence of falls for the month at the monthly QAPI meeting .The committee will determine course of action based on trends .Actions taken will be reviewed and revised as needed. Individual falls' root cause analysis and intervention monitoring had not been included in the falls policy . Interview with the Administrator and the Director of Nursing (DON) during the entrance conference on 9/18/17 at 8:45 AM in the conference room, revealed the facility was asked to produce the complete investigation files back to (MONTH) (YEAR) for 10 specific investigations. 1. Review of the facility's Event Reports revealed Resident #9 had falls on 6/23/17, 8/5/17, and 9/17/17. Review of Resident #9's 6/23/17, 8/5/17, and 9/17/17 Fall Investigations, Nursing Assessments, Progress Notes, and the Quality Assurance Performance Improvement (QAPI) program revealed the facility failed to have documentation regarding her falls had been completed; failed to have root cause analysis, intervention monitoring, or follow-up for intervention effectiveness. Refer to F323. 2. 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 her nursing progress notes revealed she had a fall and a behavior incident on 8/16/17. She also had a fall documented on 8/21/17. Those falls had not been included on the Event Reports. Review of Resident #14's 7/21/17, 8/16/17, 8/21/17, 8/22/17, 8/23/17, and 9/11/17 Fall Investigations, Nursing Assessments, Progress Notes, and the QAPI program revealed the facility failed to have documentation regarding her falls on 7/21/17, 8/16/17, 8/23/17, and 9/11/17 had been completed; failed to have root cause analysis, intervention monitoring, or follow-up for intervention effectiveness. Her fall on 8/21/17 had not been investigated. Refer to F323. 3. Interview with the DON in her office on 9/21/17 at 10:15 AM, regarding fall investigations, confirmed root cause analysis of individual falls was not determined or documented. Staff talked about recent falls in daily stand-up meetings but did not document anything. Interview with the Administrator in the conference room on 9/21/17 at 11:30 AM, regarding fall monitoring during QAPI meetings, revealed the committee went over root cause analysis of falls as a whole to look for patterns so they can determine facility-wide interventions. They did not analyze each individual fall during QAPI for root cause and intervention monitoring for effectiveness. The computer program that was used to document data for falls had the ability to be used to look at falls individually but it was used for more general data as indicated above. 4. Review of the facility's undated policy titled, Abuse, Neglect and Exploitation and Misappropriation of Property, 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 DON will conduct interviews of interviewable residents on the resident's unit or the entire facility as appropriate. Review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation of Property, reviewed 5/22/17 and retired 8/12/17 (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 . 5. Review of the following resident to resident altercation incident reports revealed the facility failed to include documentation as evidence of a complete investigation: a. Per review of the facility investigation document dated 11/25/16 revealed Resident #10 was involved as the aggressor in a witnessed resident to resident altercation with Resident #13 on 11/25/16. b. Per review of the facility investigation document dated 11/28/16 revealed Resident #11 was involved as the aggressor in a witnessed resident to resident altercation with Resident #13 on 11/28/16. c. Per review of the facility investigation document dated 4/8/17 revealed Resident #12 was involved as the victim in a witnessed resident to resident altercation with Resident #13 on 4/7/17. d. Per review of the facility investigation document dated 4/8/17 revealed Resident #13 was involved as the aggressor in a witnessed resident to resident altercation with Resident #12 on 4/7/17. e. Per review of the facility investigation document dated 4/18/17 revealed Resident #13 was involved as the aggressor in a witnessed resident to resident altercation with Resident #15 on 4/18/17. f. Per review of the facility investigation document 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. Interview with the DON in the conference room, on 9/18/17 at 9:30 AM, and on 9/20/17 at 2:15 PM in the conference room confirmed the facility investigations related to resident to resident incidents, which involved Residents #10, #11, #12, #13 and #15, were requested on 9/18/18 at 8:45 AM by the survey team. Observation and interview on 9/18/17 at 3:30 PM in the conference room revealed the Administrator provided the facility investigation files related to the resident to resident incidents to the surveyor. Interview with the Administrator when asked if all information relevant to the investigations was provided, he replied .Yes, I believe so . Review of the provided facility investigations on 9/18/17 at 3:45 PM revealed incomplete investigations for the incident between Resident #10 and Resident #13, Resident #12 and Resident #13, Resident #12 and Resident #13, Resident #13 and Resident #15 and a missing investigation for the incident between Resident #11 and Resident #13. Further review of the facility investigations revealed no interviews were conducted with the residents involved in the incidents, no interviews with staff involved or on duty, and no witness statements were obtained. The Abuse Prohibition Investigation form lacked any documentation of the interventions implemented, resident plan of care updated, specifics of the incident, and the identity of the aggressor and the victim. The Abuse Prohibition Investigation form failed to contain any documentation which offered a determination of what happened, a root cause analysis of the incident or if the incident was substantiated or not. Interview with the DON on 9/20/17 beginning at 2:20 PM in the conference room revealed the completed facility investigations were in the electronic medical record (EMR) and the Abuse Prohibition Investigation forms we had were not actually required for her to complete. When the DON was asked where in the EMR the investigations could be found, she referenced a location which was not accessible to the surveyors. Continued interview at 3:30 PM revealed .we (the surveyors) probably didn't have access to them . The DON was then asked why the electronic Facility Investigations were not provided 2 days ago, when requested, she could not provide an answer. The EMR Facility Investigations were requested and provided to the surveyors approximately an hour after the end of the interview. Review of the EMR Facility Investigations on 9/20/17, revealed no additional information was included on the EMR investigations. The EMR record also failed to include interviews, what interventions were implemented to prevent future events, and no conclusion to the incident was documented.",2020-09-01
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
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
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
1947,ELK RIVER HEALTH & REHABILITATION OF ARDMORE,445321,25385 MAIN STREET,ARDMORE,TN,38449,2019-05-08,839,D,1,0,J0EN11,"> Based on license review and interview, the facility failed to ensure professional staff were licensed in accordance with applicable State laws for 1 of 3 (Registered Nurse (RN) #1) registered nurses reviewed. The findings include: Review of the facility Personnel Action Form for RN #1, revealed a new hire date effective 4/1/19 as Director of Nursing (DON). Review of the State of Tennessee Department of Health Division of Health Licensure and Regulation Division of Health Related Boards, revealed a licensure issue date of 5/1/19 license number 9 for RN #1. Interview with the Human Resource Director on 5/8/19 at 12:50 PM, in the Meeting Room, the Human Resource Director confirmed RN #1 was hired as the DON on 4/1/19 with no licensure in the State of Tennessee. Interview with RN #1 on 5/8/19 at 1:45 PM, in her office, RN #1 confirmed she had no licensure in Tennessee until 5/1/19. RN #1 was asked if she had performed any procedures prior to 5/1/19 for any resident in the facility. RN #1 stated, Yeah, I did. Started an IV (Intravenous Access) on (Named Resident) .I didn't have Tennessee license. Interview with the Administrator on 5/8/19 at 2:07 PM, in his office, the Administrator was asked if RN #1 had performed any nursing procedures prior to issuance of Tennessee license. The Administrator stated, Yes, she did an IV. She had been told not to do any procedures .",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
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
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
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
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
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
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
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
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
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
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
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
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
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
2083,SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE,445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2019-08-22,600,D,1,0,W56I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observations, and interviews, the facility failed to prevent abuse for 2 residents (#2 and #4) of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect and Misappropriation of Property, not dated, revealed .It is this organization's intention to prevent the occurrence of abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment .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 7/20/19 revealed Resident #1 rolled out into the courtyard in a wheelchair and up to a table. Continued review revealed Resident #2 cussed Resident #1 and then Resident #1 spit in the face of Resident #2. Further review revealed the two residents reached for each other and Resident #1 proceeded to hit and scratched Resident #2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) for Resident #2 dated 6/27/19 revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderately impaired cognition. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident # 1 dated 7/18/19 revealed a BIMS score of 15 indicating the resident was cognitively intact. Observation and interview with Resident #2 on 8/21/19 at 8:05 AM, in her room, revealed the resident seated on the side of her bed eating breakfast. Continued observation revealed the resident was pleasant and no anxious or fearful behaviors were observed. Interview revealed the resident was able to recall the incident and replied .(Resident #1) scratched me up .my face looked like a road map. It healed up pretty fast. She spit in my face too she is just mean . She was spitting and I told her to stop. That's when she spit on me. Observation and interview with Resident #1 on 8/21/19 at 9:00 AM, in her room, revealed the resident lying in bed awake and alert. Interview revealed .I remember that she (Resident #2) started running her mouth and she made me mad. I remember that much, I didn't want to hit her so I spit on her, then she said some more stuff and I scratched her face. I know I shouldn't have done that, I know better, but she made me mad . Telephone interview with Licensed Practical Nurse (LPN) #2 on 8/21/19 at 10:45 AM revealed .It was right at time for smoke break, but they weren't smoking yet .I was going down the sidewalk and was about half way down the walk way when I saw they were intertwined .(Resident #1) had her claws in .(Resident #2's) face .(Resident #1) didn't have any marks on her .(Resident #2) had some scratches on her face .There were 3 other residents out there and they all told me that .(Resident #1) started it and that she had spit in (Resident #2)'s face . Interview with Resident #5 on 8/21/19 at 2:50 PM, in her room, revealed .(Resident #1) was spitting and .(Resident #2) told (Resident #1) to quit spitting then .(Resident #1) spit in (Resident #2's) face .(Resident #2) swung at (Resident #1) but I don't think she actually hit (Resident #1) .(Resident #1) was clawing (Resident #2's) face. I didn't see .(Resident #2) do anything to provoke (Resident #1) . Interview with Resident #7 on 8/22/19 at 9:00 AM, on the patio, revealed .they (Resident #1 and Resident #2) were arguing about something and (Resident #1) spit on (Resident #2) .(Resident #2) said hey you spit on me and (Resident #1) went for (Resident #2's) eyes . Interview with the Director of Nursing (DON) on 8/22/19 at 9:30 AM, in the conference room, revealed .(LPN #2) called me and told me what happened .I went to .(Resident #2's) room the first thing out of her mouth was she (Resident #1) is always antagonizing me .we had words and she (Resident #1) spit on me and I pulled her hair .I went to .(Resident #1)'s room .I said what happened between you and (Resident #2) and (Resident #1) said I'm tired of (Resident #2) every time she is around me she cusses me. I asked (Resident #1) if she had spit on (Resident #2) and she said no, I said are you sure several people said you did and she said 'I guess I did' .through the investigation it appeared that (Resident #1) was the aggressor and(Resident #2) was defending herself . Review of a facility investigation dated 7/19/19 revealed Resident #4 was sitting in front of the dining room entrance across from the nurses' station and Resident #3 walked out of the dining room, up behind Resident #4, and began hitting Resident #4 on the back several times. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] for Resident #4 revealed the resident had a BIMS score of 10, indicating the resident had moderate cognitive impairment. 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] for Resident #3 revealed the resident had short and long-term memory problems. Observation and interview with Resident #4 on 8/21/19 at 10:30 AM, in her room, revealed the resident was awake and alert and exhibited no anxious or fearful behaviors. Interview revealed .she (Resident #3) knocked the hell out of me . Interview with LPN #1 on 8/21/19 at 8:30 AM, at the 300 hall Nurses' Station, revealed .(Resident #3) was kind of agitated she gets that way sometimes, and she was in the dining room pacing around, but she wasn't bothering anybody. I was behind the nurses' desk and .(Resident #4) was sitting right outside the dining room door she had just came out of the dining room and had stopped .(Resident #3) came out of the dining room and walked up behind (Resident #4) and started punching (Resident #4) in the back. It wasn't an accident (Resident #3) meant to hit (Resident #4) . Interview with the DON on 8/22/19 at 9:30 AM, in the conference room, confirmed Resident #1 willfully spit on and scratched Resident #2. Further interview confirmed Resident #3 hit Resident #4 on the back. Continued interview confirmed the facility failed to protect Resident #2 and Resident #4 from abuse.",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
2085,SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE,445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2018-09-10,600,D,1,0,8TIQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, review of facility investigations, medical record reviews, and interviews, the facility failed to prevent abuse for 5 residents (#4, #10, #13, #15, and #16) of 18 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse, Neglect and Misappropriation of Property dated 11/16/17 revealed .It is .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 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 . Review of a facility investigation dated 4/23/18 revealed on 4/23/18 at approximately 8:30 PM Resident #4 was involved in a verbal altercation with Certified Nursing Assistant (CNA) #16 in the facility's outdoor smoking shack. Further review revealed CNA #40 witnessed the incident, removed Resident #4 from the smoking shack and reported the incident to the Director of Nursing (DON) and the charge nurse. Continued review revealed CNA #40 reported CNA #16 cursed and physically threatened Resident #4. 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 a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and required some assistance with set up for activities of daily living (ADLs). Interview with CNA #40 (witness to the incident) on 9/5/18 at 6:20 PM, in the therapy office, revealed Resident #4 asked CNA #16 if she had changed the secure door code to the smoking shack. Further interview revealed CNA #16 became angry, slammed a box of smoking materials down on the table, and stated .I don't have to take your (Resident #4's)[***].then (CNA #16) challenged (Resident #4) .to lay hands on her (CNA #16) . Continued interview revealed CNA #16 threatened to call law enforcement to the facility. Further interview revealed .(Resident #4) flinched forward in his wheelchair in a threatening manner as (CNA #16) approached (the resident) with the smoking materials .(CNA #16) drew her fist .said .I dare you m***********(expletive) . Further interview revealed CNA #16 then angrily stormed out of the smoking shack past Resident #4, across the courtyard, to the nursing unit where and told the nurse .somebody needs to finish this [***] ing smoke break because I am done . Observation and interview with Resident #4 on 9/4/18 at 6:00 PM, in the resident's room, revealed he was alert and oriented and recalled the incident. Interview with the resident revealed .I think she (CNA #16) had a bad day or something . Interview with the Director of Nursing (DON) on 9/6/18 at 10:50 AM, in the therapy office, confirmed the facility failed to protect the resident from verbal abuse. Review of a facility investigation dated 6/27/18 revealed on 6/27/18 at 1:40 PM Resident #9 was observed by staff in her wheelchair near the nursing station drinking with her weighted cup. Continued review revealed Resident #10 was seated in her wheelchair in close proximity to Resident #9 and Resident #9 picked up her weighted cup from the nursing station and struck Resident #10 in the face with the base of the cup, resulting in a 1 centimeter laceration above Resident #10's eye. 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 a 3 (severe cognitive impairment) on the BIMS. Continued review revealed the resident had physical behaviors directed at others 1-3 times weekly, verbal behaviors directed at others 4-6 days weekly, and other behaviors 1 to 3 days weekly. Further review revealed the resident was dependent upon others for assistance with ADLs and used a weighted cup with a non-spill lid for fluids due to chronic tremors. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #10 had short and long term memory loss and was dependent on others for assistance with ADLs. Interview with Licensed Practical Nurse (LPN) #8 on 9/6/18 at 3:30 PM, at the secure unit nurses' station, revealed Resident #9 deliberately struck Resident #10 in the face. Interview with the DON on 9/6/18 at 4:30 PM, in the therapy office, confirmed Resident #9 willfully struck Resident #10 and the facility failed to protect Resident #10 from abuse. Review of the facility investigation dated 6/16/18 revealed on 6/16/18 at 5:50 PM LPN #15 was at the medication cart and heard Resident #14 scream .get out my damn room . and then observed Resident #13 rolled out of Resident #14's room. Further review revealed Resident #14 followed Resident #13 out of the room and then screamed .you old f***** (expletive) . Continued review revealed Resident #14 then slapped Resident #13 slapped on the back of the head with his open hand. 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 a 4 (severe cognitive impairment) on the BIMS and was dependent for (ADLs). Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed the resident scored a 15 on the BIMS and required extensive assistance with ADLs. Interview with LPN #15 on 9/6/15 at 10:22 AM, in the common area of the 200 unit, revealed she heard Resident #14 scream .get out of my damned room . which prompted her to immediately respond. Continued interview revealed she observed Resident #14 scream .you old f***** (expletive) . and then follow Resident #13 through the doorway and deliberately slap Resident #13 on the back of his head with his open hand. Interview with the DON on 9/6/18 at 11:20 AM, in the therapy office, confirmed the Resident #14 deliberately struck Resident #13 on the back of the head with an open hand. Further interview confirmed the facility failed to protect Resident #13 from abuse. Review of the facility investigation dated 8/14/18 revealed on 8/14/18 at 1:20 a staff therapist observed Resident #15 attempt to push Resident #16 in his wheelchair around the secure unit hallway. Further review revealed Resident #16 did not want to be moved and resisted the efforts. Continued review revealed while staff attempted to redirect Resident #15, the resident let go of the wheelchair handles, moved around to the side of the wheelchair, and drew his fist back as if to strike Resident #16. Further review revealed Resident #16 then hit Resident #15 in the abdomen with his fist, which then triggered Resident #15 to remove his baseball cap and swat Resident #16 three or four times atop the head with it. Medical record review revealed Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the discharge MDS dated [DATE] revealed the Resident #15 had short and long term memory loss and was dependent on others for ADLs. Continued review revealed the resident had a history of [REDACTED]. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed of the quarterly MDS dated [DATE] revealed the resident scored an 8 (moderate cognitive impairment) on the BIMS and was dependent on other for ADLs. Interview with the DON on 9/10/18 at 10:00 AM, in the dietary office, confirmed Resident #15 drew his fist back as if to strike Resident #16, which caused Resident #16 to willfully punch Resident #15 in the abdomen, resulting in Resident #15 hitting Resident #16 repeatedly with his baseball cap in retaliation. Further interview confirmed the facility failed to protect both residents from abuse.",2020-09-01
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
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
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
2089,HOLSTON HEALTH & REHABILITATION CENTER,445344,3916 BOYDS BRIDGE PIKE,KNOXVILLE,TN,37914,2018-05-31,688,D,1,0,8J5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the facility policy review, medical record review and interview the facility failed to provide restorative nursing care for 1 resident (#1) of 3 residents reviewed. The findings included: Review of the facility policy, Restorative Guidelines, undated revealed .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services .physical, occupational or speech therapies . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive 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 and required extensive assistance for bed mobility, transfers, dressing, personal hygiene and toilet use. Medical record review of a Restorative Care Plan dated 6/14/17 revealed .Frequency: 3/day x 8/week (3 days per week for 8 weeks) .BUE (bilateral upper extremities with AROM (active range of motion) .BUE strengthening exercises . Medical record review of a Restorative Care Plan dated 6/15/17, revealed .Frequency: 3/day x 12/week (3 days per week for 12 weeks) .patient will perform AROM/AAROM (Assisted Active Range of Motion) to BLE (Bilateral Lower Extremities) to prevent contractures, and decline in her mobility .BLE .AROM 20 x (20 times) . Medical record review of a Physical Therapy (PT) Discharge Note dated 6/15/17 revealed .patient is d/c (discontinued) from therapy due to patient is not making progress at all; she is declining more due to her dementia is getting worse .Patient discharged to same SNF (Skilled Nursing Facility) with recommendations including restorative to work on ROM (Range of Motion) exercise to BLE to prevent further contractures (permanent shortening of a muscle or joint) . Medical record review of a computerized Restorative Nursing Treatment sheet initiated on 6/15/17 revealed 1 treatment documented on 7/5/17 only. Interview with the Director of Nursing on 5/31/18 at 11:40 AM, in the conference room confirmed the facility failed to provide restorative nursing services for Resident #1.",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
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
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
2106,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2017-12-12,602,E,1,0,EHAW11,"> Based on review of facility policy, review of resident trust funds accounts, and interview, the facility failed to ensure 18 resident trust fund accounts (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18) of 64 residents trust accounts reviewed were free from misappropriation. The findings included: Review of facility policy Abuse, Neglect and Misappropriation, undated, revealed .It is Signature's policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property . Review of facility document Resident Trust Funds dated 4/2017, revealed 14 withdrawal discrepancies in the amount of $1,531.84. Interview with the Administrator on 12/12/17 at 1:15 PM, in the conference room, revealed the facility was in the process of a facility audit and had discovered the Assistant Business Office Manager (ABOM) made unauthorized withdrawals from resident funds accounts. Further interview revealed the misappropriation was reported to local law enforcement and the ABOM was no longer employed by the facility. Continued interview confirmed the facility failed to ensure resident funds were not misappropriated and the facility failed to follow facility policy. Telephone interview with a Detective with the local policy department on 12/13/17 at 11:30 AM revealed the ABOM admitted to misappropriation of resident funds and the investigation was on going.",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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
2166,STANDING STONE CARE AND REHAB,445363,410 W CRAWFORD AVENUE,MONTEREY,TN,38574,2019-01-31,727,D,1,0,R68T11,"> Based on review of the facility's Payroll Based Journal (PBJ) and interview, the facility failed to provide the services of a Registered Nurse (RN) for the minimum requirement of 8 hours a day on 3 days (between the period of 12/1/18 - 12/31/18) of 31 days reviewed. The findings included: Review of the PBJ worksheet dated 12/1/18 - 12/31/18 revealed no RN services were provided on 12/16/18, 12/29/18, and 12/30/18. Interview with Administrator on 1/31/19 at 4:25 PM, in the conference room, confirmed the facility failed to meet the minimum requirement of 8 hours of RN coverage per day on 12/16/18, 12/29/18, and 12/30/18.",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
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
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
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
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
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
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
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
2191,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2019-03-24,727,D,1,0,M9YS11,"> Based on review of the facility's Payroll Based Journal (PBJ) and interview, the facility failed to provide the minimum requirement of 8 hours of Registered Nurse (RN) coverage on 4 days reviewed between the period of 12/1/18 - 3/21/19 (111 days). Review of the facility's PBJ dated 12/1/18 - 3/21/19 revealed the RN staffing was for one RN for the following time period: 12/1/18 12:50 AM to 6:09 AM (5 hours and 19 minutes) 12/2/18 9:44 PM to 12:00 AM (2 hours and 16 minutes) 3/2/19 12:09 AM to 6:02 AM (5 hours and 53 minutes) 3/16/19 1:43 AM to 6:27 AM (4 hours and 44 minutes) Interview with the Administrator on 3/21/19 at 6:30 PM, in the conference room, confirmed the facility failed to provide 8 hours of RN coverage on 12/1/18, 12/2/18, 3/2/19, and 3/16/19.",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
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
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
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
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
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
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
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
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
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
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
2297,HORIZON HEALTH AND REHAB CENTER,445383,811 KEYLON STREET,MANCHESTER,TN,37355,2019-02-20,609,D,1,0,SHR011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility documentation, medical record review, and interview, the facility failed to 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/Reporting Policy and Procedure dated 2013, revealed .Every resident has the right to be free from abuse .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 .reporting .report all allegations .to the facility management .state agency .it the events that cause the allegation involve abuse .must be within 2 hours of the allegation being made . Review of a facility investigation dated 2/8/19 revealed .On 2/8/19 this Administrator received a call at 9:54 PM from the facility with an allegation of verbal abuse. The incident occurred earlier in the day at approximately 5:30 AM. The allegation is that a CNA (Certified Nursing Assistant) cursed and made degrading remarks towards (Resident #1) after an incontinence episode. This was overheard by an LPN (Licensed Practical Nurse) . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Continued review revealed the resident required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and was always incontinent of both bowel and bladder. Telephone interview with Registered Nurse (RN) #1 on 2/19/19 at 12:45 PM revealed .(LPN #1) said I have to talk to you about something, she said I've got the paper (incident report) out now and when I finish I will give it to you. I said what is it about and she (LPN #1) said well its bad one the CNA's is verbally abusing the resident's back here. I said oh my gosh who and she said .(Resident#1) I said who is the (CNA) and she said .(CNA #1) I said well you need to finish that right now and bring it to me. I asked her if she had told anyone and she said I thought I was supposed to tell my supervisor and you are my direct supervisor. She was one of those nurses that thought she knew everything but evidently she didn't know everything because she didn't go by the abuse policy for reporting abuse. After she gave me the report, I asked her why she waited why she hadn't called the DON (Director of Nursing), the Administrator, or me and she said I just wasn't thinking .she was supposed to report any suspected or alleged abuse immediately . Telephone interview with LPN #1 on 2/19/19 at 2:30 revealed .It was close to the end of the shift and he (Resident #1) had urinated on the floor, she (CNA #1) went in and closed the (resident's) door .I heard her curse she said 'what are you a (expletive) dog, if my dog peed on the floor I would rub his nose in it' .and if she rubbed his nose in it maybe he would quit .she left after she cleaned him (Resident #1) up and I didn't see her any more .I was waiting on my supervisor to come in which was the next night to report it. I didn't report it to anyone before that . Interview with the Administrator on 2/20/19 at 6:10 PM, in the conference room, revealed .the LPN who reported the incident as verbal abuse did not report the incident timely . Further interview confirmed the incident took place on 2/8/19 at approximately 5:30 AM, but was not reported to the Administrator until 2/8/19 at 9:50 PM (16 hours and 20 minutes later). Continued interview confirmed the facility failed to report an allegation of abuse timely to the Administrator and to the State Survey Agency.",2020-09-01
2312,HORIZON HEALTH AND REHAB CENTER,445383,811 KEYLON STREET,MANCHESTER,TN,37355,2019-08-29,600,D,1,0,RLS411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observations, and interviews the facility failed to prevent abuse for 2 residents (#1 and #2) of 6 residents reviewed for abuse. The findings included: Review of facility policy Abuse Prevention/Reporting Policy and Procedure updated 5/9/18 revealed .Every resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone .Abuse is defined as the 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 8/4/19 at 6:00 PM revealed Resident #1 asked Certified Nursing Assistant (CNA) #2 to look at the scratches on her resident's forearm. Continued review revealed Resident #2 came out of Resident #1's room and reported that Resident #1 hit her in the head. Further review revealed Licensed Practical Nurse (LPN) #1 asked Resident #1 if she hit Resident #2 and Resident #1 stated .yes I hit her (Resident #2) she dared me after she scratched me. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 10 indicating the resident had 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 Resident #2's Quarterly MDS dated [DATE] revealed the resident had short and long term memory problems. Observation of Resident #1 on 8/28/19 at 2:30 PM, in her room, revealed the resident was calm and pleasant and no aggressive behaviors were observed. Observation of Resident #2 on 8/28/19 at 2:45 PM, in her room, revealed the resident did not appear anxious or fearful and no aggressive behaviors were observed. Interview with the Director of Nursing (DON) on 8/28/19 at 2:15 PM, in the conference room, revealed .(LPN #1) called me and said we had a resident to resident .(Resident #2) had wandered into .(Resident #1's) room and at some point (Resident #2) grabbed (Resident #1)'s arm and caused two skin tears on (resident #1)'s right forearm. At some point (Resident #2) dared (Resident #1) to hit her and she (Resident #1) did on the left side of her (Resident #2's) head .I interviewed both residents, all I could get from .(Resident #2) was that she (Resident #1) hit me, but she couldn't tell me who .(Resident #1) said that woman (Resident #2) came in my room and grabbed my arm .she dared me to hit her so I hit her . Interview with LPN #1 on 8/29/19 at 7:30 AM, in the conference room, revealed .I was at the nurses' station and (Resident #1) came out of her room, she told (CNA #2) to look at her arm .she had two skin tears to her right arm. I went to get her and I brought her to the nurses' station to the treatment cart. About that time .(Resident #2) came out of .(Resident #1's) room and said she (Resident #2) hit me in the head. I looked at (Resident #1) and said 'did you hit her' and she said 'yes she (Resident #2) dared me to after she scratched me' . Interview with CNA #2 on 8/29/19 at 8:20 AM, in the conference room, revealed .I was picking up supper trays .(Resident #1) was hollering come look at my arm .she had two skin tears on her right arm .about that time (Resident #2) came out of (Resident #1's) room and said 'she hit me in the head.' I asked (Resident #1) if she had hit her (Resident #2) and she said yes because she scratched my arm . Interview with the Administrator on 8/29/19 at 9:45 AM, in the conference room, revealed .this was unwitnessed so we can't say exactly what happened . (Resident #2) did willfully go into (Resident #1's) room and did scratch (Resident #1) .(Resident #1) did admit to hitting (Resident #2) on the head . Further interview confirmed the facility failed to prevent abuse to Resident #1 and Resident #2.",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
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
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
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
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
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
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
2356,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-02-21,679,D,1,0,Q3XO11,"> Based on review of facility policy and interview, the facility failed to ensure the facility had an ongoing resident centered activities program on 1 unit (Secure Unit) of 5 nursing units for 16 residents of 93 facility residents reviewed. The findings Included: Review of facility policy Activity Program, last revised 7/25/17, revealed .Activities are scheduled daily .will recruit and schedule volunteer and/or community based organizations to assist with activity programs . Interview with Licensed Practical Nurse (LPN) #6 on 2/14/18 at 11:30 AM, on the secure unit hallway, revealed activities on the secure unit had been curtailed for several months, which resulted in less assistance with physical, mental, and psychosocial well-being of residents. Continued interview revealed there was an increase in resident to resident behaviors sinced the reduction of resident activities on the secure unit. Further interview confirmed there were no daily activities scheduled on the secure unit after 4:30 PM on weekdays and activities staff were only present on Saturday mornings for about 30 minutes. Continued interview confirmed the facility had no scheduled activities on the secure unit on Sunday. Interview with Activity Assistant (AA) #3 on 2/14/18 at 12:40 PM, on the secure unit hallway, revealed since 11/2017 activities on the secure unit consisted of approximately a hour on Monday, 1-2 hours per day on Tuesday through Friday, 1/2 hour on Saturday morning, and none on Sundays. Continued interview revealed activities on the secure unit were reduced under the direction of the Administrator because it was .not in the budget . Further interview confirmed since the reduction in activities there was an increase in the number of resident behaviors on the secure unit. Interview with Certified Nurse Aide CNA (CNA) #14 on 2/20/17 at 12:29 PM, on the secure unit hallway, revealed resident behaviors had increased since the activities had been reduced. Interview with the Activity Director (AD) on 2/20/18, at 2:35 PM, in the Activities Office, revealed activities provided by her staff were limited to 3 times weekly on Monday, Wednesday, and Fridays and the activities department expected clinical staff to provide activities to the residents during off hours on weekdays and weekends. Continued interview revealed the activity department budget was reduced around 11/2017 and the facility did not utilize community volunteers to assist with activities on the secure unit (as it did throughout the rest of the facility) due to concerns related to the frequency of resident altercations on the unit and the potential for negative resident behaviors against volunteers. Continued interview confirmed the facility failed to provide an ongoing activity program on the secure unit to maintain the residents' highest practicable state of mental, physical, and psychosocial well-being and the facility 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
2358,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-02-21,835,E,1,0,Q3XO11,"> Based on review of facility policy and interview, the facility failed to ensure the facility was administered in a manner to effectively maintain the highest practicable physical, mental, and psychosocial well-being for residents on 1 unit (secure unit) of 5 units reviewed. The findings included: Review of facility policy Abuse, Neglect, Exploitation and Misappropriation of Property reviewed 8/24/17 revealed .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 Director of Nursing (DON) on 2/21/18 at 9:40 AM, in the front office, revealed the facility Interdisciplinary Team (IDT) and Quality Assurance (QA) committee did not routinely perform root cause analysis of resident incidents or altercations. Continued interview revealed the IDT team was responsible for the investigation of incidents on the secure unit and the facility failed to identify frequent resident to resident behaviors on the secure unit. Further interview revealed the secure unit was populated with individuals with various memory loss disorders and co-morbid psychiatric conditions and due to the nature of resident population resident incidents were considered commonplace and were expected. Continued interview confirmed the facility failed to investigate behavioral disturbances and related incidents; failed to track and trend resident behaviors on the secure unit; and failed to ensure residents maintained the highest level of physical, mental, and psychosocial well-being on the secure unit.",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
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
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
2374,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2017-10-03,223,D,1,0,PN8611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the facility's Abuse Policy review, facility investigation review, medical record review, and interview, the facility failed to ensure 1 resident (#5) was free from abuse of 12 residents reviewed for abuse. The findings included: Review of the facility's policy titled Abuse, Neglect and Misappropriation or Property, no date, revealed .policy to prevent the occurrence of abuse, neglect, 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 .For purposes of this policy, 'willful' means non-accidental, or not reasonably related to the appropriate provision of ordered care and services, depending on the context . Review of a facility investigation dated 8/25/17 revealed a nurse observed a resident to resident altercation between Resident #4 and Resident #5. Continued review revealed the nurse looked into the day room and saw Resident #4 shaking his finger at Resident #5 and before was able to intervene Resident #4 struck Resident #5 on the arm, the nurse removed Resident #4 from the day room. Further review revealed Resident #4 was upset because Resident #5 changed the television channel. Continued review revealed Resident #5 stated .he (Resident #4) just tapped me .didn't hurt .no big thing . Medical record review revealed Resident #5 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 a 14/15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident was totally dependent on staff for transfer and required extensive assistance for ambulation, dressing, and hygiene/bathing. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Behavioral Assessment/[MEDICAL CONDITION] Medication/Management Plan Initial Assessment/Quarterly dated 4/4/17 revealed the resident had documented behaviors of screaming at staff, cursing at staff, noisiness, and refusal of medications. Medical record review of a quarterly MDS dated [DATE] revealed the resident had short and long term memory loss and had the presence of physical and verbal behavioral symptoms directed toward others. Medical record review of a Behavioral Health Progress Note dated 7/24/17 revealed .moods fluctuate . Medical record review of a Behavioral Health Progress Note dated 8/22/17 revealed .seems frustrated yet pleasant with me .monitor behaviors . Medical record review of a physician's progress note dated 8/22/17 revealed .(Resident #4) exhibits increased anxiety towards other resident. Elder becomes very anxious if another resident walks by or gets near his doorway . Interview with the Director of Nursing (DON) on 9/26/17, at 1:00 PM in the Admissions Office, revealed Resident #4 has .a personal space area as big as the side of this building and we don't go into his room unannounced .thinks the couch in the day room is his . Further interview confirmed Resident #5 was sitting on the couch and when Resident #5 changed the television, Resident #4 approached Resident #5 and hit him on the arm. Interview with Licensed Practical Nurse (LPN) #3 on 9/26/17, at 3:30 PM, in the Medication Room, revealed Resident #4 was agitated by noise and could be explosive. Interview with Resident #5 on 9/26/17, at 4:35 PM, in his room, revealed he had no hard feelings regarding the incident and was not injured by Resident #4.",2020-09-01
2375,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2017-10-03,225,D,1,0,PN8611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the facility policy review, review of facility investigation, medical record review, and interviews, the facility failed to promptly report an allegation of abuse for 1 resident (#3) 12 residents reviewed. The findings included: Review of the facility's policy titled Abuse, Neglect and Misappropriation of Property, no date, revealed .policy to prevent the occurrence of abuse, neglect, injuries of unknown origin .misappropriation of resident property .to assure .abuse, neglect, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator .Abuse includes physical abuse, mental abuse, verbal abuse and sexual abuse .Every Stakeholder, contractor and volunteer immediately shall report any 'allegation of abuse' .to the charge nurse on duty .Failure to report an allegation of abuse .may result in disciplinary action, including termination of employment . Review of a facility investigation dated 8/18/17 revealed on 8/17/17 at 11:00 AM Certified Nursing Assistant (CNA) #8 heard someone screaming in the shower room. Continued review revealed CNA #8 entered the shower room and witnessed CNA #12 and #13 in the shower room with Resident #3. Further review revealed CNA #8 asked if everyone was okay and questioned if they needed any help and CNA #12 stated yes. Continued review revealed CNA #8 saw Resident #3 attempt to grab items off shelves and attempting to hit CNA #12 and #13. Further review revealed CNA #8 got the shower chair and put it behind the resident then they sat the resident down in it, and in the process of taking the resident's gown off, CNA #12 hit the resident in the face knocking her glasses off in the process. Continued review revealed CNA #12 had a bottle in her hand and squirted the liquid on the resident's body. Further review revealed the resident swatted at CNA #12 and CNA #12 stated two can play at this game and hit the resident on the hands with the bottle. Further review revealed CNA #8 got in between the resident and CNA #12 and after CNA #8 and #13 finished the resident's shower, CNA #8 took the resident back to her room. Review of a witness statement dated 8/18/17 completed by CNA #12 revealed CNA #12 and CNA #13 took the resident in to the shower room and attempted to undress the resident but the resident became combative when the CNAs couldn't get her pants off. Further review revealed CNA #8 opened the shower room door and assisted CNA #12 and #13 with undressing the resident. Continued review revealed CNA #8 then exited the shower room and did not return. Review of a witness statement dated 8/18/17 completed by CNA #13 revealed CNA #12 and CNA #13 had Resident #3 in the shower room and CNA #8 asked if she could help. Continued review revealed CNA #13 denied a physical interaction or abuse occurred between the resident and CNA #12 or CNA #13. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 scored a 04/15 (severely cognitively impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 1 staff member for dressing and bathing. Medical record review of Resident #3's care plan dated 7/7/17 revealed the resident was care planned for behavior problems including aggression, resisting care, wandering, verbal abuse, and wandering into others personal space. Telephone interview with CNA #8 on 10/2/17 at 3:25 PM revealed she witnessed CNA #12 hit Resident #3 on the hands multiple times with a shower bottle and CNA #8 told CNA #12 .Woah wait .sometimes giving her a washcloth will calm her down .in the shower room about 7 to 10 minutes maybe . Further interview revealed CNA #8 finished the shower, got the resident dressed, and then took the resident to her room. Continued interview confirmed CNA #8 did not report the alleged allegation until the next day. Interview with the Administrator on 10/3/17 at 7:15 AM, in the Admissions Office, confirmed the facility failed to report an allegation of abuse timely and failed to follow facility policy.",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
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
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
2379,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-11-13,867,D,1,0,8ME911,"> Based on review of facility policy, review of recent surveys, review of facility plans of correction (P[NAME]), 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 facility policy Abuse, Neglect, Exploitation, and Misappropriation of Property, last 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 . Review of a recent complaint survey and the facility's P[NAME] with a completion date of 5/24/18 revealed the facility was cited for failure to ensure 2 residents of 6 sampled residents were free from abuse. Review of the P[NAME] revealed the facility was to track and trend new or worsening behaviors exhibited by residents. Continued review revealed the administrator was to monitor all incidents of alleged abuse, including tracking and trending of resident to resident altercations to identify patterns. During the current survey, conducted on 11/13/18, review of facility incidents revealed an incident of resident to resident abuse involving Resident #1 and Resident #2 on 10/28/18. Continued review revealed Resident #2 had exhibited behaviors of anxiety, pacing, and combativeness beginning on 10/22/18 and up until the incident involving Resident #1 on 10/29/18. Interview with the Administrator on 11/13/18 at 3:05 PM, in the conference room, confirmed the facility failed to follow facility policy and failed to prevent abuse to Resident #1. Refer to F600.",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
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
2389,ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER,445397,409 PARK AVENUE,ADAMSVILLE,TN,38310,2019-07-16,835,J,1,0,98W311,"> Based on the Administrator's Job Description, Director of Nursing (DON) Job Description, medical record review, and interview, the Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to provide oversight and training of staff to prevent a cognitively impaired, vulnerable resident from eloping from the Secure Unit of the facility. The resident walked 0.7 miles to a local grocery store. The Administrator's failure to provide resident safety placed Resident #1 in Immediate Jeopardy when staff did not complete assessments related to elopement risks, investigate an incident when Resident #1 exited a Secure Unit of the facility to an unsecured area, failed to ensure Resident #1 was free from neglect, and failed to ensure a safe environment for Resident #1. 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-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are 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: The Nursing Home Administrator job description with a revision date of 6/2006 documented.lead and direct the overall operations of the facility in accordance with .government regulations and Company policy, with focus on maintaining excellent care for the residents .This facility expects their employees to promote an atmosphere .hospitality and comfort for its residents .oversee regular rounds to monitor delivery of nursing care .ensure residents needs are being addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .improvement of services . The facility's Director of Nursing Job description with a revision date of 6/2006 documented, .manage the overall operations of the Nursing Department in accordance with .policies, standards of nursing practice and governmental regulations so as to maintain excellent care of all residents' needs .plan, develop, organize, implement, evaluate and direct the nursing services department .assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .resident care of the nursing service department .participate in coordination of resident services .provide appropriate departmental in-service education .in compliance with .State and Federal Guidelines .complete investigative analysis .study .resident Incident Reports for corrective action .Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures .efficient operation .Assure residents are comfortable, clean .safe environment .Verify that medical and nursing care is administered .assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident .review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided . Interview with the Administrator on 7/11/19 at 3:50 PM in the 100 Hall, the Administrator was asked about the incident when Resident #1 eloped. 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 . The Administrator was asked if Resident #1 had ever eloped before. The Administrator stated, .he left the Secure Unit 1 time and he was found on the 100 hall .we didn't investigate it as an incident because he didn't leave the facility .no incident report . Administration failed to update Resident #1's Care Plan with new interventions for his exit seeking behavior. Refer to F657 Administration failed to ensure supervision of residents with wandering/exit seeking behaviors. Administration neglected to ensure staff were knowledgeable of the location of the residents with wandering/exit seeking behaviors when a resident exited the Secure Unit and was not identified as missing until the police returned the resident to the facility. Refer to F600 and F689. The surveyor verified the A[NAME] by: 1. 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. 2. 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. 3. 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. 4. 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. 5. 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. 6. 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. 7. 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-835 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
2390,ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER,445397,409 PARK AVENUE,ADAMSVILLE,TN,38310,2019-07-16,865,J,1,0,98W311,"> Based on review of the Administrator job description, review of the Director of Nursing (DON) job description, Quality Assurance (QA) Coordinator job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to exit seeking behavior assessments, completion of incident investigations, completion of elopement assessments, developing plans of action and interventions for exit seeking behaviors, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns, and failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure the facility implemented and/or provided new interventions related to active exit seeking, and that staff ensured a safe environment for residents placed 1 of 4 (Resident #1) sampled residents in Immediate Jeopardy when Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors, 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 when Resident #1 was wandering outside of a local grocery store located 0.7 miles from the facility. This resulted in an IJ 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 (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are 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: The Nursing Home Administrator job description with a revision date of 6/2006 documented.lead and direct the overall operations of the facility in accordance with .government regulations and Company policy, with focus on maintaining excellent care for the residents .This facility expects their employees to promote an atmosphere .hospitality and comfort for its residents .ensure residents needs are being addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .improvement of services . The facility's Director of Nursing Job description with a revision date of 6/2006 documented, .manage the overall operations of the Nursing Department in accordance with .policies, standards of nursing practice and governmental regulations so as to maintain excellent care of all residents' needs .plan, develop, organize, implement, evaluate and direct the nursing services department .resident care of the nursing service department .participate in coordination of resident services .provide appropriate departmental in-service education .in compliance with .State and Federal Guidelines .complete investigative analysis .study .resident Incident Reports for corrective action .Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures .efficient operation .Assure residents are comfortable, clean .safe environment .Verify that medical and nursing care is administered .assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident .review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided . Review of the QA Coordinator job description revised 6/2008 documented, .reports to Director of Nursing .supports successful implementation and maintenance of clinical and quality initiatives and protocols for use at the facility .to assure the facility is following .regulations .Identify deficit(s) related to policy/procedures and develop draft policy for review .identify weakness .of clinical initiatives to provide/promote resident well-being .new clinical initiatives to correct weaknesses .develop a detailed report on findings to report to QA Committee. Report any high risk areas immediately .staff .to provide accurate information and correct negative trends .Identifies Safety and Risk Management issues and communicates areas of weakness to Administrator .conduct meaningful weekly Quality Assurance meetings .weekly Quality Services department meetings .Protect residents from neglect . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, Clinical Manager #1 was asked if she attended Interdisciplinary Team (IDT) Meetings. Clinical Manager #1 stated, .yes I attend the meetings . Clinical Manager #1 was asked if exit seeking behaviors were discussed in the meetings. Clinical Manager #1 stated, .I don't recall discussing exit seeking behavior or (discussing) him (Resident #1) leaving the Secure Unit in (MONTH) (2019) . Clinical Manager #1 was the staff member who saw Resident #1 leave the Secure Unit on (MONTH) 20, 2019. Interview with the QA Coordinator on 7/15/19 at 3:04 PM, in the Conference Room, the QA Coordinator was asked if any concerns related to behaviors and exit seeking behaviors had been identified. The QA Coordinator stated, .no . Interview with the QA Coordinator on 7/16/19 at 5:15 PM, in the Conference Room, the QA Coordinator was asked if the QA committee was effective. The QA Coordinator stated, .no .the things we put in place (indicating the A[NAME]) will help it to be better . 1. The facility's QA committee failed to identify areas of improvement related to active exit seeking behaviors. Refer to F600, F657, F689, F835 2. The facility's QA committee failed to identify an incident of elopement, failed to investigate the incident to determine the root cause of the incident, failed to identify appropriate plans of action, and failed to ensure new interventions related to the incident of elopement were added to the resident's care plan. Refer to F 600, F657, F689, F835 3. The facility's QA committee failed to identify that elopement risk assessments were not current and updated for residents of the facility's Secure Unit. Refer to F 600, F657, F689, F835 The surveyor verified the A[NAME] by: 1. 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. 2. 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. 3. 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. 4. 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. 5. 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. 6. 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. 7. 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-865 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
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
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
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
2480,MAPLEWOOD HEALTH CARE CENTER,445412,100 CHERRYWOOD PLACE,JACKSON,TN,38305,2020-02-26,689,D,1,0,1M5011,"> Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents' safety during transportation for 1 of 7 sampled residents (Resident #2) reviewed for van transportation. The findings include: Review of the facility's policy titled, Suicide Threats, dated 12/2017, showed, .Resident suicide threats must be taken seriously and immediately reported to the nurse supervisor/charge nurse.Resident threats of suicide must be reported immediately to the nurse supervisor/charge nurse, AND placed the on intense supervision.A staff member must remain with the resident until the nurse supervisor/charge nurse arrives to examine the resident. Review of the Progress Notes dated 1/28/2020, showed that Resident #2 stated, .I'd be better off dead. Resident #2 was placed on 15 minutes checks until she was sent out to a behavioral facility by a transportation van on 1/31/2020. Review of the Health Status Note dated 1/31/2020, showed Resident #2 was transported in van, was very anxious, and stated, I just don't understand. Review of the (Named Behavioral Facility) High Risk Alert Handoff Report dated 1/31/2020, showed that Resident #2 was suicidal and was accompanied by no one. The facility was unable to provide documentation or an assessment, showing that Resident #2 would be safe to transfer in a van without an escort. Observation in the resident's room on 2/26/2020 at 10:27 AM, 11:36 AM, and 1:49 PM, showed Resident #2 was ambulating in the room. Resident #2 had no memory of being transported to the behavioral facility. During an interview on 2/26/2020 at 11:10 AM, the Social Worker #1 confirmed the findings and stated, No she (Resident #2) did not (have an escort).it was a one way trip and it was 7:00 or 8:00 at night when she left.a family member was supposed to meet her there for the paperwork. During an interview on 2/26/2020 at 11:17 AM, Social Worker #2 confirmed the findings and stated, No, they (Resident #2) did not (have an escort) They (Resident #2) were just going to another facility.she was placed on 15 minutes checks before she was sent out. During an interview on 2/26/2020 at 2:54 PM, the Director of Nursing stated that Resident #2 was not safe riding in the van without an escort.",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
2498,"NHC HEALTHCARE, FARRAGUT",445415,120 CAVETT HILL LANE,KNOXVILLE,TN,37922,2017-06-20,323,J,1,0,MVUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of manufacturer's recommendations, medical record review, review of facility fall investigations, observations, and interviews, the facility failed to ensure safety devices were in place and functioning properly for 1 resident (#1), failed to provide adequate supervision to prevent falls for 1 resident (#3), and failed to ensure implementation of falls interventions based on facility investigation of causes of falls for 5 residents (#1, #2, #5, #7, and #9) of 10 residents reviewed for falls. Resident #1 sustained a fractured wrist and head laceration requiring sutures and Resident #3 sustained a fractured hip. The facility's failure to implement interventions to prevent falls 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 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 facility was cited Substandard Quality of Care at F-323. The findings included: Review of the facility policy Falls and Fall Risk, Managing revised (MONTH) 2007, revealed, .staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped .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 .until falling is reduced or stopped .staff will monitor and document each resident's response to interventions .if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriated to continue or change interventions . Review of the facility policy Assessing Falls and Their Causes revised (MONTH) 2010 revealed, .After an observed or probable fall, the staff will clarify the details of the fall .Within 24 hours of a fall, the nursing staff will begin to identify possible or likely causes of the incident .Staff will evaluate chains of events or circumstances preceding a recent fall .When a resident falls, the following information should be recorded in the resident's medical record .Appropriate interventions taken to prevent future falls . Review of the Manufacturer's Recommendations for the facility's Pressure Pad Alarm, undated, revealed .plug the pad into the bottom of the monitor .place monitor out of reach of the resident. Suitable mounting locations include: back of headboard, back of wheelchair, wall or under the bed. Make sure the resident cannot tamper with monitor or reach the 'Reset' button .apply pressure to the pad to activate the sensor device. The monitor will beep twice .alarm will sound when pressure is removed from the pad .the 'in use' light will blink every 3 seconds to indicate pressure has been applied to the pad. When the alarm is activated press the Reset button. This will deactivate the alarm .apply pressure to the pad to reactivate the alarm . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Falls Risk assessment dated [DATE] revealed .Total score of 10-13 represents High Risk. Total score of 14 or more represents Severe Risk . Continued review revealed the resident scored a 23 (severe risk). Medical record review of the Interim Care Plan (ICP) dated 5/8/17 revealed .Problem: Fall Risk/Potential for injury .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 . 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. Continued review revealed the resident required extensive assist for transfers, dressing, and personal hygiene with 1 person assist. Further review revealed resident had a fall with a fracture in the past month (prior to admission). Medical record review of a 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 pathways . Medical record review of a nurse's note dated 5/20/17 revealed .13:25 (1:25 PM) .EMS (emergency medical service) at bedside to transfer to (hospital) . Medical record review of the hospital Discharge Instructions dated 5/20/17 revealed .Diagnosis: [REDACTED].Lip Laceration . The resident's wrist was splinted and the head laceration required 6 sutures. 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 . Medical record review revealed Resident #1's ICP was updated 5/20/17 with a [DIAGNOSES REDACTED]. Medical record review of a physician progress notes [REDACTED].Pt (patient) was found in floor on 5/20 & (and) hit head & injured (L) (left) wrist .found to have (L) distal radius fx (fracture). Laceration to (L) eyebrow sutured .Now pt using considerably more Tramadol (pain medication) to prevent pain .(L) arm in splint . Medical record review of the Occupational Therapist (OT) Progress Note dated 5/22/17 revealed .Prior Level of Function 5/15/17 .The patient demonstrates standing balance of F- static (able to maintain static balance with UE (upper extremity) support) and holds for 7 minutes to complete self-care tasks .able to transfer to toilet/commode requiring minimal assistance (1-25%) due to increased fatigue with 25% verbal instruction/cues for proper body positioning and feet placements to enhance task .Current level of function .demonstrates standing balance of F-static and holds for 0 minutes due to fall over the weekend that resulted in a left wrist fracture and facial lacerations .able to transfer to toilet/commode requiring moderate/maximum assistance (76-99% assist) with initiation cue and 60% tactile and verbal instruction/cues for safety .STG (short term goals) have been extended to more accurately reflect patient's functional needs/requirements .may use platform walker (specialized walker for persons unable to grip regular walker handles) . Observation of Resident #1 on 6/7/17 at 11:45 AM, in her room, revealed the resident was seated in a wheelchair with steri-strips to her left forehead and a hard cast on her left arm. Continued observation revealed a pressure pad alarm was in place and the in use indicator light was flashing. Interview with OT #1 on 6/8/17 at 9:50 AM, in the therapy room, revealed .don't turn alarms off any more. I used to but I would sometimes forget to turn them back on so I just reset them now . Interview with Registered Nurse (RN) #3 on 6/8/17 at 10:40 AM, on the second floor hallway, revealed .her (Resident #1) daughter normally stays with her .she had left after the therapist took the resident (to the therapy room) .saw (Resident #1) coming down the hallway with the therapist .reminded her where her daughter was and that she would return shortly .entered room across the hall and as I was coming back out (Certified Nurse Assistant (CNA) #5) called my name .she (Resident #1) was lying on the floor in the prone position with a gash to her left brow . Continued interview with RN #3 revealed the resident was sent to the hospital for evaluation of her left wrist pain and treatment for [REDACTED]. Further interview 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) .can't say for sure who unplugged it . Continued interview confirmed the resident was wearing nonskid socks at the time of the fall. Interview with Certified Nurse Assistant (CNA) #5 on 6/8/17 at 11:00 AM, in the second floor living area, revealed .had taken a resident downstairs .came back down the hall and I could see the top of her (Resident #1) head sticking out of the door .alarm was not sounding . Continued interview revealed .called for the nurse .assisted (Resident #1) back to bed .then checked the alarm .it was just dangling unplugged .still had same alarm .I don't know who had unplugged it . Observation and interview with RN #3, CNA #5, and Resident #1's daughter on 6/8/17 at 11:10 AM, in the resident's room, revealed Resident #1 was seated in her wheelchair, the alarm box was attached to the wheel chair handle with a strap, and the alarm box and pressure pad cord were connected with the in use indicator light blinking. Continued observation revealed RN #3 demonstrated pulling on the cord of the pressure pad and was unsuccessful in separating the alarm box and cord. Further observation revealed the pad cord alarm connector had to be manually depressed by the RN before it could be disconnected from the alarm box. Interview with Resident #1's daughter revealed Resident #1 .has had to stay longer (in the facility) than we were first told because of the fall .set her back .had to get a different walker for her to use to prop her arm up . Telephone interview with 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 .not aware of a standard procedure for trouble shooting when an alarm isn't working .I know I reviewed her call light use before I left her .no did not report it (alarm not working) to the nurse. It was not uncommon for people to come to therapy and the alarm not sound .it just slipped my mind . 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 based on the cause of Resident #1's fall. Interview with the Therapy Rehabilitation Manager on 6/15/17 at 12:40 PM, in her office, revealed .no official (training) to show them (therapist) how they (alarms) work. Basically you return them (residents) the way you found them .if alarm is off when they come they (residents) are returned that way . 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 functioning properly. Continued interview revealed .Alarms will alert you if a person is getting up .It's an alerting system with a safety feature so is an intervention but it is not fool proof . In summary, Resident #1 was admitted to the facility for rehabilitation therapy after a fall with a fractured hip 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. 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 was found on the floor and 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 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 the resident scored a 21 (severe risk). Medical record review of a physician's order dated 5/20/17 revealed Seroquel (antipsychotic medication) 12.5 mg (milligrams) po (by mouth) q (every) 0600 (6:00 AM) .Seroquel 25 mg po q 8:00PM . Medical record review of a physician progress notes [REDACTED].behaviors no better .new Seroquel orders 12.5 mg po at 4:00 AM, 12.5 mg po at 3:00 PM, 25 mg po at 9:00 PM . 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 to 7 AM) getting out of bed. No sitter present. Nurse contacted daughter .inquired where is sitter. Daughter stated resident's meds (medications) were adjusted and resident no longer needs sitter. Nurse told daughter resident has gotten out of bed unassisted twice this shift 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 revealed the resident had a fall on 5/22/17 at 8:45 PM, 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 and diagnosed with [REDACTED]. The resident was discharged on [DATE] and readmitted to the facility. Medical record review revealed of the ICP dated 5/23/17 revealed use of a clip alarm (a personal safety alarm) was implemented. 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]. Review of the facility floor plan revealed Resident #3's room was located 3 rooms down the hall from the nurse's station. Interview with CNA #4 on 6/7/17 at 3:00 PM, in the hallway, revealed Resident #3 .is alert, aggressive, violent, will spit and bite .has a sitter (family provided) 24 hours a day . Observation with RN #3 on 6/8/17 at 11:00 AM, outside of Resident #3's room, revealed the nurse instructed a visitor it was probably not a good time to visit the resident. Interview with RN #3 on 6/8/17 at 11:05 AM, outside of Resident #3's room, revealed .she (Resident #3) is very agitated. I was just about to give her something to help calm her down . Interview with the Risk Manager on 6/8/17 at 11:30 AM, in the conference room, revealed Resident #3 .previously (before the fall) had a sitter (family provided) .she was trying to climb out bed .we don't provide one to one care . Telephone interview with RN #5 on 6/8/17 at 12:20 PM, revealed on the night the resident fell , .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 6/19/17 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 (in reference to time between resident setting off alarms and RN leaving resident unattended to call the daughter) . 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 1:1 supervision would consider them inappropriate for our facility . In summary, 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 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 fractured hip. The resident was admitted to the hospital, underwent a left hip hemiarthroplasty, returned to the facility on [DATE], and remained in the facility. 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). Medical record review of the facility Post Falls Nursing assessment dated [DATE] at 6:30 PM, revealed .PT (patient) found lying on the floor, states she was trying to sit in wheelchair . Further review revealed the resident had no injuries. Review of the facility Post Falls Investigation dated 5/19/17 revealed, .Interventions: Teach PT (patient) to rise slowly from sitting position . Medical record review of the Post Falls Nursing assessment dated [DATE] at 12:50 PM revealed, .night shift CNA went into pt room and observed pt on batroom (bathroom) on floor on back with arms at side . and the resident had no injuries. Review of the facility Post Falls Investigation dated 5/24/17 at 12:50 PM, revealed .Walking assessment or wheelchair assessment . Medical record review of the ICP revealed hand written updates, with no dates, .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 .Patient was found on the floor by CNA .safety devices in use: Alarm . Review of a facility Post Falls Investigation dated 6/2/17 revealed Alarm .in place .Alarm working .No .Educated pt (patient) to use call light before getting up and if needs assistance . Review of the care plan dated 5/31/17 revealed it was updated 6/2/17 with the 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 5/11/17, and the Complete Patient Care Plan 5/31/17. 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 Assistant Director of Nursing (ADON) on 6/12/17 at 2:45 PM, in the conference room, revealed .don't recall where I got the information the alarm wasn't sounding .don't remember if investigated . 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 . Continued interview confirmed a walking or wheelchair assessment was not an appropriate intervention. Interview with the ADON on 6/15/17 at 10:20 AM, in the conference room, confirmed the resident 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 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. Interventions of educating the resident to use the call light were supposed 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 was a routine assessment performed 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 . Medical record review of a facility Post Falls Nursing assessment dated [DATE] at 10:00 AM, revealed PT (patient) was getting up from wheelchair to try to get some deodorant from PT dresser and lost his balance and landed on bottom .Interventions: Medication Review by Pharmacist . Further review revealed the resident did not have any injuries. Medical record review of the Consultant Pharmacist Patient Evaluation dated 5/30/17 revealed the medications were reviewed by the pharmacist with no recommendations for medication changes or adjustments. 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 to prevent further falls. In summary, 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. 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 problems and moderately impaired cognition. Continued review revealed the resident required extensive assistance for transfers, dressing, and bathing with 1-2 person assist. Medical record review of the facility Post Falls Nursing assessment dated [DATE] at 7:46 PM revealed .PT (patient) found seated on floor of bathroom in front of toilet. PT pulled emergency cord to alert staff. Could not explain transition to floor. PT had removed non-skid socks and pants . The resident had no injuries. Review of the facility Post Falls Investigation dated 3/9/17 revealed .Someone needs to be with the patient while he is toileting . Medical record review of the Post Falls Nursing assessment dated [DATE] at 3:30 AM, revealed Resident #7 .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 . The resident had no injuries. Review of the facility Post Falls Investigation dated 3/10/17 revealed .Patient needs not to be left unattended while toileting . (Same intervention from fall on 3/9/17.) Medical record review of the ICP revealed a handwritten intervention dated 3/10/17 .reeducated the PT (patient) on proper use of call light and importance of calling for assistance . (Intervention of instruct resident and family to call for assist with mobility/transfers was initiated on 3/3/17). Medical record review of the Post Falls Nursing assessment dated [DATE] at 6:35 AM revealed .CNA responded to alarm sounding and PT (patient) sitting in the floor at bedside .no sitter w(with)/patient this shift . The resident had no injuries. Review of the Post Falls Investigation dated 3/14/17 revealed .requested family stay as much a possible . Medical record review of the Post Falls Nursing assessment dated [DATE] at 4:20 AM revealed .PTS (patient's) daughter was assisting PT to restroom. Daughter stated she stepped out to give her dad privacy. Daughter went back in and found PT on floor. Daughter pulled emergency light in bathroom and staff alerted to room . Review of a Post Falls Investigation dated 3/15/17 revealed .Pt (patient) not to be left alone in bathroom . (Same intervention as 3/9/17 and 3/10/17). Interview with the DON on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting .staff makes rounds if observe someone is restless will take them to the bathroom . 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 an appropriate intervention after the fall on 3/10/17. In summary, Resident #7 had a moderate cognitive impairment and had 4 falls. The ICP 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. The 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. 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 dated [DATE] 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 needed .Alarm pressure pad Bed Wheelchair . Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 16 (severe risk). Medical record review of a Post Falls Nursing assessment dated [DATE] at 7:00 AM revealed .heard alarm sounding entered room found patient sitting on floor . The resident had no injuries. Review of the Post Falls Investigation dated 3/23/17 revealed the intervention .scheduled toileting . Medical record review of a Post Falls Nursing assessment dated [DATE] at 3:00 AM revealed .observed PT (patient) on floor, supine with legs extended towards the HOB (head of bed) PT states was reaching for the table. Table was observed at the foot of his bed . The resident had no injuries. Review of a Post Falls Investigation dated 3/25/17 revealed Alarm in place and working .Yes .Alarm sounding .No .Scheduled toileting . Medical record review revealed no new interventions were put in place after the",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
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
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
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
2527,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2019-08-05,609,D,1,0,8H6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of an online social media post, medical record review, observation, and interviews, the facility failed to report potential resident abuse or neglect to the State Survey Agency within 2 hours for 1 resident (#1) of 8 residents reviewed for abuse and neglect, of 11 sampled residents. The findings included: Review of facility policy, Abuse Prevention Guidelines, undated, revealed .ABUSE .means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting .harm or mental anguish .this presumes that instances of abuse of all residents, even those in a coma, cause harm .this includes .abuse facilitated or enabled through the use of technology, social media and or photographs .mental abuse also includes abuse that is facilitated or caused by nursing home staff or using photographs or recording in any manner that would demean or humiliate a resident .the Administrator .or designee .will submit an initial report to Tennessee Department of Health within 2 hours .upon completion of the investigation .Administrator .or designee will report .results to the appropriate State Agency per State and Federal Regulations . Review of facility policy, Social Media Policy, undated, revealed .This facility understands that some employees participate in social networking sites .This facility respects employees' online social networking and personal internet use, However, your online presence can affect this facility as your words, images, posts and comments can reflect or be attributed to the facility .you should be mindful to use electronic media .responsibly and respectfully .The facility's policy is that you, the employee, may use Social Media for personal use only during non-working time and in strict compliance with all other terms of this other facility's policies . Review of a social media post of a picture posted online by Certified Nurse Aide (CNA #1) dated 7/20/19 at 10:20 PM revealed CNA #1 was standing in the foreground of the picture while CNA #2 was seated in a mechanical lift located behind CNA #1. Continued review revealed the photograph was captioned with the text .felt cute, might drop your grandma later . Further review revealed in the background of the photo was an oversized pink craft flower affixed to a bulletin board and an over the bed light fixture (typical to one used in a healthcare setting) hanging on the wall. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 3 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident had impaired vision and limited mobility, which required 2 person assist for Activities of Daily Living (ADLs). Further review revealed the resident was dependent upon a mechanical lift for transfers. Interview with the Assistant Director of Nursing (ADON) on 8/1/19 at 1:30 PM, in the conference room, revealed the ADON first became aware of the online social media post and photograph when questioned by a church member at church on 7/21/19 and the ADON then reported the incident to the facility Administrator. Continued interview confirmed the facility did not report the incident to the State Survey Agency within 2 hours after becoming aware. Observation and interview with CNA #5 and CNA #6 on 8/1/19 at 2:15 PM, in Resident #1's room, revealed a pink flower attached to a bulletin board identical to the one in the social media post. Interview with CNA #5 and CNA #6 confirmed the photograph posted online was taken Resident #1's room. Continued interview revealed sometime between 7/21/19 - 7/22/19 CNA #5 and CNA #6 had identified the photograph was taken in Resident #1's room based upon the pink flower featured in the photograph, but had not reported their concerns to the facility. Interview with the Director of Nursing (DON) on 8/5/19 at 1:25 PM, in the conference room, confirmed the incident was not reported to the State Survey Agency. Telephone interview with CNA #2 on 8/5/19 at 10:21 AM confirmed the photograph was taken in Resident #1's room on 7/20/19 and was posted on a social media site by CNA #2. Further interview confirmed she was the person in the photograph seated in the lift sling and CNA #1 was the person in the photograph standing in foreground holding the camera. Telephone interview with CNA #1 on 8/5/19 at 12:03 PM confirmed she had taken the photograph with her personal cell phone and CNA #1 and CNA #2 captioned the photograph as a joke prior to posting it online. Further interview revealed the photograph had been staged in Resident #1's room shortly before conclusion of their shift on the evening of 7/20/19. Continued interview confirmed at the time the photograph was taken Resident #1 was in her room lying in the bed asleep. Interview with the Administrator on 8/5/19 at 2:00 PM, in the conference room, confirmed the facility failed to report the incident to the State Survey Agency within 2 hours.",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
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
2531,CENTER ON AGING AND HEALTH,445424,880 SOUTH MOHAWK DRIVE,ERWIN,TN,37650,2019-01-27,732,D,1,0,BYGH11,"> Based on observation and interview, the facility failed to ensure posted staffing was correct for 1 of 1 observations made. The findings included: Observation on 1/27/19 at 10:30 AM, on the main hallway, revealed the posted facility staffing was dated 1/18/19 (10 days earlier). Interview with the Nursing Supervisor on 1/27/19 at 10:45 AM, on the main hallway, confirmed the posted staffing was incorrect for the current date.",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
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
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
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
2541,MILLINGTON HEALTHCARE CENTER,445425,5081 EASLEY AVENUE,MILLINGTON,TN,38053,2019-01-27,865,J,1,0,Q97T11,"> Based on job description review, policy review, Invacare Reliant 450 lift (assistive transfer device) manufacturer recommendation, hospital medical record review, medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program recognized potential accident hazards by identifying the root cause, failed to ensure systems and processes were developed and implemented to address potential accident hazards and resident safety. The QA committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. The QA committee failed to ensure staff provided care according to resident care plans and acceptable standards of practice. The failure of the QA committee to recognize, identify, develop and implement corrective systems to ensure appropriate care and safety were provided resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. Resident #1 was transported by a contract transport employee unsupervised by facility staff, fell out of the wheelchair and sustained facial lacerations and a fractured nose. Resident #2 was transferred via mechanical lift (assistive transfer device) by 1 staff member and was found with discoloration on the cheek on 11/7/18. On 12/12/18 Resident #2 sustained extensive facial bruising, swelling, swallowing difficulties and 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 F865-[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 Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Monitor to determine the effectiveness of the facility's risk management program . Review of the Director of Nursing job description revealed, .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 . 2. Review of the Quality Assurance Performance Improvement Plan undated policy documented, .It is the intent of this facility to conduct an on-going quality assurance/performance improvement program designed to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified problems and identify opportunities for improvement . 3. The QA committee failed to thoroughly investigate and identify the root cause of the incidents, failed to develop and implement corrective actions to address all potential accident hazards which resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. Refer to F689-[NAME] 4. The QA committee failed to identify staff were not providing care according to resident care plans which resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. Refer to F656-[NAME] 5. The QA committee failed to ensure staff provided care according to acceptable standards of practice which resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. Refer to F658-[NAME] 6. The QA committee failed to ensure the facility was administered in a manner that its resources were effectively and efficiently used which resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. 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 and 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 (inservices or contract) . 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 he 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 F835-[NAME] The Administrator was unable to provide information that the QA process had identified processes to prevent further occurrences during outside transportation and safe mechanical lift transfers.",2020-09-01
2561,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2019-04-02,727,D,1,0,X5DN11,"> Based on review of a facility document and interview, the facility failed to provide the minimum requirement of 8 hours of Registered Nurse (RN) staffing on 2 days (1/13/19 and 2/10/19) of 92 days reviewed between the period of 1/1/19 and 4/2/19. The findings include: Review of a facility document Employee Punches by Day Report dated 1/1/19 - 4/2/19 revealed the facility staffing included only one RN during the 24 hour period for the following days: 1/13/19 from 9:57 AM to 2:48 PM (4 hours and 51 minutes) 2/10/19 from 11:11 AM 5to 6:19 PM (7 hours and 8 minutes Interview with the Administrator on 4/2/19 at 6:15 PM, in the Administrator's office, confirmed the facility failed to provide the minimum of 8 hours of RN coverage on 1/13/19 and 2/10/19.",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
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
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
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
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
2627,WOODBURY HEALTH AND REHABILITATION CENTER,445435,119 WEST HIGH STREET,WOODBURY,TN,37190,2019-01-08,607,D,1,0,IPOX11,"> Based on review of facility policy and interviews, the facility failed to provide abuse training for 1 Volunteer (#1) of 3 Volunteers reviewed and 1 Beautician (#1) of 2 Beauticians reviewed of 17 staff members reviewed for abuse education. The findings include: Review of the facility policy Abuse Prevention Policy and Procedure dated 2/18/18 revealed .It is the policy of this facility to develop, implement and maintain an on-going effective training program for all new and existing staff that includes training on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents . Telephone interview with Volunteer #1 on 1/7/19 at 11:40 AM revealed .I have residents say things to me all the time .think their mom is still alive .their family came to visit .I just don't think anything about it .I didn't know I was to report things that residents tell me if it could be abuse .I've never received any kind of abuse training from the facility . Interview with Beautician #1 on 1/7/19 at 12:30 PM, in the conference room, revealed .I've never had any in-service or education on abuse, but I would really like to. I think it would be beneficial to me . Interview with the Administrator on 1/8/19 at 8:30 AM, in the conference room, confirmed the facility failed to provide abuse education for Volunteer #1 and Beautician #1 and had failed to follow their abuse policy.",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
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
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
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
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
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
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
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
2660,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2019-07-10,813,D,1,0,DNHI11,"> Based on observation and interview, the facility failed to store resident's personal food in a safe manner for 7 of 16 resident items in the refrigerator. The findings include: Observation of the room where residents' food/drinks are to be stored on 7/9/19 at 2:30 PM revealed it is behind the nurses' station. There is a moderate size refrigerator in the room and it is over half full of juices and milk for residents; supplements Nepro, Ensure, Glucerna; puddings and apple sauce as resident snacks. Observation of the refrigerator in the Nourishment Room behind the nurses' station revealed it was being utilized for residents' personal food. Continued observation revealed a pint of chocolate ice cream not labeled; a package of American cheese not dated or labeled and partially open; and a bottled drink not labeled. Observation of the Nutrition Room on 7/10/19 at 10:40 AM revealed 4 unlabeled cans of soda as well as a bag of food with no date on it in the refrigerator. These findings were confirmed by the DON on 7/10/19 at 11:05 AM.",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
2670,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2017-06-29,356,E,1,0,92J611,"> Based on facility policy, Daily Nursing Staff Posting reports, observation and interview, the facility failed to ensure nurse staffing data was complete and posted daily for 26 of 26 (June 1 through (MONTH) 26, (YEAR)) days reviewed for (MONTH) (YEAR). The findings included: 1. Review of the Staffing policy revealed, .Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met . 2. Observations on 6/25/17 at 4:00 PM revealed the Daily Nursing Staff Posting was located on the entry hall and was dated 6/23/17. This staff posting did not have the actual hours documented for licensed and unlicensed nursing staff providing resident care. 3. Review of the Daily Nursing Staff Posting reports for (MONTH) 1 through (MONTH) 26, (YEAR) revealed 23 of 23 postings provided by the facility did not document the actual hours worked for licensed and unlicensed nursing staff. There were no Staff Posting reports provided by the facility for (MONTH) 22nd, 23rd, and 25th, (YEAR). 4. Interview with the Director of Nursing (DON) on 6/26/17 at 10:30 AM in the conference room, the DON verified the missing and incomplete reports and stated, We have had 3 staffing coordinators this year, need to do more training on postings.",2020-09-01
2671,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2017-06-29,362,E,1,0,92J611,"> Based on policy review, Dietary Schedule review, Meal Service Schedule review, Grievance Log review, observation and interview, the facility failed to ensure sufficient staff to effectively and timely carry out the functions of the food and nutrition service of the kitchen during 2 of 2 ( Dinner on 6/25/17 and Breakfast on 6/28/17) meal observations. The facility reported a current census of 89 residents. The findings included: 1. Review of facility Staffing policy revealed, .Other support services (e.g., dietary, .) are adequately staffed to ensure that resident needs are met . Review of the Resident Nutrition Services policy revealed, Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance . 2. Review of (MONTH) (YEAR) Dietary Schedule revealed 2 staff scheduled in the kitchen for the evening meal on (MONTH) 25, (YEAR). The Dietary Schedule revealed 2 staff scheduled in the kitchen for the breakfast meal on (MONTH) 28, (YEAR). The facility had a current resident census of 89. 3. Review of the Meal Service Schedule revealed the evening dinner meal carts were to arrive out of the kitchen as follows: a. Restorative and Assisted Dining- 5:30 PM b. Meadows Unit- 5:45 PM c. 100/200 Hall Carts- 5:50 PM d. Main Dining Room- 6:00 PM Observations during the evening meal delivery service on 6/25/17 revealed the meal carts arrived late out of the kitchen as follows: a. Restorative and Assisted Dining arrived at 7:00 PM (90 minutes late) b. Meadows Unit- arrived at 6:00 PM (15 minutes late) c. 100/200 Hall Carts- arrived at 6:22 PM (32 minutes late) d. Main Dining Room- arrived at 6:30 PM (30 minutes late) 4. In an interview in the kitchen on 6/26/17 at 8:20 AM Dietary Employee #1 stated, I came in around 5:00 PM to help with supper last night, was off yesterday got called in. Interview with Dietary Manager on 6/26/17 at 9:45 AM in the kitchen, the Dietary Manager stated, (Named Dietary Employee #1) was off yesterday but was called in to help with supper last night. 5. Review of the Monthly Grievance Log for June, (YEAR) revealed a grievance from a family member dated 6/25/17 that stated, Resident didn't get evening meal served until 7:30. 6. Review of the Meal Service Schedule revealed the breakfast meal carts were to arrive out of the kitchen as follows: a. Restorative and Assisted Dining- 7:30 AM b. Meadows Unit- 7:45AM c. 100/200 Hall Carts- 7:50 AM d. Main Dining Room- 8:00 AM 7. Observations on 6/28/17 at 7:30 AM in the kitchen revealed one staff member present working/preparing/serving the breakfast meal. In an interview in the kitchen on 6/28/17 at 7:30 AM Dietary Employee #1 stated, .here by myself. Observations during the breakfast meal delivery service on 6/28/17 revealed the meal carts arrived late out of the kitchen as follows: 100/200 Hall carts- arrived at 8:08 AM and 8:29 AM (18 and 39 minutes late) Main Dining Room- arrived at 8:30 AM and 8:40 AM (30 and 40 minutes late) 8. Observation in the kitchen on 6/28/17 at 8:30 AM revealed additional staff including the Administrator present and serving the breakfast meals. Interview with the Administrator on 6/28/17 at 8:30 AM in the kitchen the Administrator verified short staff in the kitchen and was helping get the breakfast meals served. The facility failed to ensure adequate dietary staff on duty to prepare and serve resident meals timely.",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
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
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
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
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
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
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
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
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
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
2843,MAGNOLIA CREEK NURSING AND REHABILITATION,445461,1992 HWY 51 S,COVINGTON,TN,38019,2017-07-19,314,D,1,0,KIR411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 639, TN 196, TN 886 Based on medical record review and interview, the facility failed to provide care and services for the treatment of [REDACTED].#1 and 10) sampled residents reviewed with pressure ulcers. The findings included: 1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. 1) Clean area to (L) )left) outer ankle with Normal Saline, apply Skin prep or Sureprep and dry dressing q (every) day (and) PRN (as needed) 2) Clean area to (L) gluteal fold with normal saline, apply Skin prep or Sureprep and dry dressing q day and PRN . Review of the October, (YEAR) TARS revealed wound care to the L outer ankle was not documented as performed on 10/23/16. The physican's orders dated 11/22/16 documented, .St II (Stage 2 pressure ulcer) to (symbol for upper) back clean c (with) wound cleanser leave OTA (open to air) .Clean wound (St. II) R (right) buttock c wound cleanser pat dry Apply [MEDICATION NAME] gel .Place Calcium Alginate to wound apply barrier island dsg (dressing) over calcium alginate (symbol for change) q (every) 3rd day / PRN (as needed) . Review of the December, (YEAR) TARS revealed wound care to the L outer ankle was not documented as performed on the following dates: 12/21/16, 12/22/16, 12/23/16 and 12/25/16. The wound care to the buttock was not documented as performed on 12/14/16 and 12/21/16. The wound care to the mid upper back was not documented as performed from 12/1/16-12/25/16 and from 12/27/16-12/31/16. The physician's orders [REDACTED].DC (discontinue) current tx (treatment) to Back and sacral area .1) clean back c WC (wound cleanser), pat dry, apply hydrogel then CA-Alg (Calcium Alginate) cover c barrier island (symbol for change) Q day (and) PRN .Clean sacral area c WC, pat dry, apply hydrogel then CA-AlG cover c barrier island (symbol for change) QD (every day) . Review of the January, (YEAR) TARS revealed wound care to the sacrum was not documented as performed on the following dates: 1/13/17, 1/30/17, and 1/31/17. The wound care to the mid upper back was not documented as performed on 1/13/17 and 1/31/17. The left outer ankle resolved 1/3/17. Review of the March, (YEAR) TARS revealed wound care to the sacrum and mid upper back was not documented as performed on the following dates: 3/6/17 and 3/17/17. 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].D/C (discontinue) current tx to sacral start clean sacral area apply hydrogel then cover c dry drsg. (dressing) (symbol for change) QD . Review of the March, (YEAR) TARS revealed wound care to the sacrum was not documented as performed on the following dates: 3/9/17, 3/10/17, 3/23/17, 3/25/17, and 3/26/17. The March, (YEAR) TARS documented, .Skin prep QD (L) heel (start date of 3/15/17) . This wound care was not documented as performed on the following dates: 3/18/17/17, 3/19/17, 3/21/17, 3/22/17, 3/23/17, 3/25/17, and 3/26/17. Review of the April, (YEAR) TARS revealed wound care to the left heel was not documented as performed on the following dates: 4/2/17, 4/7/17, 4/11/17, 4/21/17, 4/22/17, 4/24/17, 4/25/17, 4/26/17, 4/27/17, and 4/28/17. The physician's orders [REDACTED].Clean sacral area c WC, pat dry, apply Iodosorb, cover c dry dsg (symbol for change) QD . Review of the April, (YEAR) TARS revealed wound care to the sacrum was not documented as being done on the following dates: 4/22/17 and 4/23/17. Interview with the Director of Nursing (DON) on 7/19/17 at 10:10 AM, in the conference room, the DON was asked about the missing documentation on the TARS that wound care had been performed. The DON confirmed missing documentation that wound care had been performed. The DON was asked if wound care is performed, would she expect the nurse to document it. The DON stated, Yes, definitely.",2020-09-01
2844,MAGNOLIA CREEK NURSING AND REHABILITATION,445461,1992 HWY 51 S,COVINGTON,TN,38019,2017-07-19,364,E,1,0,KIR411,"> Intakes: TN 639, TN 196, TN 886 Based on policy review, observation and interview the facility failed to ensure that foods were served warm, appetizing and palatable for 21 residents receiving trays on the 400 hall. The finding included: Review of the facility's Assisting the Resident with In-Room Meals policy documented, .6. Check that hot foods are hot .and cold foods are cold .To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41 (sign for degrees) F (Fahrenheit) to 135 (sign for degrees F) will be kept to a minimum . Observations on 7/18/19 at 12:05 PM, the meal cart containing 21 lunch trays was delivered from the kitchen to the 400 hall. At 1:05 PM the last tray, the test tray, containing a mechanical chopped soft diet was removed from the cart and the food temperatures were as follows: a. chopped pork loin with gravy 78 degrees b. egg noodles 78 degrees c. green beans 80 degrees d. a roll room temperature e. chocolate cream pie 63 degrees The Dietary Manager stated as he was preparing to test the temperature of the food I know I'm already dead in the water .It should be at least 120 degrees . Interview with Licensed Practical Nurse (LPN) #1 on 7/19/17 at 9:06 AM, at the 400 hall Nurse's Station, LPN # 1 was asked how many residents needed to be fed on the 400 hall. LPN #1 stated, 9 residents .4 or 5 are in the restorative dining room and 4 or 5 in the rooms. LPN #1 was asked how many Certified Nursing Assistants (CNA) were there feeding residents on the 400 hall. LPN #1 stated, .2 are on the hall to feed the residents that need to be fed in their rooms . LPN #1 was asked when there are 4 or 5 residents that need to be fed if it is normal for there to only be 2 CNAs to feed those residents. LPN #1 stated, Yes. LPN #1 was asked if she ever got any extra help to feed the residents. LPN #1 stated, No. Interview with the Director of Nursing (DON) on 7/19/17 at 9:25 AM, in the DON's office, the DON was asked what an acceptable time would be for the residents to receive their tray after being delivered from the kitchen. The DON stated, 15 minutes from the time they (the trays) get to the floor. The DON was then asked if she would expect the food to be hot when the residents receive their trays. The DON stated, Yes. The DON was asked how many CNA's should be on the 400 hall to feed the residents. The DON stated, It would depend on how many they had to feed. The DON was then told there were 4 to 5 residents that had to be fed on the 400 hall and asked how many staff members should there be feeding residents. The DON stated, Then there should be 4 or 5 CNA's feeding the residents.",2020-09-01
2845,MAGNOLIA CREEK NURSING AND REHABILITATION,445461,1992 HWY 51 S,COVINGTON,TN,38019,2017-07-19,465,D,1,0,KIR411,"> Intakes: TN 639, TN 196, TN 886 Based on policy review, observation and interview, the facility failed to ensure the facility was odor free as evidenced by lingering urine odor in 2 of 6 (200 and 300) halls. The findings included: Review of the Quality of Life - Homelike Environment policy documented, Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike, setting. These characteristics include: .Pleasant, neutral scents .The facility staff and management shall minimize, to the extent possible, the characteristics of the facility reflect a depersonalized, institutional setting. These characteristics include: .Institutional odors . Observations in the Memory Care Unit 200 and 300 hall, on 7/17/19 at 9:20 AM, revealed a lingering urine odor. Observations in the Memory Care Unit 200 and 300 hall, on 7/18/17 at 7:30 AM, 9:15 AM, and 2:00 PM, revealed a lingering urine odor. Observations in the Memory Care Unit 200 and 300 hall, on 7/19/17 at 7:30 AM and 11:30 AM, revealed a lingering urine odor. Interview with the Administrator on 7/19/17 at 1:05 PM, in the Day Room, the Administrator was asked if he could smell a urine odor in the Memory Care Unit hall. The Administrator stated, Not at this moment but from time to time yes, because we have a corner in the hall that a resident likes to use the bathroom in .That's just where they go. From time to time we have to pull up the carpet and clean the concrete to get rid of the odor It is ongoing .",2020-09-01
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
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
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
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
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
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
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
3061,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-11-29,812,E,1,0,FDVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the manufacturer's recommendation, facility policy review, grievance log review, medical record review, observation and interview, the facility failed to store house supplement shakes according to manufacturers guidelines for 1 of 1 ( kitchen cooler) coolers in the kitchen. The facility had a census of 151 with 19 of those residents receiving supplemental house shakes. The findings included: 1. Review of the (Named Company) manufacturer's guidelines for the (Named Company) Imperial Frozen Shakes documented, .a one year shelf life from date of manufacture when kept frozen. Once thawed, product should be refrigerated and used within 14 days. 2. Review of the facility House Shakes Procedure revealed, .When house shakes are delivered .place in freezer .once refrigerated (thawed), house shakes need to be used in 14 days .Staff is to DISCARD any remaining shakes once the 14 days have passed . 3. Medical record review for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A dietary noted dated [DATE] revealed the resident received a pureed diet with house supplement milk shakes due to inadequate intake and pressure ulcers. The grievance log revealed a grievance dated [DATE] that Resident #9 had received an expired milk product dated ,[DATE] on [DATE]. A Departmental Communication form revealed written notification of the expired product to the Dietary Manager on [DATE]. There was no documentation in the medical record or the grievance report of any follow up provided by Dietary concerning the expired product. 4. Observations in the kitchen on [DATE] at 10:30 AM revealed a total of 26 cases of thawed (Named Company) Imperial Frozen Shakes in the cooler with manufacturer dates of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There were no other labels or dates recorded on the cases. There were no cases of frozen shakes observed in the freezer. Thirteen of the 26 cases of thawed shakes observed in the cooler were found to be outdated (cases dated [DATE]-[DATE]). Interview with the Head Cook on [DATE] at 10:30 AM in the kitchen, the Head Cook was asked the storage process of the house supplemental shakes. The Head Cook stated, When the box of cartons are opened we put a label for 14 days out it can not be served. The Head Cook was asked if the supplemental shakes were stored frozen and she stated, No, we do not freeze them. Interview with the Register Dietician (RD) on [DATE] at 9:55 AM in the Conference Room, the RD was asked the storage process of the house supplemental shakes. The RD stated, Keep it frozen, and thawed in the refrigerator for 14 days, when they take them out of the freezer they are suppose to put a use by sticker on them. The facility failed to ensure supplements were stored according to manufacturer recommendations.",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
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
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
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
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
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
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
3115,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2019-05-16,658,D,1,0,9LB711,"> Based on facility policy review, observation, and interview, the facility failed to provide care and services according to accepted standards of clinical practice for medication administration. The findings included: Review of facility policy, Administering Medications. revised 12/2012, revealed Medications shall be administered in a safe and timely manner .Only persons licensed by the state to prepare, administer, and document the administration of medications may do so .Medications must be administered within 1 hours of their prescribed time .For residents not in their rooms or otherwise unavailable to receive medication on the pass, the Medication Administration Record [REDACTED]. Observation of medication administration on 4/25/19 revealed the nurse prepared medication for a resident only to find he was not in his room. Continued observation revealed the nurse labeled the cup with the medication; placed it in the medication cart; and locked the cart. Interview with 7 nurses administering medications on 5/16/19 from 9:00 AM - 10:00 AM revealed statements they would take their medication cart to the resident's room to ascertain if he/she was in the room before even looking at the Medication Administration Record. Then they would pull the resident's medication and administer it. Interview with the Director of Nursing on 5/16/19 at 10:00 AM in the conference room revealed it was her expectation nurses would check to ensure the resident was in his/her room before pulling the resident's medications. Telephone interview with the Consultant Pharmacist on 5/16/19 at 10:15 AM revealed the ideal situation would be for the nurse to be sure the resident is in his/her room before pulling the medications.",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
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
3178,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2020-02-06,689,E,1,0,WVF211,"> Based on policy review, observation, and interview, the facility failed to ensure chemicals were labeled correctly on 3 of 3 housekeeping carts (First Floor, Second Floor, and Third Floor), which had the potential to cause a hazard for residents. The findings include: Review of the facility's policy titled, Hazard Communication Program, dated 6/20/2018, showed, .Manufacturing Labels.Identity of the chemical: The chemical or common name must be present. The name on the label must be identical to the name on the Material Safety Data Sheets. Observation of the housekeeping cart on the Third Floor on 2/6/2020 at 11:45 AM, showed a bottle of green liquid labeled Odor Control. During an interview conducted on 2/6/2020 at 11:45 AM, Housekeeper #1 stated, .That green liquid is Microkill in an Odor Control bottle.Odor Control is a purple liquid. Observation of the housekeeping cart on the Second Floor on 2/6/2020 at 11:55 AM, showed a bottle of blue liquid with no label, and a bottle of clear liquid labeled Maxima Disinfectant Cleaner. During an interview conducted on 2/6/2020 at 11:55 AM, Housekeeper #2 stated, .That blue liquid is Windex.No, there is no label on that bottle.The liquid in the Maxima Disinfectant Cleaner label is bleach.No, that is not a bleach label. Observation of the housekeeping cart on the First Floor on 2/6/2020 at 12:05 PM, showed a bottle of clear liquid labeled Odor Control, a bottle of blue liquid labeled Peroxy, and a bottle of purple liquid labeled Maxima Disinfectant Cleaner 3. During an interview conducted on 2/6/2020 at 12:05 PM, Housekeeper #3 stated, .That is bleach in the bottle labeled Odor Control.Windex is in the bottle labeled Peroxy.Odor Control is in the bottle labeled Maxima Disinfectant Cleaner 3. Housekeeper #3 confirmed the employee puts the liquid in the containers. During an interview conducted on 2/6/2020 at 12:41 PM, the Director of Housekeeping stated, .The spray bottle is labeled so they know what's in the bottle.The bottles are not prefilled, staff takes the bottle and fills from the chemical dispenser.",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
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
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
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
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
3247,THE HIGHLANDS OF DYERSBURG HEALTH & REHAB,445497,350 EAST TICKLE STREET,DYERSBURG,TN,38024,2019-07-22,835,J,1,0,T41H11,"> Based on policy review, review of the Administrator's job description, review of the Director of Nursing Services (DON) job description, 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 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 the residents. The facility's Administrator/Abuse Coordinator's failure to protect cognitively impaired vulnerable female residents on a Secure Unit from potential sexual abuse and the failure to thoroughly investigate an allegation of sexual abuse placed 11 females residing on the Secure Unit in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The 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, F610, and F835 were cited at a scope and severity of [NAME] The facility was cited F600-J and F610-J which are Substandard Quality of Care. A partial-extended survey was conducted from 7/20/19 through 7/22/19. The Immediate Jeopardy was effective from 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: The facility's Administrator policy dated 8/2007 documented, .The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: .Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities .In the absence of the Administrator, the .Director of Nursing Services is authorized to act in the Administrator's behalf . 1. The facility's Administration CEO (Chief Executive Officer) (Administrator) Job Description documented, .The CEO is responsible for the day to day operations and direction of the facility, and insures that the facility complies with all policies and procedures set forth by The company, as well as those required by regulatory agencies .also ensure that expectations of the corporation and our customers are met or exceeded on a continual basis . The JOB DESCRIPTION AND PERFORMANCE STANDARDS for the Director of Nursing Services (DON) documented, .The purpose of this position is to provide nursing management, set resident care standard for all direct care providers and provide complete supervision and management for the nursing department .Assume accountability for the development, organization and implementation of approved policies and procedures .Assume responsibility for nursing service compliance with federal, state and local regulations .Be responsible for safety of residents under his/her supervision .Perform other related duties as directed by the Administrator and/or governing body .Follow Residents' Rights policies at all times . Interview with the Administrator and DON on 7/19/19 at 12:45 PM in the Conference Room, the Administrator and the DON were asked about the suspicion of sexual abuse on 7/9/19. The Administrator and the DON revealed the DON had been informed of staff observations and had examined Resident #2, concluded there was no evidence of sexual abuse, had informed the Administrator of her findings, and had not investigated further. 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 suspicion of sexual abuse reported by staff on 7/9/19 did not need to be further investigated. The Administrator stated, Yes. 2. The facility's Administrative Management (Governing Board) policy documented, .The facility's governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility . Interview with the Regional Administrator and National Liaison/ Registered Nurse (RN) (Governing Board members) on 7/22/19 at 3:35 PM in the Conference Room revealed, the Board had a system process in place through which Administrators are required to report critical events, problems or concerns about what was going on in the facility. The Board was not notified of the allegation of sexual abuse on 7/9/19, the family grievance on 7/12/19, or the complaint investigation beginning 7/17/19. On the evening of 7/20/19 the Regional Administrator revealed she had been notified of the Immediate Jeopardy at F600 and F610. At that time, the Administrator and DON were immediately in-serviced on the facility Abuse Prevention policy and Federal requirements for investigation of abuse. On 7/21/19 and 7/22/19 re-education continued on the Board's required reporting process and State and Federal regulation and guidance. Monitoring by the Board would continue weekly for 2 weeks and monthly for 2 months for compliance with the Board's expectations for reporting and State and Federal regulation. Interview with the Medical Director on 7/22/19 at 5:45 PM in the Conference Room, when asked about his duties and responsibilities in the facility and the allegation of sexual abuse on 7/9/19, the Medical Director revealed he had not been informed of the allegation until after Resident #2's family entered the facility on 7/12/19 wanting to know why they hadn't been notified that Resident #2 had been sexually abused in the facility. The Medical Director also revealed he had made it clear to Administration that he was to be notified immediately of all abuse allegations in the facility from this point forward and stated, .I am ultimately responsible . The Medical Director revealed he attended Quality Assurance and Performance Improvement meetings monthly although only required to do so quarterly because it was very important to him to be aware of what was happening in the facility. 3. Administration failed to ensure 11 cognitively impaired vulnerable female residents residing in the Secure Unit were safe and protected from potential sexual abuse and failed to ensure Resident #2 was protected from sexual abuse. Refer to F600. 4. Administration failed to ensure a suspicion of resident sexual abuse was thoroughly investigated. Refer to F610. The surveyors verified the A[NAME] by: 1. Administration was in-serviced by the Regional Clinical Director and Regional Administrator on 7/21/19 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 cause 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 the Administrator and the DON. The surveyors reviewed in-service sign in sheets and interviewed the Administrator and DON, who confirmed they had received in-service on Abuse Policy and Federal and State regulations and guidelines 2. Administrator and DON will monitor compliance for correctly identifying types of abuse and following the abuse policy daily and ongoing. Regional Clinical Director and Regional Administrator will monitor compliance of Identifying, Reporting and Completing a thorough investigation of all abuse allegations weekly times 2 weeks then monthly times 2 months. Regional Clinical Director and Regional Administrator will attend Quality Assurance (QA) / Quality Assurance Performance Improvement (QAPI) meeting monthly times 2. National Liaison/RN will conduct a third level review to verify compliance in all aspects of abuse compliance. Findings will be reported to QA/QAPI meeting monthly. The surveyors reviewed the tools for education which include the State Regulations and Federal Guidance for abuse, the Performance Improvement Project and the Rapid Response tools. The surveyors interviewed the Regional Administrator and the National Liaison/RN to confirm ongoing monitoring for compliance of identifying, reporting and completing a thorough investigation of all abuse allegations and reviewed the audit forms. 3. The facility conducted a QA meeting on 7/22/19 attended by department heads and the Medical Director. The surveyors interviewed the Medical Director who confirmed he had attended QA meetings in the past and will continue to do so monthly. Noncompliance of F835 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
3282,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,835,K,1,0,POU411,"> Based on review of facility policy, medical record review, facility investigation review, observation, and interview, the Administrator failed to administer the facility in a manner to provide adequate supervision to prevent unsafe wandering and elopement from the facility for 1 resident (#6) who was an elopement risk; failed to provide adequate supervision for 1 resident (#13) with multiple incidents of inappropriate sexual contact toward other residents; failed to provide supervision to 2 resident (#15, #31) with multiple incidents of physical abuse toward other residents. The administrator's failure to provide supervision and keep residents safe placed the 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 findings included: Resident #6 eloped from the facility on 10/14/17 and staff were unaware of the resident's absence until notified via phone that the resident had been found by the local police. During this elopement, the resident was gone for an hour and crossed a 3-lane road with a speed limit of 35 miles per hour. The facility failed to conduct a thorough investigation and could not provide evidence to verify how the elopement had occurred. There was no evidence that the facility systematically examined all possible root causes, or came to a determination as to why the facility's supervision had not been adequate to prevent the elopement. Facility systems for monitoring of wanderguard placement, and functioning of the alarm system were not implemented in a manner to prevent elopements. This resident also allegedly eloped from the facility on 10/18/17. Resident #15 and Resident #31 were witnessed to hit, punch, grope an incapacitated resident's breast, and/or slap multiple other residents without provocation. Resident #13 was observed to be involved in multiple incidents of resident-to-resident abuse, including physical abuse where he hit another resident and/or touched a female resident (Resident #21) who did not have the cognitive ability to form consent to being touched in a sexual manner. The administrator failed to assure that each instance of abuse that was either alleged to have occurred or witnessed was thoroughly investigated, with the facility identifying the victim, determining possible root cause of the incident, care planning, and providing needed supervision to prevent further instances of resident to abuse. 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. 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 from 8/15/17 and is ongoing. Refer to F-600, F-689",2020-09-01
3283,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,837,K,1,0,POU411,"> Based on review of facility policy, medical record review, facility investigation review, observation, and interview, the facility's governing body failed to ensure adequate supervision was provided to prevent unsafe wandering and elopement from the facility for 1 resident (#6) who was an elopement risk; failed to ensure adequate supervision was provided for 1 resident (#13) with multiple incidents of inappropriate sexual contact toward other residents; failed to ensure adequate supervision was provided to 2 residents (#15, #31) with multiple incidents of physical abuse toward other residents. The governing body's failure to ensure supervision was provided and victims were protected placed 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 findings included: Resident #6 eloped from the facility on 10/14/17 and staff were unaware of the resident's absence until notified via phone that the resident had been found by the local police. During this elopement, the resident was gone for an hour and crossed a 3-lane road with a speed limit of 35 miles per hour. The facility failed to conduct a thorough investigation and could not provide evidence to verify how the elopement had occurred. There was no evidence that the facility systematically examined all possible root causes, or came to a determination as to why the facility's supervision had not been adequate to prevent the elopement. Facility systems for monitoring of wanderguard placement, and functioning of the alarm system were not implemented in a manner to prevent elopements. This resident also eloped from the facility on 10/18/17. Resident #15 and Resident #31 were witnessed to hit, punch, and/or slap multiple other residents without provocation. Resident #13 was observed to be involved in multiple incidents of resident-to-resident abuse, including physical abuse where he hit another resident and/or touched a female resident (Resident #21) who did not have the cognitive ability to form consent to being touched in a sexual manner. The facility failed to assure that each instance of abuse that was either alleged to have occurred or witnessed was thoroughly investigated, with the facility identifying the victim, determining possible root cause of the incident, care planning, and providing needed supervision to prevent further instances of resident to abuse. 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 from 8/15/17 and is ongoing. Refer to F-600. Refer to F-689.",2020-09-01
3284,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,842,D,1,0,POU411,"> Based on medical record review, observation, and interview, the facility failed to maintain a complete clinical record which was readily accessible for 1 resident (#6) of 10 residents reviewed with closed records. The findings included: 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 informed the facility would be required to provide resident records as part of the survey process. Continued interview revealed Resident #6 was one of multiple discharged residents for whom the closed record was requested on 1/8/18. The facility was asked to make the record available when the survey team arrived on 1/9/18. Observation on 1/9/18 at 7:30 AM in the conference room revealed that Resident #6's closed hard-copy record was not among the charts provided by the facility. Interview with the DON on 1/9/18 at 4:14 PM in the conference room revealed she stated Have they told you? We can't find her chart. Continued interview revealed the DON stated that she and the Assistant Director of Nursing (ADON), who had previously been the Medical Records staff, were here till 12:30 last night and were never able to locate it. Further interview revealed the DON stated that although she could provide some parts of the record because there was some electronic documentation and miscellaneous documents in staff files, the facility was unable at this time to provide this discharged resident's complete medical record. Interview with the Social Services Director on 1/10/18 at 9:56 AM in the conference room revealed although staff were still looking for it, they had been unable to find Resident #6's clinical record. Interview with the DON, on 1/10/18 at 12:15 PM in the conference room, revealed that although the facility had continued to look, they were still not aware of the location of the resident's clinical record, as it could not be found. Additional interview with the DON on 1/11/18 at 2:30 PM, in the conference room, confirmed that the facility had never been able to locate the resident's record.",2020-09-01
3285,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,867,K,1,0,POU411,"> Based on facility policy review, medical record review, facility investigation review, and observation, the facility's Quality Assurance (QA) Committee failed to assess and monitor behavior in and elopement from the facility; failed to identify the root cause of incidents; and failed to develop a plan with interventions to prevent abuse and elopement and protect victims of abuse. The facility's QA Committee failure 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 was notified of the Immediate Jeopardy on 1/16/18 at 2:10 PM in the conference room. The findings included: Resident #6 eloped from the facility on 10/14/17 and staff were unaware of the resident's absence until notified via phone that the resident had been found by the local police. During this elopement, the resident was gone for an hour and crossed a 3-lane road with a speed limit of 35 miles per hour. The facility failed to conduct a thorough investigation and could not provide evidence to verify how the elopement had occurred; examined all possible root causes; or came to a determination as to why the facility's supervision had not been adequate to prevent the elopement. Facility systems for monitoring of wanderguard placement, and functioning of the alarm system were not implemented in a manner to prevent elopements. This resident also allegedly eloped from the facility on 10/18/17. Resident #13 was observed to be involved in multiple incidents of resident-to-resident abuse, including physical abuse where he hit another resident and/or touched a female resident (Resident #21) who did not have the cognitive ability to form consent to being touched in a sexual manner. Residents #15 and #31 were involved with physical abuse of other residents. The facility failed to assure that each instance of abuse that was either alleged to have occurred or witnessed was thoroughly investigated, with the facility identifying the victim, determining possible root cause of the incident, care planning, and providing needed supervision to prevent further instances of resident to resident abuse. There was no evidence the QA Committee systematically assessed and investigated incidents; developed a corrective action plan to prevent future occurrences; or engaged in continued monitoring of circumstances surrounding the incidents. Refer to F-600. Refer to F-689.",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
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
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
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
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
3301,PERRY COUNTY NURSING HOME,445503,127 E BROOKLYN AVENUE,LINDEN,TN,37096,2018-03-10,684,D,1,0,7Q2111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 592 Based on medical record review, observation and staff interview, the facility failed to follow physician's orders when 1 of 1 (Licensed Practical Nurse (LPN) #1) did not crush medications as ordered by the physician. 1. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 2/19/18 documented, .Crush all Crushable meds . Review of the Comprehensive Care Plan dated 3/2/18, documented, .I require all my medications to be crushed .Interventions .Staff will comply to crushing my medications per MD order . Observations in Resident #1's room on 3/10/18 at 1:45 PM, revealed Nurse #1 administered a [MEDICATION NAME] 7.5mg/325mg tablet whole to Resident #1. During an interview at the 100 hall nurses' station on 3/10/18 at 2:35 PM, Nurse #1 was asked if there was an order to crush Resident #1's medications. Nurse #1 stated, Yes, but I forgot to crush that [MEDICATION NAME] .He (named resident) gets his (medications) crushed because he was holding in his mouth and giving to another resident. During an interview in the Director of Nursing's (DON) office on 3/10/18 at 4:10 PM, the DON was asked if she would expect the nurse to crush all medications that are crushable according to a physician's order to crush all medications for a resident. The DON stated, Yes.",2020-09-01
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
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
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
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
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
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
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
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
3358,WHARTON NURSING HOME,445510,878-880 WEST MAIN STREET,PLEASANT HILL,TN,38578,2019-09-09,600,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, observations, and interviews, the facility failed to prevent abuse 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 .Abuse means the willful inflection of injury .Instances of abuse of all residents, irrespective of any mental or physical condition .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . 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. Observation of Resident #4 on 9/6/19 at 1:30 PM, in the common area, revealed the resident was seated in a recliner, was awake and alert, and had no fearful or anxious behaviors. Observation of Resident #4 on 9/9/19 at 11:15 AM, in the dining area, revealed the resident was seated at a dining room table conversing pleasantly with other residents and had no anxious or fearful behaviors. Interview with Certified Nursing Assistant (CNA) #1 on 9/6/19 at 11:25 AM, in the common area, revealed .they (Resident #4 and Resident #5) were both in the common area (Resident #4) was at the dining room table and (Resident #5) was standing by the column by the table, I was across the dining room at the nurses' station. I heard (Resident #5) smack the table so I looked up and started towards them by the time I got to them (Resident #4) had already slapped (Resident #5) two or three times on the shoulder. (Resident #5) drew back .to kick (Resident #4) but I'm not sure (Resident #5) actually made contact with (Resident #4). (Resident #5) kept trying to kick (Resident #4) while we were trying to separate them . Continued interview revealed .yea (Resident #5) meant to slap (Resident #4) it was deliberate . Interview with the Social Service Coordinator on 9/6/19 at 2:55 PM, in the conference room, revealed .I was called by the nurse .when I got there they were having words at the dining room table. (Resident #4) was in (the) wheel chair and (Resident #5) was standing beside (Resident #4) .(CNA #1) was trying to separate them .I heard (Resident #5) call (Resident #4) a name .(Resident #5) intentionally tried to kick (Resident #4) .did not make contact with (Resident #4). (Resident #5) had already hit (Resident #4) before I got there . Interview with the Director of Nursing (DON) on 9/9/19 at 3:15 PM, in the conference room, confirmed Resident #5 hit Resident #4 on the shoulder and attempted to kick Resident #4 multiple times. Continued interview confirmed the facility failed to prevent abuse to Resident #4.",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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
3397,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2018-12-20,880,F,1,0,E5NC11,"> Based on observation, review of facility policy, interview, and record review, the facility failed to maintain infection control standards by ensuring proper handling of soiled linens for 4 of 6 halls with laundry chutes and failed to ensure proper processing and storage of contaminated linens to reduce the risk of cross contamination with clean linens for 1 of 1 laundry rooms. The findings include: Review of facility policy, undated revealed Removal of Soiled Linen, failed to address the procedure for handling soiled linens when placing them into the laundry chutes. Observation of Certified Nursing Technician (CNT) #105 on 12/17/18 at 11:23 AM, was observed providing incontinence care for Resident #16. The resident had soiled her gown, cloth pad and bed sheet. CNT #105 removed the soiled linens and placed them directly into the laundry chute that was located in the resident's private room. The linens were not bagged prior to placing them into the laundry chute. Interview with CNT #105 revealed the laundry staff collect the soiled linens through the laundry chute door, which was located outside the resident's room in the hallway. She stated each resident had their own laundry chute. She stated it wasn't her practice to bag the soiled linens prior to placing them in the laundry chute. 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 on 12/18/18 at 6:21 AM, Laundry Aide #181 was observed collecting the soiled linens from the laundry chutes on the 300 and 400 hall. Outside of each resident's room was a reach-in latching door, below the hallway handrails. When she opened the chute door, the soiled laundry was not bagged. When she pulled the soiled linens out of the chute, the linens were touching the carpeted floor, falling on the floor, touching the wall/baseboards and handrail as she placed them into the large gray rolling hamper she was using to collect all the soiled linens. Interview with Laundry Aide #181 revealed the soiled linen was collected from the chutes every hour on day shift, and every 2 hours on second shift. She confirmed the linens were touching the floors, walls and handrail as she was placing them into the hamper. She stated the staff didn't usually bag the linens, but they were supposed to. She stated the failure to bag the linens was always worse on the night shift. Observation on 12/20/18 at 12:30 PM, a laundry aide was observed collecting soiled linens from the laundry chutes on the 100-hall. The soiled linens were not bagged and were falling onto the floor. A strong odor of stool was noted. During an interview on 12/18/19 at 9:18 AM, with the Director of Nursing (DON) #11 revealed the facility's policy did not indicate whether staff were to bag linens prior to placing them in the laundry chute. When questioned what the expectation had been up until this point in regards to bagging the linens, she stated she wasn't sure. When questioned how the staff would know how to handle the linens if there was no policy, she stated they wouldn't know. Yet, they do actually have a written policy. During an interview on 12/19/18 at 2:15 PM, DON #12 stated it would be her expectation that the soiled linens were bagged before being put in the chute. During an observation and interview on 12/17/18 at 12:20 PM, the laundry room containing the washing machines was observed with Laundry Aide #181. Inside the laundry room revealed two commercial sized laundry machines, a household sized laundry machine, laundry chemicals and laundry bins. Approximately four feet away from the commercial laundry machines, were 4 metal rolling laundry carts containing soiled linens. There were linens observed with what appeared to be a brown substance with the appearance of feces. Laundry Aide #181 verified the linens were soiled and waiting to be washed. The soiled linens were piled up and touching the wall behind the bins. There were brown smears on the wall above the linen carts. Laundry Aide #181 stated they bring the soiled linens in through a side door and sort the dirty linen in this corner by the laundry machines. She confirmed they do not have a separate room for handling and processing soiled linens. She stated, We need one. She indicated when the clean laundry was removed from the washing machine and placed in the clean linen bins, it passed by the metal carts containing the soiled linen. Observation and interview on 12/20/18 at 10:40 AM, approximately four feet away from the commercial laundry machines, positioned in the corner against the wall, were four metal rolling laundry carts containing soiled linens. There was what appeared to be feces on the linens. Laundry Aid #182 stated they handle and process the soiled linen in the corner by the laundry machines. She stated they did not have a separate room for processing the soiled linens. Interview on 12/20/18 at 10:28 AM, with Housekeeping Director #166 confirmed they didn't have a separate room for handling and processing the soiled linens. When questioned about the soiled linens being processed next to the laundry machines, he stated he didn't know about it but would follow up with this concern when he returned to work. A facility policy was requested for handling and processing linens, but none was provided from the facility.",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
3433,WAYNESBORO HEALTH AND REHABILITATION CENTER,445518,"104 J V MANGUBAT DRIVE, PO BOX 510",WAYNESBORO,TN,38485,2017-08-27,309,D,1,0,Y0QX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 194 Based on policy review, medical record review and interview, the facility failed to follow the physician's orders for as necessary (PRN) pain medication administration for 13 of 22 doses for 1 of 3 (Resident #3) sampled residents. The findings included: Review of the facility's policy Administering Medications documented, .3. Medications must be administered in accordance with the orders . Medical record review revealed Resident #3's was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Physicians Orders dated (MONTH) (YEAR) revealed, .[MEDICATION NAME] HCL ([MEDICATION NAME]) 10 mg (milligram) tablet take 1 tablet per tube every 6 hours as needed for pain-take with 200 mg [MEDICATION NAME] . Review of the Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on 8/26/17 at 1:20 PM at the nurses station, LPN #1 confirmed the order for [MEDICATION NAME] HCL 10 mg with [MEDICATION NAME] 200 mg and stated, .I can see how it is messed up . Interview with the Director of Nursing (DON) on 8/26/17 at 1:30 PM in the conference room, the DON confirmed the order of [MEDICATION NAME] HCL 10 mg 1 tablet with 200 mg [MEDICATION NAME] per tube every 6 hours as needed for pain. The DON also confirmed there was documentation on the MAR indicated [REDACTED].",2020-09-01
3443,NHC PLACE SUMNER,445519,140 THORNE BOULEVARD,GALLATIN,TN,37066,2019-07-18,684,D,1,0,XRXF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, review of the medical record, and interview, the facility failed to administer an intravenous (IV) antibiotic (ABT) medication per professional standard and per policy for 1 resident (#1) of 3 residents reviewing IV ABT. Findings included: Review of the facility policy, Reconstitution of Medication for [MEDICATION NAME] Administration, effective 6/2016 revealed .Policy .To provide for the safe and accurate reconstitution of [MEDICATION NAME] medications prior to administration, manufacturer information is reviewed .Procedures .Read medication package literature, medication label, or other appropriate reference to determine the correct [MEDICATION NAME] and quality to be used .Administer medication or add to intravenous (IV) solution as directed . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Medications form dated 5/8/19 revealed .[MEDICATION NAME] (Trade Name: [MEDICATION NAME]) (IV ABT) 2000 mg (milligrams) Intraven.(Intravenous) every 12 hours .until 6/10/19 . Further review revealed .[MEDICATION NAME] (IV ABT) 1 gram Intraven. every 24 hours .until 6/10/19 . Medical record review of the facility admission Physician Order Report dated 5/8/19-5/28/19 revealed .[MEDICATION NAME] ([MEDICATION NAME]) (IV ABT) recon soln (reconstituted solution); 2 gram .intravenous Special Instructions: 2000 mg every 12 hours IV for left foot osteo[DIAGNOSES REDACTED] . was ordered on [DATE] and to be ended on 6/11/19. Further review revealed .[MEDICATION NAME] recon soln; 1,000 mg .intravenous Special Instruction: one gram IV every 24 hours .for Left foot osteo[DIAGNOSES REDACTED] . was ordered on [DATE] and discontinued (DC) on 5/17/19. Further review revealed an order dated 5/17/19 for .[MEDICATION NAME] recon soln; 1000 mg; intravenous Special Instructions: one gram IV every 24 hours .for Left foot osteo[DIAGNOSES REDACTED] (dosed per (named physician)) . was DC on 6/11/19. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing and vision, clear speech, and made self understood and understood others. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating the resident was cognitively intact. The resident was administered insulin and ABT for the past 7 days of the review period. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED].Drug/Item Unavailable . The [MEDICATION NAME] was administered daily as ordered except for 5/21/19 when .Drug/Item Unavailable . Medical record review of the Event Report dated 5/28/19 at 4:22 PM revealed Resident #1 had a .Medication Error .Date Error Began/Ended .5/28/19 .Date Error Found .5/28/19 .Error Found By .(Licensed Practical Nurse (LPN) #1) .What is Correct Order? .[MEDICATION NAME] 1 gram to be infused in 250 mL (milliliter) .Type of Error .Incorrect Dose .Describe .Supposed to be in 250 mL bag, but gave it in a 150 mL bag .Observation .Are any of the following adverse drug reactions present? .None of the above . Interview with the Consulting Pharmacist Coordinator on 7/17/19 beginning at 5:10 PM in the admission room or the medication room revealed the First Dose Box contents included the [MEDICATION NAME] powder. Further interview revealed a separate storage container held a variety of fluids, including normal saline IV solution in 100 mL, 250 mL, 500 mL, and 1000 mL. Further interview revealed the fluid storage container contents included the .IV .Reconstitution Guideline . which specified what amount of fluid to use based on the [MEDICATION NAME] dose order . Further interview confirmed Resident #1's [MEDICATION NAME] order of 1000 mg required a 250 mL normal saline solution for reconstitution. When asked what reaction a resident would have if the [MEDICATION NAME] 1000 mg were reconstituted in 100 mL solution, the Pharmacist revealed .would have reaction to [MEDICATION NAME], like [MEDICAL CONDITION] .and would be at the time of administration . Interview with the Director of Nursing on 7/18/19 at 9:00 AM in the admission office when asked what her expectations were when nurses were administrating medications, revealed she .expected nurses to administer medications by the physicians orders . as per policy. Telephone interview with LPN #1 on 7/18/19 beginning at 9:20 AM confirmed LPN #1 had administered .went to the First pick box to get the [MEDICATION NAME] and then got fluid stored in a separate box. Only 1 normal saline in the box, was 100 mL or 150 mL, can't remember now. I got the medication set up and got the MDS nurse to help. I verified set up was right but later knew infused wrong bag. The MDS nurse realized it was the wrong (normal saline) bag, stopped the infusion and removed the bag. The bag may have been half gone .",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
3497,LAKESHORE HEARTLAND,445526,3025 FERNBROOK LANE,NASHVILLE,TN,37214,2018-03-14,658,D,1,0,TCIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Findings Include: 1. Urinary output amount was not monitored for residents with indwelling urinary catheters. Specifically: a. Review of the FACE SHEET revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 08/01/2017 HISTORY AND PHYSICAL revealed Resident #8's past medical history was significant for history of previous [MEDICAL CONDITION] problems. Review of Resident #8's physician orders [REDACTED]. The interventions included, in pertinent part: Foley Catheter as ordered, Observe for decreased urinary output, Record output q shift. Review of the Vital Sign record for the certified nursing aide (CNA) to document urinary catheter output, for the entire length of stay from 09/05/2017 to 09/20/2017, revealed only 4 entries documenting when the drainage collection bag was emptied; the bag was emptied on 09/06/2017 at 2:04 AM, 4:11 PM, and 9:13 PM, and on 09/08/2017 at 5:14 AM. There was no documented evidence the amount of the output was measured or monitored. Review of each Skilled Nurse's Note and Nurse Note for the entire length of stay from 09/05/2017 to 09/20/2017 revealed no documented evidence of monitoring the urinary output. Licensed Practical Nurse (LPN) #1 was interviewed on 03/14/2018 at 10:38 AM in the conference room. LPN #1 stated she did not know why there were only 4 documented entries of the CNAs emptying Resident #8's urinary drainage bag on the Vital Sign record, or why the rest of the dates/times were blank. LPN #1 stated the computer did not have a place for the CNAs to document the output amount or characteristics of the urine. The LPN stated she thought the care plan was followed; however, she added, Well, output was not recorded. b. Review of the FACE SHEET revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's physician orders [REDACTED]. Review of the 9/18/17 CARE PLAN for Indwelling catheter: At Risk for Complications revealed the goal for Will not exhibit complications r/t catheter use for 120days from update/last review. The interventions included, in pertinent part: Foley Catheter as ordered, Observe for decreased urinary output, Record output q shift. Review of the (MONTH) (YEAR) Vital Sign record for the CNA to document urinary catheter output , from 03/01/2018 to 03/13/2018, revealed 25 entries documenting when the drainage collection bag was emptied. However, there was no documented evidence the amount of the output was measured or monitored. Review of the (MONTH) 2014 facility policy titled Catheter Care, Urinary revealed Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. The Director of Nursing (DON) was interviewed on 03/13/2018 at 2:53 PM in the conference room. The DON stated the CNTs were documenting when they emptied the indwelling urinary catheters, but not the amount of output. The DON said the nurses documented the characteristics of the urine (such as clear, cloudy, dark, color, or smell). The DON confirmed for both of these residents, no urinary output was measured or monitored, and no output was documented. The DON stated she would be adding urinary output to the Vital Sign records for those residents with indwelling urinary catheters. 2. A thorough nursing assessment was not performed when Resident #8 experienced a change of condition. Specifically: Review of the FACE SHEET revealed Resident #8, who was in his mid-fifties, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 08/01/2017 HISTORY AND PHYSICAL revealed Resident #8 usually is ambulatory and able to eat and ambulate; the past medical history was significant for Diabetic ketoacidosis related, causing [MEDICAL CONDITION] in 1990, history of insulin-dependent diabetes, hypertension, [MEDICAL CONDITION], history of previous [MEDICAL CONDITION] problems. Review of the admission 09/12/2017 MINIMUM DATA SET (MDS) revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment, had an indwelling urinary catheter, and required extensive assistance to total dependence for activities of daily living. Review of Resident #8's physician orders [REDACTED]. Review of the 09/05/2017 CARE PLAN for Indwelling catheter: At Risk for Complications revealed the goal for Will not exhibit complications r/t (related to) catheter use for 120days from update/last review. The interventions included, in pertinent part: check tube placement, ensure tubing has no twists or kinks, Foley cath care q (every) shift, changes q month and prn (as needed) displacement, Foley Catheter as ordered, Observe for bladder discomfort or leaking around catheter, Observe for decreased urinary output, Observe for temp, c/o (complaints of) abdominal or flank pain, odor, N/V (nausea/vomiting), change in urinary output or urine, hematuria, low back pain, scrotal pain in males or altered mental status, Record output q shift. Review of the Vital Sign record for the certified nursing aide (CNA) to document urinary catheter output, for the entire length of stay from 09/05/2017 to 09/20/2017, revealed only 4 entries documenting when the drainage collection bag was emptied; the bag was emptied on 09/06/2017 at 2:04 AM, 4:11 PM, and 9:13 PM, and on 09/08/2017 at 5:14 AM. There was no documented evidence the amount of the output was measured or monitored (see above). Review of the 10:15 AM Skilled Nurse's Note from 09/20/2017 revealed Resident #8's blood pressure was 128/76, pulse was 84, (respirations, temperature and oxygen saturation levels were blank), the resident was awake, alert, oriented to person, restlessness, calm, abdomen soft and non-tender, no urinary complaints, urine clear, and he had an indwelling urinary catheter. Review of the 4:40 PM Nurse Note from 09/20/2017 revealed Entered resident's room at approximately 4:00 PM and found resident with eyes open but not verbally responding. Checked blood glucose level and it was at 586. Blood glucose was checked at 1:30 pm and at 3:37 PM. 6 units of [MEDICATION NAME] given at that time. Abdomen was distended and hard. Called NP (Nurse Practitioner) for further instructions. Instructed to send resident to hospital. Called POA and was advised to send resident to (name of hospital). (Name of) ambulance service called. Family, NP, DON notified. Licensed Practical Nurse (LPN) #1 was interviewed on 03/14/2018 at 10:38 AM in the conference room. LPN #1 stated she did not know why there were only 4 documented entries of the CNAs emptying Resident #8's urinary drainage bag on the Vital Sign record, or why the rest of the dates/times were blank. LPN #1 stated the computer did not have a place for the CNAs to document the output amount or characteristics of the urine. The LPN stated she remembered Resident #8 and working with him; she remembered his blood sugar was high and he had a fever. She said she checked on Resident #8 several times throughout the day on 09/20/2017, including her last interaction with him before 4:00 PM, which was between 1 and 1:30 PM, when she checked his blood sugar and administered insulin. LPN #1 stated she thought Resident #8's care plan was followed; however, added, Well, output was not recorded. The LPN stated she did not conduct a full head-to-toe assessment of Resident #8 on 09/20/2017. LPN #1 also stated she should have obtained a full set of vital signs when Resident #8 experienced a changed in condition. Review of the hospital records revealed, on 09/20/2017, Resident #8 presents with altered mental status and [MEDICAL CONDITION]. On presentation, the patient is ill appearing. He is somnolent. He is only oriented to name. His vital signs were significant for a heart rate in the 130s and a temperature of 103 (degrees Fahrenheit). On exam, his abdomen was distended with suprapubic ecchymosis . Cultures were obtained and he was given [MEDICATION NAME] and [MEDICATION NAME]. A portable CXR (chest X-ray) demonstrated atelectasis versus pneumonia. A bedside ultrasound was obtained to evaluate for a source of his abdominal distension. He was found to have an extremely distended bladder. The foley catheter was removed and a large amount of purulent urine came out. A foley catheter was replaced. His abdominal distention improved. He was also given rectal Tylenol and a total of 3L IV (intravenous) fluids. His EKG demonstrated sinus [MEDICAL CONDITION]. I believe his symptoms are due to [MEDICAL CONDITION]. A CT of the head, chest, abdomen/pelvis was obtained to evaluate further. This demonstrated evidence of [MEDICAL CONDITION]. The patient likely developed [MEDICAL CONDITION] from [MEDICAL CONDITION] related to an improperly draining foley catheter . We have also discussed the patient's critically ill status . The patient will be admitted to the MICU for further evaluation and treatment. The 09/20/2017 Hospital Emergency Department History and Physical revealed EMS (Emergency Medical Services) reports that they were originally called to the facility because the patient had elevated blood sugars as well as a increasingly distending abdomen . when EMS arrived at the home, they noticed that his urine was dark and cloudy in the Foley bag and the nurse reported that she did not think she had any urinary output since 1 PM but that she had recently changed the bag. The urine collection bag had the date 08/07/2017 (over one month before this date) written on it. The patient was [MEDICAL CONDITION] on route . with EMS. Review of the 09/20/2017 Medical Decision Making /ED Course revealed the patient was altered, unable to speak . on 4 L nasal cannula. Was able to swallow his secretions. His abdomen was distended and rigid and very apparently tender to touch. We placed an ultrasound on the abdomen which revealed an enlarged bladder filled with urine. The patient had a Foley in place with a bag with date 8/7/17.this Foley was removed and immediately there was release of pus and cloudy urine from the penis. We placed a new Foley that released over 2 L of cloudy urine .the patient is normally able to speak and is normally alert and oriented. Review of the (MONTH) 2014 facility policy titled Catheter Care, Urinary revealed Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure . Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . If the resident indicates that his or her bladder is full or that he or she needs to void (urinate), notify the physician or supervisor . Check the urine for unusual appearance (i.e., color, blood, etc.) . Report any complaints the resident may have of burning, tenderness, or pain in the urethral area . Observe for other signs and symptoms of urinary tract infection or [MEDICAL CONDITION]. Report findings to the physician or supervisor immediately . The following information should be recorded in the resident's medical record . Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor . Any problems notes at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain . Any problems or complaints made by the resident related to the procedure. Review of the (MONTH) (YEAR) facility policy titled Change in a Resident's Condition or Status revealed 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 . significant change in the resident's physical/emotional/mental condition . need to transfer the resident to a hospital/treatment center . A 'significant change' of condition is a major decline or improvement in the resident's status that . Impacts more than one area of the resident's health status . Requires interdisciplinary review and/or revision to the care plan . Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form . The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The Director of Nursing (DON) was interviewed on 03/13/2018 at 2:53 PM in the conference room. The DON stated the indwelling urinary catheter collection bag should be changed every 30 days or more often as needed if it was leaking, if it were broken, if it were damaged, if there was sediment, and if the bag was visually gross or nasty. The DON stated when a resident experienced a change in condition, her expectation was for the nurse to obtain a full set of vital signs, including blood pressure, pulse, temperature, respirations, and blood sugar when appropriate, before calling the physician or nurse practitioner. The DON stated she was previously unaware the resident's condition was as described in the hospital records. She said then nurses' skills were tested on an annual basis. The DON confirmed Resident #8 received poor care at the facility. This deficiency resulted from complaint #TN 448.",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
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
3572,BLEDSOE COUNTY NURSING HOME,4.4e+233,107 WHEELERTOWN AVENUE,PIKEVILLE,TN,37367,2017-12-20,607,D,1,0,VZ8X11,"> Based on facility policy review and interview, the facility failed to revise their abuse policy to meet federally required standards for reporting abuse to the State Survey Agency, resulting in the facility failing to report an allegation of abuse 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 policy Abuse, Neglect, Misappropriation Protocol dated 8/17 revealed .There are two-time limits for the reporting of reasonable suspicion of a crime .Serious Bodily injury - 2 Hour Limit: If the events that cause the reasonable suspicion result in serious bodily injury to a resident .All others - Within 24 Hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident . Review of the facility's Resident Abuse Investigation Report Form dated 11/27/17, involving Resident #3, revealed .date incident occurred 11/23/17 .Individual reporting incident (Activity Assistant) .Wasn't reported until following Monday . 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 10:25 AM, in the Social Service Directors office, confirmed the facility failed to revise their abuse policy to meet the federally requirement for reporting allegations of abuse to the State Survey Agency within 2 hours, and failed to report allegations of abuse to the state agency within the required time frame for Residents #3 and #6. Refer to F-609",2020-09-01
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
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
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
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
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
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
3593,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2017-04-27,247,D,1,0,G6OT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 143 Based on policy review, medical record review, and interview, the facility failed to immediately notify the resident's legal representative before a change in room assignments for 1 of 3 (Resident # 1) sampled residents reviewed for roommate change notification. The findings included: The facility's Room to Room Transfers policy documented, .A roommate will be informed of any new transfer into his/her room . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Facility's Daily Census sheets for (MONTH) and April, (YEAR) revealed that Resident #1 had 3 different roommates between (MONTH) 1 and (MONTH) 25, (YEAR). There was no documentation in the medical record that Resident #1 or Resident #1's responsible party (RP) had been notified about the new roommates. Phone interview with Resident #1's responsible party (RP), on 9/14/16 at 2:42 PM, the RP confirmed that they had not been notified of roommate changes. Interview with the Social Worker on 4/26/17 at 4:30 PM, in the family room, the Social Worker was asked to review the Daily Census Sheets for (MONTH) and April, (YEAR). The Social Worker was then asked if Resident #1 had 3 new roommates between (MONTH) 1 and (MONTH) 25, (YEAR). The Social Worker stated, Yes. The Social Worker was asked if Resident #1 or his RP had been notified before any of the roommates were admitted to Resident #1's room. The Social Worker stated, No. Interview with the Director of Nursing (DON) on 4/26/17 at 8:45 PM, in the conference room, the DON was asked if every resident in the facility should receive advance notice of a new roommate or a roommate change. The DON stated, Yes.",2020-08-01
3594,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-04-05,159,D,1,0,H4FE11,"> Intakes: TN 919, TN 933 Based on a facility document and interview, the facility failed to ensure families and residents were aware they could access their money after hours Monday through Friday. The findings included: A typed letter dated (MONTH) 3, (YEAR) documented, Dear Resident and/or Responsible Party .Business Office .Resident Trust Fund is available during business hours Monday through Friday from the business office, and on the Weekends from the Nurse Supervisor for those residents that have a Resident Trust Fund Account . This letter did not address what to do or who to see regarding the availability of money after business hours Monday through Friday. Telephone interview with Resident #8's Responsible Party (RP) on 4/5/17 at 9:25 AM, the RP stated, .They didn't have any petty cash, they (office personnel) were gone. They would go to lunch and never come back. She (Business Office Manager (BOM) had (Named Resident #8) sign a paper that no one could pull money but her .They don't have any petty cash. They could only keep so much .I asked what is the best time to get it, the first of the month or the last of the month .I could get an attorney .I told them I thought it was wrong . Interview with the Business Office Manager (BOM) on 4/5/17 at 10:20 AM, the BOM was asked if residents have access to their money 24 hours per day 7 days per week. The BOM stated, We have money in a box at the nursing station Monday through Sunday with a receipt box. The BOM was asked if they run out of money in the box, and someone wants some money, what happens. The BOM stated, If they need something they would call me .",2020-08-01
3595,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-04-05,164,D,1,0,H4FE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 919, TN 933 Based on resident rights, medical record review, observation and interview, the facility failed to provide privacy during peri-care for 1 of 3 (Resident #7) sampled residents reviewed for privacy. The findings included: The RESIDENT'S RIGHTS form documented, .9. Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. Resident #7 was occasionally incontinent of bowel and bladder. Review of a care plan dated 4/3/17 revealed Resident #7 has a potential for constipation and had an episode of constipation on 3/31/17. Resident #7 is occasionally incontinent of bowel and bladder. Observations in Resident #7's room on 4/4/17 at 8:00 AM, revealed Resident #7 lying in bed, CNA #1 is at her bedside providing peri-care. CNA #1 left the room, leaving Resident #7 uncovered with her brief and her buttocks exposed. There was a small amount of feces on the sheet. Resident #7's roommate was sitting in a wheelchair at the foot of her bed and was able to see Resident #7 in the bed. The privacy curtain was not pulled. Interview with Resident #7 on 4/4/17 at 8:04 AM, in Resident #7's room, Resident #7 was asked where did the CNA go. Resident #1 stated, I think she went to get something to clean me up with .When peri-care was completed, and CNA #1 left the room, Resident #7 was asked if it bothered her that her roommate could see her being cleaned up. Resident #7 stated, Yes, it bothers me .",2020-08-01
3596,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-04-05,166,F,1,0,H4FE11,"> Intakes: TN 919, TN 933 Based on a grievance form and interview, the facility did not provide a grievance policy as outlined in the federal regulation and has the potential to affect all residents. The findings included: Review of a blank grievance form revealed the following: a. Grievance filed by b. Staff Member initiating this grievance form c. Nature of grievance d. Resident's name e. Findings of the investigation f. Interventions/corrective actions as indicated g. Date of notification of results to resident/involved party when indicated. The facility's grievance form does not address the effectiveness of the interventions. Interview with the Administrator on 4/4/17 at 7:15 PM, in the fine dining room, she was asked for the grievance policy. The Administrator stated, I have no grievance policy, they (grievance forms) are on the social worker's door and families can get them anytime.",2020-08-01
3597,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-04-05,225,E,1,0,H4FE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 919, TN 933 Based on medical record review, and interview the facility failed to ensure a complete and thorough investigation was conducted for 4 of 4 (Resident #1, 2, 3 and 6) sampled residents reviewed for incidents. The findings included: 1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Adult Failure to Thrive, Intra-Abdominal and Pelvic Swelling, Mass and lump, [MEDICAL CONDITIONS], Hypertension, Dysphagia, [MEDICAL CONDITION], Muscle Weakness, Difficulty in Walking, [MEDICAL CONDITION], Constipation, Pain and Dementia. A quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment. The care plan dated 2/16/17 documented, .Focus .Resident is at risk for alterations in nutritional status r/t (related to) .mechanically altered diet; hx (history) of pocketing food .Interventions .Monitor and assist with meals PRN (as needed) .report PRN any s/sx (signs/symptoms) of dysphagia: Pocketing, choking .Holding food in mouth .Focus .The resident has impaired visual function .Interventions .Tell the resident where you are placing their items . A physician order [REDACTED].NAS (No Added Salt) diet Pureed texture .Assisted Dining for Lunch and Dinner . A meal tray card for Resident #1 dated 3/17/17 documented, Pureed Baked Chicken . A nutrition services progress note written by the contract dietary company's District Director CDM (Certified Dietary Manager) dated 3/17/17 documented, Met with R.P. (Responsible Party) today where R.P. was assisting Resident (#1) c (with) meal at lunch. R.P. pointed out a clean plastic strand that RP claimed came out of residents pureed Chicken. I stated that I would investigate source of plastic in food. I did however observe that the plastic has 0 food residue on object. Food was covered before served c parchment paper and foil when awaiting service. Resident was served in the club room away from normal dining c rest of Residents. Source of Plastic defined from unknown sources. Interview with the contract District Director CDM on 4/3/17 at 1:58 PM, in the Admission Office, he was asked about the situation with the plastic particles in Resident #1's food. He stated, It was in the garden room, and they are never out there. That was odd .It was lunch time back in March. I wrote a note about it. I went to the garden room and I saw little shreds of plastic. There was no food on the plastic. He was asked if the meat is frozen in plastic shrink wrap when it is delivered. The CDM stated, Beef and Pork are Cryovac (vacuum packaging) packed. Fish and chicken are not individually wrapped in vacuum packs. They come in bulk in a box frozen in a plastic bag. We do not use plastic wrap in the kitchen. We use parchment paper, aluminum foil and lids to cover the food on the steam table. That was a hard plastic he showed me. There were no other complaints from anyone else that day . The CDM was asked if he reported this to the facility administration. He stated, Yes, (Named Director of Nursing) was here. I was here because (Named Dietary Manager) was off that day. Interview with the Administrator on 4/3/17 at 5:40 PM in the club room, she was asked about the incident regarding the plastic strands in Resident #1's food. She stated, We do not use plastic wrap on the food, we use parchment paper prior to serving .She (Resident #1) has very specific dietary requests, often her foods are made to order and are placed immediately in the plate and covered . The facility was not able to produce an incident/investigation report for the plastic strands in Resident #1's pureed chicken. 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Cerebral Infarction, Adult Failure to Thrive, [MEDICAL CONDITIONS] Fibrillation, Hypertension, Contracture, Dementia, Diabetes, [MEDICAL CONDITIONS], Left Ventricular Failure, [MEDICAL CONDITION], and [MEDICAL CONDITION]. An SBAR (Situation, Background, Assessment, Response) Communication form dated 3/8/17 documented, .Situation .Bruising & swelling L (left) shoulder .Background .fx (fracture) L humerous .Pain Evaluation .flenches c (with) movement of LUE (Left Upper Extremity) . A physician order [REDACTED]. A RADIOLOGY REPORT dated 3/8/17 documented, .SHOULDER 1 VIEW, LEFT .Results: Moderately displaced [MEDICAL CONDITION] head and neck .Conclusion .Moderately displaced [MEDICAL CONDITION] head and neck . A typed timeline dated 4/4/17 and signed by the Director of Nursing (DON) documented, .The following CNA's (Certified Nursing Assistant) provided care on 3/6/17. All were interviewed by telephone .(Named CNA #2) states .she .noticed 2 small red areas to the left arm around the antecubital area. (Named CNA #2) states this was reported to (Named Licensed Practical Nurse (LPN) #1 and LPN #1 observed the area and stated that it appears to possibly be from a blood draw and she would keep an eye on it as it was 2 small red dots .(Named LPN #2) documented that he notified the spouse of Resident #2 of the fracture and that spouse stated that he may have caused the fracture as he had been massaging the resident with an electric massager on both Saturday (3/4/17) and Sunday (3/5/17) .As a result .the DON phoned (Named Spouse) on 3/9/2017 who also repeated that he felt he may have caused the dislocation as he used an electric massager on her arms and back to relax her on Saturday 3-4-17 and Sunday 3-5-17 .(Named Spouse) them came to the facility on [DATE] and .gave a visual display of how he took one hand and pushed on (Named Resident #2) shoulders and rolled her to massage her back with the electric massager .The facility is of the belief that no harm was inflicted as a result of the staff or inappropriate transfer but incidentally occurred from the spouse rolling the resident over in the bed to her side. It is also noted that the resident has a contracture of the left shoulder and a dx (diagnosis) of [MEDICAL CONDITION] which could easily result in a dislocation of (if) turned inappropriately . A handwritten note dated 4/4/17 signed by (Named CNA #2) with a fax stamp of Apr. 4, (YEAR) 10:53 AM, documented, .I .was bringing (Named Resident #2) in room .on 3-6-17 from her shower and I noticed a bruise on her arm and I informed the nurse (Named LPN #1) immediately . Interview with Resident #2's husband on 4/4/17 at 10:50 AM, in Resident #2's room, he was asked if he had used an electric massager on his wife. He stated, I was using a massager, I don't know if it (shoulder fracture) caused it or not . He was asked if he heard a pop or did his wife ever appear in pain while he was using the massager. He stated, I did not hear a pop, if fact she said the massaging felt good .They (facility staff) tell me she has a history of [MEDICAL CONDITION] and the slightest toughing will cause something. He was asked if he knew who told him. He stated, It was a nurse, I am not sure which one it was .I don't think it was the massager, but I don't know, she hasn't complained of pain since it happened. An undated handwritten statement by CNA #4 documented, .3/6/17 .As I began to shower patient I noticed two small circle red dots on her inner arm. I notified nurse .Nurse came to shower and I showed her what I found. her nurse told me that the finding I found on her arm came from having blood drawn from arm .On 3/8/17 patient was again brought to shower I noticed the bruising as well as swelling o the same particular arm that I had already reported to her nurse on 3/6/17 .I found patient nurse and explained to her of my findings. I again was told that patient arm was like that because of [MEDICAL CONDITION] . This statement was read and verified by CNA #4 as true and accurate. Telephone interview with CNA #2 on 4/4/17 at 11:55 AM, She was asked about Resident #2's bruising. CNA #2 stated, It was on 3/6/17, I was bringing her back to her room from the shower, and I saw a yellowish-green bruise on the left at the top between the elbow and the shoulder. I let the (Named LPN #1) immediately . Interview with CNA #5 on 4/4/17 at 2:25 PM, in the club room, CNA #5 was asked about Resident #2's bruise on her left arm. CNA #5 stated, .It was a yellowish bruise about the size of a quarter outside of left arm. I think the nurse said she thought she got some blood work and that's why it was looking like that. On the 9th (March) it had got darker over her shoulder and she had a sling around it . A handwritten statement dated 3/9/17 by CNA #5 documented, .When I was giving am care for (Named Resident #2) on Tuesday 3/7/17, I noticed a yellowish looking bruise on upper part of arm (left arm), I then went and notified my charge nurse (Named LPN #1) and she came to look at it . This statement was read and verified by CNA #5 on 4/4/17 at 2:25 PM. Interview with CNA #3 on 4/4/17 at 2:32 PM, in the club room, she confirmed she saw bruising and swelling on her shoulder on the morning of 3/8/17 while she was in the shower. CNA #3 reviewed and verified her written statement confirming she noticed the bruising and swelling while in the shower on 3/8/17, and the shower aide (CNA #4) went and got the nurse. Interview with Resident #2's friend on 4/4/17 at 3:20 PM, in the club room, the friend with Resident #2's husband stated, The doctor said there was no way it (left shoulder fracture) was caused from a massager and it was trauma . She was asked who the doctor was. She stated, (Named Physician) here is his phone number . Telephone to (Named Physician), Orthopedic Surgeon on 4/4/17 at 3:30 PM, a message was left to return the call. No one returned the phone call from the physician's office. Interview with the Director of Nursing (DON) on 4/4/17 at 6:50 PM, in the club room, she was asked when did she interview the staff listed on the typed timeline dated 4/4/17. She stated, Today, I called them on the phone . The DON was asked where the [DIAGNOSES REDACTED].she verbally told me she has severe [MEDICAL CONDITION]. The DON was asked where that [DIAGNOSES REDACTED]. The DON was asked where on the x-ray report was that documented. The x-ray report dated 3/8/17 documented, .FOREARM AP .Conclusion .unremarkable osseous appearance of the left forearm . Review of the x-ray (Radiology Report) dated 3/8/17 revealed no [DIAGNOSES REDACTED]. The facility did not complete a thorough investigation for Resident #3's fracture. There was no documented follow-up after the nurse was notified on 3/6/17 of the bruises. There was communication from nursing the bruises were caused from a blood draw and [MEDICAL CONDITION]. The radiology report did not reveal a [DIAGNOSES REDACTED].#2 during the time of the bruises, and the facility determined the fracture was caused from the electric massager. 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Hypertension, Muscle Weakness, Abnormal Posture, Dysphagia, Symbolic Dysfunctions, [MEDICAL CONDITION], Dementia, Nausea, Depression, [MEDICAL CONDITION], Diabetes, [MEDICAL CONDITION], End Stage [MEDICAL CONDITION], Urinary Tract Infection, [MEDICAL CONDITIONS], and [MEDICAL TREATMENT]. An incident report dated 3/11/17 documented, .called to room, resident noted on floor beside bed, laying on right side. Resident stated she was trying to go home. Resident stated she did not hit her head .Action Taken .Resident c/o (complained of) right upper arm and shoulder pain. Xrays ordered. Bilateral floor mats placed .Resident taken to Hospital? N (no) .Injury Type Dislocation .Injury Location .Right shoulder . The facility was asked for the investigation and was unable to provide an investigation for Resident #3's unwitnessed fall with injury. 4. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Muscle Weakness, Cognitive Communication Deficit, Lack of Coordination, Dysphagia, Hypertension, Dementia, Major [MEDICAL CONDITIONS], Gout, [MEDICAL CONDITION], and [MEDICAL CONDITION]. An incident report dated 4/3/17 documented, .OPEN AREA NOTED TO LEFT UPPER THIGH POSS R/T CLOSURE OF ADULT BRIEF AREA .Immediate Action Taken .AREA CLEANED WITH SOAP AND WATER REFERRAL WRITTEN FOR WOUND CARE NURSE TO EVAL AND TX .Resident Taken to Hospital? N (no) .No Witnesses found . The facility was asked for the investigation and was unable to provide an investigation for Resident #6's open area on left upper thigh.",2020-08-01
3598,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-04-05,253,D,1,0,H4FE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 919, TN 933 Based on observation and interview, the facility failed to ensure a comfortable and sanitary environment as evidenced by 2 chairs and 1 wheelchair with items piled on them, and a dirty floor for 1 of 8 (Room 219) resident rooms. The findings included: Medical record review revealed Resident #8 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #8's sister on 4/4/17 at 7:20 PM, in the club room, Resident #8's sister (RP) stated, I wanted to talk to you about my sister (Named Resident #8) .Her room is always cluttered and stuff is everywhere, I had to get them to move some stuff off the chair so I could sit down in there today .The floor is always dirty. It doesn't look like they ever mop in there. They have to pass by my sister's bed to mop on the other side and they put the wet floor sign in the middle of the room and they don't mop on my sister's side at all .I talked to the housekeeping director and he told me they clean the room when she is gone out to dialysis on Monday, Wednesday, and Fridays. Most every time I come here the floor is dirty and her things from dialysis are not put away. They don't put her things away .He (maintenance director) said they tell him she don't want them to clean the room while she is there .she is bedridden and she told him to his face that he was lying .Her personal things need to be put away .her dirty clothes should be put in the hamper, sometimes they are in the chair . Observations in Resident #8's room on 4/4/17 at 8:25 PM, there were 2 chairs by the wall with a bag of clothes and linens. The wheelchair had pillows, a bedspread, a foam wedge, sheets and a lift pad on it. A sandwich with white meat was in a baggie was on the bedside table. The floor around Resident #8's bed had black spots around the bed. There were food particles on the floor beside the bed under the bedside table. Interview with the Administrator on 4/4/17 at 8:00 PM, in the club room, the Administrator stated, The lady (Resident #8's sister) just in here wants housekeeping 24 hours a day, and her sister (Resident #8) won't let anyone in to clean it, so we do it on dialysis days. Observations in Resident #8's room on 4/5/17 at 2:30 PM, there was a foam wedge in 1 chair, briefs, clothes in a plastic bag and a lift pad in the wheel chair. Interview with Certified Nursing Assistant (CNA) #1 on 4/5/17 at 2:40 PM, in Resident #8's room, CNA #1 was asked who is responsible for straightening the residents' rooms. CNA #1 stated, Well, for her, she goes to dialysis on Mondays, Wednesdays, and Fridays so we straighten it up and put things away while she is gone to dialysis. She was asked why there are things out and on the chairs, and wheelchair when Resident #8 is out to dialysis. CNA #1 stated, I have not had time to clean the closet. Her family does the laundry (pointing to the clothes hamper). She won't let me do too much with her personal items, not as much as her regular CNA . Interview with the Housekeeping Director on 4/5/17 at 3:10 PM, in the patient lobby, he was asked who is responsible for straightening residents personal items in the rooms. He stated, The CNAs are responsible for making the beds, tidying up, stuff in chairs, closets, things like that . He was asked specifically about Resident #8's room. He stated, We made arrangements to clean her room when she is out to dialysis. We do a discharge clean, we clean everything .Her sister brings a lot of food after 3 (PM) every day and our staff (housekeeping) leaves at 3:00 (PM), so if food is spilled, we don't see it until the next day. We do what we can .",2020-08-01
3599,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-04-05,280,E,1,0,H4FE11,"> Intakes: TN 919, TN 933 Based on facility document review and interview, the facility failed to ensure all the required parties were involved in the development and/or revision of care plans for 6 of 6 (Resident #1, 2, 3, 4, 5 and 6) residents. The findings included: Review of the facility's Resident Care Plan Conference forms revealed the following: A care plan conference form for Resident #1 revealed a date of 2/20/17 in which neither a CNA nor the physician attended the meeting, or had any involvement in the development or revision of the care plan. A care plan conference form for Resident #2 revealed a date of 1/18/17 in which Resident #2, family members, a CNA nor the physician attended the meeting, or had any involvement in the development or revision of the care plan. Interview with the MDS Coordinator on 4/4/17 at 7:20 PM, she was asked who is involved in developing or revising care plans. The MDS Coordinator stated, MDS, Activities, Dietary, Social Services, Nursing, the ADON or Unit Manager. She was asked if the physician is involved in the discussion. The MDS Coordinator stated, Not face to face, not unless we have a question. Interview with the Social Worker (SW) on 4/5/17 at 4:20 PM, in the private dining room, the SW was asked if Named Residents # 3, 4, 5 and 6 had a care plan meeting in the last 4 months that the Physician attended or had input in the development and or revision of their care plans. The SW stated, Here is a list of those that had a care plan meeting in the last 4 months. The list revealed Resident #3 had a care plan meeting on 3/23/17, Resident #4 had a care plan meeting on 2/5/17, Resident #5 had a care plan meeting on 3/15/17 and Resident #6 had a care plan meeting on 2/15/17. The SW was asked if the physician had involvement in each of those care plan meetings regarding the development or revision of the resident care plans. The SW stated, No, he was not .",2020-08-01
3600,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-04-05,323,E,1,0,H4FE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 919, TN 933 Based on medical record review, observation, and interview, the facility failed to ensure 1 of 1 (Certified Nursing Assistant # 3) staff members properly used a lift when transferring Resident #2, and failed to ensure 1 of 3 (Resident #3) sampled residents had an immobilizer in place. The findings included: 1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 8/19/16, revised on 1/4/17 documented, .Focus .AT RISK FOR FALL RELATED TO IMPAIRED MOBILITY .Interventions .PROVIDE A MECHANICAL LIFT WITH THE SUPPORT OF 2 STAFF MEMBERS FOR ALL TRANSFERS . Interview with CNA #4 on 4/4/17 at 8:15 AM, in the club room, she was asked about how Resident #2 is transferred. CNA #4 stated, She is a (Named) lift .it is always 2 people . Interview with CNA #3 on 4/4/17 at 2:32 PM, in the club room, CNA #3 was asked how many people should be in the room when using a mechanical lift to transfer a resident. CNA #3 stated, Technically there should be 2 people in the room . CNA #3 was asked how she transferred Resident #3 on 3/8/17 from the bed to the shower chair. CNA #3 stated, I turned her, put the lift pad under her, I lifted her up and put her in the chair . CNA #3 was asked if there was 2 people using the lift to transfer her on that day. CNA #3 stated, No ma'am, I'm guilty of that because in the mornings it's too busy to find someone else to help .I'm honest . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident report dated 3/11/17 documented, .called to room, resident noted on floor beside bed, laying on right side. Resident stated she was trying to go home. Resident stated she did not hit her head .Action Taken .Resident c/o (complained of) right upper arm and shoulder pain. Xrays ordered. Bilateral floor mats placed .Resident taken to Hospital? N (no) .Injury Type Dislocation .Injury Location .Right shoulder . A physician's orders [REDACTED].IMMOBILIZER TO RIGHT SHOULDER D/T (due to) FRACTURE Q (every) SHIFT . A care plan dated 3/13/17 documented, .Focus .RESIDENT NOTED WITH RIGHT HUMERAL FRACTURE ON 3/11/17, SECONDARY TO A FALL .Interventions .IMMOBOLIZER TO RIGHT SHOULDER D/T FRACTURE EVERY SHIFT . Observations on 4/3/17 at 2:30 PM and 4/4/17 at 7:55 AM, in Resident #3's room, Resident #3 lying in bed. No immobilizer in place on her right arm. No immobilizer was visible laying anywhere in the room. Interview with LPN #3 on 4/5/17 at 8:05 AM, at the nurses' desk, LPN #3 was asked about Resident #3's immobilizer. LPN #3 stated, She hasn't had the immobilizer on since she came back from dialysis on Saturday. When she went to dialysis yesterday, I asked them (Emergency Medical Technicians) to ask if it was still there . LPN #3 was asked if the immobilizer was sent back with her yesterday. LPN #3 stated, No, it's still not here .I will call and get her another one . Interview with the Director of Nursing (DON) on 4/5/17 at 12:30 PM, in the club room, she was asked if she was aware Resident #3 has not had her immobilizer on since last Saturday. The DON stated, No, I was not aware, that is not acceptable. The DON was asked what she expected the nurses to do when there is an order for [REDACTED]. The DON stated, I expect them to call the orthopedic doctor and get another immobilizer .",2020-08-01
3601,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-04-05,388,E,1,0,H4FE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 919, TN 933 Based on medical record review, and interview, the facility failed to ensure physician visits were conducted every thirty (30) days for ninety (90) days on new admissions and once every sixty (60) days thereafter within the federal guidelines for 5 of 7 (Resident #1, 2, 4, 5 & 6) sampled residents reviewed. The findings included: 1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician progress notes [REDACTED].#1 from 2/17/16 to 2/12/17. 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician progress notes [REDACTED].#2 from 11/14/16 to 3/20/17. 3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician progress notes [REDACTED].#4 from 7/26/16 to 12/19/16. 4. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician progress notes [REDACTED].#5 from 11/21/16 to 3/20/17. 5. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician progress notes [REDACTED].#6 from 6/28/16 to 10/31/16. The Administrator and the DON confirmed on 4/5/17 at 5:50 PM, in the club room, the Medical Director and the Nurse Practitioner were terminated on 3/31/17 for several reasons. They also confirmed the new Medical Director and the new Nurse Practitioner began seeing residents on 3/31/17.",2020-08-01
3602,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-04-05,514,D,1,0,H4FE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 919, TN 933 Based on medical record review and interview, the facility failed to ensure the medical record was accurate for 1 of 8 (Resident #2) sample residents reviewed. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a restorative nursing care flow record revealed range of motion (ROM) to be done on BUE (Bilateral Upper Extremities). Interview with the Lead Restorative Aide on 4/4/17 at 3:21 PM, in the club room, she was asked about the documentation of BUE. The Lead Restorative Aide stated, That is incorrect, it should be RUE (Right Upper Extremity) .I do hand, fingers, elbow and shoulder .",2020-08-01
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
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
3605,REELFOOT MANOR HEALTH AND REHAB,445285,1034 REELFOOT DRIVE,TIPTONVILLE,TN,38079,2017-04-20,323,E,1,0,VW4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 078, TN 324, TN 060 Based on policy review, observation and interview, the facility failed to ensure housekeeping carts were attended in 2 of 3 (300 Hall and 400 Hall) Halls, failed to ensure a razor was secured in 1 of 35 (Resident #90) resident rooms during the stage 1 review, and failed to initiate appropriate interventions to prevent falls for 1 of 3 (Resident #79) sampled residents reviewed of the 37 residents included in the stage 2 review. The findings included: 1. Review of the facility's HOUSEKEEPING IN-SERVICE policy documented, .a cart should never be left unattended in any work area . Observations in the 300 Hall on 4/17/17 at 10:01 AM, between Room 310 and 312, revealed an unattended mop bucket with mop water on a housekeeping cart in the hall beside a resident room. Observations in the 300 Hall beside Room 314 on 4/19/17 at 11:05 AM, revealed Housekeeping Technician #1 left a housekeeping cart with mop water unattended in the hall. Housekeeping Technician #1 was asked what was in the mop water. Housekeeping Technician #1 stated, Bleach. Observations in the 400 Hall beside Room 418 on 4/19/17 at 10:30 AM, revealed an unattended housekeeping cart with used mop water. Interview with Housekeeping Technician #2, on 4/19/17 at 10:30 AM, beside room 418 Housekeeping Technician #2 was asked what was in the mop water. Housekeeping Technician #2 stated, I put a little bleach in it. Housekeeping Technician #2 was then asked if the mop water should be left unattended. Housekeeping Technician #2 stated, No ma'am . Interview with the Housekeeping Supervisor on 4/19/17 at 11:05 AM in the 300 hall beside the men's shower, the Housekeeping Supervisor was asked if it is acceptable to leave mop water with bleach unattended in the hall. The Housekeeping Supervisor stated, No ma'am. 2. Observations in Resident #90's room on 4/17/17 at 11:18 AM, and on 4/19/17 at 10:20 AM, revealed an unsecured razor on the sink in the bathroom. Observations in Resident #90's room on 4/19/17 at 10:20 AM, revealed a razor in a baggie on the left side of the sink. Interview with the Director of Nursing (DON) on 4/19/17 at 2:20 PM, in the DON office, the DON was asked what her policy is for razors being stored in the resident rooms. The DON stated, They should be at the nurse's station in the Med (medication) room . The DON was asked if it is acceptable for the razors to be in the resident rooms. The DON stated, No. 3. Review of the facility's Fall Risk Assessment policy documented, .The interdisciplinary team will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are modifiable . Review of the facility's Falls-Clinical Guidelines policy documented, .If a fall should occur (witnessed or un-witnessed), the staff will complete the Falls Investigative Worksheet as well as an Incident Report. The plan of care will be updated at that time with a review of current interventions . Immediate treatment and intervention will be rendered by the nursing staff post any fall . Documentation is to occur every shift for 48 hours post fall, addressing the fall, the interventions and the patient condition . Discuss the fall in daily clinical meeting . 4. Medical record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] and 3/7/17 documented Resident #79 had moderate cognitive deficits, required supervision to extensive assistance with activities of daily living, and had functional limitations in range of motion with impairment on one side in lower extremity. The significant change MDS dated [DATE] documented Resident #79 had severe cognitive deficits, required extensive assistance with activities of daily living, and had functional limitations in range of motion with impairment on 1 side in left extremity. The Care Plan dated 9/12/16 and last updated 4/14/17 documented Resident #79 had a risk for falls related to injury due to a history of falls on the following dates: On 3/29/17 a fall with an intervention of encourage resident to call for assistance when transitioning from sit, standing and walking. On 4/13/17 a fall with an intervention of instruct resident to utilize call light and wait for assist before transferring or ambulating. The intervention was an inappropriate intervention due to her cognition status. Review of the facility's Situation, Background, Assessment and Recommendation Communication report to the Physician dated 4/13/17 documented, .Situation: resident fell in floor in her room . Resident ambulates per w/c (wheelchair) but has been attempting to walk short distances without assist . Review of an Incident Report #630 documented, .resident was sitting in her w/c in doorway . instructed to utilize call light and wait for help . Observations on 4/17/17 at 11:27 AM, in the main dining room, revealed Resident #79 sitting in her wheelchair waiting for lunch. Resident #79 was clean, appropriately dressed, and was wearing a walking boot on her left foot. Resident #79 is alert but unable to answer screening questions. Interview with the DON on 4/19/17 at 9:18 AM, in the DON's office, the DON was asked if the intervention was appropriate after Resident #79's 4/13/17 fall. The DON stated, .Probably not because she will forget .",2020-08-01
3606,ELK RIVER HEALTH & REHABILITATION OF ARDMORE,445321,25385 MAIN STREET,ARDMORE,TN,38449,2017-04-05,514,D,1,0,D95811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 695 Based on medical record review and interview, the facility failed to ensure medical records were complete and accurate for a pressure ulcer for 1 of 15 (Resident #46) sampled residents reviewed of the 28 residents included in the stage 2 review. The findings included: Closed medical record review revealed Resident #46 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The nurses' notes dated 11/19/16 documented, .Upon resident's DSG (dressing) (symbol for change) to R (right) foot, 2 other areas of Nonstageable Wounds Noted to be eschar (and) is on R outer foot just under little toe and the other is on L (left) heel . The WOUND EVALUATION FLOW SHEET forms documented pressure ulcers to the right outer foot and left heel since 10/25/16, with an onset of 10/24/16 on readmission, and there were no other new pressure ulcers documented in the wound assessments for this date. The nurses' notes dated 11/20/16 documented, .Res (Resident) c (with) exuderm off of sacral area. Noted New open areas x 4 .No new order written due to already has an order for [REDACTED]. The WOUND EVALUATION FLOW SHEET forms only documented 2 new pressure ulcers on 11/20/16 to the left upper buttock and the left lower buttock that were a stage 2. The WOUND EVALUATION FLOW SHEET forms documented a pressure ulcer to the sacrum since 10/14/16 and a pressure ulcer to the right gluteal fold since 10/25/16, that were already being treated, for a total of 4 wounds. Interview with the Treatment Nurse on 4/4/17 at 11:20 AM, in the Admissions office, the Treatment Nurse confirmed the nurses' notes dated 11/19/16 were inaccurate and stated, .those were wounds we were already treating, there were no new wounds . The Treatment Nurse confirmed the nurses' notes dated 11/20/16 were inaccurate and stated, there were only 2 new areas, he (Resident #46) had 4 areas in the sacral area, but only two were new, I think the nurse on the floor was charting an assessment, and then the wound nurse was charting an assessment also. I have told them since I started to notify me of new wounds, I will document the assessments .",2020-08-01
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
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
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
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
3621,TRINITY HEALTH AND REHABILITATION CENTER,445533,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2019-11-26,845,F,1,0,POO311,"> Based on review of facility policy, review of facility census, review of electronic mail, interview, and review of facility transfer logs, the facility Administrator failed to submit written notice of the facility's impending closure to the State Survey Agency, the State Long-Term Care Ombudsman, residents, resident representatives, and other responsible parties, at least [AGE] days prior to the date of closure, and failed to submit and obtain approval of the written closure plan from the State Survey Agency prior to transferring residents, potentially affecting all 51 residents residing in the facility on [DATE]. The findings included: Review of the facility policy Transfer or Discharge Notice, revised 12/2016, revealed .If the facility will be closing, the Administrator will provide written notices to the residents and the residents' representatives of the impending closure at least sixty ([AGE]) days prior to the date of closure. 8. 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 transfer and adequate relocation of the residents.At the time of the notification, the facility will provide each resident and responsible party with the following information: a. The plan for the transfer and adequate relocation of the resident; b. The date by which the transfer/relocation will be completed; and c. Assurances that the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, service and location. 11. In determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interests of that resident. Review of the facility's census revealed 51 residents resided in the facility on [DATE]. Review of electronic mail messages between the facility and the State Survey Agency (SA) revealed the SA was informed a new owner would be acquiring the facility around 12/1/19. On [DATE], the SA informed the new ownership of the requirements necessary for closure of a facility, via email. On 11/6/19, the SA was informed the new owner would take over operations of the facility on 11/12/19. On 11/13/19, the SA was notified the facility was proceeding with closure of the facility and had begun transferring residents out of the facility. Further review of all electronic mail received by 11/13/19, revealed the facility had not submitted a closure plan to the SA. Review of electronic mail revealed the Chief Operating Officer (COO) of the Facility submitted a written closure plan to the SA on [DATE]. Review of an electronic mail message (written on the facility corporate letterhead) addressed to C[CONDITION] (Centers for Medicare and Medicaid Services) and copied to the SA, dated [DATE] and electronically signed by the facility COO, revealed RE (Regarding): Notice of Closure.Although we acknowledge that Operator shall provide [AGE] days' written notice prior to closure, we are seeking to close the Facility as soon as possible. Please note that we notified the Tennessee Department of Health on November 1, 2019 and sought input regarding the requirements.Per the process given to us by the State of Tennessee, we are providing you elements of our closure plan. Review of the facility's daily census for [DATE] revealed the facility had 7 residents remaining in the facility. Interview with the Administrator on 11/25/19 at 10:00 AM, in the conference room, revealed he was made aware the facility had been purchased on 11/6/19, immediately before he left the country on a planned vacation. The Administrator reported at that time on 11/6/19, he had not been informed the facility was to close. The Administrator stated he learned of the closure during his return trip to the United States around 11/14/19. The Administrator stated his staff informed him the new ownership had announced the facility closure during a meeting on [DATE] with staff and again during a meeting on 11/12/19 with residents, responsible parties, local media, and the volunteer ombudsman. The Administrator stated he was not aware of any advance notice of the intent to close the facility being provided to the SA, Ombudsman, residents, resident representatives, or community stakeholders prior to [DATE]. The Administrator stated, to his knowledge, representatives of one State Medicaid Agency (SMA) Health Maintenance Organization (HMO #1) were not notified of the new ownership's intent to close the facility until [DATE], when they arrived to the facility to find a letter that had been placed on the entrance door on [DATE] announcing the facility closure, and their case managed residents had been transferred to other facilities, without notification. The Administrator stated he informed the SMA HMO #1 representatives at that time of the new ownership, pending closure, and where their clients had been transferred. The Administrator confirmed he did not submit a written closure plan to the SA and had not provided a [AGE] day notice of the facility closure to the SA, Ombudsman, residents, resident representatives, or community stakeholders. Interview with the facility Regional Director of Clinical Services (RDCS) on 11/25/19 at 12:33 PM, in the conference room, revealed the facility provided oral notice of the facility closure to employees on [DATE], around 13 hours after the new owners assumed operational control of the facility. The RDCS confirmed oral notice of the facility closure was provided to residents, resident representatives, and the Ombudsman Volunteer during a meeting on 11/12/19. The RDCS confirmed the facility had informed case managers from SMA HMO #2 the facility would close on 11/12/19, during the family meeting, and confirmed SMA HMO #1 representatives were not notified until a few days later, when they arrived at the facility. The RDCS confirmed written notice was not given to residents, family representatives or the Ombudsman before or after the meeting. The RDCS confirmed resident transfers due to the closure had begun on [DATE] and were ongoing. The RDCS confirmed the facility written closure plan was submitted to the SA [DATE], 7 days after the facility had begun resident transfers in anticipation of closure. Interview with the Medical Director on 11/25/19 at 1:30 PM, in the conference room, revealed the Physician was not informed the facility was closing until a meeting held between senior executives of the new facility leadership and employees on [DATE] around 1:30 PM. 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 .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 he was not provided any information regarding placement options other than facilities in the area that were owned/managed by the same company. Telephone interview with the Chief Operating Officer (COO) on 11/25/19 at 8:00 PM, revealed he was unaware of the precise date his corporation had decided the facility would be closed. The COO confirmed the facility had not given [AGE] days advance notice of the impending closure to the SA, C[CONDITION], or the State Ombudsman office, and acknowledged the written closure plan electronically submitted to the SA and C[CONDITION], dated [DATE], had been provided 7 days after the facility informed employees of the impending closure. The COO confirmed his corporation had not provided the SA a written closure plan for approval until 6 days after they informed residents of the impending closure and need to relocate, and confirmed by that time, a majority of the facility residents had already been relocated with the assistance of the facility. The COO confirmed the facility had not submitted daily census reports and logs of resident transfers until [DATE]. Interview with the Business Officer Manager (BOM) on 11/26/19 at 2:00 PM, in the conference room, confirmed she was present on 11/12/19 when the COO informed family members of the pending closure. The BOM reported multiple resident representatives expressed dismay about the abrupt notice given during and after the meeting. The BOM stated the COO informed family members the goal was to close the facility by the end of November and the COO began to promote a sister facility (SF #1) nearby (15 miles away) as well as 2 other facilities under the same management in nearby counties. The BOM stated there was no mention of any other facilities as options for placement and no written information regarding local facilities in the area or number of available beds in the area was provided to residents/resident representatives. The BOM stated the COO informed families those who chose to transfer to sister facilities would receive rooms of their choosing on a first come first served basis, but the COO did not inform families 1 of 2 sister facilities nearby only had 2 male beds open. The BOM confirmed case managers from SMA HMO #2 were present at the meeting on 11/12/19, but case managers from SMA HMO #1 and #3 were not informed of the closure until days later, when they arrived at the facility and were unable to locate their clients, and were informed of the closure plan by the Administrator. Review of the facility's final transfer log submitted to the SA on [DATE], revealed the facility transferred or discharged 49 residents between 11/12/19 and [DATE]. Of those 49 residents, 41 residents were relocated to facilities owned by the same company. As of [DATE], all the residents in the facility had been transferred or discharged . 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 stated families were informed the facility was slated to close 11/30/19. RP #5 stated her spouse asked the COO during the meeting on 11/12/19 for an explanation as to why no [AGE] day written notice had been provided to residents and families if the company knew it was closing the facility after the purchase, and the COO replied the company was not required to provide a [AGE] day notice, only a 30 day notice. RP #5 stated they were not provided with information on nursing home bed availability in the area and were not given information on facilities not owned by the same company. RP #5 stated she and her family did not receive assistance from the facility in their search for alternative placement to meet their needs. RP #5 stated .we felt compelled to take what they offered us and we had little time to do otherwise. RP #5 reported she observed the facility daily between [DATE] and 11/15/19 and .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. Refer to F-623 and F-[AGE]6",2020-07-01
3622,TRINITY HEALTH AND REHABILITATION CENTER,445533,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2019-11-26,846,F,1,0,POO311,"> Based on review of facility policy, review of facility census, review of electronic mail, and interview, the facility Administrator failed to follow facility policy for facility closure and failed to provide written notices of closure to the State Survey Agency, the State Long-Term Care Ombudsman, residents, resident representatives, and other responsible parties, potentially affecting all 51 residents residing in the facility on [DATE]. The findings included: Review of the facility policy Transfer or Discharge Notice, revised 12/2016, revealed .If the facility will be closing, the Administrator will provide written notices to the residents and the residents' representatives of the impending closure at least sixty ([AGE]) days prior to the date of closure. 8. 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 transfer and adequate relocation of the residents.At the time of the notification, the facility will provide each resident and responsible party with the following information: a. The plan for the transfer and adequate relocation of the resident; b. The date by which the transfer/relocation will be completed; and c. Assurances that the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, service and location. 11. In determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interests of that resident. Review of the facility's census revealed 51 residents resided in the facility on [DATE]. Review of electronic mail messages between the facility and the State Survey Agency (SA) revealed the SA was informed a new owner would be acquiring the facility around 12/1/19. On [DATE], the SA informed the new ownership of the requirements necessary for closure of a facility, via email. On 11/6/19, the SA was informed the new owner would take over operations of the facility on 11/12/19. On 11/13/19, the SA was notified the facility was proceeding with closure of the facility and had begun transferring residents out of the facility. Further review of all electronic mail received by 11/13/19, revealed the facility had not submitted a closure plan to the SA. Review of electronic mail revealed the Chief Operating Officer (COO) of the Facility submitted a written closure plan to the SA on [DATE]. Review of an electronic mail message (written on the facility corporate letterhead) addressed to C[CONDITION] (Centers for Medicare and Medicaid Services) and copied to the SA, dated [DATE] and electronically signed by the facility COO, revealed RE (Regarding): Notice of Closure.Although we acknowledge that Operator shall provide [AGE] days' written notice prior to closure, we are seeking to close the Facility as soon as possible. Please note that we notified the Tennessee Department of Health on November 1, 2019 and sought input regarding the requirements.Per the process given to us by the State of Tennessee, we are providing you elements of our closure plan. Review of the facility's daily census for [DATE] revealed the facility had 7 residents remaining in the facility. Interview with the Administrator on 11/25/19 at 10:00 AM, in the conference room, revealed he was made aware the facility had been purchased on 11/6/19, immediately before he left the country on a planned vacation. The Administrator reported at that time on 11/6/19, he had not been informed the facility was to close. The Administrator stated he learned of the closure during his return trip to the United States around 11/14/19. The Administrator stated his staff informed him the new ownership had announced the facility closure during a meeting on [DATE] with staff and again during a meeting on 11/12/19 with residents, responsible parties, local media, and the volunteer ombudsman. The Administrator stated he was not aware of any advance notice of the intent to close the facility being provided to the SA, Ombudsman, residents, resident representatives, or community stakeholders prior to [DATE]. The Administrator confirmed he did not submit a written closure plan to the SA and had not provided a [AGE] day notice of the facility closure to the SA, Ombudsman, residents, resident representatives, or community stakeholders. Interview with the facility Regional Director of Clinical Services (RDCS) on 11/25/19 at 12:33 PM, in the conference room, revealed the facility provided oral notice of the facility closure to employees on [DATE], around 13 hours after the new owners assumed operational control of the facility. The RDCS confirmed oral notice of the facility closure was provided to residents, resident representatives, and the Ombudsman Volunteer during a meeting on 11/12/19. The RDCS confirmed written notice was not given to residents, family representatives or the Ombudsman before or after the meeting. The RDCS confirmed resident transfers due to the closure had begun on [DATE] and were ongoing. The RDCS confirmed the facility written closure plan was submitted to the SA [DATE], 7 days after the facility had begun resident transfers in anticipation of closure. 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 .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.The families were given too short a notice. Resident #10's POA confirmed he was not provided written notice of the facility's closure and was not given any information regarding placement options, other than facilities in the area that were owned/managed by the same company. Telephone interview with the Chief Operating Officer (COO) on 11/25/19 at 8:00 PM, revealed he was unaware of the precise date his corporation had decided the facility would be closed. The COO confirmed the facility had not given [AGE] days advance notice of the impending closure to the SA, C[CONDITION], or the State Ombudsman office, and acknowledged the written closure plan electronically submitted to the SA and C[CONDITION], dated [DATE], had been provided 7 days after the facility informed employees of the impending closure. The COO confirmed his corporation had not provided the SA a written closure plan for approval until 6 days after they informed residents of the impending closure and need to relocate, and confirmed by that time, a majority of the facility residents had already been relocated with the assistance of the facility. The COO confirmed the facility had not submitted daily census reports and logs of resident transfers until [DATE]. 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 stated families were informed the facility was slated to close 11/30/19. RP #5 stated her spouse asked the COO during the meeting on 11/12/19 for an explanation as to why no [AGE] day written notice had been provided to residents and families if the company knew it was closing the facility after the purchase, and the COO replied the company was not required to provide a [AGE] day notice, only a 30 day notice. RP #5 stated they were not provided with information on nursing home bed availability in the area and were not given information on facilities not owned by the same company. RP #5 stated she and her family did not receive assistance from the facility in their search for alternative placement to meet their needs. RP #5 stated .we felt compelled to take what they offered us and we had little time to do otherwise. RP #5 reported she observed the facility daily between [DATE] and 11/15/19 and .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. Refer to F-623 and F-[AGE]5",2020-07-01
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
3706,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-03-28,224,D,1,0,E6GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to prevent misappropriation of resident property for 1 Resident (#7) and failed to prevent misappropriation of medication for 2 residents (#13, 14) of 15 residents reviewed. The findings included: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revealed .It is the facility's policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish .Misappropriation of resident property means deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or property without the resident's consent .The facility administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS), indicating she was alert, oriented, and able to make her needs known. Continued review revealed Resident #7 required extensive assistance of 2 people for transfers; extensive assistance of 1 person for dressing and grooming; was dependent on 1 person for bathing; supervision for eating; and was often incontinent of bowel and bladder. Review of the facility investigation dated 10/17/16, revealed during a care plan meeting the family brought in a bank statement from the bank of Resident #7 with some money withdrawals from the account. The family stated Resident #7 gave her bank card to 2 staff members to buy things for her. Resident #7 was interviewed and reported she had given her card multiple times to Certified Nursing Assistant #3 (CNA) and CNA #4 to purchase items for her. She denied giving permission for any of the CNAs to withdraw money from the account, or loan any money. Review of the facility investigation revealed a written statement from the Social Worker (SW) dated 10/18/16 revealed Resident #7 gives her debit card and pin numbers to CNAs #3 and #4 to go to vending machines or grocery stores to get food Resident #7 stated the charges for the vending machine purchases should be around $3.00 and the charges for going to the grocery store would be cash withdrawals from the ATM in amounts of about $100.00. She reports CNA #3 brings her receipts from the ATM cash withdrawals so she knows how much is being taken out and she will bring back the change from the shopping trip if there is some. Does not want police involved because it would be too much trouble. Denies the card has ever been gone overnight and not returned. She denies she has ever loaned anyone money or given permission for any sum of money to be taken from the card. Resident #7 was given information SW or QOL (Quality of Life) staff were the only ones to purchase items for the resident. Review of an undated written statement from CNA #5 revealed she .worked with (Resident #7) who stated to her she (Resident #7) wanted me to go get her some cold drinks with her card. I stated to her we couldn't take money or cards from them. She stated to me that (CNA #3 and #4) and some more of the staff do it all the time. I reported it to the nurse and she said she would speak to them about it . Review of an undated written statement from CNA #3 revealed .About 2 1/2 weeks ago (Resident #7) asked me to take her debit card and go to the drink machine to get her and her roommate a drink. I took the card and went to the drink machine, the card reader denied her card so I took it back to her and gave her card back to her and told her it was denied so out of my personal money I bought (Resident #7) and her roommate 1 bottled drink . Review of a written statement dated 10/13/16 from CNA #5 revealed .I witness one day (CNA #4) going down to get (Resident #7) and roommate some things from outside and I stated to her personally Please if you are using the credit card for them you need to stop before it be trouble . Review of an undated written statement by the Interim Director of Nursing (IDON) from an interview with CNA #4, revealed CNA #4 had the debit card of Resident #7 on 2 occasions. CNA #4 stated Resident #7 asked her to make several withdrawals from her account. CNA #4 stated she went to the blue store down the road and made the first withdrawal then Resident #7 asked her to withdraw more money. CNA #4 stated she withdrew a total of $640.00 for the resident. Resident #7 told CNA #4 to keep the card and get everything she could from the card. Review of the facility investigation revealed the nurse who was notified of the 2 CNAs using the resident's card was terminated for failure to report allegations of abuse to the Administrator, Director of Nursing (DON), or ADON (Assistant DON). The nurse had knowledge 2 CNAs were taking a resident's debit card and using it inside and outside the facility. She failed to report the misappropriation immediately and failed to start the investigation timely. Review of the facility investigation revealed CNA #3 was terminated for failing to report an allegation of misappropriation of resident funds and admitted to using resident's debit card when she understood the policy not to. Continued review revealed CNA #4 was terminated for using a resident's debit card at various locations; admitted to leaving the facility during working hours to use the debit card; and the resident was missing funds from her account. Review of the facility investigation revealed the police were called but Resident #7 denied any money was missing from her account. She stated she had just been to the ATM and got $500.00 but was unable to state which staff member accompanied her to the ATM. Resident #7 stated she gave her card to CNA #3 but it was always declined and the bank stated it was because she was trying to take out too much money. Resident #7 stated CNA #4 had also used her card. The police said there was nothing he could do since Resident #7 denied money was missing. Interview with the IDON, ADON, and Administrator on 3/16/17 at 9:45 AM in the conference room, revealed Resident #7 had allowed CNA #3 and CNA #4 use her debit card for drinks and groceries. This was a violation of facility policy and the 2 CNAs were terminated. The Administrator stated the funds which were removed by the CNAs were reimbursed to Resident #7. The Administrator also stated it was a hard lesson for the CNAs to learn but he needed to set an example for the facility this type of behavior would not be tolerated. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed Resident #13 was severely impaired cognitively. Continued review revealed Resident #13 was dependent on 2 people for transfers; was dependent on 1 person for dressing, eating, grooming, and bathing; and was always incontinent of bowel and bladder. Review of physicians orders dated 1/30/17 revealed Resident #13 was ordered [MEDICATION NAME] 7.5/325 mg (milligram) twice daily and it was scheduled for 8:00 AM and 8:00 PM. Review of the Narcotic Sign-Out Sheet and the MAR dated 2/23/17 revealed a dose was signed out at 6:00 PM but not documented on the Medication Administration Record (MAR). A dose was signed out at 9:00 PM and documented on the MAR so the resident had an extra dose signed out. Review of the Narcotic Sign-Out Sheet and MAR dated 2/18/17 revealed a dose was signed out at 2:00 PM but not documented on the MAR. A dose was signed out at 9:00 PM so the resident had an extra dose signed out. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed Resident #14 scored 15 on the BIMS indicating she was alert, oriented, and able to make her needs known. Continued review revealed Resident #14 required extensive assistance with transfers, dressing, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Review of physicians orders dated 2/7/17 revealed Resident #14 was ordered [MEDICATION NAME] 10/325 mg twice daily to be administered at 6:00 AM and 6:00 PM. Review of the Narcotic Sign-Out Sheet and the MAR dated a dose was signed out on 2/23/17 at 2:00 PM but not documented on the MAR. Review of the Narcotic Sign Out Sheet and the MAR revealed a dose was signed out on 2/28/17 at 1:00 PM and 6:30 PM and neither dose was documented on the MAR. All these medications were signed out by the same nurse. Review of the facility investigation of a statement from the Unit Manager dated 3/2/17 revealed .Upon doing weekly reports and audits it was noted on a resident's Controlled Drug Record she was ordered medication [MEDICATION NAME] 7.5/325 mg twice daily but the medication had been signed out twice in one shift. This resulted in the amount of pills signed out was more than the medical staff ordered. After checking several sheets were found with this same situation. This information was given to Nursing Administration on 2/27/17 . Review of a statement from the IDON dated 3/2/17 revealed .On Monday 2/27/17, Unit Manager came to me with copies of narcotic sheets and MARS and asked me to review. Upon review there were some discrepancies noted regarding administration of medication times and the actual MAR. On 2/28/17 reviewed with ADON and she was in agreement. Mentioned possible drug diversion to Assistant Administrator . Review of a written statement by the Assistant Administrator dated 3/1/17 of a meeting with the IDON, ADON, and Corporate Nurse and the nurse who signed out narcotics but failed to document them on the MAR. When questioned the nurse admitted to administering two resident's medications by memory resulting in her giving a narcotic that was not scheduled to be given at the time she signed it out on the narcotic log. When questioned as to why she didn't document them being given on the MAR she stated she had intended to go back later after she finished her med pass and sign them out but she forgot. She admitted she realized later she had given a medication when it wasn't due and knew she had made a medication error, yet she did not tell anyone. When questioned why she did not report it to anyone she responded :I don't know. She was asked to write out her statement then was informed she was being placed on suspension pending further investigation. The IDON requested she count off her cart with the other nurse and leave the premises. When she got to the floor the IDON called her to say she needed to return to Human Resources (HR) for a drug screen. She arrived at the Assistant Administrator's office and stated she had to leave because she had received a call from the hospital saying her mother's condition was worse. She was informed HR was ready and the test would only take 5 minutes. She then stated she couldn't go to the bathroom and needed some water. She again said her mother was sick and she had to leave. The IDON informed her if she refused to take the drug test she could possibly lose her job. She then walked toward the front of the building and stated Y'all can fire me, I don't care. Review of a written statement from the accused nurse dated 3/1/17 revealed .On the dates mentioned there were only 2 nurses and at time 3 techs. I messed up by giving extra med by mistake. I know being busy is not an excuse but I did not look at the MAR and passed out one or two by memory . Review of interview dated 3/3/17 with Resident #14 revealed she did not remember getting an extra dose of pain medication on 2/23/17. Interview with the Administrator, IDON, and ADON on 3/16/17 at 11:30 AM in the conference room revealed the nurse in question signed out medications and was inconsistent in documentation. Residents received medications when they were not scheduled. IDON and ADON reviewed all MARs and sign-out sheets and found discrepancies on her unit. She said she took out the medications and thought it was the right time. She did not look at the MAR and gave the medications by memory resulting in significant medication errors for the residents.",2020-03-01
3707,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-03-28,225,D,1,0,E6GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility nurse failed to report to the Administrator and begin an investigation of an allegation of misappropriation of resident property for 1 Resident (#7) of 3 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revealed .It is the facility's policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish .Misappropriation of resident property means deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or property without the resident's consent .The facility administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS), indicating she was alert, oriented, and able to make her needs known. Continued review revealed Resident #7 required extensive assistance of 2 people for transfers; extensive assistance of 1 person for dressing and grooming; was dependent on 1 person for bathing; supervision for eating; and was often incontinent of bowel and bladder. Review of the facility investigation dated 10/17/16, revealed during a care plan meeting the family brought in a bank statement from the bank of Resident #7 with some money withdrawals from the account. The family stated Resident #7 gave her bank card to 2 staff members to buy things for her. Resident #7 was interviewed and reported she had given her card multiple times to Certified Nursing Assistant #3 (CNA) and CNA #4 to purchase items for her. She denied giving permission for any of the CNAs to withdraw money from the account, or loan any money. Review of the facility investigation revealed a written statement from the Social Worker (SW) dated 10/18/16 revealed Resident #7 gives her debit card and pin numbers to CNAs #3 and #4 to go to vending machines or grocery stores to get food Resident #7 stated the charges for the vending machine purchases should be around $3.00 and the charges for going to the grocery store would be cash withdrawals from the ATM in amounts of about $100.00. She reports CNA #3 brings her receipts from the ATM cash withdrawals so she knows how much is being taken out and she will bring back the change from the shopping trip if there is some. Does not want police involved because it would be too much trouble. Denies the card has ever been gone overnight and not returned. She denies she has ever loaned anyone money or given permission for any sum of money to be taken from the card. Resident #7 was given information SW or QOL (Quality of Life) staff were the only ones to purchase items for the resident. Review of an undated written statement from CNA #5 revealed she .worked with (Resident #7) who stated to her she (Resident #7) wanted me to go get her some cold drinks with her card. I stated to her we couldn't take money or cards from them. She stated to me that (CNA #3 and #4) and some more of the staff do it all the time. I reported it to the nurse and she said she would speak to them about it . Review of an undated written statement from CNA #3 revealed .About 2 1/2 weeks ago (Resident #7) asked me to take her debit card and go to the drink machine to get her and her roommate a drink. I took the card and went to the drink machine, the card reader denied her card so I took it back to her and gave her card back to her and told her it was denied so out of my personal money I bought (Resident #7) and her roommate 1 bottled drink . Review of a written statement dated 10/13/16 from CNA #5 revealed .I witness one day (CNA #4) going down to get (Resident #7) and roommate some things from outside and I stated to her personally Please if you are using the credit card for them you need to stop before it be trouble . Review of an undated written statement by the Interim Director of Nursing (IDON) from an interview with CNA #4, revealed CNA #4 had the debit card of Resident #7 on 2 occasions. CNA #4 stated Resident #7 asked her to make several withdrawals from her account. CNA #4 stated she went to the blue store down the road and made the first withdrawal then Resident #7 asked her to withdraw more money. CNA #4 stated she withdrew a total of $640.00 for the resident. Resident #7 told CNA #4 to keep the card and get everything she could from the card. Review of the facility investigation revealed the nurse who was notified of the 2 CNAs using the resident's card was terminated for failure to report allegations of abuse to the Administrator, Director of Nursing (DON), or ADON (Assistant DON). The nurse had knowledge 2 CNAs were taking a resident's debit card and using it inside and outside the facility. She failed to report the misappropriation immediately and failed to start the investigation timely. Interview with the IDON, ADON, and Administrator on 3/16/17 at 9:45 AM in the conference room, revealed Resident #7 had allowed CNA #3 and CNA #4 to use her debit card for drinks and groceries. This was a violation of facility policy and the 2 CNAs were terminated as well as the Nurse who had failed to report the misappropriation to the Administrator once the Nurse was aware of resulting in the failure to investigate the allegation timely as required The Administrator stated the funds which were removed by the CNAs were reimbursed to Resident #7. The Administrator also stated it was a hard lesson for the CNAs to learn but he needed to set an example for the facility this type of behavior would not be tolerated.",2020-03-01
3708,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-03-28,333,D,1,0,E6GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to prevent significant medication errors from occurring for 2 residents (#13, #14) of 15 residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 was severely impaired cognitively. Continued review revealed Resident #13 was dependent on 2 people for transfers; was dependent on 1 person for dressing, eating, grooming, and bathing; and was always incontinent of bowel and bladder. Review of physician's orders [REDACTED].#13 was ordered [MEDICATION NAME] 7.5/325 milligrams (mg) twice daily and was scheduled for 8:00 AM and 8:00 PM. Review of the Narcotic Sign-Out Sheet and the Medication Administration Record (MAR) dated 2/23/17 revealed a dose was signed out at 6:00 PM but not documented on the MAR. A dose was signed out at 9:00 PM and documented on the MAR indicating the resident had an extra dose signed out. Review of the Narcotic Sign-Out Sheet and MAR dated 2/18/17 revealed a dose was signed out at 2:00 PM but not documented on the MAR. A dose was signed out at 9:00 PM indicating the resident had an extra dose signed out. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed Resident #14 scored 15 on the Brief Interview Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review revealed Resident #14 required extensive assistance with transfers, dressing, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Review of the physician's orders [REDACTED].#14 was ordered [MEDICATION NAME] 10/325 mg twice daily to be administered at 6:00 AM and 6:00 PM. Review of the Narcotic Sign-Out Sheet and the MAR revealed a dose was signed out on 2/23/17 at 2:00 PM but not documented on the MAR. Review of the Narcotic Sign Out Sheet and the MAR revealed a dose was signed out on 2/28/17 at 1:00 PM and 6:30 PM and neither dose was documented on the MAR. All these medications were signed out by the same nurse. Review of the facility investigation of a statement from the Unit Manager dated 3/2/17 revealed .Upon doing weekly reports and audits it was noted on a resident's Controlled Drug Record she was ordered medication [MEDICATION NAME] 7.5/325 mg twice daily but the medication had been signed out twice in one shift. This resulted in the amount of pills signed out was more than the medical staff ordered. After checking several sheets were found with this same situation. This information was given to Nursing Administration on 2/27/17 . Review of a statement from the Interim Director of Nursing (IDON) dated 3/2/17 revealed .On Monday 2/27/17, the Unit Manager came to me with copies of narcotic sheets and MARS and asked me to review. Upon review there were some discrepancies noted regarding administration of medication times and the actual MAR. On 2/28/17 reviewed with the Assistant Director of Nursing (ADON) and she was in agreement. Mentioned possible drug diversion to Assistant Administrator . Review of a written statement by the Assistant Administrator dated 3/1/17 of a meeting with the IDON, ADON, and Corporate Nurse and the nurse who signed out narcotics but failed to document them on the MAR. When questioned the nurse admitted to administering two resident's medications by memory resulting in her giving a narcotic that was not scheduled to be given at the time she signed it out on the narcotic log. When questioned as to why she didn't document them being given on the MAR she stated she had intended to go back later after she finished her med pass and sign them out but she forgot. She admitted she realized later she had given a medication when it wasn't due and knew she had made a medication error, yet she did not tell anyone. When questioned why she did not report it to anyone she responded, I don't know. She was asked to write out her statement then was informed she was being placed on suspension pending further investigation. The IDON requested she count off her cart with the other nurse and leave the premises. When she got to the floor the IDON called her to say she needed to return to Human Resources for a drug screen. She arrived at the Assistant Administrator's office and stated she had to leave because she had received a call from the hospital saying her mother's condition was worse. She was informed HR was ready and the test would only take 5 minutes. She then stated she couldn't go to the bathroom and needed some water. She again said her mother was sick and she had to leave. The IDON informed her if she refused to take the drug test she could possibly lose her job. She then walked toward the front of the building and stated Y'all can fire me, I don't care. Review of a written statement from the accused nurse dated 3/1/17 revealed .On the dates mentioned there were only 2 nurses and at the time 3 techs. I messed up by giving extra med by mistake. I know being busy is not an excuse but I did not look at the MAR and passed out one or two by memory . Review of interview dated 3/3/17 with Resident #14 revealed she did not remember getting an extra dose of pain medication on 2/23/17. Interview with the Administrator, IDON, and ADON on 3/16/17 at 11:30 AM in the conference room revealed the nurse in question signed out medications and was inconsistent in documentation. Residents received medications when they were not scheduled. IDON and ADON reviewed all MARs and sign-out sheets and found discrepancies on her unit. She said she took out the medications and thought it was the right time. She did not look at the MAR and gave the medications by memory resulting in significant medication errors for Resident #13 and #14.",2020-03-01
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
3710,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-03-03,166,E,1,0,UP9L11,"> Based on review of facility policy, review of facility audits and action plan, and interview, the facility failed to respond timely to resident grievances of staff response to call lights. The findings included: Review of facility policy, Call Light, Use Of, dated 12/17/15 revealed .the purpose is to respond promptly to resident's call for assistance. All facility personnel must be aware of call lights at all times. Answer ALL call lights promptly whether or not you are assigned to the resident . Review of the grievance log for (YEAR) revealed 3 occasions when residents complained about call lights taking a long time to be answered on 1/19/16, 8/9/16, and 9/8/16. Review of a Nursing Meeting dated 9/2016 revealed a statement .we are a team and as such it is all of our responsibility to make sure the residents get the best possible care. It is everyone's responsibility to answer call lights . Review of an in-service dated 10/12/16 titled Call lights revealed .Call lights are to be made a priority. Call lights are to be answered by ALL staff. Nurses are responsible for answering call lights. Audits will be on going and those lights not answered in a timely manner will be wrote up! . Review of 3 inservices dated 11/18/16 titled Call Lights revealed .Call lights answered as quickly as possible. Focus on customer service . Review of an inservice dated 1/4/17 titled Call light response time, revealed .Call lights are to be answered within 3-5 minutes . Review of a Process Improvement Plan for Call Lights dated (MONTH) (YEAR) revealed the opportunity existed to improve Customer Service in the area of resident call lights with the goal of resident call lights will be answered within 5 minutes or less. Interventions included affected residents were identified; interviews will be completed; and grievances initiated with follow up auditing for compliance. Other interventions included monitoring to ensure correction: 1. random call lights audits of 10 lights will be completed by department leaders as follows: a. daily for 4 weeks on each unit b. 3 times weekly for 4 weeks on each unit c. weekly for 8 weeks d. 3 random call light audits should be completed by the Staff Development Coordinator and Director of Nursing (DON) or her designee 2. while in the room the Department Head will notice a. if call light is within reach of resident b. if clip attachment is securing call light c. length of time it takes for call light to be answered by staff person 3. results of audits will be forwarded to the Administrator daily for follow up. 4. all facility staff will be inserviced by Administrator/DON/her designee on the following: a. critical importance of immediate call response b. standard for call light responses within 5 minutes or less c. importance of call lights being within residents' reach when in room d. how/when to notify Maintenance regarding any call light found without clip present and/or not functioning e. reporting and resolving any residents concerns regarding call light concerns f. how to file a grievance on resident's behalf with emphasis on immediate correction of concern 6. results of audits will be forwarded to the DON for review then to the Administrator for inclusion in the monthly QA (Quality Assurance) meeting for review/recommendations Review of Call Light Audit forms dated 1/9/17 revealed 1 audit from the 100 hall, 1 audit from the 200 hall, and 1 audit from the 300 hall. Review of the form dated 1/10/17 revealed 1 audit from the 200 hall. Review of the form dated 1/19/17 revealed 3 audits from the 100 hall and 2 audits from the 200 hall. Review of the form dated 1/20/17 revealed 2 audits from the 300 hall and 1 audit from the 100 hall. Review of the form dated 2/8/17 revealed 1 audit from the 200 hall and 1 audit from the 300 hall. Review of the form dated 2/9/17 revealed 1 audit from each hall, 100, 200, 300, 400. According to the Process Improvement Plan there should have been audits of 10 lights daily for 4 weeks on each unit. Interview with 9 awake and alert residents on 2/7/16 revealed 4 residents stated sometimes it takes staff more than 1/2 hour to answer their call lights. They stated it was worse at change of shift. They also stated the wait could be bad when they were waiting to go to the bathroom. Telephone interview with the Ombudsman on 2/8/17 at 9:30 AM revealed she had issues with call light response time and officially addressed it with the Administrator on 1/4/17. Interview with the Administrator on 2/9/17 at 11:30 AM in the conference room confirmed the facility was aware there was a problem with call light response time in 9/2016; 3 inservices were held; but no real plan was put into place until 1/4/17 after the visit of the Ombudsman. In continued interview the Administrator confirmed the audits had not been completed as recommended in the Action Plan.",2020-03-01
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
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
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
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
3716,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2017-03-07,441,D,1,0,F4XQ11,"> Based on review of the facility policy, observation, and interview, the facility failed to follow infection control guidelines during 1 of 5 observations made on 1 of 4 hallways observed. The findings included: Review of the facility policy Infection Control .Using Gloves, not dated, revealed .gloves should be used .when providing treatment or services to the resident and when cleaning contaminated surfaces .wash hands after removing gloves .gloves do not replace handwashing .When to Use Gloves .when handling potentially contaminated items .when it is likely that hands may come in contact with .potentially infectious material . Observation of Certified Nursing Assistant (CNA) #1 on 3/6/17 at 11:20 AM, on the 200 unit hallway, revealed the CNA exited a resident's room with dirty linens in her ungloved hands. Continued observation revealed the CNA placed the dirty linens in the dirty linen bin and without washing the hands obtained 2 clean blankets from the clean linen cart and gave them to 2 residents seated in the hallway. Interview with the Director of Nursing (DON) on 3/6/17 at 12:15 PM, in the DON's office, confirmed gloves should be worn and the hands should be sanitized after handling potentially infectious materials. Further interview confirmed the facility failed to follow infection control guidelines and failed to follow facility policy.",2020-03-01
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
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
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
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
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
3724,AHC NORTHBROOKE,445401,121 PHYSICIANS DR,JACKSON,TN,38305,2017-03-20,282,D,1,0,USTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 754 Based on medical record review and interviews, the facility failed to follow care plan interventions related to transfers for 1 of 3 (Resident #1) sampled residents. 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) assessment with a reference date of 3/4/17 documented a Basic Interview of Mental Status score of 3, which signifies severely impaired in cognitive skills. Review of the Comprehensive Care Plan documented, .Self care deficit-assistance required .Interventions .Assist x 2 for positioning, transfers, and ADLs (activities of daily living) . Review of the ADL Verification Worksheet dated 2/19/17, 2/20/17, and 2/21/17 revealed Resident #1 was coded as .Transfer . 4, 2 (Total dependence, One person physical assist) . on the three dates. During an interview with the Director of Nursing (DON) on 3/11/17 at 4:45pm in the Conference room, the DON was asked what was the procedure to be used for Resident #1 when transferred from bed to chair or from chair to bed. The DON stated, They (CNAs) pick her (Resident #1) up, like cradled in their arms, when they transferred her because she was so light. They should have used two people to transfer. It was probably on the care plan for two person lift. I'm not certain. During an interview with the MDS nurse on 3/11/17 at 4:56pm in the Conference room, the MDS nurse was asked if the Comprehensive Care Plan, prior to the injury, included a two person assist was to be used to transfer Resident #1. The MDS nurse stated, Yes, two person assist was in place before the transfer to the hospital . During a telephone interview with CNA #1 on 3/18/17 at 8:40pm, CNA #1 was asked how Resident #1 was transferred from chair to bed on the evening of 2/21/17. CNA #1 stated, Picked her (Resident #1) up the same way as always .I lifted her, got her and put her in bed. CNA #1 was asked if a two person assist was to be used any time when transferring Resident #1. CNA #1 stated, Yes, two person assist . CNA #1 was asked if anyone assisted her to transfer Resident #1 to bed on the evening of 2/21/17. CNA #1 stated, No, they didn't help. I always did it . During a telephone interview with CNA #2 on 3/19/17 at 1:16pm, CNA #2 was asked how Resident #1 was transferred from bed to chair on 2/21/17. CNA #1 stated, I was with (named CNA). She lifted her (Resident #1) from bed to chair with her pants . CNA #2 was asked if Resident #1's care plan included a two person assist to transfer. CNA #2 stated, Yes, I think so .",2020-03-01
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
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
3727,DYER NURSING AND REHABILITATION CENTER,445468,1124 NORTH MAIN,DYER,TN,38330,2017-03-17,225,D,1,0,F42111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Intakes: TN 801 Based on policy review, review of the facility's investigation of an abuse allegation, personnel file review, observation and interview, the facility staff failed to report allegations of abuse timely for 4 of 4 (Resident #1, 2, 3, and 4) sampled residents. The findings included: 1. The facility's Abuse Prevention Program policy documented, .Our residents have the right to be free from abuse, neglect .Our facility is committed to protecting our residents from abuse .abuse prevention program provides policies and procedures that govern, as a minimum .Anyone who witnesses a suspicious situation of possible abuse is to immediately notify the supervisor, who will begin an investigation into the reported occurrence . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], and the quarterly MDS dated [DATE], documented Resident #1 was cognitively intact and required extensive to total staff assistance for activities of daily living (ADLs). The quarterly MDS (1/18/17) documented Resident #1 exhibited verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others for 1 to 3 days. The care plan dated 1/19/17 documented Resident #1 had a self-care deficit, and required assistance with all ADLs, including staff was to provide the resident with a touch call light and encourage the resident to use it to call for assistance as needed. The nurses' notes dated 2/26/17, 2/8/17, 2/6/17, 1/29/17, 1/15/17, 1/10/17, and 1/5/17 documented Resident #1's repetitive use of the call light. The facility's investigation of an allegation of abuse documented, .Complaint Investigation .Complaint received .February 22, (YEAR) .Incident date(s) .Various .On (MONTH) 22, (YEAR), aide (Certified Nursing Assistant (CNA) #3) informed nurse management that she had found a drinking straw inserted into the call light socket in Resident #1's room. Later she said that (CNA #2) admitted disabling the call light with the straw . Observations in Resident #1's room on 3/15/17 at 10:45 AM, revealed Resident #1 to be alert and in bed, and her touch call button was within easy reach. Resident #1 was rubbing her chin, and complained her chin was sore. Resident #1 pressed her call button for assistance. When the nurse arrived to assist, Resident #1 changed her complaint from chin pain, to chest pain and heartburn pain. Interview with Licensed Practical Nurse (LPN) #1 on 3/15/17 at 1:01 PM, in the Dayroom, LPN #1 was asked about finding Resident #1's call light disabled with a drinking straw. LPN #1 stated, I don't have any way of knowing how it got there .I noticed it on the 11-7 shift around midnight . LPN #1 was asked whether she reported it to management. LPN #1 stated, I didn't. Telephone interview with CNA #3 on 3/16/17 at 11:56 AM, CNA #3 was asked whether she reported it when CNA #2 allegedly disabled Resident #1's call light with a drinking straw. CNA #2 stated, .I told her not to do it again . 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE], and the quarterly MDS dated [DATE], documented Resident #2 had moderate cognitive impairment and required staff assistance for all ADLS. The care plan dated 3/2/17 documented staff was to keep the call light easily accessible to Resident #2, and remind the resident to call for assistance as needed. The facility's investigation of an allegation of abuse documented, .Complaint Investigation .Complaint received .February 22, (YEAR) .Incident date(s) .Various .On (MONTH) 22, (YEAR), aide (CNA #3) informed nurse management that aide (CNA #2) drew her hand back as if she were about to strike (Resident #2) .Aide (CNA #4) said that (CNA #1) had said that (CNA #2) Would pinch and slap (Resident #2) . Observations of Resident #2 on 3/15/17 at 10:40 AM, revealed the resident to be alert, seated in a wheelchair with a lap belt in place, and confused. Resident #2 was not interviewable due to confusion. Interview with CNA #4 on 3/15/17 at 10:16 AM, in the Dayroom, CNA #4 was asked whether she was aware of the abuse allegations against CNA #2. CNA #4 stated, Well, I didn't see or hear anything .I was staying late to help out .I asked (CNA #1) to help me get (Resident #2) out of bed, and (CNA #1) .said .(CNA #2) slaps (Resident #2) .(CNA #2) pinched her . CNA #4 was asked what she did when she was told about the alleged abuse. CNA #4 stated, .I was off the next day .Then the next day I came back to work I really didn't think about it until I saw (Resident #2) .and I went straight to the office . CNA admitted she did not report the allegation immediately when she was informed about the allegation. Interview with CNA #1 on 3/15/17 at 11:42 AM, in the Dayroom, CNA #1 was asked what happened regarding the allegation of abuse against CNA #2. CNA #1 stated, .It was me and (CNA #2) in the room with (Resident #2) .(Resident #2) started scratching at (CNA #2), and (CNA #2) pinched her arm .and slapped her leg twice .The second time was another day .that time she just slapped her leg twice . CNA #1 was asked what she did when she witnessed the alleged abuse. CNA #1 stated, I didn't know what to do. (CNA #2) been here 2 or 3 years, and I thought they're not going to believe me .Later I told someone else, and she reported it for me . CNA #1 stated she had been employed at the facility 3 months. CNA #1 confirmed she did not report the alleged abuse allegation immediately when it occurred. 4. Medical record review revealed Resident #3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Anxiety, Pleural Effusion, Chest Pain, [MEDICAL CONDITION], and [DIAGNOSES REDACTED]. The admission MDS dated [DATE], and the quarterly MDS dated [DATE], documented Resident #3 had moderate cognitive impairment, no behaviors, and required staff assistance with ADLs. The care plan dated 1/5/17 documented Resident #3 had a self-care deficit, and required staff assistance with ADLs. The care plan documented staff was to ensure the call light was easily accessible at all times while Resident #3 was in bed. The facility's investigation of an allegation of abuse documented, .Complaint Investigation .Complaint received .February 22, (YEAR) .Incident date(s) .Various .On (MONTH) 22, (YEAR), aide (CNA #3) informed nurse management that (Resident #3) told her that 'long legs' ((CNA #2)) told her that she could not go to the restroom and raised her hand as if to strike her .We interviewed (Resident #3) on (MONTH) 27, (YEAR) regarding the allegations. She states that one night she asked long legs ((CNA #2)) to take her to the bathroom. She did not want to and told her that she would change her. I told her no, I wanted to go to the bathroom. She drew her hand back and I said 'Don't hit me.' She said 'I'm just having fun.' She got me to the bathroom and didn't help me at all. I even had to pin myself up (pull up/adjust own clothing). And she stood there and watched me . Observations in Resident #3's room on 3/15/17 at 2:40 PM, revealed Resident #3 to be alert, seated in a wheelchair in her room, and watching television. There was a personal chair alarm in place on the wheelchair. Resident #3 was able to answer screening questions, but repeatedly spoke of not liking that she had to live in the facility, and that she had lost all of her furniture. 4. Medical record review revealed Resident #4 was admitted to the facility on [DATE], and discharged home from the facility on 2/17/17. [DIAGNOSES REDACTED]. The admission MDS dated [DATE], and the discharge MDS dated [DATE], documented Resident #4 had moderate cognitive impairment, required limited staff assistance for ADLs, and had no behaviors. The care plan dated 1/17/17 documented staff was to keep the call light easily accessible to Resident #4, and remind her to call for assistance as needed. The facility's investigation of an allegation of abuse documented, .Complaint Investigation .Complaint received .February 22, (YEAR) .Incident date(s) .Various .(CNA #1) stated on (MONTH) 22, (YEAR) .that on or about (MONTH) 28, (YEAR) she witnessed (CNA #2) talked (talk) badly to (Resident #4), when she told her she couldn't wait for her to go home .When (Resident #4) said she never had to ask to be able to use the restroom, (CNA #2) (said) she had to ask because she ((CNA #2)) was the boss . The personnel file for CNA #1 documented, .PERSONNEL ACTION .3/3/17 .WARNING .Failed to report observed abuse timely .It is never acceptable to delay reporting abuse .(DON's signature) .(Administrator's signature .(CNA #1's signature) . The personnel file for CNA #2 documented, .SEPARATION NOTICE .Employed .7/06/15 .to .2/21/17 . circumstances of this separation .Mistreatment of [REDACTED]. The personnel file for CNA #3 documented, .PERSONNEL ACTION .3/3/17 .WARNING .Failed to report observed abuse timely .It is never acceptable to delay reporting abuse .(DON's signature) .(Administrator's signature .(CNA #3's signature) . Telephone interview with the Assistant Administrator on 3/16/17 at 5:35 PM, the Assistant Administrator was asked whether the staff should have reported the abuse allegation immediately. The Assistant Administrator stated, Yes .",2020-03-01
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
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
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
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
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
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
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
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
3736,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,441,D,1,0,CJSQ11,"> Based on policy review, observation and interview, the facility failed to ensure practices were followed to prevent the potential spread of infection as evidenced by improper storage of a garbage can in 1 of 155 (Resident #9) personal resident areas, and 1 of 10 (Certified Nursing Assistants, CNA #8) CNAs failed to ensure linens were handled in a manner which prevented the spread of infection and decreased the potential of biohazard exposure, 2 of 10 (CNA's #1 and #8) CNAs failed to perform appropriate hand hygiene after providing care to a resident on contact isolation,1 of 10 (CNA 4) CNAs applying barrier cream inappropriately during Activities of Daily Living (ADL) care. The findings included: 1. Observations in Resident #9's room on 1/10/16 at 2:35 PM, revealed a garbage can sitting on top of an opened package of incontinent pads on the bedside table. Interview with CNA #13 on 1/10/16 at 2:37 PM, in Resident #9's room, CNA #13 was asked what was under the garbage can. CNA #13 stated, They are protective pads (incontinent). CNA# 13 was asked about the garbage can sitting on top of the incontinent pads. CNA #13 stated, Ain't supposed to be there. CNA #13 removed the garbage can off of the pads and sat it on the floor by the bed. Interview with the Administrator on 1/17/16 at 9:40 AM, in the Administrator's office, the Administrator was asked if it was acceptable to place a garbage can on top of incontinent pads. The Administrator stated, Uh-uh. (No) 2. The facility's Laundry Handling . policy documented, .Laundry .will be handled in a manner to prevent the spread of microorganisms. The facility's INCONTINENT CARE . policy documented, .11. When washing perineal area, wash entire area moving from front to back .12. Rinse .other skin surfaces .from front to back. The facility's HAND WASHING . policy documented, .Staff will use proper handwashing .to prevent the spread of infection. 3. Observations in Resident #76's room on 1/11/17 at 9:00 AM, 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. Incontinence care was provided by both CNAs and barrier cream was applied by CNA #4. CNA #4 applied the barrier cream from back to front and not front to back. When changing bed linen CNA #8 placed the soiled linen on the floor. CNA #8 immediately stated, I know I shouldn't put that (sheet) on the floor but we didn't bring a bag in. CNA #8 removed gloves and exited the room. CNA #8 did not wash her hands before leaving the isolation room. Interview with CNA #8 on 1/11/17 at 9:10 AM, on east hall by Resident #76's room, CNA #8 was asked if she washed her hands before leaving Resident #76's room. CNA #8 stated, 'No. CNA #8 was asked if she should have washed her hands before leaving Resident #76's room. CNA #8 stated, Yes. Interview with CNA #4 on 1/11/17 at 9:12 AM, on east hall by Resident #76's room. CNA #4 was asked what is the proper way to provide peri-care to a resident. CNA #4 stated, You wipe from front to back. CNA #4 was asked how she should apply the barrier cream. CNA #4 stated, The same way, from front to back. CNA #4 was asked if she applied the barrier cream from front to back. CNA #4 stated, No, I didn't, I did it from back to front. CNA # 4 was asked if applying the barrier cream from back to front was a break in infection control. CNA #4 stated, Yes. Observations in Resident#76's room on 1/15/17 beginning at 2:20 PM, the surveyor noted a foul smell. The surveyor asked LPN #2 what CNA was assigned to Resident #76. LPN #2 stated, CNA #4 . but changed her response and stated CNA #1. At 2:25 PM, CNA #1 entered Resident #76's room donned gloves, pulled curtain and proceeded to uncover Resident #76, 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 isolation room. CNA #1 returned to outside of Resident #76's room with CNA #2. The surveyor asked CNA#1 if Resident #76 was on 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 2:25 PM, in front of Resident #76's room. CNA #1 was asked if she washed her hands before leaving room to get help. CNA #1 stated, No, I didn't. CNA #1 was asked if she should have washed her hands. CNA #1 stated, Yes. 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 place soiled linen on the floor in a resident's room. The DON stated, If that is what they did, no it is not acceptable. The DON was asked if staff should wash their hands before leaving a resident's room if that resident is in isolation. The DON stated, Yes, they should wash their hands. The DON was asked if a staff member left the room of a resident on isolation or any resident's room without washing their hands would that be a break in infection control. The DON stated, Yes. The DON was asked if not following isolation protocol was a break in infection control. The DON stated, Yes. Telephone interview on 1/19/17 at 1:15 PM, the DON was asked what was the expectation of staff when providing peri care to a resident. The DON stated, Staff should wash from front to back. The DON was asked what about applying barrier cream. The DON stated, The barrier cream should be applied the same way, from front to back. The DON was asked if the staff did not apply the barrier cream from front to back was that a break in infection control. The DON stated, Yes. The DON was asked if the Infection Control policy was followed. The DON stated, No. The facility failed to follow Infection Control policy and protocol. The facility failed to ensure linens were handled in a manner which prevented the spread of infection and decreased the potential of exposure, failed to apply barrier cream consistent with policy and failed to perform appropriate hand hygiene after providing care to a resident on contact isolation, and during Activity of Daily Living (ADL) care.",2020-03-01
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
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
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
3740,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2017-03-02,253,E,1,0,4B1111,"> Based on Job Description review, policy review, observation, and interview, the facility failed to ensure a comfortable and sanitary environment as evidenced by dirty toilets, dirty floors, stained cove base, odors, build-up on walls, stained door facings and walls in 8 of 51 (room 100, 302, 305, 307, 312, 320, 323, and 325) resident rooms. The findings included: The (NAMED COMPANY) JOB DESCRIPTION documented, .TITLE: Light Housekeeper .SECTION 2: POSITION SUMMARY. Performs housekeeping and cleaning activities within well established guidelines and assigned areas and shift (s) to ensure that quality standards, safety guidelines and customer service expectations are met. The light housekeeper is responsible for satisfactory and timely completion of assigned cleaning area according to schedule .performs a variety of tasks, such as dust mopping floors in all areas .Cleans and sanitizes bathrooms including sinks, tubs, floors and commodes .JOB FUNCTION .Cleans Rooms .Cleans floors in residents' rooms: Dry mops, wet mops, sweeps and disinfects .Cleans bathrooms in residents' rooms: Cleans and disinfects sinks, mirrors, pipes; the commode tank, bowl and base; then all fixtures, floors, and walls as directed. Washes mirrors. Replenishes bathroom supplies .Cleans Rooms, continued .Cleans vertical surfaces: Dusts, spot cleans or washes, disinfects when necessary, polishes where required all walls and other vertical surfaces in resident rooms .Complete room cleaning .1 room per day . The (NAMED COMPANY) JOBS TO BE DONE: BATHROOM CLEANING policy documented, .Steps to do Job .Wet Steps: 4. Sanitize sinks, light, mirror, sink, fixtures, pipes. 5. Sanitize commode, tank, bowl, base Use brush for inside of bowl. 6. Spot clean - Walls, partitions, light switches. 7. Damp mop. Start in far corner. Get behind commode, move trash can, mop out the door . The (NAMED COMPANY) JOBS TO BE DONE: DAILY PATIENT ROOM CLEANING policy documented, .Steps to do Job .1) Empty trash .2) Horizontal dusting. With a cloth & (and) disinfect wipe all horizontal (flat) surfaces. 3) Spot clean. With a cloth & disinfect spot clean all vertical surfaces. 4) Dust mop floor .5) Damp mop floor. With germicide solution damp mop floor working from back corner to door . Observations in the 300 hall during initial tour on 2/27/17 beginning at 9:54 AM, revealed the following: a. Room 305 - the toilet in the bathroom appeared to have bowel movement stuck to the bottom of the bowl, black substance around the inside of the bowl, a dark substance on the floor in front of the toilet, and the cove base beside and in front of the toilet appeared dirty. b. Room 307 - the bathroom floor was dirty, there was no toilet paper in the room, and there was a urine odor. Observations in the 300 hall on 2/27/17 beginning at 11:30 AM, revealed the following: a. Room 312 - the bathroom floor was dirty, had a brown build-up around the wall, and on the D (door) side, behind the head of the bed was white particles from the wall on the floor. b. Room 320 - dirt and brown build up on the bathroom floors. c. Room 323 - bathroom floors appeared to be dirty and brown build-up around the walls, and the bathroom door facing and the wall had brown splatters noted. d. Room 325 - the bathroom floor was appeared dirty and had build-up around the walls. Observations in room 100 on 2/27/17 at 11:51 AM, revealed the bathroom floor appeared dirty along baseboards. Observations in room 302 on 2/27/17 at 11:59 AM and 3:44 PM, revealed the floor in the bathroom appeared dirty, and was dirty at the entrance of the bathroom with black at the threshold, wetness in front of the toilet, and the cove base appeared dirty. On 2/28/17 at 8:15 AM, revealed the floor in the bathroom appeared dirty, and the entrance to bathroom with black at the threshold, and the cove base appeared dirty. Observations in room 312 on 2/27/17 at 3:16 PM, revealed the bathroom floor with dirt, and a brown build-up around the wall, on the D side, behind the head of the bed had white particles from the wall the floor. On 2/28/17 at 8:48 AM, revealed the bathroom floor with dirt, and a brown build-up around the wall, on the D side, and the top of the head of the bed had white particles from the wall on it. Observations in room 325 on 2/27/17 at 3:28 PM and 2/28/17 at 8:13 AM, revealed the bathroom floors appeared to have dirt, and build-up around the walls. Observations in room 320 on 2/28/17 at 8:07 AM, revealed dirt and brown build up on the bathroom floors. Observations in room 323 on 2/28/17 at 8:18 AM, revealed the bathroom floors appeared to be dirty and brown build-up around the walls, and the bathroom door facing and the wall had brown splatters noted. Interview with the Administrator and the Housekeeping Supervisor during a walking rounds tour on the 300 hall, on 3/1/17 beginning at 4:45 PM, the Administrator confirmed the white particles present on the head of bed in room 312D, and dirt and brown build-up on the floors and the wall in the bathroom. In room 302, the Administrator confirmed the bathroom floor appeared dirty and black at the threshold entrance to the bathroom. They were asked how often are the rooms cleaned. The Housekeeping Supervisor stated, Daily .and certain rooms deep cleaned daily . The Administrator stated, .looks like is old wax build-up on the floors . The Housekeeping Supervisor stated, .The Plan of Correction will be need to strip these floors . The Administrator came into the Theatre room on 3/1/17 at 5:15 PM and stated the problem on the 300 Hall floor is they can not really use harsh chemicals on this floor due to residents on this floor with ventilators and tracheostomies.",2020-03-01