| 44 |
ASBURY PLACE AT MARYVILLE |
445017 |
2648 SEVIERVILLE RD |
MARYVILLE |
TN |
37804 |
2018-08-20 |
841 |
K |
0 |
1 |
Q9H011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Medical Director Contract, review of the Advanced Practice Nurse (APN) Protocol, review of the Facility Assessment, medical record review, review of facility falls investigations, observation, and interview, the Medical Director failed to ensure identification, development, and implementation of appropriate plans of action and ensure the effective use of its resources to maintain the highest practicable well-being of all residents, failed to ensure performance improvement was implemented and monitored, failed to provide an individualized pain management plan to avoid pain and mental anguish, failed to ensure interventions were implemented for residents with repeated occurrences with falls which placed residents at risk of harm, failed to ensure revision of care plans were done with appropriate and individualized interventions to prevent falls, failed to prevent avoidable pressure ulcers, failed to ensure an appropriate falls intervention program was implemented to prevent residents from having multiple falls and injuries, and failed to ensure a facility assessment was performed and implemented. The Medical Director's failure placed 7 residents (#119, #28, #34, #39, #40, #47, #80) in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F725, F 726, F 835, F 841, F 867 and F 967. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the Medical Director Contract revealed .4. Services to be performed by provider .Responsible for the overall coordination of medical care at the Facility. Coordination of care means Provider shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident care policies and providing oversight and supervision of medical services and medical care of residents .Evaluate and take appropriate steps to correct any problems associated with any possible inadequate care Provider identifies .Participate, upon request, in personnel evaluations and other quality monitoring programs established by the Facility including attendance at the Facility's Quality Assurance Committee meetings .Provider will deliver high quality services that .Promote standards of timeliness .enhance continuity of service to all Health Center residents .conform to federal and state regulations . Review of the Advanced Practice Nurse (APN) Protocol, undated, revealed .Requiring Authority .the (APN) will provide health care services under the general supervision of (Medical Director) .F. Interpret and analyze patient data to determine patient status, care management and treatment and effectiveness of interventions . Review of the Facility Assessment (YEAR), dated 6/2/18, revealed .Community Staff .The Medical Director oversees medical practice and provides guidance in the development of clinical policies and programs at our community .Currently, there is 1 Medical Doctor and 2 Nurse Practitioners who visit the community two to three times a week to see residents . During the annual Recertification survey conducted 8/13/18 - 8/20/18, review of clinical notes, accident reports, and fall investigations revealed Resident #119 had 9 falls between 7/1/17 - 7/10/18 and sustained 3 major injuries: a right tibia fracture, left femur fracture, and left [MEDICAL CONDITION]; Resident #28 had 2 falls between 2/15/18 - 6/7/18 and sustained 1 major injury: a [MEDICAL CONDITION] femur; Resident #34 had 2 falls between 2/25/18 - 7/14/18 and sustained 2 injuries: a left [MEDICAL CONDITION] and a laceration to the back of the head requiring staples; Resident #39 had 9 falls between 4/2018 - 8/2018; Resident #47 had 8 falls between 4/5/18 - 6/13/18 and sustained 1 injury: a right eye injury requiring sutures. Resident #40 had 4 falls between 4/2018 - 8/2018 and sustained 1 injury: a subdural hematoma; and Resident #80 had 5 falls between 1/27/18 - 7/2/18 and sustained 1 major injury: a Cervical 1 - Cervical 2 fracture. During the Recertification survey, review of wound reports, Wound Nurse Practitioner documentation, and interviews, revealed Resident #39 developed 3 avoidable wounds: 1 stage II on the right buttock, 1 stage III to left buttock, and an unstageable to the coccyx; Resident #80 developed 1 avoidable unstageable wound to the right clavicle; Resident #86 developed 1 avoidable stage IV wound to the right hip; and Resident #119 developed 2 avoidable wounds: 1 unstageable to the left ischium and 1 stage II to the right foot. Review of facility Quality Assurance and Process Improvement Meeting (QAPI) meeting minutes dated 8/29/17 - 7/24/18 revealed the Medical Director attended 11 out of 13 QAPI meetings. Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed she attended the QAPI meetings and falls were reviewed monthly in the meetings. Continued interview confirmed recurrent falls were reported to the Nurse Practitioners (NP) and any concerning issues went directly to the Medical Director. Further interview confirmed .I don't know how much detail is in QAPI meeting . Continued interview confirmed .involvement with pressure ulcers primarily supervisory. I use wound trained NP's and a wound Nurse . Further interview confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff that are unfamiliar. Difficult to do training with mostly on the job training, and turnovers in leadership have not been helpful .Falls .We can't tie them up . Continued interview confirmed when the Medical Director signed the Incident/Accident reports she was agreeing with the interventions put in place. The Medical Director stated .the reports are not always timely . Refer to F 550, F657, F 677, F 686, F 689, F 697, F 725, F 726, F 835, F 867, and F 947. |
2020-09-01 |