cms_TN
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid ▼ | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6366 | 6366 | BROOKHAVEN MANOR | 445174 | 2035 STONEBROOK PLACE | KINGSPORT | TN | 37660 | 2017-10-04 | 514 | D | 1 | 0 | Deficiency Text Not Available | 2018-08-01 | |
| 14017 | 14017 | VANAYER MANOR NURSING CENTER | 445423 | 460 HANNINGS LANE | MARTIN | TN | 38237 | 2009-05-20 | 225 | D | 1 | 0 | 027M11 | Complaint investigation for #TN 853 Based on review of the facility's abuse investigation, it was determined the facility failed to report all alleged violations of abuse to the State agency within 5 working days of the incident for 1 of 20 (Resident #18) sampled residents. The findings included: The facility received an allegation on 4/27/09 that Resident #18 had been abused. Review of the facility's investigation of this allegation of abuse on 4/27/09, revealed the facility was unable to substantiate the allegation of abuse. The facility was unable to provide documentation that the facility reported the allegation of abuse to the State agency within 5 working days as required per Federal regulations. | 2014-07-01 |
| 2134 | 2134 | CHRISTIAN CARE CENTER OF MCKENZIE L L C | 445357 | 150 OAK MANOR ROAD | MC KENZIE | TN | 38201 | 2019-10-10 | 684 | D | 0 | 1 | 02PN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure physician orders [REDACTED].#25) sampled residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) 2019 physician's orders [REDACTED].=0, 201-250=2u, 251-300=4u, 301-350=6u, 351-400=8 (u), > (greater than) 400 call MD (Medical Doctor) . The (MONTH) 2019 Medication Administration Record [REDACTED]. Interview with the Regional Nurse Consultant on 10/10/19 at 9:25 AM, at the 100/200 Hall Nurses' Station, the Regional Nurse Consultant was asked if the doctor had been notified of the blood sugar > 400. The Regional Nurse Consultant confirmed the MD had not been notified of the blood glucose results. | 2020-09-01 |
| 2135 | 2135 | CHRISTIAN CARE CENTER OF MCKENZIE L L C | 445357 | 150 OAK MANOR ROAD | MC KENZIE | TN | 38201 | 2019-10-10 | 686 | E | 0 | 1 | 02PN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to document treatments and provide treatment orders for pressure ulcers for 2 of 3 (Resident #3 and #27) sampled residents reviewed with pressure ulcers. The findings include: 1. The facility's Wound Prevention and Management Program policy, revised 5/17 documented, .To identify Residents at risk of developing pressure ulcers and conduct appropriate interventions to maintain intact skin .Write a separate treatment order for each wound site .D. MANAGEMENT OF WOUND INFECTION: The purpose of this procedure is to prevent wound deterioration, and other complications .provide local management that optimizes healing potential . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan dated 7/24/19 documented, .I am at risk for skin breakdown .non-compliance with being off load at times .choosing not to receive incontinence care at times .I have areas of skin breakdown now on my buttocks .Please treat areas of my skin that are broken down according to my doctors (doctor's) orders . A Physician's Order dated 6/3/19 documented, .Site: left buttock / Topical Every Shift (day shift 7 AM-7 PM, night shift 7 PM-7AM) .Treatment: Clean with W/C (wound cleanser), apply skin prep, and leave OTA (open to air) . Review of the (MONTH) 2019 Treatment Administration Record (TAR) revealed there was no treatment documented for the night shift on 6/20/19. A Physician's Order dated 6/21/19 documented, .Site: left buttock / Topical Every Shift .Treatment: Clean with W/C, air dry, skin prep around wound, and cover with moisture-balancing dressing . Review of the (MONTH) 2019 TAR revealed there was no treatment documented for the night shift on 6/23/19. Review of the (MONTH) 2019 TAR revealed there was no treatment documented for the night shift on 7/2/19, 7/3/19, 7/7/19, 7/16/19, and on both shif… | 2020-09-01 |
| 2136 | 2136 | CHRISTIAN CARE CENTER OF MCKENZIE L L C | 445357 | 150 OAK MANOR ROAD | MC KENZIE | TN | 38201 | 2019-10-10 | 842 | D | 0 | 1 | 02PN11 | **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 accurate documentation related to insulin administration for 1 of 5 (Resident #25) sampled residents reviewed for unnecessary medications and failed to ensure medical information was kept private and confidential for 1 of 13 (Resident #24) sampled residents. The findings include: 1. The facility's Medication Administration Subcutaneous Insulin policy, reviewed 1/14 documented, .Check prescriber's order for insulin .Determine the correct amount of insulin to be withdrawn . 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) 2019 physician's orders [REDACTED].=0, 201-250=2u, 251-300=4u, 301-350=6 u, 351-400=8 (u), > (greater than) 400 call MD (Medical Doctor) The Medication Administration Record [REDACTED] a. 9/3/19 at 6:00 AM the blood glucose was 283 and 54 units of insulin was documented as administered. 4 units of insulin was ordered to be administered. b. 9/3/19 at 8:30 PM the blood glucose was 388 and 73 units of insulin was documented as administered. 8 units of insulin should have been administered. c. 9/4/19 at 6:00 AM the blood glucose was 284 and 54 units of insulin was documented as administered. 4 units of insulin was ordered to be administered. d. 9/4/19 at 8:30 PM the blood glucose was 378 and 12 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. e. 9/9/18 at 6:00 AM the blood glucose was 194 and 65 units of insulin was documented as administered. Resident #25 should not have received any insulin. f. 9/12/19 at 8:30 PM the blood glucose was 390 and 73 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. g. 9/1719 at 8:30 PM the blood glucose was 486 and 73 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. h. 9/1… | 2020-09-01 |
| 12434 | 12434 | SIGNATURE HEALTHCARE OF PRIMACY | 445140 | 6025 PRIMACY PARKWAY | MEMPHIS | TN | 38119 | 2012-04-11 | 425 | D | 1 | 0 | 03VD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 522 Based on policy review, medical record review and interview, it was determined the facility failed to accurately obtain or administer controlled medication for 1 of 5 (Resident #1) residents with pain. The findings included: Review of the facility's "Medication Administration" policy documented, "...Open the MAR (Medication Administration Record) to the appropriate medication sheet... Read the medication record order(s) and compare with the prescription label(s)... Read the medication order(s), and again compare with the prescription label(s)... Re-read the medication order(s)... Document administration and/or refusal of the medication after the administration and/or the attempt to administer the medication on the MAR, and update the controlled drug record for a Schedule II drug... Documentation Guidelines 1. Documentation on the patient's MAR by the person administering the medication... b. If PRN (as needed) medication is administered, initial space provided and on the back of the MAR: Document date, time of administration, dose, route... complaints or symptoms for which the medication was given... results achieved and time results were noted..." Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "CONTROLLED DRUG RECORD" dated 3/15/12 documented Hydrocodone-Acetaminophin 7.5-500 milligrams (mg) administered, "...3/22 (2012) 6A (AM)... 3/22 (2012) 11P (PM)... 3/23 (2012) 5A (AM)... 3/25 (2012) 7:30 (AM/PM not documented... 3/26 (2012) 11:30 (AM/PM not documented...3/26 (2012) 4A..." Review of "RESIDENT PROGRESS NOTES" dated 3/26/12 at 5:00 PM documented, "Called and spoke with (daughter's name) regarding discrepancy related to receiving Lortab (Hydrocodone) in error. Explained that res (resident) had requested pain medication, c/o (complained of) that the Tylenol was not being effective, Lortab had inadvertently been sent by (name of pharmacy) for the resident… | 2015-08-01 |
| 10349 | 10349 | LIFE CARE CENTER OF BRUCETON-HOLLOW ROCK | 445326 | 105 ROWLAND | BRUCETON | TN | 38317 | 2012-02-15 | 309 | D | 0 | 1 | 041N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to follow the facility's protocol for lack of a bowel movement (bm) for 4 of 18 (Residents #7, 9, 14 and 16) sampled residents. The findings included: 1. Review of the facility's BM Protocol documented, .4. If no bowel movement is recorded for 3 days: Administer PRN (as needed) laxative or enema as ordered by physician unless contraindicated by acute abdominal symptoms . If no PRN is ordered contact physician, inform of the resident's status and request a PRN laxative order . 2. Medical record review for Resident #7 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's September 2011 Monthly Flow Report had no bms documented on September 3, 4, 5 and 6, 2011 on September 8, 9, 10 and 11, 2011 or on September 15, 16, 17 and 18, 2011. Review of Resident #7's September 2011 Medication Administration Record [REDACTED]. Review of Resident #7's October 2011 Monthly Flow Report had no bms documented on October 7, 8, 9, 10 and 11, 2011. Review of Resident #7's October 2011 MAR indicated [REDACTED]. During an interview in the family room on 2/15/12 at 4:00 PM, the Director of Nursing (DON) confirmed that no PRN medications were given to Resident #7 for lack of having a bm during the times noted above. 3. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's physician's orders [REDACTED].[MEDICATION NAME] 5MG (milligrams) TABLET DR (delayed release) . 2 TABS (tablets) BY MOUTH EVERY DAY AS NEEDED FOR CONSTIPATION . [MEDICATION NAME] SODIUM 100MG CAPSULE . TAKE 1 CAP BY MOUTH TWICE DAILY AS NEEDED . Review of Resident #9's November 2011 Monthly Flow Report had no bowel movement documented on November 25, 26, 27, 28, 29 or 30, 2011. Review of Resident #9's November 2011 MAR indicated [REDACTED]. Review of Resident #9… | 2016-07-01 |
| 10350 | 10350 | LIFE CARE CENTER OF BRUCETON-HOLLOW ROCK | 445326 | 105 ROWLAND | BRUCETON | TN | 38317 | 2012-02-15 | 333 | D | 0 | 1 | 041N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of MED-PASS COMMON INSULINS provided by the American Society of Consultant Pharmacist, policy review, medical record review, observation and interview, it was determined the facility failed to ensure that residents were free of a significant medication error when 1 of 5 (Nurse #1) nurses observed administering medications failed to ensure insulin was administered in correlation with meals. The findings included: Review of the MED-PASS COMMON INSULINS: Pharmacokinetics, Compatibility, and Properties provided by the American Society of Consultant Pharmacists for typical dosing administration of insulin related to meals documented, [MEDICATION NAME] . ONSET (IN hours, unless noted) .15 min (minutes) . TYPICAL DOSING / COMMENTS .5 - (to) 10 minutes before meals . Review of the facility's Onset Actions for Commonly Prescribed Insulin policy documented, .[MEDICATION NAME] ([MEDICATION NAME]) ([MEDICATION NAME]) . Onset . Under 15 minutes . Give immediately before or after eating . Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].[MEDICATION NAME] 100 U (units)/ (per) 1ML (milliliter) UNIT . ACCUCHECK (11AM, 4P (PM), 8P) WITH SLIDING SCALE. 0-150= (amount of insulin to be administered) 0 UNIT, 151-200=2UNITS, 201-250=4UNITS, 251-300=6UNITS, 301-350-8UNITS, 351-400=10UNITS, GREATER THAN 401=12UNITS AND NOTIFY MD (medical doctor) . Observations in Resident #11's room on 2/14/12 at 12:10 PM, Nurse #1 administered 2 units of [MEDICATION NAME]to Resident #11. Resident #11 did not receive her lunch tray until 12:30 PM. The administration of the insulin to Resident #11 20 minutes before lunch was served resulted in a significant medication error. During an interview on the A-hall on 2/14/12 at 12:27 PM, Nurse #1 was asked how soon after receiving [MEDICATION NAME]should a resident eat a meal. Nurse #1 stated, .5 to 10 minutes . During an inte… | 2016-07-01 |
| 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 |
| 8333 | 8333 | SUMMIT VIEW OF ROCKY TOP | 445259 | 204 INDUSTRIAL PARK RD | ROCKY TOP | TN | 37769 | 2014-03-26 | 157 | D | 0 | 1 | 052O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, review of facility policy, and interview, the facility failed to notify the family and the physician staff of a fall for one resident (#102) of thirty residents reviewed. The findings included: Resident #102 was admitted to the facility on [DATE], with End Stage [MEDICAL CONDITION], Convalescence and Palliative Care, Chronic [MEDICAL CONDITION] with Exacerbation, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Medical record review revealed the resident was admitted to Hospice care on February 25, 2014. Review of the Hospice care plan dated February 25, 2014, revealed the resident was to be up as tolerated. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident scored 14 out of 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was cognitively intact. Further review revealed the resident required supervision only for transfers and ambulation, did not use any assistive devices, and had no functional limitation in range of motion. Further review revealed the resident's balance was not steady, but was able to stabilize without staff assistance. Review of a facility investigation revealed the resident had sustained a fall on the morning of March 6, 2014, at 2:40 a.m., in the bathroom. Review of a hospice note dated March 6, 2014, revealed, .LPN (Licensed Practical Nurse) informed this nurse that patient was found in bathroom floor. LPN stated .believed (resident) was in bathroom to vomit and fell .LPN informed this nurse .daughter had not been notified of fall . Review of facility policy Guidelines for Assessing Falls and Their Causes revised October, 2008, revealed, .Nursing staff will notify the resident's attending physician and family . Review of facility policy Incident and Accident, implemented March 11, 2013, revealed, .Handling Accident Occurrences .Notify the physician .Notify family of accident . Interview with… | 2017-07-01 |
| 8334 | 8334 | SUMMIT VIEW OF ROCKY TOP | 445259 | 204 INDUSTRIAL PARK RD | ROCKY TOP | TN | 37769 | 2014-03-26 | 159 | F | 0 | 1 | 052O11 | Based on facility document review and interview, the facility failed to ensure commingling of resident funds with facility funds did not occur for eighty-six of eighty-six residents with trust fund accounts. The findings included: Review of a facility document for resident trust funds account balances dated March 24, 2014, revealed an account titled House, Lake City with an account balance of $2,010.58. Interview with the Accounting Manager on March 24, 2014, at 3:30 p.m., in the conference room, revealed the money was transferred into the account by corporate, it is not resident money .I don't know why it was put there. Continued interview confirmed the resident funds account should only contain resident money and not facility money. | 2017-07-01 |
| 8335 | 8335 | SUMMIT VIEW OF ROCKY TOP | 445259 | 204 INDUSTRIAL PARK RD | ROCKY TOP | TN | 37769 | 2014-03-26 | 276 | D | 0 | 1 | 052O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to complete a quarterly smoking assessment for two residents (#17 and #96) of ten residents reviewed for smoking of thirty residents sampled. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Safe Smoking Assessment revealed the last assessment was completed on October 22, 2012. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 12 on the Brief Interview for Mental Status (BIMS), indicating the resident was moderately impaired for decision making. Resident #96 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Safe Smoking Assessment revealed the last assessment was completed on May 13, 2013. Medical record review of a quarterly MDS dated [DATE], revealed the resident scored a 3 on the BIMS, indicating the resident was severely impaired for decision making. Review of facility policy Smoking Policy and Procedure, dated May 7, 2012, revealed, .all residents who wish to smoke undergo a safety assessment upon admission by nursing staff, and then quarterly and annually . Interview with the Director of Nursing (DON) on March 25, 2014, at 2:21 p.m., in the conference room, confirmed resident #17 and #96 had not been assessed for smoking quarterly and the facility had not followed policy. | 2017-07-01 |
| 8336 | 8336 | SUMMIT VIEW OF ROCKY TOP | 445259 | 204 INDUSTRIAL PARK RD | ROCKY TOP | TN | 37769 | 2014-03-26 | 279 | D | 0 | 1 | 052O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a comprehensive care plan for weight loss and nutritional status for one resident (#94) of thirty residents reviewed. The findings included: Resident #94 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Dietary notes from December 27, 2013, until March 13, 2014, revealed the resident had a 2.67% (percent) weight loss in one week during the week of February 16-20, 2014, and a significant weight loss of 6.35% in 30 days from February 28-March 6, 2014. Continued reveiw revealed dietary supplements including Ensure, magic cups, and mighty shakes were added and the resident's weight eventually stabilized by March 13, 2014. Review of the resident's comprehensive care plan dated January 5, 2014, revealed the resident's weight loss and risk for nutritional compromise had not been addressed. Interview with the Minimum Data Set (MDS) Coordinator on March 26, 2014, at 10:20 a.m., in the MDS office, confirmed the facility had not developed a comprehensive care plan for the resident's nutritional status. | 2017-07-01 |
| 8337 | 8337 | SUMMIT VIEW OF ROCKY TOP | 445259 | 204 INDUSTRIAL PARK RD | ROCKY TOP | TN | 37769 | 2014-03-26 | 323 | D | 0 | 1 | 052O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, interview, and review of facility investigation, the facility failed to ensure residents did not possess tobacco for two residents (#17 and #96) and failed to follow facility policy for reporting and investigating a fall for one resident (#102) of thirty residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 12 on the Brief Interview for Mental Status (BIMS), indicating the resident was moderately impaired for decision making. Resident #96 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS dated [DATE], revealed the resident scored a 3 on the BIMS, indicating the resident was severely impaired for decision making. Review of facility policy Smoking Policy and Procedure, last updated on May 7, 2012, revealed, .all cigarettes and lighters must be put at the nurse's desk .smokers are not permitted to .acquire or take smoking materials from another resident . Observation on March 24, 2014, at 3:18 p.m., in the dining room, revealed resident #17 was sitting at a table with a plastic container in his/her hand that contained cigarettes. Continued observation revealed resident #96 walked up to resident #17 and asked for a cigarette. Further observation revealed resident #17 removed a cigarette from the plastic container, handed it to resident #96, stated, they will light it for us outside, and then laid the plastic container containing the cigarettes on the dining room table. Continued observation revealed Licensed Practical Nurse (LPN #3) witnessed the event and walked off toward the nurses' station without asking for the cigarettes or questioning the residents about the possession of the cigarettes. Interview with LPN #3 on March 24, 2014, at 3:25 p.m., at… | 2017-07-01 |
| 8338 | 8338 | SUMMIT VIEW OF ROCKY TOP | 445259 | 204 INDUSTRIAL PARK RD | ROCKY TOP | TN | 37769 | 2014-03-26 | 514 | D | 0 | 1 | 052O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, review of facility policy, and interview, the facilty failed to document a fall in the medical record for one resident (#102) of thirty residents reviewed. The findings included: Medical record review revealed resident #102 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility investigation revealed the resident had sustained a fall on the morning of March 6, 2014. Medical record review of the nurses' notes for March 5, and 6, 2014, revealed no documentation of a fall. Review of facility policy Guidelines for Assessing Falls and Their Causes, revised October, 2008, revealed, .After a Fall .A Falls Investigation Worksheet and occurrence investigation report will be completed for resident falls. The forms should be completed by the Nurse on duty at the time and submitted to the Director of Nursing no later then the next business day after the fall occurs .When a resident falls, the following information should be recorded in the resident's medical record: a. The condition in which the resident was found (e.g., 'resident found lying on the floor between bed and chair') .d. Notification of the physician and family as indicated. e. The signature and title of the person recording the data. Review of facility policy Incident and Accident implemented March 11, 2013, revealed, .An incident is an occurrence that may not be consistent with the .routine care of a particular resident .Examples include .fall/observed on floor .Documentation .An Incident/Accident report should be completed .Initiate an investigation . Interview with the Director of Nursing (DON) on March 26, 2014, at 10:50 a.m., in the DON's office, confirmed the facility failed to document in the medical record the resident's fall on March 26, 2014. c/o # | 2017-07-01 |
| 6573 | 6573 | THE WATERS OF JOHNSON CITY, LLC | 445487 | 140 TECHNOLOGY LANE | JOHNSON CITY | TN | 37604 | 2015-05-28 | 157 | D | 0 | 1 | 05GJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to notify the physician of a resident's change in condition and death, for one resident (#101) of 38 residents reviewed. The findings included: Medical record review revealed Resident #101 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility policy, Charting and Documentation, date revised 6/2014, revealed 1. Chart all pertinent changes in the Resident's condition .4 .c. Chart on all shifts for the first three (3) days .Miscellaneous: 1. Documentation should also include any time the physician or family is called about the resident, as well as their response .Death of a Resident: 1. Documentation pertaining to the death of a resident includes: a. Pertinent information before death (i.e. symptoms, vital signs, treatment, etc.) b. date and time of death. c. Name of physician notified and when notified . Medical record review of the Interdisciplinary Progress Notes revealed 2/23/2015 4:30p (PM) Resident arrived at the facility from .MC (Local Medical Center) via stretcher escorted by EMS (Emergency Medical Services). Resident is alert & oriented x 3 (person, place, time) .VS (vital signs) 102/93 P (pulse) 78 .Denies pain or discomfort .Resident requires asst x 2 for ADLS (resident required the assistance of 2 staff for activities of daily living) . Continued medical record review revealed the next entry was a nurse's note dated 2/25/15 at 0754 (39 hours 24 minutes and 4 shifts later) .While CNA (Certified Nursing Assistant) was taken am (morning) meal into room she returned to this writer et (and) we entered this room et noted Res without respiration et pulse .ADON (Assistant Director of Nursing) aware, Res family aware. No obtainable vital signs. Modeling (mottling) noted in facial, B/L U +LE (bilateral upper and lower extremities) LPN (Licensed Practical Nurse) #2 . Further medical record review revealed a nurse's note,… | 2018-07-01 |
| 6574 | 6574 | THE WATERS OF JOHNSON CITY, LLC | 445487 | 140 TECHNOLOGY LANE | JOHNSON CITY | TN | 37604 | 2015-05-28 | 281 | D | 0 | 1 | 05GJ11 | Based on observation and interview, the facility failed to obtain a physician's order to dispense a PRN (as needed or requested) medication for one resident (#20) of 13 residents observed during medication administration. The findings included: Observation on 5/27/15 at 1:15 PM, in the resident's room revealed the Licensed Practical Nurse (LPN #1) removed the stock eye drops from the medication cart and administered 2 eye drops into each of the resident's eyes. Medical record review of the Medication Administration Record [REDACTED]. Interview with LPN #1, on 5/27/2015 at 1:40 PM, in front of the resident's room confirmed the resident had requested the eye drops, the LPN had given them in the past, and was sure the resident had a PRN order for the eye drops. Medical record review of the Physician's Orders dated 5/1/2015 and the facility Standing Orders revealed no order for eye drops for the resident. Interview with the Family Nurse Practitioner on 5/27/2015 at 3:30 PM, in the conference room confirmed there was no current order for the eye drops for Resident #20. | 2018-07-01 |
| 6575 | 6575 | THE WATERS OF JOHNSON CITY, LLC | 445487 | 140 TECHNOLOGY LANE | JOHNSON CITY | TN | 37604 | 2015-05-28 | 514 | D | 0 | 1 | 05GJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facilty policy review, medical record review and interview, the facility failed to maintain a complete and accurate medical record for one resident (#101) of 38 residents reviewed. The findings included: Medical record review revealed Resident #101 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility policy, Charting and Documentation, date revised 06/2014, revealed 1. Chart all pertinent changes in the Resident's condition .4. New Admission - c. Chart on all shifts for the first three (3) days .Miscellaneous: 1. Documentation should also include any time the physician or family is called about the resident, as well as their response .Death of a Resident: 1. Documentation pertaining to the death of a resident includes: a. Pertinent information before death (i.e. symptoms, vital signs, treatment, etc.) b. date and time of death. c. Name of physician notified and when notified . Medical record review of the Interdisciplinary Progress Notes revealed, 2/23/15 4:30 p (PM) Resident arrived at the facility from MC (Local Medical Center) via stretcher escorted by EMS (Emergency Medical Services). Resident is alert & oriented x 3 (person, place, time) .VS (vital signs) 102/93 P (pulse) 78 .Denies pain or discomfort .Resident requires asst x 2 for ADLS (resident required the assistance of 2 staff for activities of daily living) . Continued medical record review revealed a nurse's note dated 2/25/15 0754 (7:54 AM, 39 hours 24 minutes and 4 shifts later) While CNA (Certified Nursing Assistant) was taken am (morning) meal into room she returned to this writer et (and) we entered this room et noted Res without respiration et pulse .ADON (Assistant Director of Nursing) aware, Res family aware. No obtainable vitals signs. Modeling (mottling) noted in facial, B/L U +LE (bilateral upper and lower extremities) .LPN #2 Further medical record review revealed a nurse's note, dated and timed 2/23/2015 at 0754 (7:54 AM), E… | 2018-07-01 |
| 8871 | 8871 | ALLENBROOKE NURSING AND REHABILITATION CENTER | 445485 | 3933 ALLENBROOKE COVE | MEMPHIS | TN | 38118 | 2013-04-11 | 225 | D | 0 | 1 | 05X811 | **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 report an alleged allegation of abuse to the state certification agency for 1 of 1 (Resident #178) alleged abuse allegations reviewed. The findings included: Review of the facility's ABUSE PREVENTION policy documented, .REPORTING: The facility will report any knowledge of actions by a court of law against any employee, which would indicate unfitness for service as a nurse aide or other staff member to the state nurse's aide registry or licensing authorities . Medical record review for Resident #178 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a SUPERVISOR INVESTIGATION SUMMARY FORM dated 3/22/13 documented, .On 3/22 (2013)the resident (Named resident #178) daughter (Named daughter) reported to the Business Office Manager that she spoke to her mother on the evening of 3/21/2013. She alleged that her mother stated that on Tuesday 3/19 (2013) while eating lunch in the dining room, one of the C.N.A.'s (Certified Nursing Assistants) threatened the resident. Interview with the Resident revealed the alleged C.N.A. was (Named CNA) and that she has allegedly stated, I will whoop all of these mother . in her (here). The C.N.A. was immediately suspended pending further investigation . As a result of this thorough investigation, interview with the resident, other alert and oriented residents and other staff members that were present in the dining room on 3/19/2013. (Named facility) can not substantiate any abuse neglect or mistreatment to (Named Resident #178) or any other resident . Review of the facility's investigation revealed there was no documentation the alleged allegation was reported to the state. During an interview in the administrator's office on 4/10/13 at 5:00 PM, the administrator was asked if the allegation of abuse had been reported to the stated. The administrator stated, It wasn't reported (Named former a… | 2017-04-01 |
| 6760 | 6760 | SPRING MEADOWS HEALTH CARE CENTER | 445402 | 220 STATE ROUTE 76 | CLARKSVILLE | TN | 37043 | 2015-01-28 | 371 | F | 0 | 1 | 06LW11 | Based on policy review, record review, observation and interview, it was determined the facility failed to ensure food was stored under sanitary conditions as evidenced by milk stored past the expiration date, dietary staff members failed to change gloves and dietary staff failed to maintain a daily log documenting temperature and sanitizer concentration for the dishmachine and three compartment sink. The facility had 84 of 88 residents that received a tray from the kitchen. The findings included: 1. Observations in the kitchen refrigerator on 1/26/15 at 10:47 AM, revealed 3 cartons of fat free milk stored past the expiration date of January 24, 2015. During an interview in the kitchen on 1/26/15 at 10:48 AM, the Certified Dietary Manager (CDM) was asked if the date on the fat free milk was expired. The CDM stated, Sure is. 2. Review of the facility's HANDWASHING AND GLOVE USE policy documented, .when working with different food substances . following contact with any unsanitary surface . 1. Gloves must be changed as often as hands need to be washed . Gloves may be used for one task only . Observations in the dishmachine area on 1/27/15 at 2:30 PM, revealed dietary staff member #1 wore gloves and dumped food in a garbage can, rinsed the dinnerware, placed dinnerware in carrier tray, then placed in the dishmachine on the dirty side. Dietary staff member #2 took out the cleaned items from the clean side. Then put the container of silverware back into the dishmachine from the clean side (wrong side). Dietary staff member #2 then picked up plates stacked them in her arms and braced them against her body and carried them out to the kitchen. The surveyor asked dietary staff member #1 to check the sanitizer in the dishmachine. Dietary staff member #1 wearing the same wet gloves that had particles of food on them obtained a litmus strip dipped it in the water in the bottom of the dishmachine. Dietary staff member #1 stated it's 100 and threw the strip in the trash. Dietary staff member #1 never compared the strip to the … | 2018-05-01 |
| 13708 | 13708 | TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER | 445115 | 200 TORREY ROAD | LAFOLLETTE | TN | 37766 | 2010-10-12 | 246 | D | 0 | 1 | 08ED11 | **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 system was modified to ensure one resident (#10) had a method to alert staff of needs of twenty residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory problems with moderately impaired cognitive skills, and required assistance with all activities of daily living. Interview with the resident, in the resident's room on October 11, 2010, at 8:15 a.m., the resident stated, "I have to wait a long time for help sometimes, but I'm not sure I'm hitting the right button on the call light ...I did have a bell but they took it." Observation at that time revealed the facility had placed tape on the call button for the resident to feel in order to use the right button. Interview with CNA #1 (the resident's certified nursing assistant) in the hallway, on October 11, 2010, at 8:30 a.m., confirmed the resident would at times push a button on the resident's portable telephone thinking she was pushing the nursing call light. Interview further revealed the resident would knock on the bedside table to draw attention or call out for help when she could not find the call light or when she had waited a long time for help. Interview with CNA #2 (the resident's certified nursing assistant) in the hallway, on October 12, 2010, at 9:00 a.m., confirmed the resident would push buttons on the resident's phone when trying to use the call light. Interview with Licensed Practical Nurse (LPN) #4, in the hallway, on October 12, 2010, at 10:00 a.m., confirmed the LPN was aware the resident at times would push the buttons on the phone instead of the call light. | 2014-10-01 |
| 13709 | 13709 | TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER | 445115 | 200 TORREY ROAD | LAFOLLETTE | TN | 37766 | 2010-10-12 | 323 | D | 0 | 1 | 08ED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one (#8) of twenty residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory deficits, moderately impaired cognitive skills, required extensive assistance with transfers, and did not walk. Medical record review of the Plan of Care dated August 19, 2010, revealed "...Risk for falls...due to weakness &...confusion...Clip alarm for personal safety when in bed..." Observation on October 10, 2010, at 9:55 a.m., revealed the resident lying on the bed and the clip alarm was not attached to the resident. Observation and interview on October 10, 2010, at 10:00 a.m., with Licensed Practical Nurse (LPN) #1 revealed the resident lying on the bed, and confirmed the clip alarm was not attached to the resident. | 2014-10-01 |
| 13710 | 13710 | TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER | 445115 | 200 TORREY ROAD | LAFOLLETTE | TN | 37766 | 2010-10-12 | 242 | D | 0 | 1 | 08ED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure dietary choices were made available for one resident (#10) of twenty residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory problems with moderately impaired cognitive skills, and required assistance with all activities of daily living. Medical record review of a Progress Note written by the Registered Dietitian, dated September 17, 2010, revealed, "...Lost 8 lbs. (pounds) this month...Pt. (patient) states, "I'm not much hungry."...will offer the supplement [MEDICATION NAME] (high calorie nutritional supplement) if pt request it." Observation of the resident's tray on October 11, 2010, at 8:15 a.m., 1:30 p.m., revealed [MEDICATION NAME] not on the food tray. Interview with the Dietary Aide on October 12, 2010, at 11:00 a.m., confirmed the food menu was read to the resident each day to obtain the resident's preference of food. Continued interview confirmed [MEDICATION NAME] was not offered to the resident by the Dietary Aide. Interview with the resident, in the resident's room, on October 12, 2010, at 11:30 a.m., confirmed the resident was unaware the [MEDICATION NAME] could be requested. "I just love it" the resident stated. | 2014-10-01 |
| 13711 | 13711 | TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER | 445115 | 200 TORREY ROAD | LAFOLLETTE | TN | 37766 | 2010-10-12 | 280 | D | 0 | 1 | 08ED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to invite one (#20) to the care plan meeting of twenty residents reviewed. The findings included: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had difficulty with decision making in new situations only. Medical record review revealed a quarterly review of the Plan of Care was completed on September 16, 2010. Continued medical record review revealed no documentation resident #20 was invited or had attended the Plan of Care meeting. Interview on October 12, 2010, at 7:50 a.m., with the resident, in the resident's room, revealed the resident had not been invited to attend or participate in the Plan of Care meeting. Continued interview with the resident revealed the resident would like to attend or participate in the Plan of Care meeting. Interview on October 12, 2010, at 8:20 a.m., with the Care Plan Coordinator, in the nursing station, revealed the resident had been invited to attend a Plan of Care meeting sometime in the past (date unknown). Continued interview confirmed the resident had not been invited to attend the Plan of Care meeting on September 16, 2010. | 2014-10-01 |
| 13712 | 13712 | TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER | 445115 | 200 TORREY ROAD | LAFOLLETTE | TN | 37766 | 2010-10-12 | 221 | D | 0 | 1 | 08ED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to obtain a restraint specific consent and failed to attempt restraint reduction for one resident (#14) of twenty residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated October 2010, revealed "...Lap belt when up in wheelchair for personal safety. Check every 30 minutes. Release and reapply every 2 hours..." Medical record review of the resident's Acknowledgement of Facility Restraint Policy and Consent to Restrain if Required form dated June 10, 2009, revealed the consent was not device specific and did not list inclusion of all potential negative outcomes due to restraint use, such as strangulation and entrapment. Medical record review of the resident's Restraint Use Questionnaire revealed, "...Instructions: Dates evaluated/by whom and with efforts to eliminate...during the course of restraint use...(from implementation to complete reduction)..." Continued record review revealed, "July 15, 2009: still needs lap belt when up in w/c (wheelchair)...October 20, 2009: no problem with use of lap belt when up in w/c...January 19, 2010: continue with lap belt when up in w/c...April 19, 2010: continue with lap belt when up in w/c...July 14, 2010: still needs lap belt when up in w/c..." Observation on October 11, 2010, at 2:30 p.m. and 4:00 p.m., in the resident's room, revealed the resident sitting in a wheelchair with a dirty and stained lap belt restraint in place. Interview with the Minimum Data Set Coordinator (MDS Coordinator) on October 11, 2010, at 4:25 p.m., at the 2 North Nursing Station, confirmed the facility failed to obtain a device specific consent and disclose all potential negative outcomes due to the use of the lap belt. Continued interview confirmed the facility failed to attempt a restraint reduction and/or eliminatio… | 2014-10-01 |
| 13713 | 13713 | TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER | 445115 | 200 TORREY ROAD | LAFOLLETTE | TN | 37766 | 2010-10-12 | 241 | D | 0 | 1 | 08ED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to promote care in a manner and in an environment that maintained or enhanced each resident's dignity for one resident (#14) of twenty residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated October 2010, revealed "...Lap belt when up in wheelchair for personal safety. Check every 30 minutes. Release and reapply every 2 hours..." Observation on October 11, 2010, at 2:30 p.m. and 4:00 p.m., in the resident's room, revealed the resident sitting in a wheelchair with a dirty and stained lap belt restraint in place. Continued observation on October 12, 2010, at 9:10 a.m., in the resident's room, revealed the resident sitting in a wheelchair with a dirty and stained lap belt restraint in place. Observation and interview on October 12, 2010, at 9:15 a.m., in the hallway outside the resident's room, with Registered Nurse (RN) #1 confirmed, "This resident is very particular about clothing worn being clean and color-coordinated...has several colored sleeve covers that slide over the lap belt restraint and likes to wear the sleeves to match clothing colors." Continued interview with RN #1 confirmed the facility failed to provide the resident with a clean restraint and a color-coordinated restraint sleeve. | 2014-10-01 |
| 13714 | 13714 | TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER | 445115 | 200 TORREY ROAD | LAFOLLETTE | TN | 37766 | 2010-10-12 | 281 | D | 0 | 1 | 08ED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure TED hose ([MEDICAL CONDITION] Embolic Deterrent-tight, thick, elastic stockings that go on the legs and are used as a preventative measure to reduce the occurrence of blood clots in the legs) were in place as ordered by the physician for one resident (#14) of twenty residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated October 2010, revealed "...TED Hose when out of bed. Remove at bedtime..." Medical record review of the Care Plan dated June 15, 2010, revealed, "...encourage pt (patient to wear TED hose..." Medical record review of the Certified Nursing Assistant (CNA) Care Plan Worksheet (no date) revealed "...TED hose on when up in chair or w/c (wheelchair)..." Observation on October 11, 2010, at 2:30 p.m. and 4:00 p.m., in the resident's room, revealed the resident sitting in a wheelchair wearing ankle length, fuzzy socks, without TED hose on. Continued observation on October 12, 2010, at 9:10 a.m., in the resident's room, revealed the resident sitting in a wheelchair wearing ankle length, fuzzy socks, without TED hose on. Interview with Licensed Practical Nurse (LPN) #2 on October 12, 2010, at 10:35 a.m., in the resident's room, confirmed the facility failed to put the TED hose on the resident. Interview on October 12, 2010, at 10:40 a.m., at the 2 North Nursing Station, Certified Nursing Assistant (CNA) #3 confirmed the CNA got the resident up and did not attempt to put the TED hose on the resident. | 2014-10-01 |
| 13715 | 13715 | TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER | 445115 | 200 TORREY ROAD | LAFOLLETTE | TN | 37766 | 2010-10-12 | 371 | F | 0 | 1 | 08ED11 | Based on observations, review of facility policies and procedures, and interview, the facility failed to ensure food was stored, prepared, served and distributed under sanitary conditions and failed to ensure the trayline hot food temperatures were maintained at temperatures equal to or greater than 140 degrees Fahrenheit (F) and cold food temperatures were maintained at temperatures equal to or less than 41 degrees Fahrenheit (F). The finding included: Observation of the kitchen with the Food Services Director on October 10, 2010, at 9:15 a.m., revealed the following: 1. One of two soap dispensers was empty. 2. The walk-in cooler with one-half gallon of yogurt, expired October 2, 2010; one-half gallon of cottage cheese, expired October 2, 2010; a tray with four disposable plates containing pastries and fruit, without a label or date of preparation and/or expiration. 3. The freezer with one gallon of bread pudding, expired September 9, 2010; two three-pound bags of frozen broccoli, expired October 1, 2010. 4. Two light covers directly over the food prep areas contained greater than one dozen dead insects. 5. The ice machine with a brownish-black substance on the inside of the lid. Review of facility Dietary Policies and Procedures revealed, "...Food and Supply Storage Procedures...Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to maintain the safety and wholesomeness of the food for human consumption...Procedures: The "use-by" date (expiration date) is the last date that a food can be consumed...Foods past the "use-by" date should be discarded...Cover, label and date unused portions and open packages..." Interview with the Food Services Director in the kitchen on October 10, 2010, at 9:50 a.m., confirmed the facility failed to ensure: the empty soap dispenser was refilled; the expired yogurt, cottage cheese, bread pudding and broccoli was disposed of on or before the expiration date; the disposable plates containing pastries and fruit were labeled and … | 2014-10-01 |
| 13716 | 13716 | TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER | 445115 | 200 TORREY ROAD | LAFOLLETTE | TN | 37766 | 2010-10-12 | 372 | F | 0 | 1 | 08ED11 | Based on observation, review of facility policies and procedures, and interview, the facility failed to ensure the proper disposal of garbage and refuse. The finding included: Observation of the dumpster and kitchen grease refuse area with the Food Services Director on October 10, 2010, at 10:00 a.m., revealed the following: 1. Trash and refuse on the ground surrounding three of three dumpsters to include soft drink cans, milk cartons, a Sprite cardboard container, plastic wrap, aluminum foil, ice cream cups, styrofoam cups, plastic silverware, condiment packets (salt, sugar, sweet-n-low, ketchup), napkins, and disposable latex gloves. 2. Exterior refuse spillage on the doors and walls on three of three dumpsters. 3. A strong, foul, and soured odor from within and surrounding three of three dumpsters. 4. A side door was fully opened on one of three dumpsters. 5. Two large metal barrels on a concrete slab filled with kitchen grease refuse, which spilled over covering the concrete slab and ran off onto the parking lot pavement. The kitchen grease refuse and surrounding area produced a foul odor. Review of facility policies and procedures titled "Controlling Hospital and Nursing Home Pests" revealed, "...Purpose: To reduce the threat of infection and disease that accompanies pests...Good Sanitation as Applied to Pest Control: 3. Garabge and waste containers kept clean and free of odor...Rodents: Accumulation of rubbish and garbage attract destructive pests...Rodent Control and Prevention Measures: It is the general cleanliness of the hospital, nursing home, and kitchen that is most important in inspect (insect) and rodent control..." Interview with the Food Services Director at the dumpster area on October 10, 2010, at 10:10 a.m., confirmed the facility failed to ensure the proper and sanitary disposal of garbage and refuse. | 2014-10-01 |
| 11814 | 11814 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 164 | D | 0 | 1 | 08J911 | Based on policy review, observation and interview, it was determined the facility staff failed to maintain privacy and confidentiality of the residents' medical records by leaving the Medication Administration Record [REDACTED]. The findings included: 1. Review of the facility's Medication Administration General Guidelines documented, .Resident's health information needs to remain private. The pages of the MAR indicated [REDACTED] 2. Observations on the North 2 hall on 3/13/12 at 7:49 AM, revealed Nurse #5 left the MAR indicated [REDACTED]. During an interview on the North 2 hall on 3/13/12 at 8:07 AM, Nurse #5 was asked, What do you do with the MAR indicated [REDACTED]? Nurse #5 stated, .usually close it. 3. Observations on the North 2 hall on 3/14/12 at 9:12 AM, revealed Nurse #1 left the MAR indicated [REDACTED]. 4. During an interview in the Director of Nursing's (DON) office on 3/14/12 at 9:48 AM, the DON was asked, What do you expect the nurses to do with the MAR indicated [REDACTED]? The DON stated, .it (MAR) should be closed. | 2015-11-01 |
| 11815 | 11815 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 221 | D | 0 | 1 | 08J911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, it was determined the facility failed to ensure a pre-restraint assessment, an informed consent, or a restraint reduction assessment for a physical restraint was completed for 2 of 4 (Residents #4 and 8) sampled residents with physical restraints. The findings included: 1. Review of the facility's physical restraint policy documented, .Assess resident's need for restraint use. Obtain informed consent for restraint use. 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. 2. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #4's room on 3/12/12 at 10:00 AM, and on 3/13/12 at 7:40 AM and 9:00 AM, revealed Resident #4 seated in a wheelchair with a lap buddy in place. During an interview at the South 2 nurses' station on 3/13/12 at 11:15 AM, the Assistant Director of Nursing (ADON) was asked to locate the restraint reduction assessments after 8/11/11. The ADON stated, .we do not have the assessments for November (2011) or February (2012). 3. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#8. Observations in Resident #8's room on 3/12/12 at 2:25 PM, revealed Resident #8 seated in a w/c wearing a soft belt restraint. During an interview in the conference room on 3/13/12 at 2:55 PM, the Director Of Nursing (DON) was asked about a pre-restraint assessment and an informed consent for the soft belt restraint for Resident #8. The DON confirmed she was unable to find a pre-assessment or an informed consent for the use of the soft belt restraint. | 2015-11-01 |
| 11816 | 11816 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 253 | D | 0 | 1 | 08J911 | Based on observation and interview, it was determined the facility failed to keep resident care equipment properly stored in shared bathrooms for 10 of 13 (rooms 201 and (&) 203, 202 & 204, 205 & 207, 209 & 211, 210 & 212, 213 & 215, 217 & 219, 218 & 220, 221 & 223, and 222 & 224) bathrooms observed on the North 1 hall. The findings included: Observations of the North 1 hall bathrooms on 3/12/12 beginning at 9:20 AM and on 3/13/12 beginning at 9:25 AM revealed the following: a. room 201 & 203 - 2 toothbrushes in a wash basin not covered or labeled, a bed pan hung on the safety handrail beside the toilet not covered and unlabeled, a hairbrush and comb on the vanity not labeled. b. room 202 & 204 - 2 emesis basins not covered and unlabeled each containing a toothbrush. c. room 205 & 207 - an opened bar of soap and 2 toothbrushes in a bath basin on top of the vanity not covered and unlabeled, an open bar of soap and toothbrush in a plastic cup on the vanity not covered and unlabeled, a hairbrush and a comb on the vanity not covered and unlabeled, a bedside commode hat on the floor not covered and unlabeled. d. room 209 & 211 - 2 urinals on the safety handrail beside commode not covered and unlabeled, an open bar of soap on a paper towel on top of the vanity not covered and unlabeled. e. room 210 & 212 - 1 wash basin on top of a trash can and 1 pair of latex gloves on the floor behind the trash can, 2 unlabeled toothbrush holders, and 1 open bar of soap on the vanity. f. room 213 & 215 - a plastic drinking cup on a box beside the commode unlabeled and a hairbrush on the vanity not covered and unlabeled. g. room 217 & 219 - 3 emesis basins stacked together on the vanity containing 2 toothbrushes and an open bar of soap not covered and unlabeled, a bedpan on the safety handrail beside the commode not covered and unlabeled. h. room 218 & 220 - 2 emesis basins not covered and unlabeled each containing a toothbrush. i. room 221 & 223 - 2 toothbrushes, a comb and hairbrush in a plastic cup on the vanity not covered and unl… | 2015-11-01 |
| 11817 | 11817 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 280 | D | 0 | 1 | 08J911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to revise the current care plan for medications, oral care, Prostat, self feeding and heel protectors for 1 of 21 (Resident #5) sampled residents. The findings included: Review of the facility's RESIDENT CARE PLAN policy documented, .APPROACH/PLAN A. List all care to be provided for the problem listed. The care must be NECESSARY AND APPROPRIATE to accomplish the goal stated. c. Individualize care for the unique needs of the resident. RE-EVAL (re-evaluate). B. The care plan must be reviewed and revised (updated) as necessary. RESIDENT CARE PLAN DOCUMENTATION AND USE OF THE PLAN. B. The licensed nurses must review the resident care plan each time an order is received from a physician to determine if an entry is needed. Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. physician's orders [REDACTED]. Review of the care plan dated 5/4/10 and updated January 2012 documented the following interventions: a.Potential for [MEDICAL CONDITION] 8/18/10. [MEDICATION NAME] 50mg [MEDICATION NAME] (5 tabs) po (orally) q (every) hs (bedtime). b.Resident is edentulous. He can perform OH (oral hygiene) per self with setup. Provide setup for OH Q (every) am, allow him to perform per self. c.Give scheduled pain meds to decrease pain with mobility (per orders). Tylenol 650 mg bid. d.Resident is at a nutritional risk. Prostat 64 po per MD (Medical Doctor) orders. Provide tray setup and observe for self feeding q meal daily, assist him when he becomes tired or is unable to complete meal without spilling. The care plan documented no interventions for the heel protectors. Observations in Resident #5's room on 3/12/12 at 10:08 AM, 2:45 PM, 5:00 PM and 6:00 PM and on 3/13/12 at 7:50 AM, 8:15 AM and 9:55 AM, revealed Resident #5 in bed wearing bilateral heel protecto… | 2015-11-01 |
| 11818 | 11818 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 309 | E | 0 | 1 | 08J911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to follow physician's orders for notification of blood glucose levels above 400 or failed to administer medications when a resident failed to have a bowel movement for 6 of 21 (Resident #6, 10, 11, 12, 15 and 17) sampled residents. The findings included: 1. Review of FACILITY STANDING PROTOCOL dated 12/8/12 documented, .for fingerstick blood glucose levels of.over 400: (give) 12 units ([MEDICATION NAME] R or [MEDICATION NAME] R Insulin) and notify MD (Medical Director). 2. Review of the facility's Bowel Care Protocol documented, .Record bowel movements each day in ADL (Activities of Daily Living) book. If bowel movement (BM) does not occur within 72 hours follow the Facility Standing Protocol for Constipation as follows: MOM (Milk of Magnesia) 30cc (cubic centimeters) PO (by mouth) or [MEDICATION NAME] Suppository one rectally PRN (as needed). 3. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. During an interview in the South 2 hall on 3/14/12 at 9:35 AM, Nurse #4 was asked about the procedure for blood glucose levels of greater than 40. Nurse #4 stated, .give 12 units. call the doctor. document on the nurses' notes. Nurse #4 was asked if there was any other location to chart physician notification. Nurse #4 stated, No. During an interview in the conference room on 3/14/12 at 1:45 PM, the Director of Nursing (DON) confirmed there was no documentation of physician notification of the elevate blood glucose level. 4. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Resident Care Flow Recor… | 2015-11-01 |
| 11819 | 11819 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 315 | D | 0 | 1 | 08J911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to provide valid medical justification for the use of an indwelling catheter for 1 of 6 (Resident #1) sampled residents with a catheter. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. dated 2/19/12 documented, .Nurse unable to obtain enough urine by in and out cath (catheter). Foley catheter insertion to drain bag. about 50 cc (cubic centimeters) of dark amber urine noted in foley bag, UA, C+S obtained. Observations in Resident #1's room on 3/12/12 at 9:32 AM, 2:15 PM and 5:00 PM, on 3/13/12 at 8:15 AM and 11:00 AM and on 3/14/12 at 7:45 AM, revealed Resident #1 with an indwelling catheter. During an interview in the Director of Nursing's (DON) office on 3/13/12 at 9:37 AM, the Director of Nursing (DON) was asked, Why does (named Resident #1) have a catheter? The DON stated, .she had a rash.there were no open areas. | 2015-11-01 |
| 11820 | 11820 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 323 | E | 0 | 1 | 08J911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to follow interventions put in place to prevent falls, failed to update the care plan with interventions for falls and failed to complete a fall risk assessment for 4 of 7 (Residents #13, 15, 16 and 18) sampled residents with falls. The findings included: 1. Review of the facility's Fall Policy documented, .B. Documentation and Follow-up. 3. Refer to the interdisciplinary treatment team to review fall preventions and modify care-plan as appropriate. 2. Medical record review for Resident #13 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #13's nurses' notes documented falls with no injuries on 7/8/11 (6:50 AM and 11:00 AM), 8/15/11, 8/27/11, 8/29/11, 9/2/11, 9/8/11, 10/13/11, 11/4/11, 12/7/11, 12/12/11, 1/15/12, 1/16/12 and 2/17/12. Review of the care plan dated 7/21/11 and updated on 3/1/12 documented no new interventions for falls on the following dates: 12/7/11, 1/15/12 and 3/1/12. The care plan documented, .no new fall interventions. regarding the fall which occurred on 2/17/12. Review of the facility's Unusual Occurrence Report Forms for Resident #13 documented a fall on 3/1/12 that was not documented in the nurses' notes. During an interview in the conference room on 3/14/12 at 7:46 AM, the Assistant Director of Nursing (ADON) was asked if any interventions were documented on the care plan for the 12/7/11, 1/15/12, 2/17/12 or 3/1/12 falls. The ADON stated, I don't see 12/7/11 (fall interventions) on care plan. no new interventions on care plan (regarding falls on 1/15/12, 2/17/12 and 3/1/12). 3. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Investigation of Mental Status (BIMS) score of 0, indicating severe cognitive impairment and … | 2015-11-01 |
| 11821 | 11821 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 325 | D | 0 | 1 | 08J911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to implement new interventions for weight loss for 2 of 6 (Residents #6 and 16) sampled residents with weight loss. The findings included: 1. Review of the facility's WEIGHT POLICY & (and) PROCEDURE documented, .The Registered Dietitian (RD) assesses each resident with a significant weight change, makes appropriate recommendations to physicians and updates the resident's plan of care. 2. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's weight sheet documented the following weights: an admission weight of 99.8 pounds (lb) on 12/9/11; 12/13/11 - 101.4 lbs; 12/20/11 - 97.1 lbs; 12/27/11 - 109.7 lbs; 1/2/12 - 108.8 lbs and 2/2/12 - 94.2 lbs. The loss of 14.6 lbs in one month resulted in a significant weight loss of 13.4 percent (%). The weight record also documented a 3/5/12 weight of 88.6 lbs. The loss of 5.6 lbs in one month resulted in a significant weight loss of 5.9%. Review of Resident #6's nutritional progress notes had no assessments documented for February or March 2012 after the significant weight losses were documented. The care plan dated 12/28/11 had new interventions put in place February and March 2012 after the significant weight losses were documented. Review of the previous care plan interventions documented, .Offer substitute if (symbol for greater than) 5#'s (symbol for pounds) in one month. Resident #6's nurses' notes had no referrals made to the MD or to the RD for the documented weight loss. Review of Resident #6's resident care flow records for December 2011, January 2012 and February 2012 documented consistent meal intakes of 50% or less. The nurses' notes had no documentation of food substitutes being offered. During an interview in the conference room on 3/14/12 at 2:05 PM, the Director of Nursing (DON) was asked to locate documentation of asses… | 2015-11-01 |
| 11822 | 11822 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 328 | D | 0 | 1 | 08J911 | **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 there was a current physician's orders [REDACTED].#1 and 2) sampled residents receiving oxygen therapy. The findings included: 1. Review of the facility's oxygen administration policy documented, .PROCEDURE. Check physician's orders [REDACTED]. 2. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #1's room on 3/12/12 at 9:32 AM, 2:15 PM and 5:00 PM, revealed Resident #1 receiving oxygen through binasal cannula at a rate between the marks for 1 and 1 1/2 liters per minute. Observations in Resident #1's room on 3/13/12 at 8:15 AM and 11:00 AM, revealed Resident #1 receiving oxygen through binasal cannula at 1 liter per minute. Observations in Resident #1's room on 3/14/12 at 7:45 AM, revealed Resident #1 receiving oxygen through binasal cannula at 1 1/2 liters per minute. During an interview in the Director of Nursing's (DON) office on 3/13/12 at 9:37 AM, Nurse #3 was asked, Is there an order for [REDACTED].#3 stated, .they (nurses) didn't write it (oxygen orders) on here. During an interview in Resident #1's room on 3/14/12 at 7:50 AM, Nurse #5 confirmed Resident #1 was receiving oxygen at 1 1/2 liters per minute. 3. Medical record review for Resident #2 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the recertification orders dated 3/12/12 documented no order for oxygen or for a bilevel positive airway pressure ([MEDICAL CONDITION]) machine. Review of the physician's orders [REDACTED].@ (at) 3L (liters) / (per) MIN (minute) PER NASAL CANNULA CONTINUOUSLY. Observations in Resident #2's room on 3/12/12 at 10:00 AM, 2:20 PM and 5:00 PM, on 3/13/12 at 8:20 AM and 12:05 PM and on 3/14/12 at 7:53 AM, revealed Resident #2 receiving oxygen through b… | 2015-11-01 |
| 11823 | 11823 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 371 | E | 0 | 1 | 08J911 | Based on policy review, observation and interview, it was determined the facility failed to ensure food was stored or prepared under sanitary conditions as evidenced by improper storage of cleaning cloths, dirty kitchen equipment, open food containers not dated and expired food during 2 of 2 (3/12/12 and 3/13/12) days of observation in the kitchen. The findings included: 1. Review of the facility's Sanitization policy documented, .3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 6. Between uses, cloths and towel used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures. Review of the facility's Food Receiving and Storage policy documented, .6. Dry foods that are stored in original packaging will be labeled and dated when received and re-dated when opened. 7. All items with use by dates will be monitored weekly and discarded prior to expiration. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated. Observations in the kitchen on 3/12/12 at 9:10 AM, revealed the following: a. The Robo Coupe (mixer) had orange particles on the blades. b. The meat slicer had a dried brown substance under the lip of the meat holder. c. The pantry fridge had diet vanilla pudding dated 3/7/12, diet chocolate pudding dated 3/7/12, regular chocolate pudding dated 3/7/12, lemon pudding with no date, potato salad container open with no date and pimento cheese container open with no date. d. The dry storage room had 1 box of potato pearls open w… | 2015-11-01 |
| 11824 | 11824 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 431 | D | 0 | 1 | 08J911 | Based on review of the MED-PASS MEDICATIONS WITH SHORTENED EXPIRATION DATES provided by the American Society of Consultant Pharmacists, observation and interview, it was determined the facility failed to ensure medications were not stored past their open/expiration date or labeled in 2 of 10 (North 1 medication room and North 2 medication cart) medication storage areas and in Resident #1's room. The findings included: 1. Review of the MED-PASS MEDICATIONS WITH SHORTENED EXPIRATION DATES provided by the American Society of Consultant Pharmacists documented, .The following EXPIRATION DATES of insulin vials begin AFTER OPENING / PUNCTURING. Novolin = (equals) 30 days. Observations in the North 1 medication room on 3/13/12 at 12:25 PM revealed an open vial of Novolin Regular (R) insulin with a delivery date of 1/13/12 and no documented open date. During an interview in the North 1 medication room on 3/13/12 at 12:25 PM, Nurse 32 was asked how long opened insulin could be used. Nurse #2 stated, 28 days. Nurse #2 confirmed there was no open date on the vial of Novolin R insulin and did not know how long it had been opened. 2. Observations in the North 2 hall on 3/14/12 at 9:12 AM, revealed a 10 count card of Tamiflu with an expiration date of 9/16/10 in the North 2 hall medication cart. During an interview on the North 2 hall on 3/14/12 at 9:20 AM, Nurse #1 confirmed the 10 count card of Tamiflu was out of date and stated, .that should be sent back. 3. Observations in Resident #1's room on 3/14/12 at 7:45 AM, revealed an unlabeled 30 cubic centimeter (cc) cup filled with white cream on the resident's bedside dresser. During an interview in Resident #1's room on 3/14/12 at 7:50 AM, Nurse #5 was asked to identify the cream in the 30 cc cup. Nurse #5 stated, .it's Calmoseptine cream. it shouldn't be there. | 2015-11-01 |
| 11825 | 11825 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 441 | E | 0 | 1 | 08J911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure practices to prevent the spread of infection were maintained when 4 of 13 Certified Nurse Assistants (CNAs #1, 2, 5 and 7) failed to practice sanitary hand hygiene during dining and CNA #3 and CNA #4 failed to wear appropriate personal protective equipment in an isolation room or failed to appropriately store equipment from the isolation room. The findings included: 1. Review of the facility's Handwashing/Hand Hygiene policy documented, .5. Employees must wash their hands for 15 seconds using antimicrobial or non - antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents. f. Before and after eating or handling food; and before and after assisting resident with meals. 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% (percent) [MEDICATION NAME] or [MEDICATION NAME] for all the following situations. p. After contact with objects (.medical equipment) in the immediate vicinity of the resident. 2. Observations during dining observations on the North 1 hall on 3/12/12 beginning at 5:30 PM, revealed CNA #1 carried a meal tray into room [ROOM NUMBER], set up the tray and rubbed the resident's back. CNA#1 returned to the meal cart, removed a meal tray and carried it into room [ROOM NUMBER] without performing hand hygiene. CNA #1 moved the overbed table, opened the items on the tray and placed a clothing protector on the resident. CNA #1 returned to the meal cart, removed a meal tray without and carried it to a resident in the day room and set up the tray without performing hand hygiene. CNA #1 returned to the meal cart, removed a meal tray and carried it into room [ROOM NUMBER] and began feeding the resident without performing hand hygiene or handwashing.… | 2015-11-01 |
| 11826 | 11826 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 456 | E | 0 | 1 | 08J911 | Based on policy review, observation and interview, it was determined the facility failed to monitor the refrigerator freezer temperatures in the nourishment rooms for 4 of 4 (North 1 hall, South 1 hall, South 2 hall and North 2 hall) resident halls. The findings included: 1. Review of the facility's Food Receiving and Storage policy documented, .Food items and snacks kept on the nursing units must be maintained as indicated below. Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines. 2. Observations in the North 1 hall nourishment room on 3/13/12 at 12:20 PM, revealed the refrigerator freezer containing ice cream with no thermometer. During an interview in the North 1 hall nourishment room on 3/13/12 at 12:20 PM, Nurse #1 stated, We don't check the freezer (temperature readings for the freezer). Nurse #1 confirmed there was no thermometer in the freezer. 3. Observations in the South 1 hall nourishment room on 3/14/12 at 9:00 AM, revealed the refrigerator freezer with no thermometer. 4. Observations in the South 2 hall nourishment room on 3/14/12 at 9:10 AM, revealed the refrigerator freezer containing ice cream with no thermometer. 5. Observations in the North 2 hall nourishment room on 3/14/12 at 9:15 AM, revealed the refrigerator freezer with no thermometer. | 2015-11-01 |
| 11827 | 11827 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2012-03-14 | 514 | E | 0 | 1 | 08J911 | **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 physician's orders for laboratory (lab) tests were accurate; complete bowel movement (BM) records were in medical records and quarterly dietary documentation was completed for 5 of 21 (Residents #2, 5, 7, 9 and 17) sampled residents. The findings included: 1. Medical record review for Resident #2 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 6/20/11 documented, .BMP (Basic Metabolic Panel) in 2 weeks then q (every) 6 mos (months) (March, Sept (September)). CMP (Comprehensive Metabolic Panel), CBC (Complete Blood Count) q 6 mos (June, Dec (December)). HgbA1C (Hemoglobin A1C) q 3 mos (March, June, Sept, Dec). Review of the physician's orders dated 3/12/12 did not include orders for routine laboratory (lab) work. Review of lab test results revealed results for the following labs that were drawn: 10/20/11 - CBC, CMP and HgbA1C, 11/3/11 - BMP, 12/2/11 - CBC, CMP and HgbA1C and 3/1/11 - BMP. During an interview in the conference room on 3/14/12 at 1:24 PM, the Assistant Director of Nursing (ADON) confirmed Resident #2's routine lab orders were not on the current recertification orders. The ADON was asked, Would you expect to see the routine lab orders on the recertification orders? The ADON stated, Yes. 2. Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the medical record had no BM record for December 2011. During an interview in the conference room on 3/14/12 at 9:50 AM, the DON was asked if Resident #5's December 2011 BM record was located. The DON stated, No. 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the medical record documented no BM record for December 2011. During an interview i… | 2015-11-01 |
| 11477 | 11477 | HERITAGE CENTER, THE | 445215 | 1026 MCFARLAND STREET | MORRISTOWN | TN | 37814 | 2012-09-27 | 309 | D | 0 | 1 | 08KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to follow a physician's order for one resident (#133) of forty-two residents reviewed. The findings included: Resident #133 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's quarterly bowel and bladder assessments from re-admission to present (February 22, 2011 through September 27, 2012) revealed the resident had been continent of bowel in bladder until a recent decline, documented on the August 20, 2012, assessment, when the resident's bowel and bladder status changed to incontinent. Continued medical record review of the attending physician's notes revealed the physician had communicated with the family on more than one occasion and the resident's decline, was .an expected course of disease . Medical record review of a physician's order dated March 2, 2011, revealed an order for [REDACTED]. Medical record review of the Medication Administration Records (MAR) for January 2012 through September 2012, revealed the facility failed to administer the laxative as ordered during the months of June and July 2012, resulting in 31 missed doses of the medication. Interview with Licensed Practical Nurse (LPN)#2, on September 27, 2012, at 9:35 a.m., in the 100 hall, at the medication cart, confirmed the medication order was active, and the medication continued to be administered every other day. Review of the September 2012 MAR indicated [REDACTED]. Interview with the Director of Nursing on September 27, 2012, at 9:58 a.m., in the conference room, confirmed the laxative omission occurred thirty one times during June and July of 2012, resulting in thirty one missed medication doses. C/O # | 2016-01-01 |
| 11478 | 11478 | HERITAGE CENTER, THE | 445215 | 1026 MCFARLAND STREET | MORRISTOWN | TN | 37814 | 2012-09-27 | 323 | D | 0 | 1 | 08KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility to ensure a safety device was in place for one (#66) of forty-two sampled residents. The findings included: Resident #56 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review and review of documents provided by the facility revealed the resident sustained [REDACTED]. The interventions put in place following the fall were to apply fall mats to the bedside. Observatrion with Registered Nurse (RN) #1 on September 26, 2012, at 11:00 a.m., revealed the resident lying in a low bed. Interview at that time confirmed the fall mats were not in place at bedside. | 2016-01-01 |
| 11479 | 11479 | HERITAGE CENTER, THE | 445215 | 1026 MCFARLAND STREET | MORRISTOWN | TN | 37814 | 2012-09-27 | 502 | D | 0 | 1 | 08KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain laboratory services as ordered by the physician for one (#86) of forty-two sampled residents. The findings included: Resident #86 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. twice daily. Further review revealed a physician order [REDACTED]. Further review revealed a physician's orders [REDACTED]. Medical record review revealed no documentation the lab was obtained in June 2012. Interview with the Director of Nursing (DON) in the DON's office on September 26, 2012 at 11:10 a.m., confirmed the lab had not been obtained as ordered by the physician. | 2016-01-01 |
| 2535 | 2535 | CENTER ON AGING AND HEALTH | 445424 | 880 SOUTH MOHAWK DRIVE | ERWIN | TN | 37650 | 2019-11-06 | 656 | D | 0 | 1 | 08LF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of fall investigation documentation, observation, and interview, the facility failed to implement the comprehensive care plan for falls for 1 resident (#48) of 3 residents reviewed for falls of 27 residents reviewed. The findings include: Review of the facility policy Interdisciplinary Team Care Plan, reviewed 5/2011, revealed .Interdisciplinary plans of care are developed, implemented, coordinated, and evaluated . Medical record review revealed Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Fall Investigation dated 5/12/19 revealed Resident #48 had an unwitnessed fall out of bed without injury. Further review revealed the intervention put in place to prevent future falls was an evaluation by Occupational Therapy (OT). Medical record review of Resident #48's Quarterly Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16 indicating the resident was a high risk for falls. Review of a Fall Investigation dated 6/2/19 revealed Resident #48 had an unwitnessed fall in the hallway outside his room without injury. Further review revealed the intervention put in place to prevent future falls was a medication adjustment. Medical record review of Resident #48's Annual Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16, indicating the resident was a high risk for falls. Review of a Fall Investigatio… | 2020-09-01 |
| 2536 | 2536 | CENTER ON AGING AND HEALTH | 445424 | 880 SOUTH MOHAWK DRIVE | ERWIN | TN | 37650 | 2019-11-06 | 689 | D | 0 | 1 | 08LF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of fall investigation documentation, observation, and interview, the facility failed to ensure fall interventions were in place to prevent future falls for 1 resident (#48) of 3 residents reviewed for falls. The findings include: Review of the facility policy Interdisciplinary Team Care Plan, reviewed 5/2011, revealed .Interdisciplinary plans of care are developed, implemented, coordinated, and evaluated . Medical record review revealed Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Fall Investigation dated 5/12/19 revealed Resident #48 had an unwitnessed fall out of bed without injury. Further review revealed the intervention put in place to prevent future falls was an evaluation by Occupational Therapy (OT). Medical record review of Resident #48's Quarterly Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16 indicating the resident was a high risk for falls. Review of a Fall Investigation dated 6/2/19 revealed Resident #48 had an unwitnessed fall in the hallway outside his room without injury. Further review revealed the intervention put in place to prevent future falls was a medication adjustment. Medical record review of Resident #48's Annual Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16, indicating the resident was a high risk for falls. Review of a Fall Investigation dated 8… | 2020-09-01 |
| 13659 | 13659 | COUNTRYSIDE HEALTHCARE AND REHABILITATION | 445280 | 3051 BUFFALO ROAD | LAWRENCEBURG | TN | 38464 | 2010-11-03 | 157 | D | 0 | 1 | 08U511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure staff notified the physician of an emergency transfer for 2 of 22 (Residents #21 and 22) sampled residents. The findings included: 1. Review of the facility's "Making an Emergency Transfer or Discharge" policy documented, "...Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician..." 2. Medical record review for Resident #21 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Nurse's Note dated [DATE] documented, "...called to Rm (room) per staff, upon entry resdt. (resident) in bed... unresponsive to verbal + (and) tactile stimuli... unable to obtain V/S (vital signs)... CPR (cardiopulmonary resuscitation) initiated...( named emergency management service) leaving facility c (with) resident-destination (named hospital) CPR still in progress." There was no documentation in the medical record that the physician had been notified of Resident #21's emergency transfer. During an interview in the quiet room on [DATE] at 10:30 AM, the Director of Nursing (DON) confirmed there was no documentation the physician was notified. The DON stated, "It (physician notification) is not documented, I know it should be." 3. Medical record review for Resident #22 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated [DATE] documented, "...transferred pt (patient) to (named hospital) ER (emergency room )..." There was no documentation in the medical record that the physician was notified of Resident #22's emergency transfer. During an interview in the quiet room on [DATE] at 5:05 PM, the DON was asked if the physician was contacted when Resident #22 was sent to the … | 2014-11-01 |
| 13660 | 13660 | COUNTRYSIDE HEALTHCARE AND REHABILITATION | 445280 | 3051 BUFFALO ROAD | LAWRENCEBURG | TN | 38464 | 2010-11-03 | 241 | D | 0 | 1 | 08U511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review and observations, it was determined the facility failed to ensure 1 of 7 (Nurse #4) medication nurses and 1 of 3 Certified Nursing Assistant (CNA #3) maintained residents' dignity and respect by entering residents' rooms without knocking or gaining permission prior to entering the residents' room. The findings included: 1. Review of the facility's "Quality of Life - Dignity" policy documented, "...6. Resident's private space and property shall be respected at all times. a. Staff will knock and request permission before entering resident's rooms..." 2. Observations during medication administration on 11/2/10 at 9:20 AM, Nurse #4 entered room [ROOM NUMBER] without knocking on the door or gaining permission to enter. Observations during medication administration on 11/2/10 at 5:50 PM, Nurse #4 entered room [ROOM NUMBER] without knocking on the door or gaining permission to enter. 3. Observations during dining on 11/2/10 at 6:00 PM, CNA #3 entered room [ROOM NUMBER] without knocking on the door or gaining permission to enter. | 2014-11-01 |
| 13661 | 13661 | COUNTRYSIDE HEALTHCARE AND REHABILITATION | 445280 | 3051 BUFFALO ROAD | LAWRENCEBURG | TN | 38464 | 2010-11-03 | 309 | D | 0 | 1 | 08U511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to follow physician's orders for no caffeine for 1 of 22 (Resident #14) sampled residents. The findings included: Medical record review for Resident #14 documented an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 10/26/10 documented, "Send for Lexiscan Thalium Test 11-3-10... No caffeine for 24 (hours) before test..." Observation in Resident #14's room on 11/2/10 at 1:05 PM, revealed Resident #14 was served regular tea. During an interview in the hall outside Resident #14's room on 11/2/10 at 11:05 PM, the Licensed Practical Nurse #8 confirmed the tea was not caffeine free. | 2014-11-01 |
| 13662 | 13662 | COUNTRYSIDE HEALTHCARE AND REHABILITATION | 445280 | 3051 BUFFALO ROAD | LAWRENCEBURG | TN | 38464 | 2010-11-03 | 332 | D | 0 | 1 | 08U511 | **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 administer medication with a medication error rate of less than 5 percent (%) when 2 of 7 nurses (Nurses #4 and 5) made three (3) medication errors out of 47 opportunities for error. These errors resulted in a medication error rate of 6.38%. The findings included: 1. Medical Record review for Random Resident (RR) #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in RR #2's room on 11/1/10 at 4:00 PM, Nurse #5 administered three drops of [MEDICATION NAME] ophthalmic eye drops in RR #2's left eye. The failure to administer the correct Artificial Tears ophthalmic drops as ordered resulted in medication error #1. During an interview at RR #2's bedside on 11/1/10 at 4:05 PM, Nurse #5 was asked what medication was administered in the left eye. Nurse #5 stated, "...I had it ([MEDICATION NAME] ophthalmic eye drops) in my pocket, it was the roommate's eye drops..." 2. Review of the facility's "Medication Administration via Enteral Tubes" policy documented, "...12) Put 15- (to) 30ml (milliliters) of water in syringe and flush tubing using gravity flow..." Medical record review for Resident #13 documented an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in Resident #13's room on 11/2/10 at 9:25 AM, revealed Nurse #4 connected a syringe to the PEG tube [MEDICATION NAME]/[MEDICATION NAME] dissolved in water, and pushed the medication into the PEG tube. Nurse #4 did not flush the PEG tube prior to administration of medication which resulted in medication error #2. 3. Medical Record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician 's orders dated 9/8/10 documented "...MVI (Multi-Vitamin) with minerals one po (by mouth)… | 2014-11-01 |
| 13663 | 13663 | COUNTRYSIDE HEALTHCARE AND REHABILITATION | 445280 | 3051 BUFFALO ROAD | LAWRENCEBURG | TN | 38464 | 2010-11-03 | 322 | D | 0 | 1 | 08U511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined Nurse #4 failed to administer medications appropriate by failing to check the placement of the Percutaneous Endoscopy Gastrostomy (PEG) Tube prior to administering medications to 1 of 1 (Resident #13) sampled residents with a PEG tube. The findings included: Review of the facility's "Medication Administration via Enteral Tubes" policy documented, "...8) Check for proper tube placement..." Medical record review for Resident #13 documented an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].Check placement and residual q shift..." Observations in Resident #13's room on 11/2/10 at 9:25 AM, Nurse #4 connected a syringe with [MEDICATION NAME]/[MEDICATION NAME] and pushed the medication into the PEG tube. Nurse #4 did not check Resident #13's tube placement prior to administering medications to Resident #13. During an interview in Resident #13 room on 11/2/10 at 9:30 AM, Nurse #4 was asked if she had checked the placement of Resident #13's PEG tube. Nurse #4 stated, "No ma'am." | 2014-11-01 |
| 9055 | 9055 | MT PLEASANT HEALTHCARE AND REHABILITATION | 445374 | 904 HIDDEN ACRES DR | MOUNT PLEASANT | TN | 38474 | 2013-07-10 | 278 | D | 0 | 1 | 098D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual, medical record review and interview, it was determined the facility failed to accurately assess a resident for falls, vision, [MEDICAL TREATMENT] or terminal prognosis for 4 of 20 (Residents #19, 36, 47 and 66) sampled residents of the 33 residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of incident reports documented Resident #19 fell [DATE], 4/15/13 and 6/6/13 with no injuries. Review of the fall risk assessment dated [DATE] and 4/15/13 documented, .HISTORY OF FALLS (Past 3 months) . 2 (indicating 1 to 2 falls in past 3 months) . Review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 6/15/13 in section J1800 was coded as a 0, indicating no falls since prior assessment. During an interview in the conference room on 7/10/13 at 8:30 AM, the MDS Coordinator was asked if the falls in March, April and June 2013 were documented on the quarterly MDS dated [DATE]. The MDS Coordinator confirmed that it was not documented and stated, I don't know . 2. Review of the CMS's RAI Version 3.0 Manual documented, .B1000: Vision . Steps for Assessment . Test the accuracy of your findings . Ensure that the resident's customary visual appliance for close vision is in place (e.g. (example), eyeglasses, magnifying glass) . Medical record review for Resident #36 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment with an assessment reference date of 4/18/13 in section B1000 was coded as a 2, indicating moderately impaired - limited vision and B1200 was coded as a 0, indicating no corrective lenses used. During an interview in Resident #36's room on 7/8/13 at 3:30 PM, Resident #36 stated she uses the magnifying glasses … | 2017-03-01 |
| 9056 | 9056 | MT PLEASANT HEALTHCARE AND REHABILITATION | 445374 | 904 HIDDEN ACRES DR | MOUNT PLEASANT | TN | 38474 | 2013-07-10 | 279 | D | 0 | 1 | 098D11 | **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 a comprehensive care plan was developed to address vision for 1 of 20 (Resident #36) sampled residents of the 33 residents included in the stage 2 review. The findings included: Medical record review for Resident #36 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] documented, .Section V Care Area Assessment (CAA) Summary . 03. Visual Function . Care Area Triggered (checked) . The care plan dated 4/19/13 did not address vision. During an interview in the MDS office on 7/10/13 at 8:56 AM, the MDS Coordinator confirmed that vision was not addressed on the care plan. | 2017-03-01 |
| 9057 | 9057 | MT PLEASANT HEALTHCARE AND REHABILITATION | 445374 | 904 HIDDEN ACRES DR | MOUNT PLEASANT | TN | 38474 | 2013-07-10 | 280 | D | 0 | 1 | 098D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to revise the care plan for emergency bleeding related to [MEDICAL TREATMENT] for 1 of 20 (Resident #47) sampled residents of the 33 residents included in the stage 2 review. The findings included: Medical record review for Resident #47 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].[MEDICAL TREATMENT] 3X (times) / (per) WK (week) ON TUES (Tuesday), THURS (Thursday) & (and) SAT (Saturday) . The care plan dated 5/24/13 does not address emergency bleeding related to [MEDICAL TREATMENT]. During an interview in the Minimum Data Set (MDS) office on 7/10/13 at 10:45 AM, the MDS Coordinator was asked if the [MEDICAL TREATMENT] care plan addressed emergency bleeding. The MDS Coordinator stated, No. During an interview in the conference room on 7/10/13 at 10:53 AM, the Director of Nursing (DON) was asked if she expected the care plan to address emergency bleeding. The DON stated, Yes. | 2017-03-01 |
| 9058 | 9058 | MT PLEASANT HEALTHCARE AND REHABILITATION | 445374 | 904 HIDDEN ACRES DR | MOUNT PLEASANT | TN | 38474 | 2013-07-10 | 309 | D | 0 | 1 | 098D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to follow physician's orders for 1 of 2 (Resident #23) sampled residents observed receiving medication patches of the 33 residents included in the stage 2 review. The findings included: Medical record for Resident #23 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 6/5/13 documented, .[MEDICATION NAME] 9.5 MG (milligram) / 24 HR (hour) PATCH APPLY 1 PATCH TOPICALLY DAILY *REMOVE OLD PATCH . Observations in Resident #23's room on 7/10/13 at 7:15 AM, revealed an [MEDICATION NAME] on Resident #23's right upper back dated 7/9/13 and an [MEDICATION NAME] on her left upper chest dated 7/10/13. During an interview in Resident #23's room on 7/10/13 at 7:15 AM, the Director of Nursing was asked about the second patch on Resident #23. The DON stated, .She (Nurse #1) should have removed the patch ([MEDICATION NAME] dated 7/9/13) . During an interview in Resident #23's room on 7/10/13 at 7:20 AM, Nurse #1 stated, I couldn't find it ([MEDICATION NAME] dated 7/9/13) . | 2017-03-01 |
| 9059 | 9059 | MT PLEASANT HEALTHCARE AND REHABILITATION | 445374 | 904 HIDDEN ACRES DR | MOUNT PLEASANT | TN | 38474 | 2013-07-10 | 318 | D | 0 | 1 | 098D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, it was determined the facility failed to ensure residents with limitations in range of motion (ROM) received care and treatment to prevent further decline in ROM for 1 of 4 (Resident #12) sampled residents with contractures of the 33 residents included in the stage 2 review. The findings included: Review of the facility's ROM active and passive policy documented, .For some residents, this ROM can be achieved during their normal daily routine of ADL's (Activities of Daily Living) . Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented in .Section G.400. Functional Limitation in Range of Motion . Upper extremity . (coded) 2 (indicating impairment on both sides) . Lower extremity .(coded) 2 . Review of the care plan dated 9/18/12 and updated 1/18/13 documented, .Self care deficit with risk for decline in skin integrity . Gentle PROM (passive ROM) to BUE (bilateral upper extremities) and BLE (bilateral lower extremities) during ADL . palm protectors to bilateral hands . Review of the physician orders [REDACTED].GENTLE PROM TO BUE & (and) BLE DURING ADL CARE, PALM PROTECTORS TO BIL (bilateral) HANDS, OFF DURING BATH . Review of Resident #12's personal care record for 7/1/13 through 7/31/13 documented, .PROM BUE . Palm Protectors . There is no documentation on the form that this intervention was done. Observations in Resident #12's room on 7/8/13 at 11:30 AM and 2:18 PM, revealed Resident #12 lying in bed with no palm protector on the left hand. Observations in Resident #12's room on 7/9/13 at 7:56 AM and 8:30 AM, revealed Resident #12 lying in bed with the palm protector partially on the right hand. There was not a palm protector on the left hand. At 9:30 AM, the palm protector was completely off the right hand. Observati… | 2017-03-01 |
| 5827 | 5827 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-11-10 | 223 | D | 1 | 0 | 09ZM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure the safety of a resident immediately after an inappropriate incident for 1 (Resident #1) of 5 residents reviewed. The findings included: Review of the facility policy entitled Abuse & Neglect of Residents and Misappropriation of Residents' Property approved 2/20/13, revealed .Any alleged violations involving mistreatment, neglect, abuse, or misappropriation including injuries of unknown source, must be reported immediately to the Administrator . Continued review of the policy revealed the investigation includes: 1. Notification of the involved resident's legal guardian or responsible family member. 2. Facility investigation will include: a. Interviewing the resident victim. b. Interviewing the alleged perpetrator. c. Interviewing all persons with firsthand knowledge of alleged incident. d. Physical examination of resident victim for evidence of abuse or neglect. f. Photographing evidence where appropriate. g. Obtaining written statements from victim, witnesses, other persons with reported knowledge as appropriate. i. Collecting, reviewing, and retaining pertinent facility documentation which may have a bearing on a full and proper investigation. 3. Any employees/volunteer/ contractor alleged to be involved in suspected abuse, neglect, or misappropriation will be removed from direct care until completion of the investigation. 4. If the alleged violation is verified, appropriate corrective action will be taken. 5. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. 6. Analysis of further staff training and/or monitoring needs related to residents' rights, resident care needs of the confused or behaviorally disturbed resident, etc . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED… | 2018-11-01 |
| 5828 | 5828 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-11-10 | 328 | D | 1 | 0 | 09ZM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview the facility failed to correctly transcribe a physicians order for the use of oxygen, failed to follow the facility policy for transcribing and reviewing physician orders [REDACTED].#4) of 5 residents reviewed. The findings included: Review of a facility policy titled, Transcription of Physician order [REDACTED].Guidelines have been established to ensure physician orders [REDACTED].The licensed nurse is responsible to clarify any physician order [REDACTED].or confusing prior to transmission to the pharmacy or transcription on the medication administration record .Information must not be added in to any order .The night shift charge nurse .completes a 24 hour chart check each night indicating that all orders for the preceding 24 hours period orders have been properly transcribed and executed .any issue or discrepancies shall be addressed at this time and communicated to ensure 100% of all physician orders [REDACTED]. If discrepancies are found they are to be corrected by the .nurses. This will serve as a triple check of all orders. Review of a facility policy titled, Oxygen Policy dated 2/20/13 revealed, .Oxygen will only be administered with a physician's orders [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was seen in the Emergency Department on 9/2/15 with a [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, had symptoms of inattention and altered level of consciousness that fluctuated for 1-3 days, needed extensive assistance from 2 people for activities of daily living, did not ambulate, used a wheel chair for mobility and had received oxygen therapy within the previous 14 days while in the facility. Medical record review of a Physician's Telephone Orders sheet dated… | 2018-11-01 |
| 13304 | 13304 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 309 | E | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's physician protocols, medical record review and interview, it was determined the facility failed to follow physician's orders [REDACTED].#3, 7, 8, 15 and 6) sampled residents. The findings included: 1. Review of the facility's "...PHYSICIANS PROTOCOLS" documented, "...Constipation... MOM (Milk of Magnesia) 30 cc (cubic centimeters)... BID (twice daily) prn (as needed) on res (resident) Request or if no BM (bowel movement) in 3 days..." 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. with no BM. Review of the August 2011 MAR had no prn laxatives documented as being administered when Resident #3 failed to have a BM as per facility's protocol for constipation. During an interview at the nurses' station one on 9/13/11 at 9:10 AM, the Director of Nursing (DON) reviewed the documentation of BM on Resident #3's MAR and stated, "Looks like no BM from the 18th till the 26th... Should get something after 3 days. They (nurses) know that." 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MAR dated June 2011 had no BM documented from 6/16/11 through 6/20/11 for a total of 5 consecutive days with no BM. Review of the June 2011 MAR had no prn laxatives documented as being administered when Resident #7 failed to have a BM as per facility's protocol for constipation. 4. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MAR dated August 2011 had no BM documented from 8/23/11 through 8/25/11 for a total of 3 consecutive days with no BM. Review of the August 2011 MAR had no prn laxatives documented as being administered when Resident #8 failed to have a BM as per facility's protocol for constipation. During an interview in the treatment nurse's office on 9/14/11 at 2:00 PM, when asked about n… | 2015-02-01 |
| 13305 | 13305 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 221 | D | 0 | 1 | 09ZW11 | **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 an informed consent and an order for [REDACTED]. The findings included: 1. Review of the facility's "Use of Restraints" policy documented, "...1. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor)... 7. Physical restraints for behavior control shall only be used on the signed order of a physician... 12. Should a resident not be capable of making a decision the surrogate or sponsor may exercise the right of the use or non-use of a restraint..." 2. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan reviewed 7/6/11 documented, "...Fall Risk... Place personal alarm onto lap buddy while ^ (up) in chair..." Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 6/18/11 documented, "...Section P Restraints... 2 (used daily) E. Trunk Restraint..." Review of the physicians' orders had no documented order for a lap buddy restraint to be used. The facility was unable to provide documentation that a consent was obtained for the use of a lap buddy restraint. Observations in the main dining room on 9/12/11 at 12:10 PM and on 9/13/11 at 8:15 AM and 12:00 PM, revealed Resident #7 seated in a wheelchair with a lap buddy restraint in use. During an interview in the Director of Nursing's (DON) office on 9/14/11 at 1:40 PM, the DON reviewed the medical record of Resident #7 and stated, "I don't see an order for [REDACTED]." 3. Medical record review for Resident #12 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a care plan dated 8/10/11 documented, "...DC (discontinue) front-closure belt upon hosp. (hospital) return 8/10/11..… | 2015-02-01 |
| 13306 | 13306 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 425 | D | 0 | 1 | 09ZW11 | **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 timely pharmacy services for 3 of 20 (Residents #3, 5 and 8) sampled residents. The findings included: 1. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the nurses's medication notes on the back of the August 2011 MAR indicated [REDACTED]..8/26/11 2A (after midnight) Miralax not available..." During an interview in the Director of Nursing's (DON) office on 9/14/11 at 1:50 PM, the DON was asked to explain the reason for a medication to be unavailable. The DON stated, "There is no reason a nurse should ever not have a medication... Probably the nurse didn't look. There should not be a time when a medication is not available. I guess she (nurse) didn't try." 2. Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED]. Review of the nurse's medication notes on the back of the August 2011 MAR indicated [REDACTED]..8/8/11 8A No Valium 10 available... 8/9/11 8P Zyrtec not available... 8/10/11 8P Zyrtec not available..." 3. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. MAR indicated [REDACTED]. Review of the nurse's medication notes on the back of the September 2011 MAR indicated [REDACTED]..9-2-11 6A Nicotine patch 24 mg not available... 9-10-11 6A Hydrocodone 10/500 not available... 9-10-11 6P... Hydrocodone 10/500 not available..." 4. During an interview in the treatment nurse's office on 9/14/11 at 2:00 PM, the DON was asked about the medications that were unavailable. The DON reviewed the back up plan for obtaining medications and stated, "...Nurse just probably didn't carry through..." | 2015-02-01 |
| 13307 | 13307 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 371 | D | 0 | 1 | 09ZW11 | Based on policy review, observation and interview, it was determined the facility failed to ensure proper kitchen sanitation practices were maintained as evidenced by plastic pitchers and cups stored wet nesting on 2 of 3 (9/12/11 and 9/13/11) days of the survey. The findings included: 1. Review of the facility's "Sanitization" policy documented, "...The food service areas shall be maintained in a clean and sanitary manner... Air Drying... Food preparation equipment and utensils that are manually washed will be allowed to air dry..." 2. Observations in the Pot and Pan room on 9/12/11 at 2:00 PM, revealed six plastic pitchers stacked wet nesting. Observations in the kitchen on 9/12/11 at 2:04 PM, revealed nineteen plastic cups stacked wet nesting. 3. Observations in the kitchen on 9/13/11 at 9:00 AM and 11:15 AM, revealed two plastic pitchers stacked wet nesting. Observations in the Pot and Pan room on 9/13/11 at 9:09 AM, revealed seventeen plastic cups stacked wet nesting. 4. During an interview in the Pot and Pan room on 9/13/11 at 11:15 AM, the Dietary Manager (DM) was asked about dishes stacked after they are washed. The DM stated, "...dishes are air dried before they are stacked up... when they are bone dry... I need to do an inservice..." | 2015-02-01 |
| 13308 | 13308 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 514 | D | 0 | 1 | 09ZW11 | **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 physician's orders were accurate for 1 of 20 (Resident #15) sampled residents. The findings included: Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 4/6/11 documented, "...ACCUCHECK 4 TIMES A DAY (AC (before meals) HS (hour of sleep)) WITH SLIDING SCALE..." There was a large X over the order. Review of the physician's orders dated 5/3/11 and 6/2/11 documented, "... ACCUCHECK WITH SLIDING SCALE..." There was no frequency documented. Review of the physician's orders dated 7/7/11, 8/2/11 and 9/8/11 documented, "...ACCUCHECKS AT BEDTIME... HOUR 06/01/11... ACCUCHECK WITH SLIDING SCALE..." Review of the Medication Administration Record (MAR) for April, May, June, July, August and September 2011 documented Accuchecks were being done at 7:00 AM, 11:00 AM, 5:00 PM and 8:00 PM. During an interview in the treatment nurse's office on 9/14/11 at 9:30 AM, the ADON was asked to clarify when accuchecks should be done. The ADON stated the accucheck frequency was marked off the April 2011 MAR and 4/6/11 orders by mistake so it was left off the 5/3/11 and 6/2/11 orders. The ADON stated that an order was written on another resident on 6/1/11 for accuchecks at bedtime and the pharmacy transcribed the order to this resident. There was no order to change the accuchecks from 4 times a day. The ADON confirmed the nurses failed to reconcile the orders correctly. | 2015-02-01 |
| 13309 | 13309 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 332 | D | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the "GERIATRIC MEDICATION HANDBOOK" provided by the American Society of Consultant Pharmacists, review of the "Mosby's NURSING DRUG REFERENCE", medical record review, observation and interview, it was determined the facility failed to ensure that 2 of 9 (Nurses #1 and 6) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors was observed out of 40 opportunities resulting in a medication error rate of 7.5%. The findings included: 1. Review of the "GERIATRIC MEDICATIONS HANDBOOK, TENTH EDITION" provided by the American Society of Consultant Pharmacists, page 57 documented, "Inhaled Medications... Press down on inhaler once to release medication as resident starts to breathe in slowly through the mouth...If another puff of the same or different medication is required, wait 1- (to) 2 minutes... then repeat procedures above..." Review of the "Mosby's NURSING DRUG REFERENCE, 22nd Edition" pages 758 through (-) 759 documented, "[MEDICATION NAME] NURSING CONSIDERATIONS Assess ...B/P (blood pressure), pulse prior to and after administration..." Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in RR #1's room on 9/12/11 at 12:23 PM, revealed Nurse #1 administered 2 puffs of Proair one right after the other. The failure to wait 1-2 minutes between the 2 puffs resulted in medication error #1. Observations in RR #1's room on 9/13/11 at 8:38 AM, revealed Nurse #1 administered [MEDICATION NAME] 2.5 mg without checking any vital signs. Failure to check the blood pressure and pulse prior to administering this medication resulted in medication error #2. During an interview in the Director of Nursing's (DON) office on 9/14/11 at 2:50 PM, the DON was asked how long she expects nurses to wait between two puffs of inhaled medication. The DON stated, "...at least a good 30… | 2015-02-01 |
| 13310 | 13310 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 502 | D | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure laboratory (lab) tests were obtained according to physician orders [REDACTED].#12) sampled residents. The findings included: Medical record review for Resident #12 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. The PT/INR was due to be drawn on 3/10/11 and was not obtained until 3/22/11. Review of a physician's orders [REDACTED]. During an interview in the Director of Nursing's (DON) office on 9/13/11 at 2:07 PM, the DON stated, "No, I don't think the time frame is acceptable." | 2015-02-01 |
| 13311 | 13311 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 315 | E | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observations and interview, it was determined the facility failed to ensure appropriate [DIAGNOSES REDACTED].#4, 5, 8 and 11) sampled residents with Foley catheters. The findings included: 1. Review of the facility's "CATHETER CARE, URINARY" policy documented, "...11. Be sure catheter tubing and drainage bags are kept off the floor..." 2. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #4's room on 9/12/11 at 8:35 AM and 11:50 AM, revealed Resident #4 lying in the bed with a Foley catheter drainage bag in a privacy bag and the Foley tubing laying on the floor under the bed. Observations in Resident #4's room on 9/12/11 at 4:30 PM, revealed Resident #4 lying in the bed with a Foley catheter drainage bag in a privacy bag laying on the floor. Observations in Resident #4's room on 9/13/11 at 8:05 AM and 11:15 AM, revealed Resident #4 lying in the bed with a Foley catheter drainage bag in a privacy bag and the Foley tubing laying on the floor under the bed. Observations in Resident #4's room on 9/13/11 at 4:00 PM, revealed Resident #4 lying in the bed with a Foley catheter drainage bag and the Foley tubing laying on the floor under the bed. During an interview at Nurse's Station one on 9/13/11 at 3:45 PM, the Assistant Director of Nursing (ADON) was asked if there was an order for [REDACTED]. 3. Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in Resident #5's room on 9/12/11 at 11:50 PM, 2:00 PM and 4:25 PM and on 9/13/11 at 8:00 AM, 10:05 AM, 12:00 PM, 2:00 PM and 4:00 PM, revealed Resident #5 resting in bed with a Foley catheter. 4. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order… | 2015-02-01 |
| 13312 | 13312 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 314 | G | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the "National Pressure Ulcer Advisory Panel (NAUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE," policy review, medical record review, observation and interview, it was determined the facility failed to accurately identify, assess, treat and document complete treatment orders for pressure ulcers for 3 of 6 (Residents #5, 6 and 8) sampled residents with pressure ulcers. The failure to identify and prevent skin breakdown prior to the development of a Stage 3 pressure ulcer resulted in actual harm to Resident #5. The failure to identify and prevent skin breakdown prior to the development of eschar resulted in actual harm to Resident #6. The findings included: 1. Review of the "National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "...3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin..." 2. Review of the facility's "Skin Assessment" policy documented, "...Educate professionals on how to undertake a comprehensive skin assessment... Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. Ongoing assessment of the skin is necessary to detect early signs of pressure damages... Document all skin assessments, noting details of any pain possibly related to pressure damage. Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals." Review of the "Giving a Bed bath" policy documented, "...Purpose... The purposes of this procedure are... to observe the condition of the resident's skin... General Guid… | 2015-02-01 |
| 13313 | 13313 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 328 | E | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined the facility failed to ensure oxygen (O2) was administered at the rate prescribed by the physician for 4 of 6 (Residents #2, 4,13 and 16) sampled residents receiving O2 therapy. The findings included: 1. Review of the facility's "Oxygen Administration" policy documented, "...Review the physician's orders...for oxygen administration...Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered..." 2. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The physician's order dated 8/2/11 documented, "...O2 @ (at) 2L (liters) / (per) min (minute) BNC (binasal cannula)..." Observations in Resident #2's room on 9/12/11 at 9:15 AM, revealed Resident #2's O2 rate was set at 4L/min, instead of the physician's prescribed rate of 2L/min. 3. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 9/6/11 documented "...O2 at 2L/MIN BNC R/T (related to) [MEDICAL CONDITION]" Observations in room [ROOM NUMBER]A on 9/12/11 at 8:35 AM,11:50 AM and 4:30 PM, revealed Resident #4 lying in bed with O2 being administered between 3 to (-) 3 1/2 L/min BNC. Observations in room [ROOM NUMBER]A on 9/13/11 at 8:05 AM, 9:40 AM and 11:15 AM, revealed Resident #4 lying in bed with O2 being administered at 3 L/min BNC. During an interview in room [ROOM NUMBER]A on 9/13/11 at 9:40 AM, Nurse #1 was asked what the flow rate of the O2 Resident #4 was receiving was set on. Nurse #1 stated, "...It's (O2) on 3 liters..." Observations in room [ROOM NUMBER]A on 9/13/11 at 4:00 PM, revealed Resident #4 lying in bed with O2 being administered at 3 L/min BNC. During an interview in room [ROOM NUMBER]A on 9/13/11 at 4:00 PM, Nurse #5 confirmed Resident #4 was receiving O2 at "...3 liters." Observations in room [ROOM NU… | 2015-02-01 |
| 13314 | 13314 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 280 | D | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to revise the care plan for a Foley catheter, a [DEVICE] or emergency bleeding for a [MEDICAL TREATMENT] resident for 3 of 20 (Residents #8, 15 and 17) sampled residents. The findings included: 1. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. comprehensive care plan dated 8/31/11 documented, "...Wound to be assessed daily with dressing change..." The care plan does not reflect the current treatment or the NPWT [DEVICE]. During an interview in the treatment nurse's office on 9/14/11 at 1:30 PM, Nurse #7 confirmed the care plan does not reflect the current wound therapy regarding [DEVICE] and dressing changes. 2. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#16/FR (french) FOLEY CATH (catheter) WITH 10CC (cubic centimeters) BULB D/T (due to) [MEDICAL CONDITION]" Review of the comprehensive care plan dated 6/17/11 did not include care for a Foley catheter. Observations in Resident #15's room on 9/13/11 at 2:30 PM and 9/14/11 at 2:00 PM, revealed Resident #15 with a Foley catheter to a drainage bag. During an interview in the treatment nurse's office on 9/14/11 at 1:25 PM, Nurse #7 was asked if there was a care plan for the Foley catheter. Nurse #7 stated, "...I'm not seeing it..." Nurse #7 was asked if there should be a Foley catheter care plan. Nurse #7 stated, "Yes." 3. Medical record review for Resident #17 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During an interview at the nurses' station one on 9/14/11 at 9:55 AM, the Director of Nursing (DON) was asked about emergency interventions for bleeding from the [MEDICAL TREATMENT] shunt site. The DON confirmed the care plan did no… | 2015-02-01 |
| 13315 | 13315 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 333 | D | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the "GERIATRIC MEDICATION HANDBOOK, TENTH EDITION" provided by the American Society of Consultant Pharmacists, medical record review, observation and interview, it was determined the facility failed to ensure 1 of 9 (Nurse #6) nurses administered medications without a significant medication error. The findings included: Review of the "GERIATRIC MEDICATION HANDBOOK, TENTH EDITION" provided by the American Society of Consultant Pharmacists, page 41 documented, "[MEDICATION NAME] R... ONSET (In Hours, Unless Noted)...0.5 (1/2) - (to) 2... TYPICAL ADMINISTRATION / COMMENTS... 30 minutes prior to meals..." Medical record review for Random Resident (RR) #2 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]...210-250: 4 UNITS..." Observations in RR #2's room on 9/13/11 at 11:12 AM, revealed Nurse #6 administered 4 units of [MEDICATION NAME] R. RR #2 did not receive a meal or a snack until 11:38 AM when she took her first bite of food from her lunch tray. The administration of the insulin more than 30 minutes before a meal or snack resulted in a significant medication error. During an interview in the DON's office on 9/14/11 at 2:50 PM, the DON was asked how soon she expects residents to receive a meal after insulin administration. The DON stated, "They (residents) are supposed to eat their meal or get a snack within 10 minutes..." | 2015-02-01 |
| 13316 | 13316 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 504 | D | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to obtain a physician's order for blood samples drawn on 1 of 20 (Resident #15) sampled residents. The findings included: Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders had no order documented for the following laboratory tests obtained: a. Basic Metabolic Panel (BMP), Lipid Profile (LP) and [MEDICATION NAME] level on 4/12/11. b. Hemaglobin A1C on 5/16/11. c. [MEDICATION NAME]/Internationalized Ratio (PT/INR) on 7/22/11, 8/10/11, 8/22/11, 8/25/11 and 8/30/11. During an interview in the Assistant Director of Nursing's (ADON) office on 9/14/11 at 9:50 AM, the ADON was asked about the PT/INR's with no orders. The ADON stated, "...did too many, we didn't pull it (lab slips) out of the file... should not have been done..." The DON was asked about the BMP, LP and [MEDICATION NAME] level on 4/12/11 and the Hemaglobin A1C on 5/16/11. The ADON stated, "...I don't have orders for those..." | 2015-02-01 |
| 13317 | 13317 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 431 | D | 0 | 1 | 09ZW11 | Based on policy review, observation and interview, it was determined the facility failed to store medications properly by having expired medications in 1 of 8 (Central Supply) medication storage areas. The findings included: Review of the facility's "Storage of Medications" policy documented, "...The nursing staff shall be responsible for maintaining medication storage... The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed..." Observations in the Central Supply on 9/14/11 at 1:56 PM, revealed 5 unopened bottles of Aspirin 325 milligrams (mg) containing 100 tablets each with an expiration date of 6/11 and 1 unopened bottle of Vitamin B 12 100 mg containing 100 tablets with an expiration date of 8/11. During an interview in the Central Supply on 9/14/11 at 1:56 PM, Certified Nursing Assistant (CNA) #2 was asked who is responsible for checking for expired medications. CNA #2 stated, "(Nurse #2) does... and I help her..." CNA #2 was asked if the Aspirin and Vitamin B 12 were expired. CNA #2 confirmed that the Aspirin tablets had expired 6/11 and that the Vitamin B 12 tablets had expired 8/11. During an interview at nurses' station one on 9/14/11 at 2:10 PM, Nurse #2 was asked who is responsible for checking for expired medications in the Central Supply. Nurse #2 stated, "Me or (CNA #2)." Nurse #2 was asked how often she checks for expired medications. Nurse #2 stated, "I try to check at least once a month, but sometimes I get busy and forget.." | 2015-02-01 |
| 13318 | 13318 | HUNTINGDON HEALTH & REHAB CENTER | 445210 | 635 HIGH STREET | HUNTINGDON | TN | 38344 | 2011-09-14 | 157 | D | 0 | 1 | 09ZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to notify the physician of a resident leaving the facility against medical advice (AMA) for 1 of 20 (Resident #19) sampled residents. The findings included: Review of the facility's "Discharging a Resident Without a Physician's Approval" policy documented, "...1. Should a resident, or his representative (sponsor) request an immediate discharge, the resident's Attending Physician must be promptly notified. 2. The order for a discharge without physician's approval must be signed and dated by a physician and recorded in the resident's medical record at the time of or after the discharge..." Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes dated 7/3/11 documented, "...12noon Left c (with) son in law for few hours... 650p Attempted to call... concerning res (resident) not returning from LOA (leave of absence). Also attempted to call res other daughter... No answer at any numbers... 7Pm Contacted... Social Services...@ (at) 7:45 this evening... phone call from son-in-law... who said he brought Resident back but he (Resident #19) refused to get out of truck... they left... Resident (#19) was back at home... and didn't plan to come back (to nursing home)..." The facility was unable to provide documentation that the attending physician was notified of the resident leaving the facility AMA. During an interview in the Director of Nursing's (DON) office on 9/14/11 at 2:50 PM, the DON was asked what her expectations are for nursing staff when a resident leaves AMA. The DON stated, "...notify the physician immediately, notify the administrator, document the resident's condition when they left..." The DON was asked if the physician was notified of Resident #19 leaving AMA. The DON stated, "...I didn't see any documentation..." | 2015-02-01 |
| 4852 | 4852 | SODDY-DAISY HEALTH CARE CENTER | 445408 | 701 SEQUOYAH ROAD | SODDY-DAISY | TN | 37379 | 2016-04-13 | 371 | F | 0 | 1 | 0BR011 | Based on review of facility policy, observation, and interview, the facility failed to store food under sanitary conditions, discard out of date items, and maintain clean food preparation equipment in 1 of 1 kitchen that could have affected 101 residents. The findings included: Review of the facility policy Food Storage Supply, with the revised date of 11/01/2014, revealed .Any expired or outdated food products should be discarded .Foods should be stored in their original containers if designed for freezing .or wrapped in heavy-duty aluminum foil or special laminated papers. Label and date all food items . Review of the facility policy Deep-Fat Fryer, with the revised date of 09/01/2011, revealed .Cleaning/Sanitation of Equipment Frequency: After each use .scrape off oxidized fat from sides of fryer with a spatula. Drain and strain fat using a cheesecloth or filter paper . Observation of the walk-in freezer on 4/11/16 at 10:20 AM, revealed 60 biscuits unwrapped and unlabeled. Interview with the Assistant Administrator on 4/11/16 at 10:20 AM, in the freezer,confirmed the biscuits were unwrapped and unlabeled and available for resident's consumption. Observation of the milk cooler on 4/11/16 at 10:25 AM, revealed 13 half pint, 2% buttermilk with the expiration date 4/9/16. Interview with the Assistant Administrator on 4/11/16 at 10:25 AM, beside the milk cooler, confirmed the milk was out of date and available for resident's consumption. Observation of the deep fryer on 4/12/16 at 10:11 AM revealed food debris floating on the top and on the sides of the deep fryer. Interview with the Dietary Manager on 4/12/16 at 10:11 AM, beside the deep fryer, confirmed the deep fryer was dirty and had not been cleaned since 4/8/16. | 2019-07-01 |
| 13469 | 13469 | MABRY HEALTH CARE | 445272 | 1340 N GRUNDY QUARLES HWY P O BOX 7 | GAINESBORO | TN | 38562 | 2011-01-27 | 371 | F | 0 | 1 | 0CMI11 | Based on observation, review of facility policy and interview, the facility failed to maintain the dietary department in a clean and sanitary manner. The findings included: Observation on January 25, 2011, at 10:15 a.m., with the administrator (interim Dietary Manager), revealed six mixing bowls and ten cereal bowls stacked wet. Continued observation of the walk-in cooler revealed one flat of thirty-six whole, raw, eggs placed on a metal cart, on top of a tray of pre-poured glasses of milk ready to be served. Continued observation revealed a case of whole, raw, eggs, which contained six flats (of thirty-six eggs each) placed on the second shelf above cartons of liquid eggs. Review of the facility policy, "...Staff will allow all dishes to air dry before storage...allow the pots, pans, and stainless steel bowl to air dry before storage...Dietary Manager will monitor storage procedure...Liquid eggs and raw eggs are stored on the bottom shelf in the walk in cooler...Dietary Manager will monitor storage procedure..." Interview with the administrator on January 25, 2011, at 11:30 a.m., in the dietary department, confirmed the mixing and cereal bowls were stacked wet and the eggs were placed on the second shelf above other food items. | 2014-12-01 |
| 13470 | 13470 | MABRY HEALTH CARE | 445272 | 1340 N GRUNDY QUARLES HWY P O BOX 7 | GAINESBORO | TN | 38562 | 2011-01-27 | 315 | D | 0 | 1 | 0CMI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess and remove an indwelling catheter for one (#6) of twenty residents reviewed, following the healing of a pressure ulcer. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Continued medical record review of the resident's care plan dated January 13, 2011, revealed " ...wounds currently healed..." Observation on January 25, 2011, at 10:45 a.m., and January 26, 2011, at 3:52 p.m., revealed the resident lying in bed with an indwelling catheter in place. Interview with the Director of Nursing on January 26, 2011, at 4:05 p.m., at the AB hall nursing desk confirmed the resident's wound was healed and the catheter was not removed. | 2014-12-01 |
| 6787 | 6787 | SKYLINE OF MIDSOUTH HEALTHCARE AND REHABILITATION | 445436 | 2380 JAMES ROAD | MEMPHIS | TN | 38127 | 2016-01-07 | 247 | D | 0 | 1 | 0CT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to give advance notification of room change for 1 of 3 (Resident #92) sampled residents of three family member interviews concerning a room change. The findings included: Review of the facility's Transfer, Room to Room policy revealed, .3. Prior to room transfer . the resident's representative . will be provided with information concerning the . room transfer . 6. Documentation of a room transfer is recorded in the resident's medical record . Medical record review for Resident #92 documented an admitted [DATE] with [DIAGNOSES REDACTED]. The nurses note dated 11/14/15 documented, .resident adjusting well to recent room change . The social service progress note dated 11/19/15 documented, .was moved . RP (responsible party) called today stating she was not informed of a room change . Interview with Resident #92's family member on 1/5/16 at 9:51 AM, in the 300 hall dining room, the family member was asked if notification was given upon room change. Resident #92's family member stated, No we were not notified when she got moved. My daughter is the RP and she did not get notified. Interview with the Social Worker (SW) on 1/5/16 at 4:44 PM, in the conference room, the SW was asked about the facility's procedure for room change and who and is informed and when. The SW stated, The RP should be notified when a resident is moved to another room. We did not follow protocol (for Resident #92). | 2018-05-01 |
| 6788 | 6788 | SKYLINE OF MIDSOUTH HEALTHCARE AND REHABILITATION | 445436 | 2380 JAMES ROAD | MEMPHIS | TN | 38127 | 2016-01-07 | 278 | D | 0 | 1 | 0CT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure assessments were accurate for 2 of 33 (Residents #13 and 130) sampled 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 admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/15 documented no impairment in range of motion (ROM) or functional limitations. Observations in Resident #13's room on 1/4/16 at 11:53 AM and 2:39 PM, and on 1/5/16 at 8:52 AM, revealed Resident #13's right index finger was contracted and wrapped around her right thumb. Interview with MDS Coordinator #1 on 1/6/15 at 8:00 PM, at nursing station 2, MDS Coordinator #1 was asked if the functional limitation portion of the MDS was coded accurately for Resident #13. MDS Coordinator #1 stated, No, it is inaccurate. 2. Medical record review revealed Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 8/3/15 documented no functional limitations in range of motion. Observations in Resident #130's room on 1/5/16 at 8:22 AM, revealed Resident #130 was lying in bed and the resident's feet were observed with bilateral foot drop. Interview with MDS Coordinator #1 on 1/6/16 at 8:10 AM, in the conference room, MDS Coordinator #1 was asked how does she know which residents have contractures. MDS Coordinator #1 stated, I assess the residents with my own eyes. MDS Coordinator #1 was asked if Resident #130 had a contracture. MDS Coordinator #1 stated, Yes, she has bilateral foot drop. Interview with MDS Coordinator #1 on 1/6/15 at 8:00 PM, at nursing station 2, MDS Coordinator #1 was asked if the functional limitation portion of the MDS was coded accurately for Resident #130. MDS Coordinator #1 stated, No, it is inaccurate. | 2018-05-01 |
| 6789 | 6789 | SKYLINE OF MIDSOUTH HEALTHCARE AND REHABILITATION | 445436 | 2380 JAMES ROAD | MEMPHIS | TN | 38127 | 2016-01-07 | 279 | D | 0 | 1 | 0CT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to develop a comprehensive care plan for contractures or range of motion for 2 of 33 (Residents #13 and 130) sampled residents included in the stage 2 review. The findings included: 1. Review of the facility's Care Planning - Interdisciplinary Team policy documented, .Our facility's Care Planning / Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . 2. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide a care plan for range of motion or contractures for Resident #13. Observations in Resident #13's room on 1/4/16 at 11:53 AM and 2:39 PM, and on 1/5/16 at 8:52 AM, revealed Resident #13's right index finger was contracted and wrapped around her right thumb. Interview with Minimum Data Set (MDS) Coordinator #1 on 1/6/16 at 8:10 AM, in the conference room, MDS Coordinator #1 was asked who was responsible for completing the care plans. MDS Coordinator #1 stated, MDS. MDS Coordinator #1 was asked how does she know which residents have contractures. MDS Coordinator #1 stated, I assess the residents with my own eyes. MDS Coordinator #1 was asked if Resident #13 should have a care plan addressing contractures and range of motion. MDS Coordinator #1 stated, Yes. I don't see one (care plan). It should have been on the ADL (activities of daily living) care plan. Interview with the Assistant Director of Nursing (ADON) on 1/6/16 at 4:25 PM, in the conference room, the ADON was asked should a resident with contractures have a care plan related to the contractures. The ADON stated, Sure. The ADON was asked if she saw a care plan related to contractures on Resident #13's medical chart. The ADON stated, Not in the care plan section. The ADON was asked if there should be a care plan. The ADON stated, Yes. 3… | 2018-05-01 |
| 6790 | 6790 | SKYLINE OF MIDSOUTH HEALTHCARE AND REHABILITATION | 445436 | 2380 JAMES ROAD | MEMPHIS | TN | 38127 | 2016-01-07 | 309 | D | 0 | 1 | 0CT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to obtain a physician's order for [MEDICAL TREATMENT] or communicate with [MEDICAL TREATMENT] for 1 of 1 (Resident #54) sampled resident reviewed of the 5 residents receiving [MEDICAL TREATMENT] and the facility failed to follow physician's orders for restorative care for 1 of 3 (Resident #10) sampled residents reviewed of the 4 residents with limitations in range of motion (ROM). The findings included: 1. The facility's [MEDICAL TREATMENT] Access Care policy documented, .The general medical nurse should document in the resident's medical record every shift as follows: 1. If [MEDICAL TREATMENT] was done during shift. 2. Any part of report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given. 3. Observations post-[MEDICAL TREATMENT] . Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/14/15 admission Minimum Data Set (MDS) assessment documented Resident #54 received [MEDICAL TREATMENT] while a resident and not a resident. The care plan dated 12/28/15 documented, .has AV (arteriovenous) shunt and receives [MEDICAL TREATMENT] 3 days weekly . Review of the (Named Resident #54) [MEDICAL TREATMENT] Info. (Information) form documented, .Clinic-(Named) [MEDICAL TREATMENT] Ctr. (Center) . Days T (Tuesday) - Th (Thursday) - Sat (Saturday) . There was no documentation of communication with [MEDICAL TREATMENT] or an order for [REDACTED].>Interview with the Assistant Director of Nursing (ADON) on 1/6/15 at 3:10 PM, at nursing station 2, the ADON was asked how the nurses communicate with the [MEDICAL TREATMENT] center. The ADON stated there is a communication form ([MEDICAL TREATMENT] communication record form) the nurse fills out, weighs the resident prior to [MEDICAL TREATMENT], takes vital signs, the form goes with the resident to [MEDICAL TREATMENT], [MEDICAL TREATMENT] sends the… | 2018-05-01 |
| 6791 | 6791 | SKYLINE OF MIDSOUTH HEALTHCARE AND REHABILITATION | 445436 | 2380 JAMES ROAD | MEMPHIS | TN | 38127 | 2016-01-07 | 315 | D | 0 | 1 | 0CT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observations, and interviews, the facility failed to provide a clean urinal to empty the urinary catheter bag, the facility failed to keep a urinary catheter bag off of the floor, and failed to obtain a current [DIAGNOSES REDACTED].#164) sampled residents with a urinary catheter. The findings included: The facility's Catheter Care, Urinary policy documented, The purpose of this procedure is to prevent catheter-associated urinary tract infections . Be sure the catheter tubing and drainage bag are kept off the floor. Empty the drainage bag regularly using a separate, clean collection container for each resident .it is suggested to change catheters and drainage bags based on clinical indications such as infection . Medical record review revealed Resident #164 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of a [DIAGNOSES REDACTED].#164's medical record since the resident's pressure ulcer resolved on 12/2/15. Observations in Resident #164's bathroom on 1/5/16 at 11:37 AM, revealed a dirty, unlabeled, and uncovered urinal hanging on the bathroom rail. Observations in Resident #164's room on 1/6/16 at 8:40 AM, revealed his Foley catheter bag was touching the floor. Interview with Resident #164's mother on 1/4/16 at 3:42 PM, in Residents #164's room, Resident #164's mother was asked if the building was clean. Resident #164's mother stated, Well, there is a urinal in the bathroom that is dirty. They use it to empty his catheter and it has something black in it. I am not even sure if they only use it for him. Interview with the Assistant Director of Nursing (ADON) on 1/6/16 at 5:41 PM, at nursing station #1, the ADON was asked about the protocol for urinary catheters. The ADON stated, We are only allowed to use Foley catheters for justification of [MEDICAL CONDITION] bladder, stage 3 or 4 pressure wounds. The ADON was asked what is the ju… | 2018-05-01 |
| 6792 | 6792 | SKYLINE OF MIDSOUTH HEALTHCARE AND REHABILITATION | 445436 | 2380 JAMES ROAD | MEMPHIS | TN | 38127 | 2016-01-07 | 371 | F | 0 | 1 | 0CT011 | Based on policy review, observation, and interview, the facility failed to ensure food was prepared under sanitary conditions when 2 of 4 (Dietary Aides (DA) #1 and 2) dietary staff did not have their hair completely covered and did not have mustaches covered. This could potentially affect 117 residents who received trays from the kitchen of the 128 residents residing in the facility. The findings included: 1. The facility's Food Service/Distribution policy documented, .dietary staff shall wear hair restraints (hair nets, hat beard restraint .) so that hair does not contact food . 2. Observations in the kitchen on 1/4/16 at 12:21 PM, revealed DA #1 and DA #2 did not have all their hair covered and their mustaches were not covered with the beard / mustache hair net. 3. Interview with the Assistant Dietary Manager (ADM) on 1/4/16 at 12:21 PM, when asked if the the dietary aide's hair and mustaches were covered. The ADM stated, Naw. | 2018-05-01 |
| 6793 | 6793 | SKYLINE OF MIDSOUTH HEALTHCARE AND REHABILITATION | 445436 | 2380 JAMES ROAD | MEMPHIS | TN | 38127 | 2016-01-07 | 431 | D | 0 | 1 | 0CT011 | Based on policy review, observation, and interview, 1 of 5 (Licensed Practical Nurse (LPN) #1) nurses failed to ensure medications were not left unattended. The findings included: The facility's Storage of Medications policy documented, .Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . drugs and biologicals . shall not be left unattended . Observations at the medication cart in front of Resident #52's room on 1/4/16 beginning at 4:40 PM, revealed LPN #1 pulled the medications, Levetiracetam and Brilinta from the cart, prepared the Levetiracetam and crushed this medication, and left the Brilinta on top of the cart, out of her sight in the hall, as she went into Resident #52's room and administered the Levetiracetam. Interview with Director of Nursing (DON) on 1/6/16 at 2:20 PM, in the conference room, the DON was asked if medications should be left unattended. The DON stated, They should not be left unattended. | 2018-05-01 |
| 6794 | 6794 | SKYLINE OF MIDSOUTH HEALTHCARE AND REHABILITATION | 445436 | 2380 JAMES ROAD | MEMPHIS | TN | 38127 | 2016-01-07 | 441 | D | 0 | 1 | 0CT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, 2 of 5 (Licensed Practical Nurse (LPN) #1 and 2) nurses failed to ensure practices to prevent the potential spread of infection and cross contamination were maintained during medication administration. The findings included: 1. The facility's Handwashing/Hand Hygiene policy documented, .Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions . u. After removing gloves . The facility's Personal Protective Equipment - Using Gloves policy documented, .Objectives 1. To prevent the spread of infection . Miscellaneous . 5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) . 2. Observations in Resident #52's room on 1/4/16 beginning at 4:32 PM, revealed LPN #1 washed her hands, obtained a blood pressure on this resident, applied gloves, without performing hand hygiene, checked placement of a Percutaneous Endoscopy Gastrostomy (PEG) tube, and checked the residual. LPN #1 removed her gloves, without performing hand hygiene, went to the medication cart and prepared a medication, dropped a piece of paper on the floor, picked up the paper, and continued to prepare medications, without performing hand hygiene. LPN #1 entered Resident #52's room, applied gloves, administered this medication per PEG tube to this resident, and removed her gloves, without performing hand hygiene. LPN #1 went to the medication cart, prepared another medication at the cart, entered Resident #52's room, applied gloves, administered this medication per PEG tube, and removed her gloves, without performing hand hygiene. LPN #1 went to the medication cart and prepared a medication, entered Resident #52's room, applied gloves, and administered this medicatio… | 2018-05-01 |
| 6795 | 6795 | SKYLINE OF MIDSOUTH HEALTHCARE AND REHABILITATION | 445436 | 2380 JAMES ROAD | MEMPHIS | TN | 38127 | 2016-01-07 | 514 | D | 0 | 1 | 0CT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure the medical record was accurate for a pressure ulcer, contractures, and/or a Foley catheter for 3 of 33 (Residents #10, 13 and 130) sampled residents included in the stage 2 review. The findings included: 1. Review of the facility's Charting and Documentation policy documented, .All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record . All observations, medications administered, services performed . must be documented in the resident's clinical records . 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 9/14/15 documented, .Problem . Resident has scabbing to Rt (right) lateral foot arterial ulcer . The care plan dated 10/28/15 documented, .Antibiotic therapy x (times) 14 days secondary to Left Lateral Foot Wound . The care plan dated 12/3/15 documented, .Antibiotic therapy x 14 days . Right foot infection . The physician's orders [REDACTED].(1) Apply duoderm to (L) (left) lateral foot . The physician's orders [REDACTED].Clean R (right) lateral foot w (with) / wd (wound) cleanser pat dry apply skin prep to area daily . The physician's telephone order dated 10/20/15 documented, .May culture (L) lateral foot wound . The physician's telephone order dated 10/28/15 documented, .Aerobic/Anaerobic C & S (culture and sensitivity) (L) lat (lateral) foot wound . The physician's telephone order dated 10/28/15 documented, .Cleanse area to (L) lat foot c (with) wd (wound) cleanser, pat dry, apply silver collogen, cover drsg (dressing) daily . The physician's telephone order dated 11/11/15 documented, .Cleanse area to (L) lat foot c wd cleanser. Pat dry, apply ca (calcium) alginate c 4 x (by) 4 and [MEDICATION NAME] . The physician's telephone orders dated 12/23/15… | 2018-05-01 |
| 494 | 494 | THE WATERS OF WINCHESTER, LLC | 445145 | 1360 BYPASS ROAD | WINCHESTER | TN | 37398 | 2017-06-21 | 159 | D | 0 | 1 | 0D6Y11 | Based on review of facility policy, review of the trial balance for resident trust funds, and interview, the facility failed to make trust funds available on the week-end for 1 resident (#78) of 15 residents interviewed. The findings included: Review of the facility policy titled, Resident Trust issued: 10/20/15, included under the section: Procedure, numbered 1 through 12. Review of procedure 6. Banking Times will be posted and access to resident funds will be available on Saturday and Sunday during banking hours. Those residents wishing to withdraw or deposit money may do so at these times. Observation on entrance revealed there was no posting of banking hours on 6/19/17 or on 6/20/17. Interview of Resident #78, on 6/19/17 at 4:19 PM, revealed he does have a personal funds account with the facility. Resident #78 stated he is not able to withdraw funds from his account on the week-ends. You can only get money when the business office is open and she works Monday thru Friday. A sign posted on 6/21/17 outside the door of the business office included the following information: Resident Trust Banking Hours Monday through Friday from 9am to 5pm Interview of Business Office Manager (BOM), at 7:45 a.m. on 6/21/17, verified the residents had no access to funds on Week-ends. We have nothing in writing or posted in regards to time to access funds from personal accounts. The BOM stated she was aware that residents should have access to funds on the week-ends but she just hadn't implemented a program. | 2020-09-01 |
| 495 | 495 | THE WATERS OF WINCHESTER, LLC | 445145 | 1360 BYPASS ROAD | WINCHESTER | TN | 37398 | 2017-06-21 | 241 | G | 0 | 1 | 0D6Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and interviews, the facility failed to honor 1 resident's (#62) preferences for grooming services, identified through 1 of 3 family interviews conducted, of 35 residents sampled. This failure resulted in Harm to Resident #62. The findings included: Medical record review of Resident #62's History and Physical dated 12/28/15 revealed Resident #62 was a [AGE] year-old male with a past medical history of [REDACTED]. The history further revealed the resident was immobile, with [DIAGNOSES REDACTED]. A review of Resident #62's Physician's Progress Note dated 4/13/17 indicated the resident's judgement/insight was appropriate. The note indicated the resident communicated by pointing and shaking his head yes or no. Review of the most recent Minimum Data Set (MDS) Quarterly assessment dated [DATE], indicated the resident required extensive assistance and was dependent on 1-2 staff for bed mobility, transfers, toilet use, dressing, and personal hygiene. Under the section titled E0800: Rejection of Care - Presence & Frequency Resident #62 was coded as .behavior not exhibited. Continued review revealed a staff assessment for mental status was conducted, and the resident had no problems with short or long term memory, was able to recall the current season, location of his room, names and faces of staff members and that he is in a nursing home. Observations on 6/19/17 at 11:42 AM, 6/19/17 at 2:51 PM, 6/19/17 at 4:53 PM, and 6/20/17 at 8:13 AM, revealed Resident #62 in his room lying in bed. Resident #62 had facial hair (whiskers) noted on his face and his hair was unkempt and had not been combed. Continued observation revealed the resident was wearing a gown with brown stains around the front chest area in 3 of the observations. A family interview on 6/20/17 at 9:35 AM with Family Member #1, revealed the family member was very concerned about Resident #62 not receiving his showers as scheduled. The family member s… | 2020-09-01 |
| 496 | 496 | THE WATERS OF WINCHESTER, LLC | 445145 | 1360 BYPASS ROAD | WINCHESTER | TN | 37398 | 2017-06-21 | 309 | D | 0 | 1 | 0D6Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician's orders for 1 resident (#80) of 4 residents reviewed for weight loss, of 34 residents reviewed. The findings included: Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated 6/1/17 revealed XXX[AGE] year-old .female, who comes to the hospital because of severe swelling all over, shortness of breath (SOB) .She was known to have jugular venous distention, bilateral [MEDICAL CONDITION] .She had been recently admitted 9 days prior from .a fall where she had rib fracture and the effusion in her chest has apparently worsened .Exertion makes her shortness of breath worse, rest and oxygen makes it better .Impression: 1. [MEDICAL CONDITION] . Medical record review of a physician's order dated 6/2/17 revealed Daily weights for [MEDICAL CONDITIONS] in the morning . Medical record review of the Weights and Vitals Summary revealed the following: on 6/6/17 weight recorded as 223 lbs. (pounds) via wheelchair; on 6/7/17 weight recorded as 220.4 lbs. via mechanical lift; on 6/8/17 weight recorded as 220.4 lbs. via wheelchair; on 6/10/17 weight recorded as 212.4 lbs. via mechanical lift; on 6/11/17 weight recorded as 207 lbs. via mechanical lift; on 6/12/17 weight recorded as 203.6 lbs. standing; on 6/13/17 weight recorded as 198.6 lbs. via mechanical lift; on 6/14/17 weight recorded as 197 lbs. via mechanical lift; on 6/17/17 weight recorded as 197 via bedscale; and on 6/20/17 weight recorded as 165.4 lbs. via mechanical lift. Medical record review of a nursing note dated 6/8/17 revealed Assessment: Resident cont (continues) to have +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities), crackles to lower ls (?lungs), Dr .notified, new order for [MEDICATION NAME] 80mg bid (twice a day), Potassium 20 meq bid, Resident alert with confusion a… | 2020-09-01 |
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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 );