cms_TN
Data source: Big Local News · About: big-local-datasette
14,361 rows sorted by address
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name | facility_id | address ▼ | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8 | 8 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2019-01-16 | 842 | D | 0 | 1 | 6O2811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure Physician order [REDACTED].#340 and #341) of 3 residents reviewed of 29 residents sampled. The findings include: Medical record review revealed Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form, undated, revealed the physician had not signed and dated the resident's POLST form. Medical record review revealed Resident #341 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form dated 1/4/19 revealed the POLST form was not signed by the resident and the health care professional preparer of the form. Interview with the Director of Nursing (DON) on 1/16/19 at 8:47 AM, in the DON's office, confirmed the POLST forms were to be completed within 24 hours of admission to the facility. Continued interview confirmed the facility failed to ensure the POLST forms were complete for Resident #340 and #341. | 2020-09-01 |
| 9 | 9 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2020-02-20 | 574 | C | 0 | 1 | UNET11 | Based on facility policy review, admission packet review, interview, and observation, the facility failed to support each resident's rights by ensuring the required State Survey Agency's contact information was made available for 3 of 3 residents (Resident #1, Resident #2, and Resident #16). Interviews obtained during the resident group meeting revealed the residents had not been given information on how to file a complaint with the State Survey Agency. This failure had the potential to affect all 43 residents of the facility who may want to exercise their right to file a complaint directly with the State Survey Agency. Findings include: Review of the facility's policy titled, Patient Rights and Responsibilities-Siskin West Subacute, undated, revealed the residents had the right to .contact the Tennessee Department of Health directly at (telephone number) to lodge any concerns you may have about your care. Review of the facility's policy titled, Resident Rights, undated, located in the facility's admission packet provided during the entrance conference, revealed at the time of admission, and periodically through their stay, the facility would inform each resident, orally and in writing, of their rights. The policy stated the resident had the right to voice grievances to the facility, or other agency or entity that hears grievances, without discrimination or reprisa,l and without fear of discrimination or reprisal. The policy also stated the resident had the right to be afforded the opportunity to contact these agencies. The policy stated the resident had the right to immediate access to any of the following: any representative of the Secretary of the U.S. Department of Health and Human Services, any representative of the State, the resident's individual physician, the State's long-term care ombudsman, and the agency responsible for the protection of, and advocacy system for, mentally or developmentally disabled individuals. Review of an untitled and undated form, located in the Admission Packet provided by the fa… | 2020-09-01 |
| 10 | 10 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2020-02-20 | 679 | D | 0 | 1 | UNET11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of activity calendars, observations, and interviews, the facility failed to provide activities for 4 of 25 sampled residents (Resident #131, Resident #132, Resident #230, and Resident #232) who resided on the Sub-Acute Unit. Failure to provide residents with an activity program has the potential to affect the residents' physical, mental, and psychosocial well-being. Findings Include: Review of the St. Barnabas/Siskin West Policy Activities Department updated/revised 12/2018 indicated the definition of an activity was any activity other than activities of daily living that enhanced the resident's well-being. The policy indicated the activities would be person-centered and highlight the resident's quality of life. The procedure indicated the AD would visit the resident after admission to obtain likes and dislikes. The procedure further indicated the AD would educate the resident on happenings on the unit and she would provide an activity calendar for the resident. The policy stated, .should the patient/resident decline to attend activities .they will be provided with in-room options or 1:1 (one on one) opportunities .puzzles, books, magazines, movies and music. Resident #131 was admitted to the facility on [DATE] for occupational and physical therapy following a motor vehicle accident. Review of the Baseline Care Plan dated 2/17/2020, revealed it did not address Resident #131's activity preferences. Review of Resident #131's Resident Activities Assessment Preferences for Customary Routine Activities dated 2/19/2020, revealed it was very important for the resident to do her favorite activities; and it was somewhat important for the resident to have books, newspapers, and magazines to read, to listen to music she liked, to do things with groups of people, to go outside to get fresh air when the weather was good, and to participate in religious services or practices. Review of the a… | 2020-09-01 |
| 3623 | 3623 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2017-01-25 | 279 | D | 0 | 1 | BSB511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a specific care plan for allergies and non- pressure related skin conditions that included measurable goals and interventions to ensure that Resident #30's skin concerns would be addressed in a timely fashion for 1resident (#30) of 21 residents reviewed. The findings included: Review of the facility's policy, Nursing Plan of Care, undated, revealed the following information: .1. Registered nurses initiate Nursing Plans of Care to identify teaching and discharge needs. Both RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) may maintain/update Nursing Plan of Cares. RNs are to supervise LPN care and documentation on the Nursing Plan of Care. 2. Nursing Plans of Care reflect the nursing process of assessment, planning, implementing and evaluating of care. The Care Plan is to be reassessed no less than weekly and updated or resolved by assigned nurse. 3. The Nursing Plan of Care is initiated within the first 24 hours of admission. It reflects nursing care provided and discharge planning. 4. The Nursing Plan of Care reflects nursing interventions and responses . Review of the medical record for Resident #30 revealed that she was readmitted to this facility on 3/2/12 with [DIAGNOSES REDACTED]. Review of the medical record and the physician's orders [REDACTED].#30 had allergies to antibiotics such as, [MEDICATION NAME], Cephalosporin, Cipro, and Carbapenems. She was also allergic to vaccines such as Tetanus and [MEDICATION NAME]. Per the physician's orders [REDACTED]. The order was dated 6/22/15. Review of the plans of care for Resident #30 revealed a care plan for allergies which was dated 3/15/12. The Goal &Target Date included Will have no allergic reactions during review period which was revised on 9/13/16 and 12/23/16. The target date was 3/20/17. The Approaches included: List of all know allergies will be kept on physic… | 2020-04-01 |
| 3624 | 3624 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2017-01-25 | 309 | D | 0 | 1 | BSB511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide the necessary care and services for one resident (#30), of one resident reviewed for non-pressure related skin conditions of 21 residents reviewed. The findings included: Review of the medical record for Resident #30 revealed the resident was readmitted to this facility on 3/2/12 which [DIAGNOSES REDACTED]. Review of the medical record and the physician's orders [REDACTED].#30 had allergies [REDACTED]. She was also allergic to vaccines such as Tetanus and [MEDICATION NAME]. Per the physician's orders [REDACTED]. The order was dated 6/22/15. Review of the Treatment Administration Record (TAR) dated 10/15/16 - 1/24/17 revealed the PRN order for [MEDICATION NAME] 0.5% cream had not been added to the TAR. Review of the Medication Administration Record [REDACTED]. Observation of Resident #30 on 1/24/17 at 8:37 AM revealed the resident was lying in bed eating her breakfast. Resident #30 had several large red blotches, approximately the size of a quarter on her neck. In addition, she had red scaly areas all over her face and scalp. Resident #30 continuously scratched and picked at her head, neck and face. An interview with Resident #30 on 1/24/17 at 8:37 AM, revealed she had some kind of allergic reaction that caused her to scratch and pick at her skin continuously. When interviewed about if she had shared her symptoms with the nursing staff, Resident #30 stated that she thought that she had but she could not be sure. Resident #30 stated that she would like for the red, scaly blotches on her face, neck and scalp to go away. An interview on 1/24/17 at 1:00 PM with Certified Nursing Assistant (CNA) #1 who was assigned to Resident #30, revealed that while she was providing activities of daily living with Resident #30 she had noticed that she had a rash on her neck, face and scalp. When interviewed about what she had done relative for Resident #30's skin rash, CNA… | 2020-04-01 |
| 3625 | 3625 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2017-01-25 | 362 | F | 0 | 1 | BSB511 | Based on facility policy and procedure review, dish machine log review, personnel file review, observation, and interview, the facility failed to employee sufficient kitchen staff and provide them with the appropriate training to ensure they could perform their duties and responsibilities effectively. This deficient practice had the potential to affect all of the residents who resided in this Long-Term Care (LTC) facility. The findings included Review of the facility's policies and procedures revealed a document titled, HACCP (hazard analysis critical control points)/Food Safety Program. Food Safety Standards & Requirements dated 8/17/16 which provided the following information: .Employee Training: Employees must be trained in safe food handling practices, per company policy, when hired and must complete on-going training during the course of their employment. The Unit Manager is responsible to ensure food safety training programs are in place and properly conducted . Review of the Dishwashing/Warewashing Machine Temperature Log(s) dated from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the water temperature during the wash cycle was documented below the manufacturer's recommendations for safe water temperatures on most of the days of the month. In (MONTH) (YEAR), the temperature of the water during the wash cycle reached the minimum of 160 degrees F only on 8 days of the month; 11/1/16, 11/6/16, 11/7/16, 11/8/16, 11/10/16, 11/14/16, 11/24/16, and on 11/27/16. The remaining days in the month of (MONTH) (YEAR), the temperature of the water during the wash cycle averaged about 155 degrees F (Fahrenheit) which was below the manufacturers recommendation. Review of the temperature log for the month of (MONTH) (YEAR), revealed that the temperature of the water during the wash cycle only reached the minimum temperature of 160 degrees F on 5 days of the month. Review of the temperature log for the month of (MONTH) (YEAR), revealed the temperature of the water during the wash cycle only reached the minimum temperature o… | 2020-04-01 |
| 3626 | 3626 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2017-01-25 | 371 | F | 0 | 1 | BSB511 | Based on observation and interview, the facility failed to ensure food safety when they failed to clean and sanitize the meat slicer after use and when they failed to discard potentially hazardous food in a timely fashion. This deficient practice had the potential to affect all of the residents (57) who consume food orally in this Long-Term Care (LTC) facility. The findings include: 1. Observation of the kitchen on 1/23/17 at 9:30 AM revealed a kitchen employee, Cook #1, was preparing lunch for the residents. He was preparing sandwiches on the Cook's preparation counter. At the end of the Cook's preparation counter there was a large meat slicer. When interviewed about the use of the meat slicer, Cook #1 stated the slicer was clean and ready for use. Observation of the metal blade on the meat slicer revealed it was covered with food debris. There was a thick continuous line of debris around the entire edge of the blade. The line of debris was orange in color and was easily wiped off. An interview with the General Manager of the Food Service Department (GM) on 1/23/17 at 9:35 AM confirmed the slicer had been used the previous day and had not been cleaned and sanitized effectively. 2. Observation of the 3rd floor nursing unit on 1/25/17 at 3:00 PM revealed a nourishment room that contained a refrigerator. The refrigerator was observed to have 40 individual health shakes that were defrosted and ready for use. An interview with the GM, at that time, revealed the health shakes were used for those residents who had a nutritional concern. Review of the manufacturer's recommendations, which were posted under the spout on each health shake, revealed the health shakes needed to be stored frozen and discarded 14 days after defrost. The 40 defrosted health shakes did not contain a defrost date or a use by date. Review of the undated LTC Patient /Diets list that was provided by the GM revealed the facility had 3 residents who were ordered health shakes on a daily basis. An interview with the GM and the Assistant Director of Nu… | 2020-04-01 |
| 3627 | 3627 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2017-01-25 | 456 | F | 0 | 1 | BSB511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure their essential kitchen equipment specifically, the [NAME]ot Coupe blades and the dish machine, were maintained in a safe operating fashion. The deficient practice had the potential to affect each of the 62 residents who resided in the facility. The findings included: 1. Observation of the kitchen on 1/23/17 at 10:15 AM, revealed the kitchen staff utilized 2 [NAME]ot Coupes (blenders) to grind and puree food for residents who had a physician ordered therapeutic diet. Closer inspection of the inside of the blender revealed the metal blade was chipped and missing pieces of metal. Observation of the counter above the [NAME]ot Coupes revealed 2 more metal blades that were used as spares. They were also chipped and missing small pieces of metal. When the smooth-edged metal blades became chipped, there was a potential for small pieces of metal to become dislodged and enter the resident's food. An interview with the General Manager of the Food Service Department (GM) on 1/23/17 at 10:20 AM confirmed the facility utilized the [NAME]ot Coupes to grind and puree food for those residents who had difficulties chewing and swallowing. The GM stated she was unaware the blades were chipped and missing metal pieces. Review of the undated, LTC Patients/Diets list that was provided by the GM revealed that the facility had 10 residents who had a physician's orders [REDACTED]. 2. Observation of the kitchen on 1/24/17 at 11:15 AM, revealed the dish machine was in operation. During observation of five separate trials revealed the water temperature during the wash cycle only reached 143.9 degrees F. Observation of the dish machine on 1/24/17 at 12:05 PM, revealed a metal label which was affixed to the underside of the dish machine. The metal label contained information about the use of the dish machine and it included the manufacturer's minimum water temperature for wash cycle of 160 degrees Fahrenhei… | 2020-04-01 |
| 5462 | 5462 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2015-12-16 | 242 | D | 0 | 1 | 69C911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure personal choices were honored for 1 resident (#29) of 35 residents reviewed for choices. The findings included: Medical record review revealed Resident #29 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #29 on 12/15/15 at 9:53 AM, in the residents room revealed don't put me to bed when I want to go to bed .I asked to go back to bed Friday (12/11/15) around 5:30 PM .they came in and told me they would put me back as soon as they could .the shift changed and second shift put back to bed after 7 .I called and I went out in the hall a couple of timesl .they were at the desk .I called my brother and he called them .they just didn't come put me back to bed .they were just sitting at the desk . Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and requires assist with tranfers to be from the wheelchair. Interview with Certified Nurse Aide (CNA) #2/Unit Clerk on 12/15/15 at 2:00 PM at the 300 nursing station confirmed when the call light rings .I tell whoever the person is that is working with the resident or find someone to go take care of the problem, or I do it myself .I work 8-4:30 (8 AM-4:30 PM) Monday through Friday .after that everyone answers the call lights .shifts change at 7:00 PM . Interview with Licensed Practical Nurse (LPN) #2 Nursing Supervisor for 300 hall on 12/15/15 at 4:35 PM at the 300 nursing station confirmed (resident) had requested to go to bed Friday at approximately 5:30 PM and wasn't assisted to bed until after 7 PM when night shift came on . Continued interview confirmed .my expectation is within 30 minutes of the request depending on what is going on, on the unit or if there is extenuating circumstances .any staff certified or licensed can put residents to bed or get them up . Interview with CNA #1 on 12/16/15 at 12… | 2019-02-01 |
| 5463 | 5463 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2015-12-16 | 329 | D | 0 | 1 | 69C911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to attempt a Gradual Dose Reduction (GDR) of a [MEDICAL CONDITION] medication, or document the reason the [MEDICAL CONDITION] medication should not be reduced for 1 (#23) resident of 5 residents reviewed for unnescessary medications. The findings included: Medical record review revealed Resident #23 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Rcapitulation Orders dated from 9/1/14 to present revealed Resident #23 received [MEDICATION NAME] (antidepressant) 60 milligrams (mg) daily, and on 9/12/14, the dosage for the [MEDICATION NAME] was changed to 60 mg in the morning and 30 mg at bedtime. Continued review revealed the [MEDICATION NAME] was changed again on 10/23/15, to 60 mg in the morning and 60 mg at bed time, no other changes noted for the [MEDICATION NAME]. Medical record review of the Psych Services note dated 9/11/14 revealed the Psych Services Nurse Practitioner (NP) recommended to increase the [MEDICATION NAME] to 60 mg in the morning and 30 mg at bedtime due to the resident had increased Depression and was verbally aggressive with staff at times. Continued review of the Psych Services NP notes dated 10/5/15 revealed .Patients' current Status: Stable/Manageable w/o (without) Clinical Complications .Reason for this Encounter: Maintenance Medication Monitoring .remains sad and irritable at times. Verbally aggressive with staff. Presently alert, oriented X 2 (times 2 knows; her name and where she is). Compliant with meds . Continued review of the Psych Services notes dated from 11/2014 to present revealed no recommendations for reducing the dosage of [MEDICATION NAME] or documentation of the reason to not reduce the dosage of the [MEDICATION NAME]. Medical record review of the Consultant Pharmacist Progress Notes dated 1/6/15 to 12/2/15 revealed the Consultant Pharmacis… | 2019-02-01 |
| 7242 | 7242 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2014-10-22 | 333 | D | 0 | 1 | UNTM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure significant medication errors did not occur for one resident (#18) of four residents reviewed for medications. The findings included: Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED]. Medical record review of a communication form from the [MEDICAL TREATMENT] center dated October 8, 2014, revealed the [MEDICAL TREATMENT] center desired the Phoslo 667 mg be increased to two tablets three times a day to lower the phosphorus level of 7.4 to a goal of 3.5-5.5. The recommendation was noted by the physician on October 9, 2014, but the order was not written until October 10, 2014. Further medical record review of a physician order [REDACTED]. Medical record review of a Medication Administration Record (MAR) for October 2014, revealed Phoslo 667 mg 1 tablet was being given three times a day with meals from October 1, 2014, through October 14, 2014. Further review of the MAR revealed the Phoslo 667 mg was not increased to 2 tablets three times a day until October 14, 2014, at 5:00 p.m. Interview with Licensed Practical Nurse (LPN) #1 on October 22, 2014, at 1:40 p.m., at the 300 nursing station, confirmed the resident was receiving Phoslo 1 tablet since September 5, 2014. Further interview confirmed the LPN noticed a lot of pills in the medication drawer, checked the physician's orders [REDACTED]. Interview with the Director of Nursing on October 22, 2014, at 2:45 p.m., in the conference room, confirmed the order was not documented on the MAR and the patient did not receive the medication as was ordered for four days. | 2018-02-01 |
| 7243 | 7243 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2014-10-22 | 371 | F | 0 | 1 | UNTM11 | Based on observation, interview, review of facility policy, an review of manufacturer's recommendations, the facility dietary department failed to maintain food temperatures on the steam table for two of three tray lines observed during one of two meal times; failed to sanitize dishes according to manufacturer's recommendations for one of one three compartment sink; and failed to maintain a sanitary environment in the food service area and the dish room. The findings included: Observation and interview on October 20, 2014, at 11:37 a.m., of the Third Floor Resident Dining Room, revealed the food temperatures were obtained by a dietary staff member (DA) #1 with a calibrated thermometer. The following temperatures were obtained: 1. Marinated Chicken Breasts were 130 degrees Fahrenheit (F). 2. Country Fried Steaks were 112 degrees F. 3. Chopped Country Fried Steak was 118 degrees F. 4. Mashed Potatoes were 128 degrees F. 5. Gravy was 133 degrees F. Interview with the Certified Dietary Manager (CDM) on October 20, 2014, at 11:50 a.m., at the Third Floor Dining Room tray line, confirmed the foods were not at or greater than 135 degrees F and the Ground Chicken temperature was not obtained due to the pan was barely warm to touch. Further observation revealed the following: 1. All hot foods less than 135 degrees F were removed from the steam table at 11:53 a.m., and transported to be reheated. 2. The reheated food items were delivered to the Third Floor Dining Room from the main kitchen at 12:48 p.m., (55 minutes from the time the food left the floor). The reheated food temperatures obtained by the CDM on October 20, 2014, at 12:52 p.m., revealed the Ground Chicken was 129 degrees F and was not in the appropriate temperature range. Interview with the CDM on October 20, 2014, at 12:55 p.m., at the Third Floor Dining Room tray line, confirmed the reheated Ground Chicken was not at an appropriate temperature. Observation on October 20, 2014, at 11:58 a.m., of the Second Floor Resident Dining Room, revealed the food tempera… | 2018-02-01 |
| 7244 | 7244 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2014-10-22 | 431 | E | 0 | 1 | UNTM11 | Based on observation and interview, the facility failed to ensure expired medications and supplies were removed from the shelves and not available for resident use in one (second floor) of two medication storage rooms. The findings included: Observation of the medication storage room on the second floor on October 21, 2014, at 3:00 p.m., revealed nine Intravenous Start Kits (all supplies needed to start an intravenous line) in the Intravenous start basket had an expiration date of February 2014, and were available for resident use. Observation of a basket containing lancets (used to test blood glucose) revealed a screwdriver, three batteries, a 20 milliliter syringe, an insulin syringe, and rubber bands in the same basket, and the lancets were available for resident use. Observation of the stock medication cabinets revealed: 1. one bottle of Bisacodyl (laxative) with an expiration date of January 2014. 2. one bottle of Pain Reliever Plus with an expiration dated of September 2014. 3. one tube of Desitin (used for diaper rash) with an expiration date of October 2013. 4. one tube of 1% Hydrocortisone with an expiration date of April 2014. 5. one tube of Itch Relief Cream with an expiration date of August 2014. 6. one tube of Miconazole 2% (used for yeast infections) with an expiration date of November 2013. 7. three packets of Hemorrhoidal suppositories with an expiration date of January 2014. 8. one tube of Muscle and Joint Ointment with an expiration date of November 2013. Interview with Licensed Practical Nurse #2, who was administering medications, on October 21, 2014, at 3:30 p.m., in the second floor medication room, confirmed the medications and supplies were expired and were still available for resident use. | 2018-02-01 |
| 9108 | 9108 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2013-09-11 | 221 | D | 0 | 1 | 3NWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to complete a restraint assessment and attempt restraint reduction for one resident (#48) of thirty residents reviewed. The findings included: Resident #48 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set, dated dated dated [DATE], revealed the resident had severely impaired cognitive skills for daily decision making and used a trunk restraint daily. Medical record review of the Physical Restraint Reduction assessment dated [DATE], revealed Instructions: Restrained individuals should be reviewed at least quarterly to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or total restraint elimination. For each category listed below, assess the resident by circling the corresponding score(s) that best describe his/her current status in the appropriate assessment column. Add the column of numbers to obtain the total score. Continue evaluation and review on the reverse . Medical record review of the Physical Restraint Reduction assessment dated [DATE], revealed the resident scored a 25 (21-35 Good Candidate). Medical record review of the reverse side of the Physical Restraint Reduction Assessment revealed no documentation of the continued evaluation and review of the restraint assessment on August 18, 2013. Medical record review of a physician's orders [REDACTED].soft self release velcro belt while up in chair .check restraint and release per facility protocol . Observation and interview on September 10, 2013, at 7:45 a.m., with Licensed Practical Nurse (LPN) #3, in front of the nursing station, revealed the resident seated in a tilt/recline chair, with a soft velcro seat belt in place. Continued observation revealed the resident was unable to self release the seat belt when asked by LPN #3. Observation on September 11, 2013, at 7:45 a.m., rev… | 2017-02-01 |
| 9109 | 9109 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2013-09-11 | 246 | D | 0 | 1 | 3NWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure the call light was within reach for one resident (#58) of thirty residents reviewed. The findings included: Resident #58 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set, dated dated dated [DATE], revealed the resident scored fourteen on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making and was able to be understood, and understood others. Observation and interview with the resident on September 9, 2013, at 2:10 p.m., revealed the resident seated in a wheelchair on the left side of the bed and the call light was wrapped around the assist bar on the right side of the bed. Interview with the resident at the time of the observation revealed the resident needed the call light to ask for assistance with transfers. Continued interview revealed the resident had previously asked the staff to ensure the call light was within reach. Observation and interview with Licensed Practical Nurse (LPN) #2 on September 9, 2013, at 2:15 p.m., confirmed the resident's call light was not within the resident's reach. | 2017-02-01 |
| 9110 | 9110 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2013-09-11 | 279 | D | 0 | 1 | 3NWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to develop a comprehensive care plan for one (#118) of thirty residents reviewed. The findings included: Resident #118 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the [MEDICAL CONDITION] Medical Management Progress Note dated July 25, 2013, revealed .Long and short term memory impaired, chronic (scored 5 on a scale with 10 indicating the most severe impairment); Recall impaired, chronic with a score of 5; Attention and Judgement impaired; and Appetite - Decreased with a score of 7, Acute . Record review of the Monthly Weight Record revealed a weight of 137 pounds in March 2013 and 124 pounds in August 2013 with the weight decreasing each month. Review revealed the September weight of 123 pounds represented a 10% weight loss over the previous six months. Review of the Certified Dietary Manager (CDM) Dietary Notes for May 8, 2013, revealed .Weight showing a trending down x (for) 90 days. Review of the CDM's Dietary Notes dated August 9, 2013, revealed Recommendation placed in MD (doctor) communication book for [MEDICATION NAME] for increased appetite due to poor intake and weight decline . Review of the resident's Care Plan Meeting held on August 7, 2013, revealed the family .concerned .weight. Noted Ensure seems to give (resident) diarrhea. Review of the Care Plan approaches to address the Problem/Need of a Therapeutic Diet on admission in June 2012 revealed Offer foods high in protein, Praise resident's attempts to follow diet, and Provide calculated diabetic diet, including snack. Review of the Care Plan dated May 8, 2013, at the annual review after the resident had been identified with significant weight loss revealed no approaches were developed to address the weight loss. Review of the quarterly Care Plan update of August 8, 2013, revealed no new approaches to address the continued weight loss. Review revealed an… | 2017-02-01 |
| 9111 | 9111 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2013-09-11 | 312 | D | 0 | 1 | 3NWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide adequate grooming assistance for one resident (#64) of thirty residents reviewed. The findings included: Resident #64 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the Care Plan revealed under the problem of .decreased functional status .approaches .Nail care done weekly .Assist with dressing .grooming as needed. Observation and interview with the resident on September 9, 2013, at 12:10 p.m., in the resident's room revealed the resident remained in the bed, had a beard, and dirt under long fingernails on each hand. Observation revealed the resident's glasses were on the bedside table and the lenses were visibly dirty. Continued interview revealed the resident stated shaving was done on shower days. Interview with the Certified Nursing Assistant (CNA #3) on September 9, 2013, at 12:30 p.m., after the CNA prepared the lunch tray for the resident (who remained in the bed) and began to exit the room confirmed the resident usually wore glasses during the day and confirmed they were dirty and had not been cleaned or provided for the resident. Interview with the Interim Charge Nurse at the third floor nursing station on September 11, 2013, at 9:30 a.m., confirmed the resident required assistance with all activities of daily living, had a beard on Monday, September 9, 2013, and on that day the Charge Nurse had requested (the resident) be shaved. Interview confirmed residents should be shaved even on days they are not showered. Continued interview confirmed the resident had long fingernails and dirt under the nails of both hands. Interview confirmed the expectation for assistance with daily care needs included nail care and shaving if needed. | 2017-02-01 |
| 9112 | 9112 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2013-09-11 | 325 | D | 0 | 1 | 3NWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to prevent weight loss for two residents (#118, #79) of thirty residents reviewed for weight loss. The findings included: Resident #118 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the Monthly Weight Record revealed a weight of 137 pounds in March 2013. Review of the Certified Dietary Manager's (CDM) Dietary Notes dated May 8, 2013, revealed .Weight showing a trending down x (for) 90 days. Medical record review of the [MEDICAL CONDITION] Medical Management Progress Note dated July 25, 2013, revealed .Long and short term memory impaired, chronic (scored 5 on a scale with 10 indicating the most severe impairment); Recall impaired, chronic with a score of 5; Attention and Judgement impaired; and Appetite - Decreased with a score of 7, Acute . Review of the resident's Care Plan Meeting held on August 7, 2013, revealed the family .concerned .weight. Noted Ensure (liquid dietary supplement) seems to give (resident) diarrhea. Review of the CDM's Dietary Notes dated August 9, 2013, revealed Recommendation placed in MD (doctor) communication book for [MEDICATION NAME] (medication) for increased appetite due to poor intake and weight decline . Record review of the Monthly Weight Record revealed the resident weighed 124 pounds in August 2013. Continued review revealed the September weight was 123 pounds. Observation and interview of the resident on September 10, 2013, at 8:45 a.m., revealed the resident was unable to recall any information about what was served or eaten for breakfast. Interview with the Director of Nurse's (DON), in the DON's office at 4:55 p.m., on September 10, 2013, confirmed the resident had experienced significant weight loss. Interview confirmed the Registered Dietitian (RD) had not provided evaluation or input on the resident's weight loss. Continued interview confirmed the resident's labwork results on May 9, 20… | 2017-02-01 |
| 9113 | 9113 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2013-09-11 | 327 | D | 0 | 1 | 3NWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, observation, and interview, the facility failed to ensure a physician's order for fluid restriction was being maintained for one (#13) of thirty sampled residents. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's order dated October 10, 2012, revealed 1500 ml (milliliters) fluid restriction per day. Medical record review of the Care Plan revealed, 10/10/12 Fluid restriction 1500 ml/day. Medical record review of Dietary notes revealed no documentation of the breakdown of fluids to be provided by dietary and or nursing for the the resident each shift. Review of facility policy, Restricted Fluids, revealed .1. Licensed Nurse will note the Physician's order in regard to fluid restriction and develop and/or follow a plan for the amount of fluids to be consumed by the resident each shift .3. The resident with an order for [REDACTED]. A door identifier will be placed on the resident's door to identify resident's on fluid restriction .8. If the resident is not consuming the amount of fluid ordered (under or over the amount ordered), the Licensed Nurse will notify the physician and document further orders. Observation of the resident's room, on September 11, 2013, at 10:05 a.m., revealed a water pitcher at bedside and no door identifier to indicate the resident was on restricted fluids. Interview on September 11, 2013, at 10:10 a.m., with the Certified Nursing Assistant (CNA #1) providing the resident's care revealed CNA #1 was unaware of how much fluid the resident was allowed per shift. Interview Licensed Practical Nurse (LPN #1) on September 11, 2013, at 10:15 a.m., in the 200 hallway revealed LPN #1 was unaware of the breakdown of fluid to be given by dietary and nursing. Further interview revealed LPN #1 was unaware how many milliliters the resident was allowed each shift. Interview with the Dietary Manager o… | 2017-02-01 |
| 9114 | 9114 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2013-09-11 | 332 | D | 0 | 1 | 3NWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a five percent or less medication error rate in 4 of 32 opportunities observed. The findings included: Medical record review of the physician's orders [REDACTED].#119 revealed .[MEDICATION NAME] [MEDICATION]) 250 mg (milligram) tablet Take 1 tab by mouth twice daily .Aspirin EC ([MEDICATION NAME] coated) take 1 tab by mouth every day . Observation with Licensed Practical Nurse (LPN) #3 of a medication pass for resident #119 on September 10, 2013, at 8:00 a.m., revealed LPN #3 omitted [MEDICATION NAME] 250 mg and Aspirin 81 mg. Medical record review of the physician's orders [REDACTED].Vitamin D (D3) 1000 IU (international units) cap take 1 by mouth every day .[MEDICATION NAME] (gastric acid pump inhibitor) (20 mg) take 1 cap by mouth every day . Observation with LPN #4 of a medication pass for resident #4, on September 10, 2013, at 8:40 a.m., revealed LPN #4 administered Vitamin D 400 IU and omitted [MEDICATION NAME] 20 mg. Interview with LPN #3 on September 10, 2013 at 8:20 a.m., in the hall confirmed the [MEDICATION NAME] and Aspirin had not been administered to resident #119. Interview with LPN #4 on September 10, 2013, at 8:45 a.m., in the hall confirmed vitamin D 400 IU was administered to resident #4 and the [MEDICATION NAME] had not been administered. | 2017-02-01 |
| 9115 | 9115 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2013-09-11 | 431 | D | 0 | 1 | 3NWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure medications were secured on one of five medication carts. The findings included: Observation on September 11, 2013, at 8:57 a.m., revealed an unattended medication cart in the hallway outside of room [ROOM NUMBER]. Further observation revealed a plastic cup containing approximately 60 ml. (milliliters) of a watery mixture. Continued observation revealed the cart remained unattended for three minutes until the nurse returned. Interview with Licensed Practical Nurse #1 at that time revealed the cup contained a Carafate tablet mixed in water. Continued interview confirmed the medication had been left unsecured for a period of time and had not been properly stored. | 2017-02-01 |
| 9116 | 9116 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2013-09-11 | 502 | D | 0 | 1 | 3NWZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a laboratory test was completed for one resident (#22) of thirty residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].TSH ([MEDICAL CONDITION] Stimulating Hormone) every six months. First draw to be done 9-2-13 . Medical record review revealed no laboratory report for the TSH level on September 2, 2013. Interview with Licensed Practical Nurse #5 on September 11, 2013, at 8:30 a.m., at the nursing station confirmed the TSH level had not been obtained. | 2017-02-01 |
| 11429 | 11429 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2012-03-07 | 166 | D | 0 | 1 | 51I011 | Based on review of the resident council meeting minutes and group interview, the facility failed to resolve grievances regarding staffing shortages and not enough linen on weekends. The findings included: Review of the Resident Council Meeting minutes dated August 3, 2011, September 9, 2011, October 6, 2011, November 10, 2011, December 2, 2011, January 5, 2012, and February 3, 2012, revealed residents complained of not enough nursing staff and the continued need for more help. Continued review revealed resident complaints of not enough linen on the weekends. Interview with residents at a group meeting on March 5, 2012, at 2:30 p.m., in the chapel room, revealed complaints of the facility not addressing the issue of needing more staff during meal trays time, and answering call lights. Continued interview revealed the residents had complained of not having enough linen on the weekends. Continued interview revealed the residents' complaints had not been addressed. Interview with the Activities Director on March 5, 2012, at 3:30 p.m., in the Activities Director office, revealed if concerns during the resident council meetings are identified, the information is given to the respectful department. Interview with the Director of Nursing and Administrator on March 7, 2012, at 9:30 a.m., in the Administrator's office, confirmed there was no documentation of the investigation for the resident council complaints or follow up for the grievances. | 2016-01-01 |
| 11430 | 11430 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2012-03-07 | 221 | D | 0 | 1 | 51I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for restraint reduction for three residents (#3, #15 & #10) of twenty residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].self releasing belt . Observation on March 5, 2012, at 10:02 a.m., in the resident room, revealed resident #3 in bed. Continued observation revealed the resident's wheelchair in the bathroom had a self releasing belt in place available for use. Medical record review of a Physical Restraint Reduction Assessment last completion date May 1, 2011, revealed no quarterly restraint assessments where completed for the months of August 2011, November 2011, and February 2012. Interview with the Director of Nursing (DON) on March 5, 2012, at 2:20 p.m., in the facility conference room, confirmed the resident was not assessed quarterly for a least restrictive device. Resident # 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physicians order dated April 8, 2009, revealed .lap belt while up out of bed . Observation on March 7, 2012, at 7:48 a.m., revealed resident #15 sitting in front of the third floor nurse's station in a gerichair (type of wheelchair) with a lap belt (restraint) in place. Medical record review of a Physical Restraint Reduction Assessment last completion date August 1, 2011, revealed no quarterly restraint assessments where completed for the months of November 2011, and February 2012. Interview and medical record review, with the Director of Nursing on March 7, 2012, at 8:03 a.m., in the facility conference room, confirmed the resident was not assessed quarterly for a less restrictive device. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Review of the Physical … | 2016-01-01 |
| 11431 | 11431 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2012-03-07 | 281 | D | 0 | 1 | 51I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow a physician's order for medication administration for one (#7) and failed to obtain psych services timely for two (#10 & #14) of twenty residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical Record review of a physician's order dated March 2, 2012, revealed order for [MEDICATION NAME] written as follows: [MEDICATION NAME] .5, TID prn (three times per day as needed). Medical record review of Medication Record from March 2012, revealed the resident was receiving [MEDICATION NAME] 0.5 mg (milligrams) three times per day at the following times: 6:00 a.m., 2:00 p.m., 10:00 p.m., and [MEDICATION NAME] 0.5 mg as needed for anxiety. Further review of Medication record revealed the resident received the [MEDICATION NAME] on March 2, 2012 at 10:00 p.m., March 3, 2012, at 6:00 a.m. and 2:00 p.m., and received another dose March 3, 2012, with no time indicated. Interview with the second floor Charge Nurse March 5, 2012, at 2:20 p.m. at the second floor nurse's station confirmed the physician's order was [MEDICATION NAME] 0.5 mg three times a day as needed. Further interview confirmed the medication had been incorrectly transcribed to the Medication Record and incorrectly administered three times per day on a routine basis instead of an as need basis. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a physician's order dated December 27, 2011, for psych (psychological) eval (evaluation) related to refusal of meds. Medical record review revealed a physician's order for [MEDICATION NAME] (antidepressant) 50 mg. to be given at bedtime. Further review revealed the resident had been refusing the medication at night. Psych services evaluated the resident on January 17, 2012, (twenty-one days later) increasing the dosage of [MEDICATION NAME] to 100 mg. … | 2016-01-01 |
| 11432 | 11432 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2012-03-07 | 323 | D | 0 | 1 | 51I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were in place for one resident (#3) of twenty residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident current care plan revealed .Problem Potential for Injury .June 24, 2011 status [REDACTED].Approaches .pressure sensitive mat while in bed . Medial record review of a facility fall investigation report dated November 22, 2011, revealed .pt (patient) slid self out of bed .alerted by patient calls .no injury noted . Continued review of the fall investigation revealed .educated CNA (certified nurse assistant) to utilize alarms in place and make sure they are on and working . Interview on March 7, 2012, at 8:42 a.m., with Licensed Practical Nurse (LPN) #3 the nurse present at the time of the fall, on the 200 hall, confirmed the alarm was not on at the time of the fall. | 2016-01-01 |
| 11433 | 11433 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2012-03-07 | 329 | D | 0 | 1 | 51I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure unnecessary medications were not administered for one resident (#7) of 20 residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the resident and interview with residents Power of Attorney (POA) on March 5, 2012, at 10:40 a.m. in resident's room revealed resident was in bed awake and confused. Further interview with POA revealed the resident had received [MEDICATION NAME] (anti-anxiety medication) on a routine schedule over the weekend which caused resident to be oversedated and family thought the [MEDICATION NAME] was only to be administered as needed. Medical record review of the facility's Medication Record from March 2012, revealed the resident was receiving [MEDICATION NAME] 0.5 mg (milligrams) three times per day scheduled for the following times: 6:00 a.m., 2:00 p.m., 10:00 p.m., and [MEDICATION NAME] 0.5 mg as needed for anxiety. Further review of Medication Record revealed resident received the [MEDICATION NAME] on March 2, 2012, at 10:00 p.m.; March 3, 2012, at 6:00 a.m., and 2:00 p.m.; and received another dose March 3, 2012, with no time indicated. Further review of the Medication Record revealed the [MEDICATION NAME] was held March 3, 2012, at 10:00 p.m., for drowsiness and family requested the [MEDICATION NAME] be held on March 4, 2012, at 6:00 a.m., 2:00 p.m., and 10:00 p.m. and March 5, 2012, at 6:00 a.m. Medical Record Review of a physician's orders [REDACTED]. [REDACTED]. Further interview confirmed the medication had been incorrectly administered three times per day routinely. | 2016-01-01 |
| 11434 | 11434 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2012-03-07 | 368 | D | 0 | 1 | 51I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide breakfast for one resident (#13) leaving the facility early for [MEDICAL TREATMENT] treatment of [REDACTED]. The findings included: Resident #13 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) (score of 15 indicates cognitive intact). Continued review of the medical record revealed the resident received [MEDICAL TREATMENT] treatment three times per week at an outpatient clinic. Interview with the resident on March 5, 2012, at 2:30 p.m., in the chapel room, revealed the resident left the faciity on [MEDICAL TREATMENT] treatment days at approximately 5:30 a.m. to 6:00 a.m. Continued interview revealed the resident was not offered any breakfast or provided a snack to take to the outpatient [MEDICAL TREATMENT] clinic. Further interview revealed the resident did not return to the facility until 10:30 a.m. to 11:00 a.m., and stated was very hungry when returned to facility. Review of the resident meal times revealed the dinner meal was provided between 4:30 p.m. and 6:30 p.m. Eleven hours between resident's dinner meal and lunch meal provided after returning to the facility from the [MEDICAL TREATMENT] treatment. Interview with the Charge Nurse on March 7, 2012, at 9:30 a.m., in the Assistant Director of Nursing office, confirmed the resident was not provided a meal before leaving the facility and was not provided any snack to take to the clinic. The Charge Nurse confirmed the resident was not provided a meal from the dinner meal until the lunch meal (over 16 hours). | 2016-01-01 |
| 11435 | 11435 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2012-03-07 | 428 | D | 0 | 1 | 51I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to notify the physician timely of a pharmacy consultant report for one resident (#15) of twenty residents reviewed. The findings included: Resident # 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Pharmacy Consultant Recommendation to the Physician dated January 5, 2012, revealed .has taken Risperidal (antipsychotic) .since February 3, 2010 .please consider a trial discontinuation . Continued review of the Pharmacy Recommendation revealed the Physician was not notified until January 29, 2012 (a twenty-four day delay). Interview with the Director of Nursing (DON) on March 7, 2012, at 8:03 a.m., in the facility conference room, confirmed the facility failed to ensure that the Pharmacy Recommendation was acted upon timely. | 2016-01-01 |
| 2471 | 2471 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-01-26 | 550 | D | 0 | 1 | XVIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 3 of 12 (Certified Nurse Assistant (CNA) #1, 3, and 6) staff members stood over residents to assist with meals, failed to knock before entering a room, and did not use courtesy titles to address residents. The findings included: 1. The facility's Dining Service policy documented, .Sit next to residents while assisting them to eat, rather than standing over them . 2. Observations on the 100 hall on 1/22/18 at 11:29 AM, revealed CNA #1 stood over the resident to assist with the meal. Observations on the 100 hall on 1/24/18 at 5:25 PM, revealed CNA #3 stood over the resident to assist with the meal. Interview with the Director of Nursing (DON) on 1/25/18 at 4:50 PM, at the main nurses station, the DON was asked if it was appropriate for staff to stand to over a resident to assist with the meal. The DON stated, .No . 3. The facility's Dignity policy documented, .Staff should attempt to knock or announce .when entering the resident's room . 4. The facility's Attachment B-Resident Rights documented, .has a right to a dignified existence . 5. Observations on the 300 hall on 1/22/18 beginning at 11:25 AM, revealed CNA #6 delivered meal trays to rooms 310, 311, 314, and 315. CNA #6 failed to knock on the door or announce herself prior to entering the rooms. Observations on the 300 hall on 1/22/18 at 11:45 AM, revealed CNA #6 entered room [ROOM NUMBER] and stated, .wake up darling, wake up darling. Let's eat darling . CNA #6 failed to address the resident by the appropriate name. Observations on the 300 hall on 1/24/18 beginning at 7:34 AM, revealed CNA #6 delivered meal trays to rooms 301, 302, 303, 309, 314 and 315. CNA #6 failed to knock on the door or announce herself prior to entering the rooms. Interview with the DON on 1/26/18 at 9:29 AM, in the activities room, the DON was asked what she expected staff to do before en… | 2020-09-01 |
| 2472 | 2472 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-01-26 | 657 | D | 0 | 1 | XVIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise a care plan related to an indwelling urinary catheter for 1of 3 (Resident #128) sampled residents reviewed with a catheter. The findings included: 1. The facility's Care Plan-Comprehensive policy documented, .an individualized comprehensive care plan that includes measureable objectives .to meet the resident's medical, nursing, mental .needs is developed for each resident .incorporate identified problem areas. Incorporate risk factors associated with identified problems .reflect treatment goals and objectives . 2. Medical record review revealed Resident #128 was admitted to the facility on [DATE], with readmission on 12/22/17, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Foley Catheter 18fr (French) .change prn (as needed) . The admission Minimum Data Set ((MDS) dated [DATE] documented the presence of an indwelling catheter. The care plan dated 12/22/17 did not address care related to the indwelling urinary catheter use. 3. Interview with the MDS Coordinator on 1/25/18 at 4:34 PM, in the activity room, the MDS Coordinator was asked if an indwelling urinary catheter should be care-planned. The MDS Coordinator stated, .yes it should . Interview with the Director of Nursing (DON) on 1/25/18 at 4:50 PM, in the activity room, the DON confirmed an indwelling urinary catheter should be included on a resident's care plan. | 2020-09-01 |
| 2473 | 2473 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-01-26 | 659 | D | 0 | 1 | XVIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to follow resident care plan interventions related to [MEDICAL TREATMENT] for 1 of 1 (Resident #438) sampled residents reviewed. The findings included: 1. The facility's Care Plan-Comprehensive policy documented, .reflect treatment goals and objectives in measureable outcomes .identify the professional services that are responsible for each element of care . 2. Medical record review revealed Resident #438 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 1/17/18 documented, .Potential for complications r/t (related to) [MEDICAL CONDITION] .is on [MEDICAL TREATMENT] .ordered 3 x (times) wkly (weekly) .Communicate with [MEDICAL TREATMENT] center .coordinate resident's care with [MEDICAL TREATMENT] center prn (as needed) . The nurse's note dated 1/24/18 at 3:57 PM, documented, .LATE ENTRY FOR 1-24-18 .1:20 PM. THIS NURSE TALKED TO (named [MEDICAL TREATMENT] Registered Nurse (RN)) .NURSE STATED .(named Resident #438) WAS NOT DIALYZED ON YESTERDAY .THIS NURSE TOLD (named [MEDICAL TREATMENT] RN) THAT I WAS NOT AWARE THAT RESIDENT WAS NOT DIALYZED ON YESTERDAY AND WANTED TO KNOW WHY WERE NOT INFORMED,AS THAT WAS VITAL INFORMATION PERTAINING TO RESIDENT'S CARE. (Named [MEDICAL TREATMENT] RN) STATED .I AM A TRAVELING NURSE .I WAS NOT HERE YESTERDAY . The [MEDICAL TREATMENT] communication forms were reviewed from admission to present. The only forms available were dated 1/9/18, 1/11/18 (missed treatment, hospitalized ), and 1/18/18. Interview with the Director of Nursing (DON) on 1/25/18 at 9:05 AM, in the activities room, the DON was asked how she expected nurses to communicate with the [MEDICAL TREATMENT] center. The DON stated, We send a packet with them each time when they go to [MEDICAL TREATMENT]. Sometimes they don't send them back. The DON was asked what she expected nurses to do if the [MEDICAL TREATMENT] center did not send back the form. Th… | 2020-09-01 |
| 2474 | 2474 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-01-26 | 684 | D | 0 | 1 | XVIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to provide services and follow physician orders [REDACTED].#436) sampled residents reviewed. The findings included: 1. The untitled policy presented by the facility documented, Residents are to have the daily BM (bowel movement) results recorded to provide tracking in (named electronic medical record system) for potential constipation and preventive or treatment initiatives .Charge nurse reviews daily and follows MD (medical doctor) orders. 2. The facility's STANDING ORDERS EFFECTIVE [NAME]TOBER (YEAR), COMMON PROBLEMS documented, [MEDICATION NAME] (a laxative medication) give one 5mg (milligram) tablet by mouth or give one 10mg suppository per rectum prn (as needed) every 24 hours. Check for impaction PRN Notify MD (medical doctor) if problem does not resolve . 3. Medical record review revealed Resident #436 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the BM Roster dated 10/1/17 through 1/24/2018 revealed Resident #436 had no BM on 1/19/17, 1/20/18, 1/21/17, 1/22/17 or 1/23/17. Review of the Medication Administration Record [REDACTED]. Review of the nurses' notes revealed no documentation for the administration of medication for constipation. Interview with Resident #436 on 1/24/18 at 2:22 PM, in Resident #436's room, Resident #436 was asked when she last had a BM. Resident #436 stated, .today is the 4th day with no BM . Interview with the Director of Nursing (DON) on 1/24/18 at 4:33 PM, in the DON's office, the DON was asked if it was acceptable for a resident to go 6 days with no BM and no medications for constipation. The DON stated, They should be calling the doc (doctor) . | 2020-09-01 |
| 2475 | 2475 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-01-26 | 690 | D | 0 | 1 | XVIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide catheter care for 1 of 3 (Resident #128) sampled residents reviewed with an indwelling urinary catheter. The findings included: Medical record review revealed Resident #128 was admitted to the facility on [DATE], with readmission on 12/22/17, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Foley Catheter 18fr (French) .change prn (as needed) . A Nursing Re-Admission assessment dated [DATE] documented, .catheter use .size of catheter and bulb 18 Fr 10cc (cubic centimeter) .date of last catheter change 12/21 date of last catheter bag change 12/21 . The admission Minimum Data Set ((MDS) dated [DATE] documented the presence of an indwelling catheter. There was no documentation that catheter care was completed or the catheter bag was changed from admission on 12/22/17 until 1/17/18. Interview with the Director of Nursing (DON) on 1/25/18 at 4:50 PM, at the main nurses station, the DON confirmed that catheter care should begin when catheter is inserted and be completed every shift. | 2020-09-01 |
| 2476 | 2476 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-01-26 | 698 | D | 0 | 1 | XVIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to ensure communication between the facility and the [MEDICAL TREATMENT] clinic for 1 of 1 (Resident #438) sampled residents reviewed for [MEDICAL TREATMENT]. The findings included: 1. The facility's [MEDICAL TREATMENT], residents': Coordination of Care and post-Care policy with a revision date of 10/13/17 documented, .All nursing personnel will be responsible for providing safe, accurate, appropriate [MEDICAL TREATMENT] care with a general coordination between outside agencies that provide [MEDICAL TREATMENT], post care assessment and interventions to improve resident outcomes .A [MEDICAL TREATMENT] Communication Form is initiated and sent to the [MEDICAL TREATMENT] center each appointment and ensure the form is received back from the clinic .The [MEDICAL TREATMENT] center will notify the facility of the following .Fluid intake and output during treatment .Post-[MEDICAL TREATMENT] .Review [MEDICAL TREATMENT] communication for pertinent information .Monitor lab work .Notify physician as ordered or when lab values are abnormal . 2. Medical record review revealed Resident #438 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].RESIDENT TO RECEIVE [MEDICAL TREATMENT] ON TUESDAY, THURSDAY, AND SATURDAY . The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment, and received [MEDICAL TREATMENT] services. The care plan dated 1/17/18 documented, .Potential for complications r/t (related to) [MEDICAL CONDITION] .is on [MEDICAL TREATMENT] .ordered 3 x (times) wkly (weekly) .Communicate with [MEDICAL TREATMENT] center .coordinate resident's care with [MEDICAL TREATMENT] center prn (as needed) . The nurse's note dated 1/24/18 at 3:57 PM, documented, .LATE ENTRY FOR 1-24-18 .TALKED TO (named [MEDICAL TREATMENT] Registered Nurse… | 2020-09-01 |
| 2477 | 2477 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-01-26 | 812 | D | 0 | 1 | XVIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed during dining when 1 of 12 (Certified Nursing Assistant (CNA) #2) staff members placed a potentially contaminated meal tray back on the cart containing clean food trays. The findings included: Observations in room [ROOM NUMBER]B on 1/22/18 at 7:25 AM, revealed CNA #10 took a tray into the room and set the tray on the overbed table. CNA #2 then picked up the tray, carried it back out of the room, and placed it on the meal cart with the clean trays. Interview with the Director of Nursing (DON) on 1/26/18 at 9:32 AM, in the activities room, the DON confirmed it was unacceptable to place a potentially contaminated tray back on the cart with clean trays. | 2020-09-01 |
| 2478 | 2478 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-01-26 | 880 | D | 0 | 1 | XVIH11 | Based on policy review, observation, and interview, the facility failed to ensure practices were followed to prevent the potential spread of infection when 3 of 8 (Licensed Practical Nurse (LPN) #1, 2, and 3) nurses failed to perform hand hygiene during medication administration. The findings included: 1. The facility's Medication Administration policy documented, .perform hand hygiene prior to medication preparation for each medication pass . 2. The facility's .Glucometer-Performing Blood Glucose Test . documented, .perform hand hygiene before putting on and taking off gloves .cleanse area that is to be punctured .with an alcohol swab. Allow area to dry . 3. Observations in Resident #196's room on 1/24/18 at 4:50 PM, revealed LPN #3 gathered supplies for a blood glucose check and donned gloves without performing hand hygiene. LPN #3 cleansed Resident #196's finger with alcohol and fanned the area with her hand. LPN #3 performed the blood glucose check and placed the container of testing strips in her pocket. LPN #3 removed the gloves, washed hands her hands, and returned to the med cart. LPN #3 then removed the container of testing strips from her pocket and placed them on the computer keyboard. LPN #3 drew up insulin, entered Resident #196's room, and administered the insulin without performing hand hygiene. Observations in Resident #439's room on 1/25/18 beginning at 3:29 PM, revealed LPN #1 administered medication to Resident #439 without performing hand hygiene. LPN #1 then washed and dried her hands, and used the same towel to turn off the water. LPN #1 returned to the medication cart, signed out the medication as administered, and gathered medication for Resident #443. LPN #1 then entered Resident #443's room, and administered the medication. LPN #1did not perform hand hygiene before or after medication administration. Observations in Resident #102's room on 1/25/18 at 3:53 PM revealed, LPN #2 administered medications to Resident #102, and did not perform hand hygiene after administering the medication. In… | 2020-09-01 |
| 2479 | 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 | 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 an… | 2020-09-01 |
| 2481 | 2481 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2019-10-17 | 584 | D | 0 | 1 | YJ6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure the environment was clean, comfortable, and sanitary when overbed tables were not clean, a nasal cannula storage bag was not clean and was undated, suction machines were uncovered, a used lancet and a contaminated alcohol pad were observed on the floor, and a fan was covered with dust in 6 of 85 (room [ROOM NUMBER], #200, #401, #209, #130 and #114) resident rooms. The findings include: 1. Review of the facility's .Clean Schedule revealed over bed tables should be cleaned every day, Monday through Sunday. The facility's .Equipment Cleaning, Disinfecting and Maintenance policy dated 9/2017 documented, .All nursing staff are accountable with Environmental Service Department for ensuring and monitoring proper and routing (routine) cleaning/disinfecting of equipment for resident use .The following equipment is cleaned/disinfected after each resident use and when visibly soiled .O2 (Oxygen) concentrators .between residents and daily while in use . The facility's Waste Disposal policy dated 9/11/90 and revised 1/30/07, documented, .Sharps and needles which are considered to be contaminated will be placed directly in an approved 'sharps container' immediately after use . 2. Observations in room [ROOM NUMBER] on 10/14/19 at 7:45 AM, 11:01 AM, and 12:32 PM, and on 10/15/19 at 7:30 AM, and 4:00 PM, revealed 2 overbed tables with dried black and brown stains, dirt, and debris covering the bottom of the tables. Interview with the Housekeeping Supervisor on 10/17/19 at 11:22 PM, in room [ROOM NUMBER], the Housekeeping Supervisor confirmed the overbed tables were not clean. Observations in room [ROOM NUMBER]B on 10/14/19 at 8:08 AM and 10:36 AM, and on 10/15/19 at 7:35 AM and 12:40 PM, revealed a nasal cannula storage bag dated 4/16/18 with a brown substance smeared on the outside. Interview with the Director of Nursing (DON) on 10/16/19 at 8:20 AM, in room [ROOM NUMBER]B, the… | 2020-09-01 |
| 2482 | 2482 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2019-10-17 | 677 | D | 0 | 1 | YJ6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide assistance with daily oral hygiene for 1 of 2 (Resident #47) sampled residents reviewed for activities of daily living. The findings include: The facility's .Oral Care policy dated 10/17 documented, .Our facility will provide oral care with adl (activities of daily living) care and as needed to maintain the oral cavity . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #47 was cognitively intact and required extensive assistance from staff for personal hygiene. Observations in Resident #47's room on 10/15/19 at 9:07 AM and 4:08 PM, and on 10/16/19 at 7:48 AM and 4:05 PM, revealed Resident #47's teeth were covered with a brownish, yellow substance with food particles between her teeth. Interview with Resident #47 on 10/15/19 at 8:48 AM, in Resident #47's room, Resident #47 stated she was not receiving assistance to brush her teeth. Interview with Certified Nursing Assistant (CNA) #1 on 10/16/19 at 9:05 AM, in Resident #47's room, CNA #1 was asked how often Resident #47 received assistance to brush her teeth. CNA #1 stated, Every other day. Interview with the Director of Nursing (DON) on 10/16/19 at 2:55 PM, in the Activity Room, the DON was asked how often residents should receive oral care, such as assistance with brushing their teeth. The DON stated, Every morning with their ADL care. | 2020-09-01 |
| 2483 | 2483 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2019-10-17 | 684 | D | 0 | 1 | YJ6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure medications were administered as ordered for 1 of 29 (Resident #25) sampled residents reviewed. The findings include: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. a. [MEDICATION NAME] Capsule 0.4 Milligrams, give 1 capsule by mouth at bedtime for [MEDICAL CONDITION]. b. Potassium Chloride, Extended Release, 20 Milliequivalents, give 2 tablets by mouth three times a day for supplement. c. [MEDICATION NAME] 20 Milligrams, give 1 tablet by mouth at bedtime for Cholesterol. d. [MEDICATION NAME] 25 Milligrams, give 1 tablet by mouth two times a day for [MEDICAL CONDITION]. Review of the October, 2019 Medication Administration Record [REDACTED]. Interview with Resident #25 on 10/16/19 8:05 AM, in his room, Resident #25 stated, I didn't receive my medicine last night .she crushed them. I don't like my meds crushed. I want to see what they are giving me. Phone interview with Licensed Practical Nurse (LPN) #4 on 10/16/19 at 1:08 PM, LPN #4 stated, I crushed up the meds, went in the room and then I think, that's not supposed to be crushed. He said, 'I'm not taking that.' LPN #4 was asked if she should have administered Resident #47's medications as they were ordered. LPN #4 stated, Yes. | 2020-09-01 |
| 2484 | 2484 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2019-10-17 | 693 | E | 0 | 1 | YJ6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review, observation, and interview, the facility failed to ensure enteral feeding water flush rates were accurate for 2 of 4 (Resident #12 and #112 ) sampled residents reviewed for enteral feedings. The findings include: 1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Enteral Feed Order every shift for enteral feeding GLUCERNA 1.2 Per PEG (Percutaneous Endoscopic Gastrostomy tube) @ (at) 70 cc (cubic centimeters)/HR (hour) CONTINUOUS X (times) 24 HOURS WITH 25 ML (milliliters)/HOUR H2O (water) FLUSH PER PUMP . Observations in Resident #12's room on 10/15/19 at 3:00 PM and 4:25 PM, and on 10/16/19 at 8:02 AM and 11:05 AM, revealed the water flush was infusing at 35 cc/hr. Interview with Licensed Practical Nurse (LPN) #2 on 10/16/19 at 11:07 AM, in Resident #12's room, LPN #2 confirmed the water flush was infusing at 35 cc/hr and confirmed the water flush was infusing at the incorrect rate. Interview with the ADON on 10/16/19 at 11:10 AM, in the DON Office, the ADON was asked if a resident has an order for [REDACTED]. 2. Medical record review revealed Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Enteral Feed Order .[MEDICATION NAME] 1.5 @ 50 cc/hr continuous per pump with 40 cc/hr H2O flush via (by) PEG . Observations in Resident #112's room on 10/15/19 at 2:34 PM and 4:36 PM, and on 10/16/19 at 8:17 AM, revealed the water flush was infusing at 45 cc/hr. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 10/17/19 at 4:15 PM, in the DON Office, the DON was asked if a water flush was ordered at 40cc/hr, should the flush be infusing at 45 cc/hr. The DON stated No. | 2020-09-01 |
| 2485 | 2485 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2019-10-17 | 695 | D | 0 | 1 | YJ6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow the physician orders [REDACTED].#100 and #112) sampled residents reviewed for respiratory services. The findings include: 1. The facility's Oxygen Administration Policy dated 12/1/07 documented, .Resident will be provided oxygen through either a tank or concentrator at the rate specified by the MD (Medical Doctor) .Oxygen tubing .will be changed weekly and prn . 2. Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Residents #100's room on 10/14/19 at 8:08 AM, 10:36 AM, and 2:59 PM, and on 10/15/19 at 7:53 AM, 12:40 PM and 4:38 PM, revealed Resident #100 was receiving oxygen per nasal cannula at a flow rate of 3 liters/minute. Interview with the Director of Nursing (DON) on 10/16/19 at 8:18 AM, outside Resident #100's room, the DON was asked if the physician orders [REDACTED]. The DON stated, No. 3. Medical record review revealed Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physican's Orders dated 4/8/19 documented, .O2 (oxygen) AT 28% (percent) (2 LPM (liters per minute)) VIA (by)[MEDICAL CONDITION] . Observations in Resident #112's room on 10/15/19 at 2:34 PM and 4:36 PM, and on 10/16/19 at 8:17 AM, revealed the oxygen tubing was not labeled or dated. Interview with the Assistant Director of Nursing (ADON) on 10/16/19 at 8:30 AM, in Resident #112's room, the ADON confirmed the oxygen tubing was not labeled or dated. | 2020-09-01 |
| 2486 | 2486 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2019-10-17 | 761 | D | 0 | 1 | YJ6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were not stored past their expiration date in 1 of 9 (Main Medication Room) medication storage areas. The findings include: The facility's MEDICATION: ordering, receiving, labeling, storage, drug regiment review reporting/documenting .and destruction of controlled substances policy revised [DATE] documented, .Medications are stored, labeled, handled, and accounted for in a safe manner complying with federal/state laws and standards of professional practice . Observations in the Main Medication Room on [DATE] at 1:50 PM, revealed 2 bags of 0.45% (percent) Sodium Chloride (Intravenous Solution) with an expiration date of (MONTH) 2019. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:53 PM, in the Main Medication Room, the ADON confirmed the 2 bags of 0.45% Sodium Chloride were expired. | 2020-09-01 |
| 2487 | 2487 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2019-10-17 | 880 | E | 0 | 1 | YJ6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 3 (Licensed Practical Nurse (LPN) #2) nurses contaminated a reusable medication basket and failed to maintain sterility of an insulin syringe needle during medication administration and when 1 of 1 (LPN #1) nurses failed to perform proper hand hygiene during [MEDICAL CONDITION] care. The findings include: 1. Observations in Resident #66's room on 10/15/19 beginning at 7:40 AM, revealed LPN #2 took a plastic basket from the medication cart containing insulin and placed it on Resident #66's over the bed table without a barrier. LPN #2 then drew up 6 units of [MEDICATION NAME] R insulin and allowed the needle to touch the side of a plastic cup sitting on the overbed table LPN #2 then used the contaminated needle to inject the [MEDICATION NAME] R insulin into Resident #66's right upper arm. LPN #2 returned the plastic basket to the medication cart without cleaning the plastic basket. Interview with the Vice President of Clinical Services on 10/17/19 at 9:50 AM, in the Director of Nursing (DON) Office, the Vice President of Clinical Services was asked if a resident should receive an injection with a needle that had touched the side of a plastic cup. The Vice President of Clinical Services stated, No. The Vice President of Clinical Services was asked if a plastic basket placed on an overbed table without a barrier should be placed back into the medication cart without cleaning the plastic basket. The Vice President of Clinical Services stated, No. 2. The Hand-Hygiene Technique policy dated 8/2017 documented, .To prevent and to control the spread of infectious disease .Appropriate .handwashing .Before or after direct contact with residents .After contact with resident's skin . Observations of [MEDICAL CONDITION] care in Resident #5's room on 10/16/19 at 10:10 AM, revealed Licensed Practica… | 2020-09-01 |
| 2488 | 2488 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-12-12 | 761 | E | 0 | 1 | O3NX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored as evidenced by medications and chemicals not stored separately, medications not dated when opened, and a medication cart was unlocked and unattended in 4 of 9 (300 Hall Medication Cart, 100 Top Hall Medication Cart, 400 Hall Medication Cart, and 200 Hall Medication Cart) medication storage areas and the facility failed to ensure medications were not left unattended in 2 of 85 (room [ROOM NUMBER] and 109) resident rooms. The findings included: 1. The facility's Medication Storage Policy undated documented, .Germicides, disinfectants, and other household substances are to be stored separately from medications .Examples of physical separation include: baggies, dividers or separate drawers . 2. The facility's Medication Administration Policy and Procedure undated documented, .The med (medication) cart is locked when out of sight and unattended .Medications at the bedside are in a locked container and have an order to be at the bedside .When opening medications, multidose vials must have a date and initial when the container is opened . 3. Observations in the 300 Hall Medication Cart on 12/10/18 at 8:41 AM, revealed the bottom drawer on the left side contained 1 container of disinfectant wipes, 3 bottles of wound cleanser, 2 bottles of [MEDICATION NAME] powder, and 1 tube of Vaseline. The right side of the bottom drawer contained 1 container of disinfectant wipes, 1 bottle of [MEDICATION NAME] cream, and 1 tube of Mupirocin ointment. Interview with Licensed Practical Nurse (LPN) #3 on 12/10/18 at 8:41 AM, at the 300 Hall Medication Cart, LPN #3 was asked if it was acceptable to have disinfectant wipes in the same drawer with the medications. LPN #3 stated, No ma'am. Observations in the 100 Top Hall Medication Cart on 12/10/18 at 8:59 AM, revealed 1 container of disinfectant wipes and 1 tube of [MEDICATION NAME] ointment.… | 2020-09-01 |
| 2489 | 2489 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2018-12-12 | 880 | E | 0 | 1 | O3NX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained as evidenced by indwelling catheter bags were on the floor for 3 of 5 (Resident #107, 10 and 97) sampled residents reviewed with indwelling catheters, 1 of 3 (Certified Nursing Assistant (CNA) #1) staff members placed dirty linens on the floor during perineal care observations, 1 of 2 biohazard storage areas (the exterior biohazard storage bins) were not secured, infection control practices were not maintained during ice pass, 1 of 1 (Licensed Practical Nurse (LPN) #1) nurses failed to maintain sterile technique during [MEDICAL CONDITION] (trach) care, a soiled dressing was placed on a bedside table in 1 of 85 (room [ROOM NUMBER]) resident rooms, and LPN #2 failed to use appropriate isolation precautions for 1 of 7 (Resident #391) sampled residents in isolation. The findings included: 1. The facility's Caring for the Patient with an Indwelling Catheter policy revised 8/23/17 documented, .12. Provide barrier for bedside drainage bag to not come in contact with the floor for cross contamination . Medical record review revealed Resident #107 was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-Pot (Potassium) Clavulanate Tablet 250-125 MG (milligram) Give 1 tablet by mouth two times a day for UTI (urinary tract infection) . Observations in Resident #107's room on 12/10/18 at 7:53 AM, and 12/11/18 at 7:39 AM, revealed Resident #107 was in the bed with the urinary catheter bag and tubing on the floor. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].FOLEY CATHETER . Observations in Resident #10's room on 12/10/18 at 8:42 AM, 12/11/18 at 8:55 AM and 9:29 AM, revealed Resident #10 was lying in the bed, and the urinary drainage bag was t… | 2020-09-01 |
| 4157 | 4157 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 226 | D | 1 | 0 | 5EH511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of a time detail sheet and assignment sheets, personnel file review, facility investigation review, medical record review and interview, the facility failed to implement their abuse policy as evidenced by failure to provide social services following an abuse allegation, failure to transfer the alleged victim to the hospital following the allegation of physical abuse, and failure to protect residents from potential abuse during an abuse investigation for 1 of 5 (Resident #166) sampled residents reviewed for abuse of the 28 residents included in the stage 2 review. The findings included: 1. The facility's ABUSE PREVENTION POLICY & PR[NAME]EDURE documented, .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment .by facility staff member .A basic definition describes abuse 'as the harmful treatment of [REDACTED].' REPORTING/INVESTIGATION/RESPONSE POLICY .Any complaint, allegation, observation or suspicion of resident abuse .is to be thoroughly reported, investigated and documented in a uniform manner .Facility Social Worker is to provide counseling and support to the resident and possibly the family .counseling is to be provided as long as necessary. The psychosocial intervention is to be documented in the resident's clinical record .Administrator shall take the following actions to address issues of resident care raised by suspected abuse .If the incident has resulted in an injury .the resident will be transferred to the hospital emergency room .The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in progress .Any employee suspected (alleged) of abuse will be suspended as the incident is reported; pending outcome of the investigation . 2. Medical record review revealed Resident #166 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Dysthymi… | 2019-11-01 |
| 4389 | 4389 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 241 | D | 0 | 1 | 5EH511 | Based on observation and interview, the facility failed to promote care for residents in a manner that maintains or enhances each resident's dignity and respect when 1 (Licensed Practical Nurse (LPN) #1) of 12 staff observed during dining, called a clothing protector a bib. The findings included: The facility's GRACE POLICY .Dietary Policies . documented, .Dining Room Residents .Residents who are unable to feed themselves shall be fed with attention to safety, comfort, and dignity . Random observations in the main dining room on 11/7/16 at 8:06 AM, revealed LPN #1 was sitting at a table with Resident #140. LPN #1 was talking to another staff member and said, .take her bib . Interview with the Director of Nursing (DON) on 11/10/16 at 4:10 PM, in the Activity Room, the DON was asked if it is acceptable to call a clothing protector a bib. The DON stated, .No . | 2019-10-01 |
| 4390 | 4390 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 242 | D | 0 | 1 | 5EH511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to honor a resident's choice for bathing for 1 of 3 (Resident #30) residents of the 16 residents interviewed related to choices in stage 1. The findings included: The facility's Shower/Bath policy documented, .Resident are bathed/ showered per their preference unless medically contraindicated-personal preferences are taken into consideration as to the frequency and type of bath/shower they receive .Notify the charge nurse if resident prefers a change in frequency or type . Medical record review documented Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, no behaviors, and was totally dependent on staff for bathing. The care plan dated 4/11/16 documented Resident #30 required assistance with activities of daily living, and interventions included staff to provide a bath/shower daily on day shift. Review of the Bath and Hygiene reports from 10/1/16 - 11/9/16 documented Resident #30 received a shower on 10/3/16, 10/17/16, and 10/31/16. A bed bath was documented daily all other days. Review of the nurses' notes for (MONTH) and (MONTH) (YEAR) revealed no documentation that Resident #30 had refused any baths or showers. Interview with Resident #30 on 11/7/16 at 3:20 PM, in her room, Resident #30 was asked whether she chose how many times a week she takes a bath or shower. Resident #30 stated, No .get a shower one time a week .Sometimes I don't get my shower when I'm due. Resident #30 was asked whether she chose whether she takes a shower, tub, or bed bath. Resident #30 stated, No. I would like to have a shower every other day or twice a week. Interview with the Director of Nursing (DON) on 11/9/16 at 2:00 PM, in the Activity Room, the DON was asked how often the residents should be offered … | 2019-10-01 |
| 4391 | 4391 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 278 | D | 0 | 1 | 5EH511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess residents for mobility and medications for 2 of 23 (Resident #13 and 69) sampled residents reviewed of the 28 residents included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented limited assistance for locomotion off unit. The quarterly MDS dated [DATE] documented extensive assistance for locomotion off unit. Interview with Certified Nursing Assistant (CNA) #1 on 11/9/16 at 2:18 PM, in the hall outside room [ROOM NUMBER], CNA #1 was asked how much assistance Resident #13 required for activities of daily living. CNA #1 stated, A lot. Interview with MDS Coordinator #1 on 11/10/2016 at 11:16 AM, in the Activity Room, MDS Coordinator #1 was asked about MDS coding for Resident #13's locomotion off unit on the quarterly MDS assessments dated 6/24/16 and 9/23/16. MDS Coordinator #1 stated The quarterly MDS dated [DATE] was an error. It should have been coded as limited . 2. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented Resident #69 was not receiving antidepressants. A physician's orders [REDACTED].[MEDICATION NAME] (antidepressant) 50 mg tablet one tablet by mouth daily . Review of the Medication Administration Record [REDACTED]. Interview with MDS Coordinator #1 on 11/10/16 at 9:17 AM, in the MDS office, MDS Coordinator #1 was asked if the quarterly MDS dated [DATE] was accurate related to Resident #69's medications. MDS Coordinator #1 stated, No. | 2019-10-01 |
| 4392 | 4392 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 282 | D | 0 | 1 | 5EH511 | **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 monitoring a code alert bracelet for 1 of 23 (Resident #192) sampled residents of the 23 residents included in the stage 2 review. The findings included: The facility's Elopement Prevention policy documented, .residents who are at risk for elopement/wandering will also be care planned with appropriate approaches to prevent elopement .The licensed nurses will use a code alert function check sheet placed with the Medication Administration Record [REDACTED].code alert .bracelet and it is checked for functioning and inspected daily for wear and tear or expiration . Medical record review revealed Resident #192 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated [DATE] documented, .Resident at risk for elopement as evidenced by the following risk factor .Wanders about facility .Exhibits exit seeking behaviors .Place monitoring device on resident that sounds alarms when resident leaves building . Review of the Code Alert Function Check Sheet for (YEAR) revealed there was no documentation that the code alert bracelet was checked for Resident #192 on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. The code alert bracelet worn by Resident #192 was not checked for 48 days between the months of (MONTH) and November. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 8:15 AM, at the main nurses station, the ADON was asked how do you monitor the code alert bracelets. The ADON stat… | 2019-10-01 |
| 4393 | 4393 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 309 | D | 0 | 1 | 5EH511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to follow the facility's policy to obtain post [MEDICAL TREATMENT] vital signs for 1 of 1 (Resident #58) sampled residents receiving [MEDICAL TREATMENT]. The findings included: The facility's Protocol for Care of Resident's Receiving [MEDICAL TREATMENT] Treatment policy documented, .Check and record vital signs .after [MEDICAL TREATMENT] treatment .If unstable .notify MD (Medical Doctor) . Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].HD ([MEDICAL TREATMENT]) .on Monday .Wednesday and Friday . Review of the vital signs records for Resident #58 revealed that a post [MEDICAL TREATMENT] blood pressure was not obtained on 10/3, 10/5, 10/10, 10/12, 10/14, 10/17, 10/19, 10/21, 10/24, 10/26, 11/2, and 11/4. Interview with Licensed Practical Nurse (LPN) #6 on 11/9/16 at 10:32 AM, at the 100 hall nurses' station, LPN #6 was asked what she would expect nurses to assess and chart when a resident returns from [MEDICAL TREATMENT]. LPN #6 stated, Weight, vital signs, monitor the graft to make sure the dressing is dry and intact, no bleeding .you could lose a whole bunch of blood real quick . Interview with the Assistant Director of Nursing (ADON) on 11/9/16 at 3:15 PM, in the Activity Room, the ADON was asked if vital signs were obtained after every [MEDICAL TREATMENT] treatment for [REDACTED]. The ADON reviewed the vital sign flow sheets, and stated, No . Interview with the Director of Nursing (DON) on 11/10/2016 at 11:11 AM, in the Activity Room, the DON was asked if the nurses should be checking the vital signs, including the blood pressure, when residents return from [MEDICAL TREATMENT]. The DON stated, .yes they should | 2019-10-01 |
| 4394 | 4394 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 314 | E | 0 | 1 | 5EH511 | **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].#225) sampled residents reviewed of the 4 residents with pressure ulcers. The findings included: 1. The facility's WOUND MANAGEMENT policy documented, .a skin risk assessment (Norton Risk Assessment) is done on every resident upon admission and updated quarterly .Once a wound/pressure ulcer is identified, an initial assessment is completed .Family and doctor are notified .daily wound treatment documentation is completed on the Treatment Administration Record (TAR) .Weekly documentation sheets on each wound . The facility's STANDING ORDERS documented, .STAGE III (3) .CONTACT MD (medical doctor) for treatment orders . 2. Medical record review revealed Resident #225 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. An Ambulance Transportation Physician Certification Statement dated 11/4/16 documented, .medical condition .at the time of ambulance transport .Decubitus Sacral Ulcer . The physician's admission orders [REDACTED].Wound care . Review of the Wound Assessment Report(s) and nurses notes revealed no wound assessment was completed upon admission on 10/19/16 for Resident #225. A physician's orders [REDACTED].Cleanse sacral wound (with) DWC (Dermal Wound Cleanser) .Apply Santyl .Ca+ (Calcium) alginate (and) secure with cover dsg (dressing) (and) (change) q (every) day (and) prn (as needed) . Review of Treatment Administration Record for (MONTH) (YEAR) revealed the treatments were not performed as ordered on 10/22 and 10/23/16. Review of the Wound Assessment Reports and nurses' notes revealed no wound assessment was completed, and no treatment orders were obtained upon readmission on 11/4/16 for Resident #225. Review of Wound Assessment Reports dated 11/7/16 documented a sacrum/lower back Stage 3 Pressure Ulcer with measurements of 3 centimeters (c… | 2019-10-01 |
| 4395 | 4395 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 322 | D | 0 | 1 | 5EH511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure 1 of 1 (Licensed Practical Nurse (LPN) #4 )nurses flushed a Percutaneous Endoscopic Gastrostomy (PEG) tube before administering PEG medications. The findings included: The facility's ENTERAL TUBE MEDICATION ADMINISTRATION POLICY AND PR[NAME]EDURES policy documented, .Flush the tube with at least 30 mls (milliliters) of water prior to medication administration . Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The November, (YEAR) physician's orders [REDACTED]. Observations in Resident #52's room on 11/8/16 beginning at 4:58 PM, revealed LPN #4 administered 2 medications via a PEG tube, and did not flush the PEG prior to the first medication given. Interview with the Director of Nursing (DON) on 11/9/16 at 1:58 PM, in the Activity Room, the DON was asked what should be done prior to giving a medication per PEG. The DON stated, .Should flush with about 30 cc water . | 2019-10-01 |
| 4396 | 4396 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 323 | D | 0 | 1 | 5EH511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure the environment was free from accident hazards as evidenced by unsecured chemicals in 9 of 85 (Room 106, 117, 125, 200, 201, 204, 210, 304, and 314) resident rooms, and failed to monitor a code alert bracelet for 1 of 23 (Resident #192) sampled residents of the 23 residents included in the stage 2 review. The findings included: 1. The facility's (Facility Name) Rules and Reminders policy documented, .The following items ARE NOT ALLOWED in resident rooms due to safety reasons .Peroxide .Spray/aerosol items .Nail Polish .Cleaning Products . A Wanderers list provided by the facility documented 20 wanderers resided in the facility. Observations in random resident rooms on [DATE] revealed the following: a. 10:45 AM in Room 314, a 28 ounce bottle of dishwashing liquid and 1 bottle of hydrogen peroxide. b. 10:50 AM in Room 304, one solid air freshener and 1 can of shaving cream. c. 10:21 AM in Room 210, 160 count germicidal wipes. d. 8:29 AM in Room 125, one bottle of nail polish. e. 8:15 AM in Room 117, one can of shaving cream. f. 8:12 AM in Room 106, one container air freshener pearls. g. 4:45 PM in Room 200, one solid air freshener. h. 4:47 PM in Room 201, 21 denture cleanser tablets and 1 razor. i. 4:50 PM in Room 204, one solid air freshener. Interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 5:02 PM, on the 200 hall, LPN #4 was asked what residents can have in their rooms. LPN #4 stated, .everything must be kept put up in cabinets and drawers, we do have wanderers. LPN #4 was asked if she would expect to find a bottle of hydrogen peroxide in a resident's room. LPN #4 stated, Absolutely not. LPN # 4 was asked if aerosol sprays or dishwashing liquid should be in the residents' rooms. LPN #4 stated, No. Interview with LPN #7 on [DATE] on 5:12 PM, at the 300 hall cart, LPN #7 was asked if she would expect to find a bottle of hydrogen peroxide in a residen… | 2019-10-01 |
| 4397 | 4397 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 371 | D | 0 | 1 | 5EH511 | Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions as evidenced by 1 of 13 (Certified Nursing Assistant (CNA) #) staff members touched residents' food during dining without performing proper hand. The findings included: 1. The facility's Hand-hygiene Technique policy documented, .to prevent and to control the spread of infectious diseases .hand washing .must be performed under the following conditions .Before and after .handling food .use an alcohol-based hand rub for all of the following situations .after contact with inanimate objects .in the immediate vicinity of the resident .after removing gloves . 2. Observations in Resident #105's room on 11/7/16 beginning at 11:50 AM, revealed CNA #4 donned gloves, touched Resident #105 to apply a clothing protector, went to the closet and opened it using gloved hands, obtained a chair and placed it beside Resident 105. CNA #4 sat in the chair and touched it to position it closer to Resident 105. CNA #4 then removed the cover to Resident #105's plate, removed the silverware, and began to cut the meat on the plate, touching it with her gloved hands. CNA #4 picked up the roll and touched the beets with her gloved hands, and fed them to Resident #105. CNA #4 did not remove the gloves or perform hand hygiene before touching the food and feeding the resident. Interview with the Director of Nursing (DON) on 11/10/2016 at 11:11 AM, in the Activity Room, the DON was asked if CNAs should wear gloves when they are assisting residents to eat. The DON stated, They don't have to wear gloves unless they are going to touch the food. The DON was asked if a CNA should put on gloves, touch the resident, the closet door, and a chair with the gloved hands, then touch and serve the food with the same gloves. The DON stated, They should remove those gloves and wash their hands . | 2019-10-01 |
| 4398 | 4398 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 431 | D | 0 | 1 | 5EH511 | Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored when 1 of 5 (Licensed Practical Nurse (LPN) #4) nurses left medications unattended during medication pass observations. The findings included: The facility's Medication Storage Policy documented, .11. Medication rooms will remain locked at all times and only accessed with a licensed nurse present . Observations in Resident #52's room on 11/8/16 at 4:58 PM, revealed LPN #4 placed crushed medications in a cup on an overbed table, left the resident's room, and walked down the hall to get a graduated cup from the medication cart, leaving the medications on the overbed table, in the room, out of the nurse's sight. Interview with the Director of Nursing (DON) on 11/9/16 at 1:58 PM, in the Activity Room, the DON was asked if medications should be left in a room unattended. The DON stated, They (medications) should be in the line of sight (of the nurse) . | 2019-10-01 |
| 4399 | 4399 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-11-10 | 441 | D | 0 | 1 | 5EH511 | Based on policy review, observation, and interview, the facility failed to prevent the potential spread of infection when 2 of 5 (Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1) nurses failed to perform proper hand hygiene and properly clean a glucometer during medication pass observations. The findings included: 1. The facility's Hand-hygiene Technique policy documented, .Policy To prevent and to control the spread of infectious diseases. Purpose The purpose of this procedure is to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that will aid in prevention of the transmission of infections .If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations .j. After removing gloves . 2. The facility's Glucometer-Maintenance, Cleaning and Disinfecting policy documented, .Policy To maintain appropriate infection control guidelines when using and maintaining the glucometer and the monitoring of blood sugar levels. Purpose To ensure that correct cleaning and disinfecting of the glucometer is followed to prevent the potential transmission of infectious organisms .Procedure .Clean and disinfect the meter between residents .A) .Cleaning and disinfecting to be completed by using an EPA-registered disinfectant detergent or germicide wipe . 3. Observations in the 200 hall on 11/8/16 beginning at 4:04 PM, revealed LPN #2 applied gloves, cleaned the glucometer with a Sani-wipe with bleach, and removed her gloves without performing hand hygiene. LPN #2 applied new gloves, obtained the supplies, and entered Resident #228's room. LPN #2 forgot the glucometer strip, removed a glove from her hand, walked to the medication cart in the 200 hall, and obtained a glucometer strip. LPN #2 applied a new glove to her hand, without performing hand hygiene, went to Resident #228's room and performed an accucheck for this resident. LPN #2 disposed of the supplies, walked to the medication cart, cleaned the glucometer and then removed her gloves. 4. … | 2019-10-01 |
| 5009 | 5009 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2016-06-29 | 205 | E | 1 | 0 | IW9S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, record review, and interview the facility failed to provide the written notification of the bed hold policy within for 3 of 3 (Resident #1, 2 and 3) sampled residents priot to discharge to a hospital/ behavioral center. The findings included: 1. The facility's ADMISSION AGREEMENT documented, .3.6 Bed Hold Policy. Before a resident may be transferred to a hospital or for a therapeutic leave, the Center is required to provide the Center's bed hold policy to the resident and a family member or Legal Representative. The bed hold policy includes any State bed hold requirements and information on how Medicare only and private pay residents may request and obtain a bed hold . The facility's Attachment D - Bed Hold Policy documented, .the time the Resident is to leave the Center for a temporary stay in a hospital or for therapeutic leave, (or within (not visable on copy) hours in case of an emergency transfer) the Resident/Legal Representative will be given a written copy of the Bed (not visable on copy) Policy . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1 was discharged to a behavioral center on 8/20/15 and did not return to this facility. There was no documentation of the bed hold policy being given to the resident or family when the resident was discharged . 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident was discharged to a hospital on [DATE] with readmission on 7/13/16 at 9:30 PM. There was no documentation of the bed hold policy being given to the resident or family when the resident was discharged . 4. Medical record review revealed Resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident was discharged to a behavioral center on 3/22/16 with readmission 4/5/16. There was no documentation of bed hold policy being given to the resident or family when t… | 2019-06-01 |
| 5674 | 5674 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2015-09-23 | 278 | D | 0 | 1 | M3UB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess a resident's vision status for 1 of 21 (Resident #115) sampled residents of the 36 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/12/15 documented adequate vision with corrective lenses. The 60-day MDS with an ARD of 7/31/15 documented impaired vision with no corrective lenses. Interview with MDS Coordinator #1 on 9/22/15 at 4:31 PM, in the MDS Office, MDS Coordinator #1 was asked about the 60 day MDS assessment that documented, .Impaired Vision . No corrective lenses . MDS Coordinator #1 stated, Her full admission assessment (MDS) has her with glasses. She had glasses, and it was just marked wrong on the 60 day assessment. MDS Coordinator #1 was then asked if the 60 day MDS dated [DATE] was inaccurate. MDS Coordinator #1 stated, Yes. | 2019-01-01 |
| 5675 | 5675 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2015-09-23 | 279 | D | 0 | 1 | M3UB11 | **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 related to vision, wandering, and/or behaviors for 3 of 21 (Residents #82, 144, and 200) sampled residents reviewed of the 36 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/7/15 documented Resident #82 had impaired vision and no corrective lenses. The care assessment trigger worksheet dated 9/7/15 documented, Will proceed to pcp (patient care plan). Resident requires larger print to read, does have reading glasses but often does not wear . The care plan dated 8/31/15 revealed there was no care plan present for vision. Observations in Resident #82's room on 9/21/15 at 10:11 AM, 10:55 AM and 3:03 PM and on 9/22/15 at 10:50 AM and 2:45 PM, revealed Resident #82 in bed, watching the television (TV) with no glasses in use. Interview with MDS Coordinator #1 on 9/22/15 at 4:20 PM, in the MDS office, MDS Coordinator #1 stated this resident does have glasses, but does not always wear them. MDS Coordinator #1 was asked if there was a care plan for vision for this resident. MDS Coordinator #1 stated, Well, no, I don't see one, will have to add it. 2. Medical record review revealed Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS with an ARD of 9/4/15 revealed the behavior of wandering. The care plan dated 8/28/15 revealed there was no care plan for wandering. Observations in Resident #144's room on 9/22/15 at 8:49 AM, revealed Resident #144 lying in bed watching TV with a wanderguard on his right ankle. Interview with MDS Coordinator #1 on 9/22/15 at 9:47 AM, in the activities room, MDS Coordinator #1 was asked if Resident #144 should have a care plan for wandering. MDS Coord… | 2019-01-01 |
| 5676 | 5676 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2015-09-23 | 431 | D | 0 | 1 | M3UB11 | Based on policy review, observation and interview, the facility failed to ensure medications were stored safely and not stored past their expiration date in 2 of 9 (200 hall medication cart and 100 hall extended medication cart) medication storage areas. The findings included: 1. The facility's Medication Storage Policy documented, .7. Expired, outdated, contaminated or deteriorated medications and those which are cracked, soiled or without secure closures should be removed from stock and discarded either in a sharps container or placed in a box in the medication room for destruction . Observations in the 200 hall, on 9/22/15 at 8:25 AM, revealed the 200 hall medication cart had a sinus rinse stored past the expiration date of 7/2015. Interview with Licensed Practical Nurse (LPN) #1 on 9/22/15 at 8:27 AM, in the 200 hall, LPN #1 was asked if the sinus rinse was expired. LPN #1 stated, Uh huh, it is. We must have thrown away the wrong box. Need to put it (expired sinus rinse) in the destroy med (medication) box. 2. Observations in the extended 100 hall on 9/22/15 at 9:00 AM, revealed the extended 100 hall medication cart contained a white tablet in a medication cup, unlabeled. Interview with LPN #2 on 9/22/15 at 9:03 AM, in the extended 100 hall, LPN #2 was asked how she would know what an unlabeled medication was. LPN #2 stated, I wouldn't know. LPN #2 was asked if she would give an unlabeled medication to a resident. LPN #2 stated, No. Interview with the Director of Nursing (DON) on 9/23/15 at 11:00 AM, in the DON office, the DON was asked how she expected nurses in the facility to handle expired medications found on a medication cart. The DON stated, Remove them and destroy them properly. The DON was asked what she expected nurses to do with opened medications in unlabeled containers. The DON stated, If I found it, I would destroy it. The DON was asked if unlabeled medications should be on the medication cart. The DON stated, No. | 2019-01-01 |
| 5677 | 5677 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2015-09-23 | 441 | D | 0 | 1 | M3UB11 | Based on policy review, observation, and interview, the facility failed to ensure 1 of 6 (Licensed Practical Nurse (LPN) #1) nurses performed hand hygiene to prevent the spread of infection and cross contamination during medication administration. The findings included: The facility's Hand-hygiene Technique policy documented, .Policy To prevent and to control the spread of infectious diseases . General Guidelines . 3. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations . j. After removing gloves . Observations in Resident #22's room on 9/22/15 starting at 11:23 AM, revealed LPN #1 applied gloves, performed an accucheck, removed her gloves, disposed of the supplies, and washed her hands. LPN #1 proceeded to the medication cart, applied gloves, cleansed the glucometer, and removed her gloves without performing hand hygiene. LPN #1 then applied gloves, prepared insulin for Resident #22, and removed her gloves without performing hand hygiene. LPN #1 entered Resident #22's room, applied gloves, and administered insulin to Resident #22. Interview with the Director of Nursing (DON) on 9/23/15 at 11:00 AM, in the DON office, the DON was asked what should be done between glove use. The DON stated, They (staff) should wash their hands. | 2019-01-01 |
| 7348 | 7348 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 176 | D | 0 | 1 | 04YV11 | **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 have an assessment or a physician's orders [REDACTED].#157) residents observed self-administering medications. The findings included: Review of the facility's Medication Administration Policy and Procedure documented, .25. The resident consumes the medications in the nurse's presence . Review of the facility's Self- Administration of Drugs Policy Statement documented, 1. Residents will not be permitted to administer . unless so ordered by the attending physician and approved by the care planning team . Medical record review for Resident #157 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #157 had significant cognitive impairment. The facility was unable to provide documentation that Resident #157 was assessed to be safe to self administer medications. Observations from the 100 hall on 8/5/14 at 3:50 PM, revealed Resident #157 alone in her room with a Nebulizer mask on, receiving a breathing treatment. Nurse #2 was 3 doors down the hallway at the medication cart. During an interview on the 100 hall on 8/5/14 at 3:52 PM, Nurse #2 was asked if she left Resident #157 unattended while she was completing a breathing treatment. Nurse #2 stated, Yes. Nurse #2 was asked if she usually stays with Resident #157 while she is receiving a breathing treatment. Nurse #2 stated, No, but I always stand close by. During an interview in the Director of Nursing's (DON) office on 8/6/14 at 2:45 PM, the DON was asked if she would expect a nurse to leave a resident unattended while a breathing treatment was being administered. The DON stated, I might step away from them, but I would make sure the resident was still in my sight. The DON was asked if it was appropriate for a nurse to be out in the hall, 3 doors down while a resident was receiving a breathin… | 2018-02-01 |
| 7349 | 7349 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 242 | D | 0 | 1 | 04YV11 | **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 staff honored the resident's choice to remain up in the wheelchair for 1 of 25 (Resident #121) sampled residents of the 38 residents in the stage 2 review. The findings included: Review of the facility's Resident Right policy documented, .The Resident has the right to exercise his or her rights as a resident of the Center as a citizen or resident of the United States . Medical record review for Resident #121 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 6/7/14 revealed section C for cognition was coded as 13 indicating Resident #121's cognition was intact for decision-making. Section G for functional status coded Resident #121 as being dependent for toileting needs, requires extensive assistance with transfers and bed mobility and bowel and bladder incontinence. Review of the care plan dated 3/13/14 documented .Requires assist with activities of daily living . assist with bathing, dressing, and grooming and personal care as needed . use communication board as needed . assist with transfers prn (as needed) . Observations in Resident's room [ROOM NUMBER] on 8/5/14 at 10:05 AM, Resident #121 requested in writing, I don't want to go back to bed. I just want to be dried. Certified Nursing Assistance (CNA) #1 entered Resident #121's room at 10:14 AM, used a hoyer lift to transfer Resident #121 from her wheelchair onto her bed. CNA #1 stated, Would come back later after lunch and get her back up. During an interview on the 200 hall on 8/5/14 at 10:20 AM, CNA #1 was asked if she had read Resident #121's dry erase board prior to beginning incontinence care. CNA #1 stated, Yes ma'am. She said she didn't want to go to bed. During an interview at the 100 hall nurses' station on 8/5/14 at 3:37 PM, CNA #2 was asked what type of care Re… | 2018-02-01 |
| 7350 | 7350 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 278 | D | 0 | 1 | 04YV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to accurately assess a resident for [MEDICAL TREATMENT] for 1 of 3 (Resident #62) sampled residents reviewed of the 38 residents included in the stage 2 review. The findings included: Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].[MEDICAL TREATMENT] TUES (TUESDAY), THUR (THURSDAY), SAT (SATURDAY), W (WITH) (named [MEDICAL TREATMENT] facility) . Review of the quarterly Minimum Data Set ((MDS) dated [DATE] did not document Resident #62 was receiving [MEDICAL TREATMENT]. During an interview in the MDS office on 8/5/14 at 5:10 PM, MDS Nurse #1 was asked why the MDS was not marked for [MEDICAL TREATMENT] for Resident #62. MDS Nurse #1 stated, She (Resident #62) should have been. She has been on [MEDICAL TREATMENT] forever. I will do a correction on that. | 2018-02-01 |
| 7351 | 7351 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 280 | D | 0 | 1 | 04YV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to revise the care plan for behaviors or nutrition for 2 of 25 (Residents #137 and 205) sampled residents reviewed of the 38 residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #137 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/14 section E was coded as 1 indicating Resident #137 exhibited physical behavioral symptoms directed toward others and rejection of care had occurred 1 to (-) 3 days. Review of the care plan dated 5/19/14 did not include interventions for Resident #137's behavioral problems. 2. Medical record review for Resident #205 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 6/20/14 documented, .Risk for further weight loss, fluid volume deficit, alteration in nutrition / electrolytes, r/t (related to) new admit with Dx (diagnosis) Failure to Thrive, Anorexia, Poor Appetite, Diabetic, recent s/p (status [REDACTED]. Review of Resident #205's weight records documented the following: a. 6/21/14 - 126 pounds. b. 6/27/14 - 120 pounds. c. 7/4/14 - 118 pounds. The weight record documented a 6.3 percent (%) weight loss over a 2 week period of 6/21/14 through 7/4/14. There were no new interventions included on the care plan when Resident #205 had experienced a 6.3 percent (%) weight loss. During an interview in the activities room on 8/6/14 at 4:50 PM, the Certified Dietary Manager verified their were no new interventions on the care plan related to Resident 205's weight loss. | 2018-02-01 |
| 7352 | 7352 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 322 | D | 0 | 1 | 04YV11 | Based on policy review, observation and interview, it was determined the facility failed to ensure 1 of 2 (Nurse #1) medication nurses checked the Percutaneous Endoscopy Gastrostomy (PEG) tube placement according to the facility's policy prior to administering medications. The findings included: Review of the facility's enteral tube medication administration policy documented, .3. Verify tube placement . (1.) Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds; or (2) aspirate stomach contents with the syringe . Observations in Resident #121's room on 8/4/14 at 10:28 AM, revealed Nurse #1 checked Resident #121's PEG tube placement by placing the stethoscope on the resident's abdomen and then flushed the PEG tube with 30 cubic centimeters (cc's) of water. Nurse #1 did not verify the tube placement by either inserting air into the tube and listen with a stethoscope for gurgling sounds or aspirate tomach contents to ensure proper placement of the PEG tube, as per the facility's policy for verify the placemnt of the PEG tube. During an interview on the 100 hall on 8/4/14 at 10:45 AM, Nurse #1 was asked how she checked placement of the PEG tube. Nurse #1 stated, I flush with 30 cc's water and listen. During an interview in the Director of Nursing's (DON) office DON's on 8/6/14 at 2:45 PM, the DON was asked what would you expect a nurse to do prior to administering medications via a PEG tube. The DON stated, Check Placement. The DON was asked how the nurse should check placement of the tube. The DON stated, By auscultating or aspiration; usually both. Inject a bolus of air and listen to the belly. | 2018-02-01 |
| 7353 | 7353 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 323 | D | 0 | 1 | 04YV11 | Based on observation and interview, it was determined the facility failed to ensure biologicals were safely stored as evidenced by a bottle of Isopropyl rubbing alcohol sitting on the overbed table in a resident's room on 2 of 3 (8/4/14 and 8/5/14) days of the survey. The findings included: Observations in Resident #186's room on 8/4/14 at 8:01 AM and 11:26 AM and on 8/5/14 at 7:41 AM and 1:45 PM, revealed a bottle of Isopropyl rubbing alcohol sitting unattended on the overbed table in Resident #186's room. During an interview on the administrative hall on 8/5/14 at 1:45 PM, the Director of Nursing (DON) was asked if it was acceptable to leave a bottle of Isopropyl rubbing alcohol unattended on the overbed table of a resident's room. The Director of Nursing stated, No. | 2018-02-01 |
| 7354 | 7354 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 325 | E | 0 | 1 | 04YV11 | **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 address the nutritional status of 2 of 3 (Residents #205 and 225) sampled residents of the 6 residents reviewed with nutritional issues in the stage 2 review. The findings included: 1. Review of the facility's Weight Variance Monitoring policy documented, .To facilitate identification and assessment of residents with unstable, unplanned weight fluctuations and to provide an interdisciplinary approach to resident assessment and intervention in the treatment of [REDACTED]. Staff members obtaining resident weights will be educated on procedures for obtaining accurate weights and for reporting unusual or significant weight variances to the licensed nurse . Residents showing a significant weight variance will be re-weighed prior to taking other action . Unusual or significant weight variances will be reported to the physician, the resident and the responsible party by the charge nurse. This will be documented in the resident's record . 2. Medical record review for Resident #205 with an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #205's weight records documented the following: a. 6/21/14 - 126 pounds. b. 6/27/14 - 120 pounds. c. 7/4/14 - 118 pounds. The weight record documented a 6.3 percent (%) weight loss over a 2 week period of 6/21/14 through 7/4/14. Review of the care plan dated 6/20/14 documented, .Risk for further weight loss, fluid volume deficit, alteration in nutrition/electrolytes, r/t (related to) new admit with Dx (diagnosis) Failure to Thrive, Anorexia, poor appetite, diabetic, recent s/p (status [REDACTED]. There were no new interventions included on the care plan when Resident #205 had experienced a 6.3 percent (%) weight loss. During an interview in the activity's office on 8/6/14 at 4:50 PM, the Certified Dietary Manager (CDM), was asked about Resident #205's weight loss. The CDM stated, I don't see it i… | 2018-02-01 |
| 7355 | 7355 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 332 | D | 0 | 1 | 04YV11 | **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 2 of 9 (Nurses #1 and 3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 12 errors were observed out of 26 opportunities for error, resulting in a medication error rate of 46.15%. The findings included: 1. Review of the facility's medication administration policy documented, .4. Medications are administered . double-checked before administering . 2. Medical record review for Resident #121 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #121's physician's orders [REDACTED].Cerovite Liquid Take 5 milliliters (ml) by mouth daily . [MEDICATION NAME] 40 mg (milligrams) tablet [MEDICATION NAME] 40 mg tablet take 1 tablet per PEG tube daily . [MEDICATION NAME] 30 mg tablet take 1 tablet per PEG tube daily . [MEDICATION NAME] Powder Polyethylene [MEDICATION NAME] 330 Mix 17 grams (cap is measure) in 8 ounces (ozs) of water/juice and take by mouth daily . [MEDICATION NAME] 75 mg tablet [MEDICATION NAME] 75 mg tablet take 1 tablet per PEG tube daily . Calcium 600 + (plus) Vitamin D 200 take 1 tablet per PEG tube 2 times daily . [MEDICATION NAME] 100 mg tablet take 1 tablet per PEG tube 2 times daily . [MEDICATION NAME] 325 mg tablet take 2 tablets (650 mg) by mouth three times daily . [MEDICATION NAME] 25 mg tablet take 1 tablet per Tube 3 times daily . [MEDICATION NAME] 50 mg tablet take 1 tablet per Tube 3 times daily . [MEDICATION NAME] 400 mg capsule [MEDICATION NAME] 400 mg capsule take 1 capsule by mouth 3 times daily . [MEDICATION NAME] 50 mg tablet [MEDICATION NAME] HCL 50 mg tab (tablet) take 1 tablet by mouth 3 times daily . [MEDICATION NAME] 8,000 U/ml (units per milliliter) Take 6.25 ml (50,000 U) by mouth once weekly on Mondays . Observations in Resident #121's room on 8/4/14 beginning at 10:28 AM, revealed Nurse #1 administered ele… | 2018-02-01 |
| 7356 | 7356 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 371 | E | 0 | 1 | 04YV11 | Based on policy review, observation and interview, it was determined the facility failed to maintain kitchen sanitation as evidenced by chicken salad stored past the 3 day storage; dirty kitchen equipment and 1 of 5 (Dietary staff member #1) dietary staff members failed to ensure hair was covered by a hair net or beard cover and plates covers were not held against clothes prior to being placed over the plates on the tray line. The findings included: 1. Review of the facility's leftover food storage policy documented, .10. The following guidelines are to be used for length of storage in refrigerators . 1 to 3 DAY STORAGE .SALADS . Observations in the kitchen on 8/4/14 at 8:08 AM revealed, a container of chicken salad in the refrigerator dated 7/28/14. During an interview in the kitchen on 8/4/14 at 8:08 AM, the Certified Dietary Manager (CDM) was asked about the length of time food was stored. The CDM stated, 2 to 3 days. 2. Review of the facility's personal hygiene policy documented, .3. HEAD COVERING WORN: a . Hair must be appropriately restrained or completely covered . c . Beards . must be covered . Observations in the kitchen on 8/5/14 at 8:35 AM and 10:55 AM, revealed dietary staff member #1 did not have a beard cover on and his hair was not completely covered by the hair net. During an interview at the main nurses' station on 8/5/14 at 2:45 PM, the CDM was asked if employees hair and beards should be covered in the kitchen. The CDM stated, Uh huh. 3. Review of the facility's meat slicer policy documented, .SANITATION OF EQUIPMENT . 4. Scrub, rinse, and sanitize parts in pot and pan sink . Observations in the kitchen on 8/5/14 at 8:40 AM, revealed the meat slicer was noted to have brown substance on the base. During an interview in the kitchen on 8/5/14 at 8:41 AM, the CDM was asked about the brown substance on the meat slicer. The CDM stated, I don't know what that is. 4. Observations in the kitchen on 8/5/14 at 11:06 AM, revealed dietary staff member #1 took plate covers off the rack and held them against … | 2018-02-01 |
| 7357 | 7357 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 431 | D | 0 | 1 | 04YV11 | Based on policy review, observation and interview, it was determined the facility failed to ensure discontinued medications were disposed of properly for 1 of 6 (200 hall) medication carts, and failed to ensure food was not stored in the medication refrigerator / freezer in 1 of 2 (500 hall) medication refrigerator / freezers. The findings included: 1. Review of the facility's medication storage policy documented, .9. Medication that is discontinued (except controlled substances) shall be returned to the pharmacy for credit when appropriate, with the next regularly scheduled medication delivery. Observations on the 200 hall on 8/5/14 at 8:40 AM, revealed Nurse #5 placed 6 Clonodine 0.1 milligram tablets in the trash bin on the 200 medication cart. 2. Review of the facility's Medication Storage Policy documented 6 . Lunches and other foods should not be kept in the refrigerator with the medication . Observations in the 500 hall medication storage room on 8/5/14 at 10:35 AM, revealed 1 can of coffee stored in the 500 hall medication refrigerator / freezer. 3. During an interview in the Director of Nursing's (DON) office on 8/5/14 1:05 PM, the DON was asked if medication should be disposed of in the trash bin on the medication cart. The DON stated, No. It should be returned or destroyed. The DON was also asked if a can of coffee should be stored in the freezer of the medication refrigerator. The DON stated, No. | 2018-02-01 |
| 7358 | 7358 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2014-08-06 | 441 | D | 0 | 1 | 04YV11 | **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 proper infection control practices were provided to prevent contamination or cross contamination in 1 of 1 (Resident #144's room) isolation room. The findings included: Review of the facility's Clostridium difficile (C-Diff) infection control policy documented, use of 10% (percent) sodium hypochlorite solution mixed fresh daily (one part household chlorine bleach mixed with nine parts tap water) has been associated with the reduction in C. (Clostridium) difficile infections in some settings. The water and mop head used to clean a resident's room should changed prior to cleaning another room . Medical record review for Resident #144 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a laboratory test result dated 8/5/14 documented a positive test for C-Dif. Observations on the 400 hall on 8/4/14 at 8:00 AM, revealed a sign on the door of Resident #144's room to see nurse before entering the room and there was an isolation cart located by the door. Observations on the 400 hall on 8/6/14 at 12:55 PM, revealed a sign on the door indicating contact isolation precautions. During an interview on the 500 hall on 8/6/14 at 2:20 PM, the Housekeeping Supervisor (HKS) was asked how are rooms cleaned when a resident has[DIAGNOSES REDACTED]. The HKS stated, Dress out, disinfect room both beds, spray garbage cans, curtains, mop. The HKS was asked to show the surveyor the products used to clean the room. The HKS stated, Yes, they (supplies) are down here in (housekeeping storage room). The surveyor followed the HKS to the 100 hall storage room. The HKS proceeded to show the surveyor the different products. The surveyor asked the HKS if the products used to mop and spray the room contained bleach. The HKS stated, No, none of these products (indicating all the cleaning products on the shelf in the room). | 2018-02-01 |
| 9371 | 9371 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2013-05-08 | 159 | D | 0 | 1 | ZF6511 | Based on policy review and interview, it was determined the facility failed to ensure that residents' had accessibility to their funds at their request for 2 of 23 (Residents 68 and 33) sampled residents of the 23 residents included in the stage 2 review. The findings included: 1. Review of the facility's .Patient Trust fund policy and procedure documented, .The petty cash needs to be available 24 hours a day 7 days a week . 2. During an interview in Resident #68's room on 5/6/13 at 10:26 AM, Resident #68 was asked, Do you have a personal funds account with the facility? Resident #68 stated, Yes. Resident #68 was asked can you get your money when you need it. Resident #68 stated, No . get it on Friday . otherwise can't get it on the weekend . 3. During an interview in Resident #33's room on 5/6/13 at 4:13 PM, Resident #33 was asked, Do you have a personal funds account with the facility? Resident #33 stated, Yes. Resident #33 was asked can you get your money when you need it. Resident #33 stated, No . just Monday through Friday . 4. During an interview in the business office on 5/8/13 at 9:15 AM, the business office manager was asked if Resident #33 and 68 had a personal funds account with the facility. The business office manager stated, Yes. The business office manager was asked if the residents had access to their funds 24 hours a day 7 days a week. The business office manager stated, No . only during business hours . | 2017-01-01 |
| 9372 | 9372 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2013-05-08 | 278 | D | 0 | 1 | ZF6511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure the accuracy of the Minimum Data Set (MDS) related to [DIAGNOSES REDACTED].#143) sampled residents of the 23 residents included in the stage 2 review. The findings included: Medical record review for Resident #143 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day MDS dated [DATE] documented, Section I. Active [DIAGNOSES REDACTED].#143 documented, .dementia. During an interview in the MDS office on 5/8/12 at 2:39 PM, the MDS Coordinator stated, .ain't marked (Dementia) is it . it did not get on the MDS . | 2017-01-01 |
| 9373 | 9373 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2013-05-08 | 280 | D | 0 | 1 | ZF6511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, it was determined the facility failed to revise the comprehensive care plan to reflect interventions for a fall, nothing by mouth (NPO) status and pressure ulcer care for 3 of 23 (Residents #64, 154 and 173) sampled residents of the 23 residents included in stage 2 review. The findings included: 1. Medical record review for Resident #64 documented an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #64 comprehensive care plan dated 3/27/13 did not include a new intervention for a fall on 4/15/13. During an interview in the Minimum Data Set (MDS) office on 5/8/13 at 2:35 PM, Nurse #1 was asked if an intervention for the fall on 4/15/13 should have been place on the care plan. Nurse #1 stated, Yes, it (new intervention) should be (on the care plan) . 2. Medical record review for Resident #154 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/17/13 documented, .Potential for fluid volume deficit related to N/V (nausea and vomiting) . fluids on trays, offer extra fluids with meds (medication), between meals, at hs (bedtime) and if awake on 11- (to) 7 shift . Review of the physician's orders [REDACTED].DIET ORDERS . NPO (nothing by mouth) . [MEDICATION NAME] RENAL AT 35 ml (milliliters) / (per) HR (hour) X (times) 24 hrs (symbol for with) 25cc (cubic centimeters) H20 (water) (symbol for every) hr auto flush . Observations in Resident #154's room on 5/6/13 at 8:45 AM and on 5/7/13 at 7:40 AM, revealed Resident #154 lying in bed with [MEDICATION NAME] Renal infusing into enteral tube at 35cc/hr. During an interview in the MDS office on 5/8/13 1:20 PM, Nurse #1 was asked if the interventions on the care plan was updated to Resident #154's current status. Nurse #1 stated, No . During an interview at the main nurses station on 5/8/13 at 1:35 PM, the Director of Nursing (DON) confirmed th… | 2017-01-01 |
| 12076 | 12076 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2012-02-08 | 280 | D | 0 | 1 | QQMK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to revise the comprehensive care plan to address emergency bleeding for 2 of 3 (Residents #18 and 20) sampled residents receiving [MEDICAL TREATMENT]. The findings included: 1. Medical record review for Resident #18 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].@ (at) 1045 AM @ (named [MEDICAL TREATMENT] facility). Review of the Comprehensive Care Plan dated 1/2/12 contained no documentation to address emergency bleeding procedures. During an interview in the activities office on 2/8/12 at 2:30 PM, the Director of Nursing (DON) was asked to review Resident #18's comprehensive care plan. The DON confirmed there was no documentation on the care plan related to emergency bleeding precautions. 2. Medical record review for Resident #20 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 8/26/11 revealed no documentation to address emergency bleeding procedures for the [MEDICAL TREATMENT] shunt. During an interview in the activities office on 2/8/11 at 2:40 PM, the DON confirmed the correct measures for emergency bleeding were not on the care plan. | 2015-10-01 |
| 12077 | 12077 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2012-02-08 | 282 | D | 0 | 1 | QQMK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to develop a care plan for oxygen therapy for 1 of 8 (Resident #16) sampled residents. The findings included: Medical record review for Resident #16 revealed an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the recertification orders dated 1/28/12 documented, .O2 (oxygen) @ (at) BNC (bilateral nasal cannula) as needed to keep sats (saturations) above 92% (percent). Observations made during initial tour in Resident #16's room on 1/6/12 at 8:44 AM, revealed Resident #16 was on oxygen at a setting between 0 and 1 liter per minute. During an interview in the activities office on 1/8/12 at 2:40 PM, the Director of Nursing confirmed that there was no care plan for oxygen therapy for Resident #16. | 2015-10-01 |
| 12078 | 12078 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2012-02-08 | 315 | D | 0 | 1 | QQMK11 | **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 valid medical justification for the use of an indwelling catheter for 1 of 6 (Resident #13) sampled residents with a catheter. The findings included: Review of the facility's Foley Catheters, Care of, Infection Control and Insertion Guidelines policy documented, .Purpose. To prevent and control Foley catheter associated urinary tract infection. Urinary catheters should be inserted only when necessary and left in place only for as long as necessary. They should not be used for the convenience of resident care personnel. Medical record review for Resident #13 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #13's room on 2/6/12 at 9:50 AM, on 2/7/12 at 7:10 AM and 2:45 PM, and on 2/8/12 at 9:00 AM, revealed Resident #13 with an indwelling catheter. During an interview in the activities office on 2/8/12 at 9:25 AM, the Director of Nursing (DON) was asked why Resident #13 had a catheter. The DON stated, .because she has VRE. | 2015-10-01 |
| 12079 | 12079 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2012-02-08 | 328 | D | 0 | 1 | QQMK11 | **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) was administered at the rate prescribed by the physician for 1 of 8 (Resident #16) sampled residents receiving O2 therapy. The findings included: Medical record review for Resident #16 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].@ (at) 2L (liters) BNC (binasal cannula) AS NEEDED TO KEEP SATS (saturations) ABOVE 92% (percent). Observations in Resident #16's room on 2/6/12 at 8:44 AM, revealed Resident #16's O2 rate was set between 0 and 1 liters per minute, instead of the physician's prescribed rate of 2 L/minute. During an interview in the activities office on 2/8/12 at 2:40 PM, the Director of Nursing confirmed that Resident #16's O2 rate should be at 2L. | 2015-10-01 |
| 12080 | 12080 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2012-02-08 | 441 | D | 0 | 1 | QQMK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Material Safety Data Sheet standards, policy review, medical record review, observation and interview, it was determined the facility failed to maintain infection control practices to prevent the potential spread of infection by not properly cleaning a graduated cylinder used to empty a foley catheter and not following facility policy for contact precautions for 1 of 2 (Resident #13) sampled residents in contact isolation. The findings included: Review of the Material Safety Data Sheet documented, .IDENTITY (As Used on Label and List) First Choice PrimaGuard No-Rinse Perineal Wash. Section VI - Health Hazard Data.Health Hazards (Acute and Chronic) No-Rinse Perineal Wash is a mild detergent solution intended for topical human use, and should be used as directed. Review of the facility's Infection Control Recommendations for Long-Term Care Facilities policy documented, .II. RESIDENTS WITH URINARY CATHETERS. Use a separate container for collection of urine from each resident. Disinfect the container after each use. Review of the facility's Contact Precautions policy documented, Purpose. It is the intent of this facility to use contact precautions for residents known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Gloves and Handwashing 1. Gloves should be worn when entering the room and while providing care for a resident. 3. Gloves should be removed before leaving the resident's room and hands should be washed immediately. 4. After glove removal and handwashing, hands should not touch potentially contaminated environmental surfaces or items. Gowns 1. A gown should be worn when entering the room if it is anticipated that clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room. 3. After removal of the gown, clothing should not contact potentially contaminated environmental surfaces… | 2015-10-01 |
| 12081 | 12081 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2012-02-08 | 502 | D | 0 | 1 | QQMK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to obtain laboratory tests as ordered by the physician for 1 of 24 (Resident #10) sampled residents. The findings included: Medical record review for Resident #10 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. During an interview in the activities office on 2/8/12 at 10:15 AM, the Assistant Director of Nursing confirmed the lipid panel was not done as ordered by the physician. | 2015-10-01 |
| 13815 | 13815 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2010-11-09 | 309 | D | 0 | 1 | PWH411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to obtain physician orders [REDACTED].#15 and 21) sampled residents. The findings included: 1. Medical record review for Resident #15 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. (Tennessee) (named physician) to follow comfort measures.." During an interview at the central nurses station on 11/9/10 at 8:55 AM, the Assistant Director of Nursing (ADON) stated, "It (hospice order) didn't get brought over to the recert. (recertification) orders..." 2. Medical record review for Resident #21 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. (international units) D/C Calcium 600 w (with) vit 'D' 200 I (international) daily... Vit 'D' units po (by mouth) a monthly x (times) 6 Calcitrol 0.25 mcg (microgram) po three times a week... [MEDICATION NAME] 20 mg (milligram) po daily from 10/22/10..." Review of the Medication Administration Record [REDACTED] a. [MEDICATION NAME] 40 milligram was given from 11/1/10 through (-) 11/8/10 instead of the prescribed [MEDICATION NAME] 20 mg. b. Vitamin D 400 IU was given from 11/1/10 - 11/8/10 though it was supposed to be discontinued. c. Calcium 600 w/vit D 200 I was given 11/1/10 - 118/10 though it was supposed to be discontinued. d. Calcitrol 0.25 mcg was not given three times a week as ordered from 11/1/10 - 11/8/10. During an interview at the nurses' station on 11/8/10 at 2:45 PM, the ADON was asked about Resident #21's physicians orders dated 10/19/10. The ADON stated, "...They (Calcitrol 0.25 mcg and vitamin D units) should be on the MAR. They're not. It was done on the October (2010) MAR but not carried over on the November (2010) MAR." The ADON also confirmed that the vitamin D 400 IU and Calcium 600 w/vit D 200 I was not discontinued … | 2014-09-01 |
| 13816 | 13816 | MAPLEWOOD HEALTH CARE CENTER | 445412 | 100 CHERRYWOOD PLACE | JACKSON | TN | 38305 | 2010-11-09 | 441 | E | 0 | 1 | PWH411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review and observations, it was determined the facility failed to ensure 9 of 11 Certified Nursing Assistants (CNA #2, 3, 4, 5, 6, 7, 8, 10 and 11) washed their hands or turned the water off in a manner to prevent the potential spread of infection during dining observations. The findings included: 1. Review of the facility's hand washing policy documented, "...POLICY Title: Hand washing: Hand-hygiene technique... General Guidelines... 1. b...When washing hands with soap and water... Use towel to turn off the faucet... 3. i...After contact with inanimate objects... medical equipment..." 2. Observations on the 100 hall on 11/8/10 revealed the following: a. At 7:25 AM - Certified Nursing Assistant (CNA) #6 entered room [ROOM NUMBER] to deliver the meal tray. CNA #6 opened the straw with bare hands and then placed the straw in the resident's juice. CNA #6 did not wash her hands. b. At 7:30 AM - CNA #7 entered room [ROOM NUMBER] to deliver the meal tray. CNA #7 picked up the toast and opened the straw with bare hands. CNA #7 did not wash her hands. c. At 11:00 AM - CNA #8 entered room [ROOM NUMBER] to deliver the meal tray. CNA #8 opened the straw with her hands and placed the straw in the resident's juice. CNA #8 did not wash her hands. d. At 11:00 AM - CNA #11 entered room [ROOM NUMBER] to deliver the meal tray. CNA #11 picked up the bread with her bare hands and spread mayonnaise on the bread without washing her hands. 3. Observations on the 300 hall on 11/8/10 at 7:45 AM revealed the following: a. CNA #2 entered room [ROOM NUMBER] to deliver the meal tray. CNA #2 washed her hand and turned off the water with bare hands. b. CNA #3 entered room [ROOM NUMBER] washed her hands and then turned off the water with her bare hand. c. CNA #7 entered room [ROOM NUMBER] to deliver the meal tray. CNA #7 washed her hands but turned the water off with her bare hand. 4. Observations on the 400 hall on 11/8/10 at 7:45 AM, CNA #10 entered room [… | 2014-09-01 |
| 1436 | 1436 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2017-01-11 | 356 | C | 0 | 1 | TU9H11 | Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on 1/9/17 at 8:35 AM, in the facility main hallway, revealed the nurse staffing sheet posted was dated 1/7/17 and 01/8/17. Interview with Registered Nurse #1 on 1/9/17 at 8:50 AM, in the facility main hallway, confirmed the nurse staffing sheet posted was not for the current date. | 2020-09-01 |
| 1437 | 1437 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2017-01-11 | 431 | F | 0 | 1 | TU9H11 | Based on facility policy review, observation, and interview, the facility failed to appropriately dispose of expired medications and biologicals for 2 of 2 medication storage rooms. The findings included: Review of facility policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 1/1/13 revealed .Facility should ensure that test reagents, stored separately from medications .expiration dated on the label .not been retained longer than recommended by manufacturer or supplier guidelines .not been contaminated or deteriorated .staff should record the date opened on the medication container .staff .record the calculated expiration date based on date opened on the medication container .facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete damaged or missing labels .facility should ensure that the medications .are stored in the containers in which they were originally received .facility should destroy or return all discontinued, outdated/expired, or deteriorated medications .facility personnel should inspect .storage areas for proper storage compliance on a regularly scheduled basis . Review of facility policy, Disposal/Destruction of Expired or Discontinued Medications, dated 1/1/13 revealed .facility staff should destroy and dispose .out-dated medications . Observation with Licensed Practical Nurse #1 (LPN) on 1/11/17 at 10:30 AM, in the East medication storage room revealed the following expired items available for resident use: 1) 4 boxes Control Solutions Blood Glucose expired 9/2016 2) 1 box Control Solutions Blood Glucose expired 4/2016 3) 1 box Control Solutions Blood Glucose expired 6/2016 4) 10 Gluco-Chlor Towelettes (disinfectant) expired 10/2011 5) One 16 fl oz (fluid ounces) bottle of sterile water opened date 5/12 with 10% (percentage) used 6) Promethazine HCL (Hydrochloride) (medication to treat or prevent nausea and vomiting) 25 mg (milligrams) rectal suppository expired 12/2016 7) 5 Albuterol Sulfate (a bronchod… | 2020-09-01 |
| 1438 | 1438 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2018-02-14 | 655 | D | 0 | 1 | RWU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a baseline care plan for 1 Resident (#12) of 23 residents reviewed. The findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED].[MEDICATION NAME] . (an anti-anxiety drug) and .Basaglar Kwikpen . (insulin). Medical record review of the Baseline Care Plan dated 12/05/17, revealed the care plan failed to address instructions and provide effective person centered care on [MEDICAL CONDITION] drug and insulin usage. Interview with the Director of Nursing (DON) on 2/14/18 at 1:00 PM, in the DON office, confirmed the facility failed to develop a Baseline Care Plan and failed to include interventions for usage of [MEDICAL CONDITION] and insulin medications for Resident #12. | 2020-09-01 |
| 1439 | 1439 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2018-02-14 | 684 | D | 1 | 1 | RWU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to provide services by a Specialty Physician for 1 resident (#23) out of 3 residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Interview with Resident #23 on 2/12/18 at 10:37 AM, in his room, confirmed he had an appointment with a specialist. Further interview confirmed the facility had not transported the resident to his appointment. Medical record review of a physician's orders [REDACTED].Refer to spine neurologist for back pain . Interview with the Social Worker on 2/13/18 at 3:50 PM, in her office, confirmed the Nurse who signed the physician's orders [REDACTED]. Continued interview confirmed the facility failed to schedule the appointment. Interview with the Director of Nursing on 2/14/18 at 9:35 AM, in her office, confirmed the facility failed to make an appointment with the Neurologist for Resident #23. | 2020-09-01 |
| 1440 | 1440 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2018-02-14 | 758 | D | 0 | 1 | RWU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide evaluation and rationale for continued use of a PRN (as needed) antianxiety drug beyond 14 days for 1 Resident (#12) of 5 residents reviewed for unnecessary mediations of 23 sampled residents. The findings included: Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED].[MEDICATION NAME] . (an anti-anxiety drug) was prescribed PRN. Medical record review of physician progress notes [REDACTED]. Interview with the Director of Nursing (DON) on 2/14/18 at 1:00 PM, in the DON office, confirmed the facility failed to document rationale of the continued use of PRN antianxiety medication beyond the 14 days. | 2020-09-01 |
| 1441 | 1441 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2018-02-14 | 761 | D | 0 | 1 | RWU011 | Based on facility policy, observation and interview, the facility failed to ensure expired medications were not available for resident use in 1 of 3 medication carts observed. The finding included: Review of the facility policy .Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications . Observation and interview with Registered Nurse #1 on 2/14/18, at 8:41 AM, of Medication Cart #1, revealed 1 opened bottle of antacid 1/4 full which expired on 6/2017. Interview confirmed the medication was expired and available for patient use. Interview with the Director of Nursing (DON) on 2/14/17 at 9:20 AM, in the DON office, confirmed the medication was expired and available for patient use and the facility failed to follow their policy. | 2020-09-01 |
| 1442 | 1442 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2018-02-14 | 812 | D | 0 | 1 | RWU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure expired nutritional supplements were not available for resident use in 1 of 3 medication carts observed. The findings included: Observation and interview with Registered Nurse #1 on [DATE], at 8:41 AM, of Medication Cart #2, revealed 1 full unopened bottle of tube feeding had expired on [DATE]. Interview confirmed the nutritional supplement was expired and available for resident use. Interview with the Director of Nursing (DON) on [DATE] at 9:20 AM, in the DON office, confirmed the facility failed to ensure expired nutritional supplement was not available for resident use. | 2020-09-01 |
| 1443 | 1443 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2019-04-10 | 692 | D | 0 | 1 | 0Z6O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement dietary recommendations to monitor weight loss for 1 resident (#59) of 2 residents reviewed for weight loss of 24 sampled residents. The findings include: Medical record review revealed Resident #59 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating the resident was cognitively intact. Continued review revealed Resident #59 was totally dependent on 2 staff for bed mobility, transfers, dressing, and toileting, and totally dependent on 1 staff for eating. Medical record review of a Baseline Care Plan dated 3/1/19 revealed .3/1 admission weight is 154.3 .Dietary goal .a. Maintain current weight .Dietary Interventions .1. Assistance with eating . Medical record review of the comprehensive care plan dated 4/1/19 revealed the resident (#59) was at risk for nutritional problems due to MS and Dysphagia (difficulty swallowing) with interventions including .staff assistance with meals .diet as indicated .RD (Registered Dietitian) to evaluate and make diet change recommendations as needed . Medical record review of a General Dietary Note dated 3/15/19 revealed .triggered sig (significant) weight loss of 6% in 30 days. She (Resident #59) receives a mech (mechanical) soft diet with fair po (by mouth) intake .Weekly weights to better monitor . Medical record review of the electronic Weights and Vitals Summary form revealed the weekly weights recommended by the RD on 3/15/19 were not documented. Medical record review of an untitled Physician's progress note dated 4/3/19 revealed the resident's weight was 153.4 and indicated a loss. Continued review revealed the resident had .monster BM (bowel movement) for past 2 days . No further doc… | 2020-09-01 |
| 1444 | 1444 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2019-04-10 | 812 | F | 0 | 1 | 0Z6O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview the facility failed to ensure expired food items and expired nutritional supplements were not available for resident use in 2 of 2 nourishment refrigerators observed. The findings include: Review of the facility policy Refrigerated Storage, dated [DATE], revealed .3.All foods should be covered, labeled and dated. All foods will be checked to assure that foods .will be consumed by their safe use by dates . Review of the facility policy, Personal Food Storage, dated [DATE], revealed .Food or beverage brought in from outside sources for storage in center pantries, refrigeration units .will be monitored by designated center staff for food safety .Designated center staff will be assigned to monitor .refrigeration units for food or beverage disposal .6. All leftover or opened items must be stored in airtight containers or zip-lock bags. All containers and bags will be dated . Review of the facility policy, Resource: Food Safety for Your Loved One, dated [DATE], revealed .Foods or beverage items without a manufacturer's expiration date should be dated upon arrival in the center and thrown away three (3) days after the date marked .Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored . Observation with the Certified Dietary Manager (CDM) on [DATE] at 8:45 AM, of the East Wing nourishment refrigerator revealed the following items available for resident use: 1 open, 1/2 pint carton of chocolate milk drink, 1/4 full, undated and unnamed 3 disposable styrofoam food containers. One with no name and three undated 1 disposable plastic bowl with food undated. Observation with the CDM on [DATE] at 8:45 AM, of the West Wing nourishment refrigerator, revealed the following food items available for resident use: 3 of the 8 ounce cans of milk shake supplement drink had expiration dates of [DATE] 4 fast food items, undated and unnamed 6 of the 1/2 pint … | 2020-09-01 |
| 1445 | 1445 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2019-04-10 | 880 | D | 0 | 1 | 0Z6O11 | **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 perform hand hygiene to prevent the potential spread of infection during wound care for 1 resident (#15) of 3 residents reviewed for hand hygiene/infection control practices of 18 sampled residents. The findings include: Review of the facility's policy, Infection Control, dated 11/1/17, revealed .All team members shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other team members, residents, and visitors .Use .soap .and water for the following situations: Before and after direct contact with residents .Before handling clean or soiled dressings, gauze pads, etc .Before moving from a contaminated body site to a clean body site .After handling used dressings .After removing gloves .The use of gloves does not replace hand washing/hand hygiene . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of the Order Summary Report, dated 4/1/19, revealed .CLEANSE WOUND TO LEFT ISCHIUM WITH NORMAL SALINE PAT DRY, APPLY CALCIUM ALGINATE WITH SILVER CUT TO SIZE TO WOUND, THEN APPLY DRY DRESSING, CHANGE DAILY one time a day . Observation of Resident #15's wound care on 4/9/19 at 1:51 PM, in the resident's room revealed Licensed Practical Nurse (LPN) #1 entered the resident's room, placed the wound care items on the over bed table, and donned gloves without washing the hands. Continued observation revealed, LPN #1 loosened the resident's drainage soiled brief, removed the soiled dressing from the left ischial wound, and discarded the soiled dressing into the trash container. Further observation revealed LPN #1 obtained a clean saline soaked gauze pad, patted the area around the wound, and crossed back and forth over the wound with the soiled gauze. Continued observation revealed LPN #1 discarded the soiled/contaminated gauze pad into t… | 2020-09-01 |
| 1446 | 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 r… | 2020-09-01 |
| 6921 | 6921 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2015-04-29 | 431 | D | 1 | 0 | XCLS11 | Based on medical record review, review of narcotic logs, and interview, the facility failed to maintain complete records of change of shift narcotic reconciliation counts and failed to maintain complete records of narcotic drug stock refills for one of six medication carts in the facility. The findings included: Review of facility policy, Medication Storage in the Facility, ID3 Controlled Substance Storage, effective 2006 revealed .At each shift change or when keys are transferred, a physical inventory of all controlled substances including the emergency supply, is conducted by two licensed nurses and is documented .two nurses witness placement of controlled substances in the secured compartment of the medication cart . Observation of narcotic drug reconciliation and review of the medication cart narcotic count sheets on 4/23/15 between 2:30 pm and 3:15 pm, on the 100 hallway medication cart revealed no signature by the off going nurse during the shift change narcotic drug reconciliation and narcotic drug stock reconciliation documentation on the following dates and shifts: 2/16/15, 7 pm to 7 am shift; 3/16/15 7 am to 7 pm shift; 3/19/15 7 am to 7 pm shift; 4/6/15 7 am to 7 pm shift; and 4/12/15 7 am to 7 pm shift. Continued review of the Narcotic reconciliation records revealed there were only one nurse signature for the following dates: 11/15/14, Hydrocodone (narcotic) one 30 count sheet; 3/7/15 Tramadol (schedule 2 controlled substance) one 30 count card; 3/11/15 Hydrocodone one 30 count card; and 3/11/15 Phenobarbital (benzodiazepine) one 30 count card. Interview with the Director of Nursing on 4/23/15 at 3:15 pm, at the 100 hallway medication cart, in the 100 hallway confirmed the facility had failed to maintain complete records of shift change narcotic drug reconciliation and failed to maintain complete records of narcotic stock reconciliation on the 100 hall medication cart. | 2018-04-01 |
| 7129 | 7129 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2014-10-29 | 502 | D | 0 | 1 | X50S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure laboratory tests were obtained for one (#103) resident of thirty-two residents reviewed. The findings included: Resident #103 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated October 2014, revealed .[MEDICATION NAME] level .CBC (Complete Blood Count) every 4 months (March-July-November) .[MEDICATION NAME] level every 6 months (January-July) . Medical record review revealed no laboratory results for the [MEDICATION NAME] level, CBC, or [MEDICATION NAME] level in July 2014. Observation on October 27, 2014, at 3:00 p.m., revealed the resident seated in a wheelchair in the resident's room. Interview on October 28, 2014, at 11:00 a.m., with Registered Nurse #1 (Unit Manager) in the conference room confirmed the [MEDICATION NAME] level, CBC and [MEDICATION NAME] level had not been obtained as ordered by the physician. | 2018-03-01 |
Advanced export
JSON shape: default, array, newline-delimited
CREATE TABLE [cms_TN] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );