cms_TN
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14,361 rows sorted by inspection_date
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 14016 | 14016 | ROAN HIGHLANDS NURSING CENTER | 445396 | 146 BUCK CREEK ROAD | ROAN MOUNTAIN | TN | 37687 | 2009-02-04 | 225 | D | 1 | 0 | 9CDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to report alleged instances of abuse for one (#3) of five residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, was non-ambulatory, required assistance with all activities of daily living, and had a sad affect. Medical record review of the resident's current care plan dated December 14, 2008, revealed the resident had behaviors of being loud and disruptive. Interview with Certified Nurse Assistant (CNA) #6 per telephone on January 23, 2009, at 12:55 p.m., revealed this CNA witnessed CNA #2 push resident #3's nose and stuck the finger in the resident's ear "to agitate" the resident (date unknown). Interview also revealed CNA #6 observed CNA #1 take pictures of resident #3 without the resident's consent. Interview also revealed CNA #6 did not report the allegations to supervisory staff, and was aware all allegations of abuse of a resident are to be reported immediately. Interview with CNA #5 per telephone on January 23, 2009, at 10:40 a.m., revealed this CNA witnessed CNA #1, #2, and #3, on multiple occasions (dates unknown) "verbally tease" resident #3 to "agitate" the resident. Interview also revealed CNA #5 did not report the allegations to supervisory staff, and was aware all allegations of abuse of a resident are to be reported immediately. Interview with CNA #4 on January 23, 2009, at 4:18 p.m., and 7:45 p.m., revealed this CNA witnessed CNA #2 (date unknown) "verbally tease" resident #3 and touch the resident's nose knowing the resident does not like that. Interview also revealed CNA #4 did not report allegations to supervisory staff, and was aware all allegations of abuse of a resident are to be reported immediately. Review of the facility's Abuse protocol revealed " ...… | 2014-07-01 |
| 13915 | 13915 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2009-02-12 | 157 | D | 1 | 1 | XMN911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to notify the physician and the family of a fall for one resident (#15) of thirty-two residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had modified independence with daily decision making (new situations only) and required assist of one person for transfers and ambulation. Review of the nurse's notes dated March 21st through April 1, 2008, revealed the resident had fallen on Easter Sunday (March 23, 2008), complained of pain on March 26, 2008, and was sent to the emergency room for evaluation on March 31, 2008, and was admitted with the [DIAGNOSES REDACTED]. Review of the nurses note dated March 31, 2008, revealed the nurse failed to notify the physiscian and the resident's family at the time of the fall. Review of the documentation provided by the facility dated April 4, 2008, revealed, " Pt. found on floor at bed ...no apparent injury. Nurse never notified anyone ... " Review of the facility's policy, Protocol for Falls, revealed, " After a fall staff will: ...3. Notify family and MD (Medical Doctor) ... " Interview with the Director of Nurses on February 11, 2009, at 1:30 p.m., in the Director's office, confirmed the physician and the family had not been notified of the resident's fall. Entity reported incident #TN | 2014-07-01 |
| 13916 | 13916 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2009-02-12 | 514 | D | 1 | 1 | XMN911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a medical record was complete for two (#14, #15) of thirty-two residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. intake. Interview on February 11, 2009, at 7:35 a.m., with Licensed Practical Nurse (LPN) #2, responsible for the resident's care, in the hallway, revealed the resident was on a 1500cc fluid restriction Interview on February 12, 2009, at 7:15 a.m., with the Registered Dietician, in the nursing station, revealed the dietary department provided 750cc of fluid daily, to the resident, with meals, and nursing provided an additional 750cc of fluid. Interview on February 12, 2009, at 7:30 a.m., with LPN #3, in the hallway, revealed dietary provides 740cc of fluids, the resident received approximately 240cc of water with the morning medications, and the Certified Nursing Assistants (CNA) notified LPN #3 of the resident's fluid intake daily. Interview with CNA #1 on February 12, 2009, at 7:35 a.m., (CNA responsible for the resident's care), in the hallway revealed an awareness of the resident's fluid restriction. Continued interview revealed the resident was provided one cup (120cc) of water on the day shift, in addition to fluids provided with meals. Interview on February 12, 2009, at 7:40 a.m., with CNA #2, in the hallway, revealed the resident was provided one cup (120cc) of water on the day shift, in addition to fluids provided with meals. Interview on February 11, 2009, at 8:00 a.m., with the Director of Nursing, in the conference room, confirmed there was no documentation of the amount of the resident's daily fluid intake. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had modified independence with daily decision making, and r… | 2014-07-01 |
| 14070 | 14070 | GALLAWAY HEALTH AND REHAB | 445440 | 435 OLD BROWNSVILLE RD | GALLAWAY | TN | 38036 | 2009-02-13 | 225 | D | 1 | 0 | I3M311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint Investigation for TN 538 Based on review of facility personnel files and a staff member interview, it was determined the facility failed to thoroughly investigate an allegation of abuse or report the allegation to the State survey and certification agency for 1 of 8 (Resident #8) sampled residents. The findings included: Review of a facility personnel file documented a hand written note dated 11/20/08, "Grievance received on (name of certified nurse assistant (CNA #1)) from resident (Resident #8) room [ROOM NUMBER]B. Ms. (Resident #8) claims (CNA #1) mistreated her, cursed her and was just plain ugly to her. (CNA #1) denied this. (CNA #1) not to be assigned to Ms. (Resident #8) again, beginning today. (Signed by Registered Nurse #2)." During an interview in the Administrator's office on 2/11/08 at 1:00 PM, the Administrator stated, "(RN #2's name) was the Assistant Director of Nursing. It appears she (RN #2) did not investigate or report it (allegation of abuse). I (Administrator) was unaware of this (allegation)." | 2014-06-01 |
| 14037 | 14037 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2009-02-19 | 280 | D | 1 | 0 | G2MS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to update the care plan to include appropriate repositioning techniques to prevent pain and potential injury to the shoulder for one resident recovering from shoulder surgery (#5) of five residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long-term memory problems, was independent with decision-making and required extensive assistance of two with bed mobility. Medical record review of the initial nursing assessment dated [DATE], revealed, " ... Incision line right shoulder has 23 staples, Incision (without) redness, a lot of bruising and [MEDICAL CONDITION] ..." Review of a Social Worker note dated November 2, 2008, revealed, " ... has use of both hands, although ... has to be careful due to ... recent right arm surgery / injury ..." Review of the care plan dated November 2, 2009, revealed the resident had discomfort related to the right shoulder surgery. Continued review of the care plan revealed, "... reposition frequently for comfort measures..." and revealed no interventions for safe and appropriate repositioning of the resident in bed. Review of documentation provided by the facility revealed on November 6, 2008, at 3:50 p.m., two Certified Nursing Assistants (CNAs) repositioned the resident in bed, with one CNA on the resident's left side and one on the right side, and the CNAs pulled the resident up in bed by the arms. The resident "cried out in pain." Continued review revealed the CNAs had no knowledge of the resident's recent surgery to the right shoulder prior to repositioning the resident in the bed and revealed the resident identified the pain level in the arm as '9' on a scale of 1 -10 (worst pain being 10) after being repositioned by the CNAs. Medical record review of a nurse's note da… | 2014-07-01 |
| 14038 | 14038 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2009-02-19 | 309 | D | 1 | 0 | G2MS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure staff appropriately repositioned to prevent pain and potential injury to the shoulder for one resident recovering from shoulder surgery (#5) of five residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long-term memory problems, was independent with decision-making and required extensive assistance of two with bed mobility. Medical record review of the initial nursing assessment dated [DATE], revealed, " ... Incision line right shoulder has 23 staples, Incision (without) redness, a lot of bruising and [MEDICAL CONDITION] ..." Review of a Social Worker note dated November 2, 2008, revealed, " ... has use of both hands, although ... has to be careful due to ... recent right arm surgery / injury ..." Review of documentation provided by the facility revealed on November 6, 2008, at 3:50 p.m., two Certified Nursing Assistants (CNAs) repositioned the resident in bed, with one CNA on the resident's left side and one on the right side, and the CNAs pulled the resident up in bed by the arms. The resident "cried out in pain." Continued review revealed the CNAs had no knowledge of the resident's recent surgery to the right shoulder prior to repositioning the resident in the bed and revealed the resident identified the pain level in the arm as '9' on a scale of 1 -10 (worst pain being 10) after being repositioned by the CNAs. Medical record review of a nurse's note dated November 7, 2008, at 7:15 p.m., revealed, "Received a call from (Physician Assistant) requesting this resident be sent to ... ER ... to have ... right shoulder evaluated for pain and possible trauma ..." Medical record review of a nurse's note dated November 7, 2008, at 8:45 a.m., revealed the resident was transported to the emergency r… | 2014-07-01 |
| 13938 | 13938 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-02-24 | 157 | D | 1 | 0 | GL7011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility delayed in notifying the physician and the resident's legal representative of a fall for one resident (#4) of five residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nursing notes dated January 25, 2009, revealed, "Late entry - 2:30 A called to res (resident) room per staff, res observed sitting on floor, full assessment done, 0 (no) injuries noted @ this time, res states 'I'm ok just get me back to bed,' bed in lowest position, alarm functional, 0 c/o (complaint of) pain, 0 distress noted..." Medical record review of the nursing notes dated Janaury 25, 2009, revealed the physician was not notified of the fall until the resident began complaining of hip pain at 10:45 a.m. Medical record review of the nursing notes dated Janaury 25, 2009, revealed the resident's family was not notified of the fall until 1:30 p.m. Medical record review revealed the resident was sent to the emergency roiagnom on Janaury 25, 2009, at 3:00 p.m, and returned to the facility the same day at 7:15 p.m., with a diagnois of contusion to the left hip and knee. Review of the facility's policy Falls Management revealed, "...Policy...The physician and family will be notified of the incident...Procedure...2. Management of Falls...f. The responsible party and physician are promptly notified of the occurrence and status of the resident..." Interview with the Assistant Director of Nursing on February 12, 2009, at 4:30 p.m., confirmed the facility had not notified the physician and family of the fall promptly. | 2014-07-01 |
| 13974 | 13974 | LAUGHLIN HEALTH CARE CENTER | 445264 | 801 E MCKEE ST | GREENEVILLE | TN | 37743 | 2009-03-04 | 278 | D | 1 | 0 | MRPB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident (#4) of five sampled residents. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the rib/chest x-ray dated January 16, 2009, revealed, "...Exam(s): Ribs - Left with/CXR (chest x-ray) Reason: Fall...No acute displaced left...rib fracture identified." Medical record review of the MDS dated [DATE], revealed the resident had no history of falls within the previous thirty days. Interview with the MDS nurse on March 4, 2009, at 1:19 p.m., in the chapel, revealed the nurse had completed the MDS, had not reviewed the x-ray dated January 16, 2009, and confirmed the resident's MDS assessment was inaccurate. C/O: # | 2014-07-01 |
| 14015 | 14015 | PICKETT CARE AND REHABILITATION CENTER | 445390 | 129 HILLCREST DRIVE | BYRDSTOWN | TN | 38549 | 2009-03-04 | 225 | D | 1 | 1 | HQCZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to implement the abuse policy for one resident (#14) of three residents reviewed with an allegation of abuse. The findings included: Resident #14 was re- admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE]; revealed the resident had no long term or short term memory impairment, and was independent with daily decision making. Medical record review of facility documentation dated January 19, 2009, revealed Certified Nursing Assistant #1 reported to the Assistant Director of Nursing #1, and Assistant Director of Nursing #2 that resident #14 reported on January 18, 2009, a Certified Nursing Assistant #2 had "slammed (resident #14) leg to the ground, and CNA#2 said" don't holler at me" Continued review revealed that resident #14 reported CNA#2 told resident #9 (resident #14 roomate) "you sure pee a lot, and resident #9 heard a slap followed by protest, and CNA #2 request not to yell at ..." Continued review revealed no documentation the Physician, Adult Protective Services, and Ombudsman were notified, and no completed incident report. Review of the facility policy Prevention of Abuse, Neglect and Misappropriation of Resident's Property revealed " ...The Administrator will report to other officals in accordance with State Law (including to state survey and investigation agency): a. Adult Protective Services ...c. Attending Physician ...e.Ombudsman ..." Interview with Assistant Director of Nursing #1 and Assistant Director of Nursing #2 on March 2, 2009, at 1:45 p.m., in the Director of Nursing office, confirmed CNA #1 reported the allegation, the resident was examined and no injury, and the resident denied her leg was hurt. Interview with resident #9 on March 3, 2009, at 10:00 a.m., revealed, resident #9 denied witnessing any mistreatment of [REDACTED]. Interview with the Soci… | 2014-07-01 |
| 14123 | 14123 | GLEN OAKS HEALTH AND REHABILITATION | 445234 | 1101 GLEN OAKS ROAD | SHELBYVILLE | TN | 37160 | 2009-03-24 | 363 | E | 8IYP11 | Complaint Investigation for TN 313 Based on review of the facility's menus, observation, and interview, it was determined the facility failed to follow the menu by serving smaller portions of pureed and ground meat for 31 of 83 diets served. The findings included: Review of the facility menu dated 2009, Week 4 Tuesday, documented, "... Lunch Beef Tips in Gravy ... grd/grvy (ground/gravy) (#10 scoop) (#10 scoop equals 2/5 cups), pur (pureed) (#8 scoop) (#8 scoop equals 1/2 cup)..." Observations in the kitchen on 3/24/09 at 11:15 AM, revealed the Cook served pureed meat with a #16 scoop and ground meat with a #16 scoop. A #16 scoop equals 1/4 cup. The Cook failed to follow the menu by not using #8 scoop for the pureed diet and not using the #10 scoop for ground meat. During an interview in the kitchen, on 3/24/09 at 12:15 PM, the Cook stated, "I've been here so long. The old one (menu) said 2 ounces and it's just a habit. If you get a bigger scoop, the food runs together." | 2014-04-01 | ||
| 14124 | 14124 | GLEN OAKS HEALTH AND REHABILITATION | 445234 | 1101 GLEN OAKS ROAD | SHELBYVILLE | TN | 37160 | 2009-03-24 | 517 | F | 8IYP11 | Based on review of the facility disaster menu plan, observation and interview, it was determined the facility failed to ensure there was an adequate food inventory for 3 of 3 days of the disaster menu. The findings included: Review of the facility's disaster menu plan, inventory needed for 100 beds, documented, "Fruits and Fruit Juices Apple Sauce 6/#10 cans, Apricots 6/#10 cans, Fruit Mix 6/#10 cans, Peaches 6/#10 cans, pears 6/#10 cans, Apple Juice 12/46 oz (ounces), Cranberry juice 12/46 oz, prune juice 12/46 oz, Orange juice 12/46 oz; Puree Fruits Peach 12/15 oz, Pear 12/15 oz, Thickened Orange juice, Thickened Apple juice, Thickened Cranberry juice; Milk and Puddings Evaporated Milk 6/#10 cans, Dry Milk 6/5 lb (pounds), Thickened Milk 12/32 oz, Chocolate Pudding 6/#10 cans, Vanilla Pudding 6/#10 cans; Vegetables Green Beans 6/#10 cans, Carrots 6/#10 cans, 3 Bean Salad 6/#10 cans, Stewed Tomatoes 6/#10 cans, Mixed Vegetables 6#10 cans, Corn 6/#10 cans, Potatoes diced/sliced 6/#10 cans, Sweet Potatoes/Yams 6/#10 cans; Puree Vegetables Peas 12/15 oz, carrots 12/15 oz, Green Beans 12/15/oz; Soups Cream of Tomato 12/50 oz, Chicken Noodle 12/50 oz; Starches Pinto Beans 6/#10 cans, Kidney Beans 6/#10 cans, Bran Flakes 4/35 oz, Corn Flakes 4/35 oz, Crispy Rice 4/35 oz, Toasted Oats 4/35 oz, Sandwich Cookies 120/2 ct (count), Vanilla Wafers 6/13 oz, Graham Crackers 200/2 ct, Saltine Crackers 500/2 ct, Unsalted Crackers 500/2 ct, Bread loaves 30 loaves; Protein and Mix Protein Beef Stew 6/#10 cans, Macaroni and Cheese 6/#10 cans, Chilli with Beans 6/#10 cans, Ravioli w (with)/Beef 6/#10 cans, Corned Beef Hash 6/#10 cans, Sausage Gravy 6/#10 cans, Tuna 6/cans, Peanut Butter 200/.75 oz, Cheese Sauce 6/#10 cans, Eggs 15 dozen, Puree Beef 12/ 15 oz, Puree Chicken 12/15 oz, Med Pass 2.0 6/32 oz; Other Iced Tea Bags 1/96 ct, Drink Mix SF (sugar free) 12/pkgs (packages), Jelly 6/32 oz, Mayo (mayonnaise)/Salad Dressing 500ct, Sugar 2000 ct, Salt 3000 ct, Pepper 3000 ct, Sweet/Low 2000 ct, Margarine". Observations in the food … | 2014-04-01 | ||
| 13957 | 13957 | MOUNTAIN CITY CARE & REHABILITATION CENTER | 445214 | 919 MEDICAL PARK DRIVE | MOUNTAIN CITY | TN | 37683 | 2009-03-26 | 224 | D | 1 | 0 | UHYU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to prevent neglect of one resident (#1) of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; required extensive assistance with bed mobility and was totally dependent on staff for transfers; required extensive assistance with toilet use; was totally dependent on staff for hygiene and bathing; and was incontinent of bowel and bladder. Review of the care plan dated February 11, 2009, revealed the resident had the potential for skin breakdown, and interventions to reduce the risk of skin breakdown included, "Keep as clean and dry as poss ... check and change ... turn and reposition q (every) 2 hrs and prn (as needed) ..." Observation on March 17, 2009, 12:10 p.m., revealed the resident was dressed and sitting in a geri-chair at the bedside. Review of documentation provided by the facility dated March 4, 2009, revealed on March 3, 2009, the Nursing Assistant (NA #1) failed to provide incontinence care for the resident every two hours. Interview in the conference room on March 18, 2009, at 10:30 a.m., with the Director of Nursing confirmed incontinence care was not provided to the resident "all day" on March 3, 2009. Interview in the conference room on March 18, 2009, at 10:45 a.m., with the Assistant Director of Nursing (CNA Instructor) confirmed NA #1 failed to provide incontinence care for the resident from 7:00 a.m., to 2:00 p.m., on March 3, 2009. Interview in the conference room on March 18, 2009, at 11:15 a.m., with the Licensed Practical Nurse (LPN) on duty on the unit on March 3, 2009, revealed the LPN assessed the resident on March 3, 2009, at the request of NA #2 (who relieved NA #1 at 2:00 p.m., on Marc… | 2014-07-01 |
| 13937 | 13937 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-03-31 | 323 | D | 1 | 0 | DQLL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide supervision to prevent elopement from the facility for one resident (#4) with dementia of five residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Continued review of the MDS revealed the resident had difficulty making self understood and understanding others. Review revealed the resident had demonstrated wandering behaviors daily and the behavior was not easily altered. MDS review revealed the resident required limited assistance with ambulating and transfers, and extensive assistance with personal hygiene and bathing. Review of the Social Service Progress Note dated July 11, 2008, revealed, " ...has been wandering at times - just walking up & down hallway. CMSW (Certified Masters of Social Work) asked for eval (evaluation) for B-wing (secured unit) ... " Medical record review of the Nurse ' s Note dated July 12, 2008, revealed, " Staff member was entering building and observed R (resident) outside the entrance way before exiting building. " Medical record review of the Nurse ' s Note dated July 13, 2008, revealed, " ...continuously wandering throughout facility ...Ambulates ad lib (as desired). " Review of the resident ' s Interim Care Plan dated July 14, 2008, revealed the resident had been identified as an Elopement Risk. Medical record review of the Nurse ' s Note dated July 15, 2008, at 7:40 p.m., revealed, " ...receptionist received a call from a (neighbor to facility) - reporting an elderly ___(resident ' s sex) walking around in (neighbor ' s) front yard. When (res) couldn ' t answer where (resident) lived, but could say (resident ' s) name ...figured out ...would give us a call to see if we were missing a resident by that name. " Medical record review revealed the unidentified person in the neighbor ' s yard was Resident #4. Interview with the Social Worker on March 24, 2009, at 3:10 p.m.… | 2014-07-01 |
| 14009 | 14009 | WOODCREST AT BLAKEFORD | 445378 | 11 BURTON HILLS BLVD | NASHVILLE | TN | 37215 | 2009-04-02 | 333 | G | 1 | 0 | HH3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined the facility failed to ensure the medication ([MEDICATION NAME]) provided by the pharmacy and administered to 1 of 5 (Resident #5) sampled residents was the correct medication ([MEDICATION NAME]) as ordered by the physician. The failure of the facility to administer the appropriate medication resulted in a significant medication error causing harm to Resident #5. The findings included: Medical record review of Resident #5 revealed an admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record of Resident #5 revealed a hospitalization from [DATE] to [DATE] during which time treatment was provided for a variety of conditions including an acute respiratory condition with infection and [MEDICAL CONDITION] arthritis and a history [MEDICATION NAME] use prior to and during hospitalization for the treatment of [REDACTED]. Review of Resident #5's hospital discharge summary dated [DATE] revealed [DIAGNOSES REDACTED]. Resident #5's admission medication orders on [DATE] included [MEDICATION NAME] 8 milligrams (mg) in the AM and 4 mg in the PM. The drug regimen continued to include an order for [REDACTED]. Review of Resident #5's initial skin assessment documented on the wound/skin healing record dated [DATE] revealed 2 pressure ulcer wounds. Wound #1 noted on the coccyx area was described as 4.5 by (x) 2.5 x 1.0 centimeters (cm) (unstageable) with scant serous exudate with whitest green slough at wound bed and 1.3 cm undermining. Wound #2 on the lower [MEDICATION NAME] spine was described as 1.5 x 1.0 x 0.0 cm. (unstageable) with scant serous drainage with white tan slough at wound bed. A review of multiple Non-pressure Skin Condition Reports for Resident #5 revealed 13 additional wounds. Wound #3 on the right posterior upper back was described as thoracotomy extubation site measuring 1.0 x 1.0 with 0.5 of depth and "undermining 1.5 cm." Wound #8 on the posterior left c… | 2014-07-01 |
| 14010 | 14010 | WOODCREST AT BLAKEFORD | 445378 | 11 BURTON HILLS BLVD | NASHVILLE | TN | 37215 | 2009-04-02 | 386 | G | 1 | 0 | HH3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined the facility failed to ensure the physician consistently reviewed the total program of care for appropriateness which led to 1 of 5 (Resident #5) sampled residents receiving the administration of [MEDICATION NAME] medication instead of [MEDICATION NAME] which lead to worsening skin conditions causing harm to Resident #5. The findings included: Medical record review of Resident #5 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5 revealed a hospitalization from [DATE] to [DATE] during which time treatment was provided for a variety of conditions including an acute respiratory condition with infection and [MEDICAL CONDITION] Arthritis (RA) and a history of the use of [MEDICATION NAME] prior to and during hospitalization for treatment of [REDACTED]. Review of Resident #5's admission medication orders dated [DATE] included an order for [REDACTED]. Review of [DATE] physician orders revealed the attending physician's signed and dated the orders [DATE]. Review of Resident #5's initial skin assessment documented on the wound/skin healing record dated [DATE] revealed 2 pressure ulcer wounds. Review of multiple Non-pressure Skin Condition Reports revealed 13 additional wounds. These wounds were documented as wounds #4, #5, #6, #7, #9, #10, #11, #12, #13, #14, and #15 which were described as full thickness injury (1); soft tissue injury (5); skin tear (2); laceration (1); blister (1). All of the wounds described above were provided treatment and all wounds were noted healed at various points between [DATE] and [DATE] except wounds #1, #2, #3 and #8. These wounds had some decrease in size with treatment as noted on the skin assessment reports. Review of recapitulation (recap) physician orders revealed orders for [MEDICATION NAME] 8 mg by mouth daily and 4 mg by mouth every bedtime for arthritis pain with attending physician signatur… | 2014-07-01 |
| 14011 | 14011 | WOODCREST AT BLAKEFORD | 445378 | 11 BURTON HILLS BLVD | NASHVILLE | TN | 37215 | 2009-04-02 | 425 | G | 1 | 0 | HH3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined the facility failed to ensure the pharmacy delivered the correct medication as ordered by the physician for 1 of 5 (Resident #5) sampled residents. The delivery and administration of Decadron instead of Medrol lead to skin conditions worsening and causing actual harm to Resident #5. The findings included: Medical record review of Resident #5 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's medical record revealed a hospitalized from [DATE] to 10/3/08 during which time treatment was provided for a variety of conditions including an acute respiratory condition with infection and rheumatoid arthritis and a history of the use of Medrol prior to and during hospitalization for treatment of [REDACTED]. Review of the hospital discharge summary dated 10/3/08 revealed [DIAGNOSES REDACTED]. Resident #5's admission medication orders on 10/3/08 included Medrol 8 milligrams (mg) in the AM and 4 mg in the PM. The drug regimen continued to include an order for [REDACTED]. Review of assessment documentation of Resident #5 dated 11/3/08 by the nurse practitioner in the interdisciplinary team notes revealed a cough for 3 days which "is deep and productive" along with a sore throat. A chest x-ray was obtained due to Resident #5's history of pneumonia. Resident #5 was subsequently transferred to the hospital for further evaluation on 11/4/08. At the time of transfer on 11/4/08, medical record documentation revealed Resident #5 had a current order for and was receiving Medrol 8 mg in the AM and 4 mg at bedtime. Review of Resident #5's hospital admission History and Physical evaluation dated 11/4/08 revealed treatment for [REDACTED]. The evaluation report noted a review of systems in which the skin was described as warm and intact except for sacral wounds with bandages in place and the extremities were noted to have no clubbing, cyanosis or edema. Documentation of … | 2014-07-01 |
| 14007 | 14007 | WOODCREST AT BLAKEFORD | 445378 | 11 BURTON HILLS BLVD | NASHVILLE | TN | 37215 | 2009-04-29 | 332 | E | 1 | 0 | FJ3O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review the "Geriatric Dosage Handbook", policy review, review of facility's "Medications Not To Be Crushed" reference, medical record review, observation and interview, it was determined the facility failed to ensure 3 of 3 Licensed Practical Nurses (LPN #1, 3, and 4) on 3 of 4 wings (J wing, K wing and L wing) on 1 of 2 shifts (day shift) administered medications without a medication error rate of less than 5 percent (%). A total of 5 medications errors were observed out of 47 opportunities for error, resulting in a medication error rate of 10.63%. The findings included: 1. Review of the facility's "Medication Administration ...General Guidelines" policy documented, "...If it is safe to do so and is acceptable according to manufacturers specification/recommendations, medication tablets may be crushed...refer to the Medications Not To Be Crushed list and the following guidelines...Long-acting...should generally not be crushed..." Review of the facility's "Medications Not to be Crushed" reference identified [MEDICATION NAME] as a time release formulation that should not be crushed. Medical record review for Random Resident (RR) #1 documented a physician's orders [REDACTED]." Observations on J wing, on 4/27/09 at 8:30 AM, revealed LPN #1 (accompanied by new LPN #2) crushed and administered two tablets of [MEDICATION NAME] ([MEDICATION NAME]) 600 mg to RR #1 resulting in medication error #1. During an interview, on J wing, on 4/27/09 at 9:19 AM, LPN #1 confirmed the [MEDICATION NAME] should not be crushed. 2. Review of the "Geriatric Dosage Handbook", Twelfth Edition, page 203, documented, "...nasal spray...Open bottles are stored at room temperature in an upright position for no more than 30 days after date opened..." Medical record review for RR #1 documented a physician's orders [REDACTED]." Continued observations on J wing, on 4/27/09 at 8:30 AM, revealed LPN #1 (accompanied by new LPN #2) enter RR#1's bedside and prepared to admini… | 2014-07-01 |
| 14008 | 14008 | WOODCREST AT BLAKEFORD | 445378 | 11 BURTON HILLS BLVD | NASHVILLE | TN | 37215 | 2009-04-29 | 431 | E | 1 | 0 | FJ3O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Tennessee Board of Pharmacy Guidelines, policy review, review of the Controlled Substance Inventory Logs, observation and interview, it was determined the facility failed to assure an inventory of all controlled medications was maintained and periodically reconciled for 4 of 4 (J wing, K wing, L wing and M wing) facility wings and failed to ensure medications were stored at the proper temperatures and within the manufacturer's expiration date in 1 of 3 (M/J wing medication storage room) medication storage rooms. The findings included: 1. Review of the facility's "Controlled Medication Administration" policy documented, "...At each shift change, a physical inventory of all controlled medications is conducted. The medication nurse on duty will verify quantities of all controlled medications with the medication nurse reporting for duty and is documented on a Controlled Dosage System-Controlled Substance-Shift Change Count Check Sheet...Current Controlled Substance Inventory Records and audit records are kept. When completed, audit and accountability records are submitted to the Director of Nursing. Any discrepancy in controlled substance medication counts is reported to the Director of Nursing immediately. The Director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies..." Review of the facility's "Shift Change Controlled Substance Inventory Log" identified the following items that required completion: date, nursing signatures shift to shift, controlled sheets added (to track in-coming controlled medications) and control sheets removed (to track out-going medications) per resident, with the total number of sheets recorded at shift change. Review of the "Shift Change Controlled Substance Inventory Log" for [DATE] through (-) [DATE] documented: a. 243 omissions of nursing signatures out of 634 possible entries for the shift to shift controlled substance counts. b. 229 omissions… | 2014-07-01 |
| 14056 | 14056 | LIFE CARE CENTER OF MORGAN COUNTY | 445239 | 419 SOUTH KINGSTON STREET | WARTBURG | TN | 37887 | 2009-04-30 | 425 | D | 1 | 0 | SENF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure intravenous (IV) antibiotics were administered in a timely manner for one resident (#5) of five residents reviewed. The findings included: Resident #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission orders [REDACTED]. Medical record review of the MAR (Medication Administration Record) revealed the resident was to receive a dose of Vancomycin on January 23, 2009, at 4:00 p.m. Medical record review of the MAR indicated [REDACTED] Interview with the Director of Nursing on April 27, 2009, at 2:15 p.m., in the conference room, confirmed the Vancomycin was not received from the pharmacy until the morning of January 24, 2009, and the resident did not receive the 4:00 p.m. dose on January 23, 2009. C/O # | 2014-06-01 |
| 14057 | 14057 | LIFE CARE CENTER OF MORGAN COUNTY | 445239 | 419 SOUTH KINGSTON STREET | WARTBURG | TN | 37887 | 2009-04-30 | 456 | D | 1 | 0 | SENF11 | Based on observation and interview, the facility failed to ensure wheelchairs were maintained in good repair for three wheelchairs of twenty-two rooms observed on the A Wing. The findings included: Observation of the A Wing on April 27, 2009, from 9:10 a.m., until 9:20 a.m., revealed three rooms contained wheelchairs, utilized by the residents in the rooms, with arms rests which were cracked and peeling, and had exposed cushion beneath the cracked covering. Interview with the Director of Nursing on April 27, 2009, at 4:20 p.m., in the conference room, confirmed the wheelchair arm rests needed repairing or replacement, and no injuries had incurred from the arm rests. C/O # | 2014-06-01 |
| 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 |
| 14030 | 14030 | HILLVIEW HEALTH CENTER | 445464 | 1666 HILLVIEW DRIVE | ELIZABETHTON | TN | 37643 | 2009-06-04 | 157 | D | 1 | 1 | DDPC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify the family when one resident (#13), had behaviors requiring a physician's intervention, of nineteen residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nursing notes dated March 31, 2009, at 1:00 a.m., revealed "...PSA (personal safety alarm) sounding - resident observed at the foot of (resident's) bed with ...feet out of bed, stated ...had to go to work, oriented to person only, assisted back into bed - PSA in place, call light in place and reminded to use call light." Review of the nursing notes dated March 31, 2009, at 3:00 a.m., revealed "...has been out of bed numerous times looking for...son. Becomes agitated when redirected. Very unsteady on...feet. Assisted into w/c (wheel chair) and brought out to lobby to be more closely observed." Review of the nursing notes dated March 31, 2009, at 5:00 a.m., revealed "...Assisted to B.R. (bathroom) voided large amount dark urine, lab here. Admission lab work, U/A (urinalysis) obtained." Review of the nursing notes dated March 31, 2009, at 7:00 a.m., revealed "remains awake - has been awake all night. Refused offer of snack, drank juice without difficulty. Temp. 98.5, pulse 110, Resp. 20, B/P 155/98, O2 SAT 96>." Review of the nursing notes dated March 31, 2009, at 7:40 a.m., revealed (Up) in w/c in hallway PSA in place Non-compliant when asked to sit down. Up numerous times attempting to walk, poor results with redirection - argumentative, (increased) agitation, attempting to strike out at other residents, wants to go home, needs to go to the bus station, will be late for work. (Physician) called, new orders received and noted." Review of the nursing notes dated March 31, 2009, at 10:45 a.m., revealed "...(Up) in w/c in and out of residents rooms, cannot easily be redirected - Requires constant 1:1 nursing supervision - Taking items off m… | 2014-07-01 |
| 11956 | 11956 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-06-10 | 157 | D | 0 | 1 | G9RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify one resident's family (#7) of significant changes in the resident's condition of thirty-four residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had no problem with memory and cognitive skills; required extensive assistance of one staff physical assist for activities of daily living, and transfers. Medical record review of the Pressure Ulcer Status records revealed on November 26, 2008, the staff identified a Pressure Ulcer (fluid filled blister) on the resident's left heel, sized 4.2 x 3.7 x 0 cm., 50% purple with 50% red fluid filled tissue, peri (around) tissue pink, pulses present, CM+S Review of the Pressure Ulcer Status Records revealed on December 23, 2008, the pressure ulcer on the resident's left heel had increased to a Stage IV, 3.4 x 3.5 x 0 cm., 50% black fluid with 50% black eschar peri (area around) pink, pedal pulse + (sign for positive) CM+S Review of the Pressure Ulcer Status Record revealed on December 7, 2008, the resident developed a second pressure ulcer on the right outer heel 0.7 x 0.8 x 0, 100% light brown, dry tissue peri pink (pedal pulse + CM+S Interview with the Treatment Nurse (#6) on June 9, 2009, at 11:00 a.m., in the Director of Nursing office, confirmed the family had not been notified of the changes in the resident's condition. | 2015-10-01 |
| 11957 | 11957 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-06-10 | 160 | D | 0 | 1 | G9RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident trust fund statement and interview, the facility failed to convey funds held in the resident trust fund to the individual or probate jurisdiction administering the estate for one (#29) of thirty-four residents reviewed. The findings included: Resident #29 was admitted to the facility on [DATE], and expired in the facility on [DATE], with [DIAGNOSES REDACTED]. Review of facility Trust (Resident) Account documentation for Resident #29, on [DATE], revealed an outstanding balance of $1,108.56. Interview on [DATE], at 4:20 p.m., with the Business Office Manager (BOM), in the BOM Office, revealed, Actually.does have a lot of money in here (Resident Trust Account). It is $1,108.56. I marked the account as expired and I should have taken care of it. Interview, on [DATE], at 4:20 p.m., with the BOM, in the BOM Office, confirmed the facility failured to convey the Resident (Trust) Funds within 30 days to the individual or probate jurisdiction administering the estate. Complaint # | 2015-10-01 |
| 11958 | 11958 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-06-10 | 164 | D | 0 | 1 | G9RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation and interview, the facility failed to provide privacy for one (#15) of thirty-four residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set assessment dated [DATE], revealed the resident was dependent upon staff for all activities of daily living including toileting and hygiene, and was incontinent of bladder and bowel. Observation of incontinence care, on June 9, 2009, at 11:20 a.m., in the resident's room, with the bed located directly next to the window, revealed Certified Nursing Assistant (CNA) #1 performed incontinence care without closing the window blinds, exposing the resident from the waist down. Review of facility policy Personal Hygiene Care for the Female Resident revealed, .Gather equipment and provide for privacy. Interview, on June 9, 2009, at 11:30 a.m., with CNA #1, in the resident's room, confirmed privacy was not maintained when the incontinence care was provided. | 2015-10-01 |
| 11959 | 11959 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-06-10 | 280 | E | 0 | 1 | G9RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to revise the care plans to address the current status for eight (#1, #2, #8, #7, #9, #11, #18, #22) of thirty-four residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory difficulty, required minimal assistance with transfers and ambulation. Medical record review of the resident's current care plan revised on May 7, 2009, revealed the resident required .Pressure alarm placed in bed . Observation on June 8, 2009, at 1:05 p.m. in the resident's room, revealed the resident out of the bed and ambulating about the room without assistance, with a steady gait, and no alarms sounding. Interview on June 10, 2009, at 1:35 p.m., at the 100 hallway nurse's station, with Licensed Practical Nurse (LPN) #2, confirmed the resident is independent with ambulation; the bed alarm was discontinued before the resident was transferred to that unit in February 2009, and the care plan was not revised to reflect the resident's current status. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's current care plan revised on May 21, 2009, revealed approaches .Monitor for changes in gait, assist with ambulation as needed . Observation of the resident on June 8, 2009, at various times between 8:30 a.m., to 2:30 p.m., and on June 9, 2009, at various times between 7:55 a.m., to 2:35 p.m., revealed the resident sitting in a wheel chair with a seat belt applied. Interview on June 9, 2009, at 2:35 p.m., in the resident's room with a Certified Nurse Assistant (CNA) confirmed the resident was non-ambulatory and required two people to assist with transfers. Interview with LPN #5 at the nurse's desk on the secured unit on June 9, 2009, at 3:20 p.m., confirmed the … | 2015-10-01 |
| 11960 | 11960 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-06-10 | 281 | D | 0 | 1 | G9RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Nursing Drug Handbook review, and interview, the facility failed to ensure physician's orders were followed for one (#15)of thirty-four residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of June, 2009, Physician Recapitulation Orders revealed, [MEDICATION NAME] XL 50 mg (milligrams) Tablet SA (extended release) (medication to treat hypertension), Oral Once Daily, Monitor Pulse/Blood Pressure. Continued record review of the Vital Sign & Weight Flow Sheets dated March, 2009, through June 6, 2009, revealed documentation of a pulse and blood pressure a total of six (6) times. Medical record review of Medication Administration Records (MARs) dated April 1, 2009 through June 8, 2009, revealed the [MEDICATION NAME] XL 50 mg was administered a total of one hundred nine (109) times. Continued review of the MARs dated April 1, 2009, through June 8, 2009, revealed a pulse or blood pressure was not documented for all one hundred nine (109) medication administrations. Review of Nursing Drug Handbook 30th Edition (Page 387) revealed, Always check patient's apical pulse rate before giving drug.Monitor blood pressure frequently; drug masks common signs and symptoms of shock. Interview, on June 9, 2009, at 8:10 a.m., with the Licensed Practical Nurse #2, in the A Hall Nurse Station, confirmed the physician order to monitor the pulse and blood pressure for [MEDICATION NAME] XL was not followed. | 2015-10-01 |
| 11961 | 11961 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-06-10 | 315 | E | 0 | 1 | G9RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to develop a toileting program for four (#3, #10, #13, and #1) of thirty-four residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had no short or long term memory deficits, was independent for decisions making, was unable to ambulate, required extensive assistance for transfers, and was incontinent for bladder and bowel. Medical record review of the Assessment for Bowel and Bladder Training dated July 3, 2008, December 10, 2008, March 16, and June 9, 2009, revealed the resident was a candidate for toileting, timed or scheduled voiding. Review of the facility policy, Restoring Bladder Function, revealed, .Prevent incontinence episodes by providing prompt transfers and/or stand-by assistance to ambulate where required for toileting. Observation on June 8, 2009, at 2:00 p.m., in the resident's room, revealed the resident alert and oriented and sitting in a wheel chair. Observation and interview with the resident on June 9, 2009, at 9:00 a.m., in the resident's room, revealed the resident at the bedside in a wheel chair. Interview with the resident at that time, confirmed the resident had recently called for assistance to the bathroom, had timed the wait to be thirty seven minutes, and was not able to control the bladder. Interview with LPN #1 on June 9, 2009, at 10:40 a.m., at the 300 nurses station, revealed the plan was for the resident to call when he/she needed help. Continued interview confirmed a toileting program had not been developed for the resident. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the long term memory was intact, required extensive assistance for transfers, was incontinent fo… | 2015-10-01 |
| 11962 | 11962 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-06-10 | 332 | D | 0 | 1 | G9RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to administer medications without error for two of forty opportunities resulting in a five percent error rate. The findings included: Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Observation on June 9, 2009, at 9:00 a.m., revealed Licensed Practical Nurse (LPN) #3 administered medications to the resident without the [MEDICATION NAME] 40 mg as ordered. Interview with LPN #3 on June 9, 2009, at 9:10 a.m., outside of the resident's room confirmed the [MEDICATION NAME] 40 mg was not administered as ordered. Resident #34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the June 2009, physician's orders [REDACTED]. Observation on June 9, 2009, at 4:15 p.m., in the resident's room, revealed LPN # 4 administered the resident's medications including the [MEDICATION NAME]. Observation also revealed no food tray present in the resident's room. Interview with LPN #4 on June 9, 2009, at 4:30 p.m., outside of the resident's room confirmed the physician's orders [REDACTED]. | 2015-10-01 |
| 11963 | 11963 | COLONIAL HILLS NURSING CENTER | 445181 | 2034 COCHRAN RD | MARYVILLE | TN | 37803 | 2009-06-10 | 371 | F | 0 | 1 | G9RQ11 | Based on observation and interview the facility failed to ensure that the sanitizing system for the kitchen's dishwasher was operational. The findings included: Observation on June 08, 2009, at 5:50 a.m., in the kitchen revealed that a variety of dishes and cooking utensils had been processed through the dishwashing machine, and test strips used by staff members indicated no sanitizing agent was present in the diswashing water. Interview with the Kitchen Manager on June 08, 2009, at 5:50 a.m., in the kitchen confirmed that the dishwashing machine sanitizing system was not operational and a variety of dishes and cooking utensils had been processed through the dishwasher but not used in food preparation. Interview with the Administrator on June 08, 2009, at 6:45 a.m., in the kitchen confirmed that the dietary dishwashing machine sanitizing system was not operational. | 2015-10-01 |
| 14024 | 14024 | WOODBURY HEALTH CENTER | 445435 | 119 WEST HIGH STREET | WOODBURY | TN | 37190 | 2009-06-25 | 226 | D | 1 | 0 | I7U111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and interview, the facility failed to follow their Investigative Guideline policy for 1 (#1) resident of 1 reviewed. The findings included: Medical record review revealed resident #1 was admitted to the facility on [DATE], and discharged home on May 21, 2009. Interview with the resident's conservator on June 26, 2009, at 8:10 a.m., by phone, revealed the facility was notified by the family on May 21, 2009, regarding the discovery of a yellowish bruise on the resident after the resident was discharged from the facility and had arrived to the home. The interview revealed the facility Director of Nursing (DON) went to the home and did a physical assessment of the resident. Interview with the DON, by phone, on June 24, 2009, at 9:45 a.m., revealed the DON visualized a very faint yellow bruise. Interview with the DON interview revealed several technicians on different shifts and the roommate of the resident were interviewed regarding the bruise. Review of the investigation data, dated May 28, 2009, provided by the Administrator revealed one unsigned and incomplete interview, two interviews from staff not providing direct care, and 3 interviews with direct care staff. Further review revealed no documentation of the direct care staff interviews from the day of the discharge or the majority of the staff assigned to the resident. Review revealed no documentation of the findings of the DON's physical assessment of the resident. Review of the Investigation policy revealed all staff, on the unit at the time of the incident occurred, must be interviewed. Written statements are to be obtained, whenever possible, in the individual's handwriting. Interview with the Administrator at 3:00 p.m., on June 25, 2009, in the conference room confirmed the facility failed to follow their policy for investigation of incidents. | 2014-07-01 |
| 14223 | 14223 | FAYETTEVILLE HEALTH AND REHABILITATION CENTER | 445320 | 4081 THORNTON TAYLOR PARKWAY | FAYETTEVILLE | TN | 37334 | 2009-07-08 | 312 | E | MV1911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint Investigation for TN 291 Based on policy review, medical record review, observations and interview, it was determined the facility failed to ensure staff provided assistance with Activities of Daily Living (ADLs) for toileting, incontinence care or repositioning for 5 of 18 (Residents #2, 6, 9, 10 and 19) sampled residents observed. The findings included: 1. Review of the facility's "Skin Care & (and) Pressure Ulcer Management Program" policy documented, "Residents face many challenges because both urine and feces contain substances that may irritate the epidermis and may make the skin more susceptible to break down. Prolonged exposure to urine and feces may cause irritation or maceration (softening of the skin), which can then hasten skin breakdown. In fact, some studies have found that fecal incontinence may pose the greater threat to skin integrity, most likely due to bile acids and enzymes in the feces. Moisture, on the other hand, may make skin more susceptible to damage from friction and sheer during repositioning ...A pressure ulcer often presents as a localized area of [DIAGNOSES REDACTED] (skin discoloration) where the urine or stool has come in contact with the skin ...If incontinence is a concern, then look for specific products and other key tactics you can use when moisture is a risk factor, such as: Checking to see if the resident is incontinent every two hours ...Nursing assistants play a key role in preventing pressure ulcers. Because they work so closely with residents, nursing assistants are most often in a position to identify the development of a pressure ulcer at an early stage. A quick acting nursing assistant can make a difference in a resident's condition by documenting and communicating new skin issues to the charge nurse immediately, so that treatment can begin as soon as possible..." 2. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the mos… | 2014-03-01 | ||
| 13973 | 13973 | LAUGHLIN HEALTH CARE CENTER | 445264 | 801 E MCKEE ST | GREENEVILLE | TN | 37743 | 2009-08-05 | 223 | D | 1 | 1 | HJJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to provide an environment free from verbal abuse for one resident (#7) of eighteen residents reviewed. The findings included: Resident # 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], through May 18, 2009, revealed the resident had no impaired hearing, no behavior problems, usually understands others, no long term memory loss, and had some difficulty in decision making in new situations only. Medical record review of the facility's documentation revealed the resident presided as the President of the Resident Council. Medical record review of the facility's Abuse Identification and Reporting Policy revealed, "The Purpose: To familiarize personnel with identifying and reporting possible abuse... Intervention:..." Any employee who suspects an instance of abuse, neglect, or exploitation of the resident shall report to their immediate supervisor after removing resident from harm's way. The supervisor will report then to the Director of Nursing. The Director of Nursing will inform the Administrator..." Observation on August 5, 2009, at 10:00 a.m., at the West Wing Nurses station, revealed Registered Nurse (R.N.) # 1, sitting directly in front of the resident, speaking in the loud, harsh tone, " I told you ..., I told you ... We are not going to..." Observation at that time, revealed the Assistant Director of Nursing was present, but did not attempt to remove R.N. #1 from the area. Interview with the resident on August 5, 2009, at 10:15 a.m., in the activity room revealed the resident was able to hear questions at a normal volumn; and revealed someone had spoken harshly; and stated, "It does make me feel bad, they do it all the time." Interview with R.N. #1 on August 5, 2009, at 10:30 a.m., at the West Nurses Station, revealed "The resident was trying to argue with me... I norma… | 2014-07-01 |
| 14000 | 14000 | TENNESSEE STATE VETERANS HOME | 445366 | 2865 MAIN STREET | HUMBOLDT | TN | 38343 | 2009-08-12 | 332 | K | 1 | 0 | R86C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of "2006 American Society of Consult Pharmacists and Med-Pass", review of the facility's dining times, medical record review, observation and interview, it was determined the facility failed to ensure the medication error rate was less than five percent (%) for Residents #11, 12, 17, 18, 19, 46 and Random Resident (RR #2). Four (4) of 8 (Residents #12, 17, 18 and 19) residents observed receiving insulin had medication errors with insulin administration. Six (6) of 13 nurses (Nurses #2, 3, 5, 6, 9 and 10) made 10 errors out of 49 opportunities for error which resulted in a medication error rate of 20%. The failure to administer insulin as ordered by the physician and the failure to administer insulin within 30 minutes of meals placed diabetic residents in immediate jeopardy. The immediate jeopardy began 7/29/09. The facility remained out of compliance at a scope and severity level "E" (a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the policies and procedures and training implemented by the facility could be reviewed by the Quality Assurance (QA) Committee. The findings included: 1. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of the physician's orders dated 7/5/09 documented "[MEDICATION NAME] R 100 UNITS/ML AS DIRECTED ACCORDING TO THE SLIDING SCALE...251- (to) 300 = (amount of insulin to be administered) 6 UNITS..." The current orders dated 7/5/09 did not include an order for [REDACTED]. Observations in Resident #12's room on 8/3/09 at 4:03 PM, revealed Nurse #3 administered [MEDICATION NAME] R 6 units (U) subcutaneous (SQ) in the right abdomen. Observations of the evening meal on the West Hall on 8/3/09 revealed the meal tray was not served to Resident #12 until 5:17 PM. Resident #12 did not take the firs… | 2014-07-01 |
| 14001 | 14001 | TENNESSEE STATE VETERANS HOME | 445366 | 2865 MAIN STREET | HUMBOLDT | TN | 38343 | 2009-08-12 | 333 | K | 1 | 0 | R86C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy reviews, review of inservice records, review of meal times, review of the "MED-PASS" provided by the American Society of Consultant Pharmacists, medical record review, observations and interviews, it was determined the facility failed to ensure that residents were free of significant medication errors. The nursing staff failed to obtain blood sugars (BS) as ordered, failed to administer correct dosages of sliding scale insulin (SSI) as ordered, failed to administer insulin within 30 minutes of meals and/or failed to obtain signed orders for insulin administration for 20 of 30 (Residents #4, 10, 11, 17, 18, 19, 20, 24, 26, 29, 32, 34, 35, 36, 37, 38, 40, 42, 43 and 46) sampled diabetic residents. The failure to administer insulin as ordered, obtain BS as ordered and/or notify the physician of BS below 60 and/or above 401, placed all residents receiving insulin in immediate jeopardy. The immediate jeopardy began 7/29/09. The facility remained out of compliance at a scope and severity level "E" (a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the policies and procedures and training implemented by the facility could be reviewed by the Quality Assurance (QA) Committee. The findings included: 1. Review of the facility's "Medication Administration General Guidelines" policy documented "...b. Medications to be given with meals are to be scheduled for administration at the resident's meal times..." Review of the facility's "Blood Sugar/Sliding Scale Monitoring" policy provided by the facility to be used as the standing order for sliding scale insulins documented, "...1.) A written physician order for [REDACTED]. (greater than) 401 call MD... 2.) Physician orders for custom sliding scale intervention may be written specifically for individual residents by the Physician and will supercede the facility approved sliding scale... 3.) Signs and sym… | 2014-07-01 |
| 13969 | 13969 | JEFFERSON CITY HEALTH AND REHAB CENTER | 445246 | 283 W BROADWAY BLVD | JEFFERSON CITY | TN | 37760 | 2009-08-19 | 153 | D | 1 | 0 | 7WTY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide copy of a resident medical records in a timely manner after requested for one resident (#1) of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Tracking HIPPA Privacy Request and Response log revealed the resident's spouse (Power of Attorney) had requested a copy of the medical records on August 4, 2009.Continued review revealed no documentation the request had been processed. Telephone interview with the Director of Nursing on August 19, 2009, at 1:45 p.m., confirmed the request had not been completed as requested on August 4, 2009. c/o tn 518 | 2014-07-01 |
| 13997 | 13997 | LIFE CARE CENTER OF BRUCETON-HOLLOW ROCK | 445326 | 105 ROWLAND | BRUCETON | TN | 38317 | 2009-08-28 | 282 | D | 1 | 0 | 1KKR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #TN 852 Based on medical record review, it was determined the facility failed to ensure the care planned intervention of a gym mat at bedside was continuously followed for 1 of 12 (Resident #31) sampled residents reviewed for falls, fractures, abrasions and/or bruises. The findings included: Medical record review for Resident #31 documented an admission date of [DATE]. Resident #31's [DIAGNOSES REDACTED]. Review of Resident #31's care plan dated 6/12/08 documented the resident had potential for falls/injury related to [DIAGNOSES REDACTED]. The care plan was updated on 9/2/08 with a new intervention of a gym mat at bedside. Review of the Nurse's Notes dated 1/29/09 at 11:00 PM documented Resident #31 was found on the floor. There was no documentation the gym mat was at the bedside as care planned. | 2014-07-01 |
| 14035 | 14035 | THE VILLAGE AT GERMANTOWN | 445482 | 7930 WALKING HORSE CIRCLE | GERMANTOWN | TN | 38138 | 2009-09-24 | 157 | D | 1 | 0 | SV2311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint Investigation for TN 028 Based on medical record review, it was determined the facility failed to ensure that a resident's legal representative was immediately informed of an incident requiring physician intervention and change in treatment for 1 of 5 (Resident #1) sampled residents. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a "Medication Error Report" dated 9/18/09 indicated that Resident #1 had an order for [REDACTED]. 5 mg (milligrams) / (per) ml (milliliter), 1ml topically q (every) 6 hrs (hours) scheduled & (and) q 4 hrs PRN (as needed)". The report further states that the "Licensed nurse administered 5mg/ml x (times) 5 ml, giving total of 25 mg". The incident occurred at 12:00 AM and was confirmed at 10:00 AM and reported at that time to the Family Nurse Practitioner (FNP). Review of the facility's "Daily Skilled Nurses Notes" and "Nurse's Notes" for 9/18/09 contain no documentation indicating that the legal representative was notified of the error or change in physician's orders [REDACTED]. | 2014-07-01 |
| 14036 | 14036 | THE VILLAGE AT GERMANTOWN | 445482 | 7930 WALKING HORSE CIRCLE | GERMANTOWN | TN | 38138 | 2009-09-24 | 514 | D | 1 | 0 | SV2311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews with staff, it was determined the facility failed to document assessments of a resident who had received an overdose of pain medication for 1 of 5 (Resident #1) sampled residents. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a "Medication Error Report" dated 9/18/09 indicated that Resident #1 had an order for [REDACTED]. 5 mg (milligrams) / (per) ml (milliliter), 1ml topically q (every) 6 hrs (hours) scheduled & (and) q 4 hrs PRN (as needed)". The report further states that the "Licensed nurse administered 5mg/ml x (times) 5 ml, giving total of 25 mg". The incident occurred at 12:00 AM and was confirmed at 10:00 AM and reported at that time to the Family Nurse Practitioner (FNP). In an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 9/18/09 at 11:30 AM, they stated that the licensed nurse had stated to them that Resident #1 was checked during the night and was easily aroused. Resident #1 was "sleeping peacefully" at 6:00 AM, and the scheduled dose of [MEDICATION NAME] was withheld at that time. The ADON states that she and the charge nurse on the day shift assessed Resident #1 immediately on discovering the medication error. However, the "Daily Skilled Nurses Notes" for 9/18/09 was blank, and the "Nurses Notes" for 9/18/09 contained no documentation until 3:30 PM when the physician changed the pain medication order. The "Nurses Notes" for 9/18/09 failed to contain an assessment of the resident's condition or reaction to the medication overdose. | 2014-07-01 |
| 14022 | 14022 | DOUGLAS NURSING HOME | 445434 | 2084 W MAIN ST | MILAN | TN | 38358 | 2009-10-06 | 157 | D | 1 | 0 | TV6811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint investigation for TN 080 Based on medical record review, it was determined the facility did not notify the responsible party of changes in medication regimen for 1 or 9 (Resident #9) sampled residents. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 7/2/09. The resident was monitored throughout the stay in the facility by psychiatric services for [MEDICAL CONDITION] drug management. There were frequent drug changes in an effort to control the resident's aggressive behavior toward other residents. The facility failed to provide documentation that the responsible party was notified of the medication changes on 3/27/09, 4/20/09, 5/6/09, 5/30/09, 6/17/09 and 6/27/09. | 2014-07-01 |
| 14023 | 14023 | DOUGLAS NURSING HOME | 445434 | 2084 W MAIN ST | MILAN | TN | 38358 | 2009-10-06 | 279 | D | 1 | 0 | TV6811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint investigation for TN 600 Based on medical record review, it was determined the facility failed to implement new interventions for a resident assessed as being at risk for falls for 1 of 9 (Resident #2) sampled residents. The findings included: Medical record review for Resident #2 documented an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) Assessment and Care Screening dated 8/3/09 indicated that Resident #2 was modified independent in daily decision making, easily altered expressions of anger and anxiety, required limited assistance of one person for transfers. The Plan of Care (POC) indicated the resident was at risk for falls, and documentation in a physician's note dated 7/30/09 documented "6/3/09 - fall - refuses to wear prosthesis." The resident had documented falls on 3/23/09, 5/10/09, 6/3/09, 7/26/09 and 9/11/09 with no injuries. On 8/14/09 Occupational Therapy for was ordered 5 times per week for 30 days for transfers. On 9/26/09 the resident was sent to the emergency room related to a fall that caused a hematoma to the forehead, a nosebleed and abrasion to the right cheek. A Cat scan was within normal limits. After the fall on 9/26/09 non-skid socks were implemented. There were no interventions implemented after each fall prior to 9/26/09. On 10/16/09 the Director of Nursing confirmed no other interventions had been implemented. | 2014-07-01 |
| 14146 | 14146 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2009-12-08 | 323 | D | 3VQT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 419 Based on medical record, observation and interview, it was determined the facility failed to follow interventions to prevent falls for 2 of 15 (Residents #8 and 12) sampled residents. The findings included: 1. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set ((MDS) dated [DATE] documented that Resident #8 was in need of full staff performance of daily activities. The significant change MDS dated [DATE] and the quarterly assessment of 6/15/09 documented Resident #8 was totally dependent for transfers for two person assist and totally dependent for ambulation requiring two person transfer. Review of Resident #8's care plan dated 3/5/09 documented the resident "At risk for injury/falls... and assist with transfer of 2." The care plan dated 4/1/09 documented "At risk for injury/falls related to impaired mobility hx (history) of falls... Approach Assist with transfers 2." An additional intervention included a body alarm on 12/6/09. Observation in Resident #8's room on 12/8/09 at 3:30 PM, revealed Resident #8 sitting in a wheelchair (w/c) with a body alarm clipped to the back of her shirt to the w/c. During an interview in Resident #8's room on 12/8/09 at 3:30 PM, Resident #8 stated, "Told (Certified Nursing Assistant (CNA) #3) there suppose to be 2 persons. She just picked me up and put me in bed and the rail fell ." The CNA failed to use two people for transfers as care planned. 2. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]." Review of the care plan dated 11/11/09 documented under the heading of problems was: Potential for falls and or injuries secondary to shuffling gait, confusion and history of falls. Under the heading of interventions, #3 intervention was: bed/chair alarm at all times. Observations in Resident #12's room on 12/8/09 … | 2014-04-01 | ||
| 14147 | 14147 | WOOD PRESBYTERIAN HOME | 445322 | 520 OLD HIGHWAY 68 | SWEETWATER | TN | 37874 | 2009-12-08 | 323 | D | R02I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 306 Based on medical record review, observation, and interview, the facility failed to provide supervision to prevent a fall for one (#1) resident of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, modified independence in cognitive skills for daily decision making, required extensive assistance with one person physical assistance for transfers, toilet use, and was continent of bowel and bladder. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the care plan dated February 24, 2009, revealed, " ...provide ext (extensive) assist x 1 for hygiene, dressing, toileting and bathing ..." Medical record review of the Resident Assessment Protocol dated February 24, 2009, revealed, " ...Most ADL's (activities of daily living) require the ext (extensive) assist of one ..." Medical record review of the investigation of unusual occurrence dated April 2, 2009, revealed, " ...Family reported CNA took ...to bathroom (and) left ...on toilet to use bathroom ...did not pull light and tried to get up without help and fell in floor ...Raised hematoma to back of head ...Changes to Care Plan: Staff to stay with ...when using bathroom ..." Observation on December 7, 2009, at 10:15 a.m., in the resident's room, revealed the resident in the wheelchair with a pressure sensitive pad alarm on the wheelchair. Interview on December 7, 2009, at 12:20 p.m., in the conference room, with the Director of Nursing, confirmed the resident was not to be left alone in the bathroom. | 2014-04-01 | ||
| 14310 | 14310 | SUMMIT VIEW OF FARRAGUT, LLC | 445258 | 12823 KINGSTON PIKE | KNOXVILLE | TN | 37923 | 2009-12-16 | 314 | D | 4T7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow dietary recommendations and obtain physician orders for a pressure area for one (#1) of twenty-three residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems with severely impaired cognitive skills and required assistance with all activities of daily living. Medical record review revealed the resident was receiving daily treatment for [REDACTED]. Medical record review of a dietary recommendation dated November 24, 2009, revealed, "Recommend, Restart Prostat 30 ml. BID (twice daily)." Medical record review revealed the Nurse Practitioner signed the recommendation on November 24, 2009, but no physician's order was written. Observation with the Unit Manager while performing a dressing change, in the resident's room, on December 15, 2009, at 12:30 p.m., revealed a healing Stage II pressure area 2.0 x (by) 2.0 x less than 0.1 cm. on the resident's left buttock. Interview with the Nurse Practitioner in the nursing office on December 16, 2009, at 10:30 a.m., confirmed the recommendation were noted however, the Nurse Practitioner failed to write a physician's order. | 2014-01-01 | ||
| 14311 | 14311 | SUMMIT VIEW OF FARRAGUT, LLC | 445258 | 12823 KINGSTON PIKE | KNOXVILLE | TN | 37923 | 2009-12-16 | 281 | D | 4T7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow the physician's order [REDACTED]. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the Daily Skilled Nurse ' s Notes revealed the following blood pressure readings: on December 9, 2009, 101/62; (normal 120/80); on December 11, 2009, 102/62; and on December 13, 2009, 110/54. Interview with the Director of Nursing on December 15, 2009, at 10:15 a.m., in the Director of Nursing 's office confirmed, per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order dated December 9, 2009, for decreasing [MEDICATION NAME] to 2.5 mg was not followed. | 2014-01-01 | ||
| 14179 | 14179 | BETHANY HEALTH CARE CENTER | 445159 | 421 OCALA DRIVE | NASHVILLE | TN | 37211 | 2010-01-06 | 371 | F | K66O11 | Based on observation, facility document review and staff interview, the facility failed to maintain dietary equipment in a sanitary manner and failed to operate the low temperature dish machine at the manufacturer's recommended temperature. The findings included: Observation of the facility dietary department on January 4, 2010, beginning at 10:10 a.m., with the Dietary Manager present during the observations revealed the following: The can opener blade, base, and base slot had a heavy, sticky, black colored build-up of debris with metal shavings on the build-up. The grill trough and trough slot had a heavy build-up of blackened debris. The interior of the dish machine doors had a heavy, sticky, white colored build-up. Interview with the Dietary Manger, present during the observation on January 4, 2010, beginning at 10:10 a.m., confirmed the can opener blade, base, and base slot had a heavy, sticky, black colored build-up of debris with metal shavings on the build-up. Further interview confirmed the grill trough and trough slot had a heavy build-up of blackened debris and the interior of the dish machine doors had a heavy, sticky, white colored build-up. Observation of two dish machine operations on January 4, 2010, beginning at 10:25 a.m., revealed wash temperatures of 84 and 92 degrees Fahrenheit and rinse temperatures of 92 and 94 degrees Fahrenheit. The manufacturer's recommended temperatures were 125 degrees minimum for wash and rinse cycles. Review of the facility document entitled Dishmachine Temperature Chart, dated January 2010, revealed wash temperature, rinse or ppm (parts per million) and staff initials for "AM Staff" (breakfast), "Noon Staff" (lunch) and "PM Staff" (supper) for each day of the month. Further review of this document revealed a total of ten recording of 150 degree wash temperature and 50 rinse or ppm from January 1, 2010, AM Staff, through January 4, 2010, AM Staff. Interview with the Dietary Manger, present during the observation of the dish machine observation on January 4, 2010, at … | 2014-03-01 | ||
| 14180 | 14180 | BETHANY HEALTH CARE CENTER | 445159 | 421 OCALA DRIVE | NASHVILLE | TN | 37211 | 2010-01-06 | 456 | D | K66O11 | Based on observation and staff interview, the facility failed to maintain the integrity of the dietary walk-in refrigerator unit. The findings included: Observation on January 4, 2010, at 10:10 a.m., of the right hand side of the interior of the walk-in refrigerator unit door jam, revealed rust had penetrated through the wall of the unit exposing the interior of the wall. Interview with the Dietary Manager, present at the observation on January 4, 2010, at 10:10 a.m., confirmed the right hand side of the walk-in refrigerator interior door jam was rusted through and the interior of the wall was exposed. | 2014-03-01 | ||
| 14224 | 14224 | BRIDGE AT SOUTH PITTSBURG, THE | 445343 | 201 EAST 10TH STREET | SOUTH PITTSBURG | TN | 37380 | 2010-01-13 | 332 | D | ZTTU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to administer four of forty medications without error for two (#26, #27) of six residents observed, resulting in a ten percent medication error rate. The findings included: Medical record review of resident #26's physician's orders [REDACTED]. Observation on January 14, 2010, 7:10 a.m., in the resident's room, revealed Licensed Practical Nurse (LPN) #1 administered two [MEDICATION NAME] coated (coating to dissolve in the small intestine and is non-chewable) Aspirin 81 mg; one Calcium 500 mg (no vitamin D); and one Multivitamin with minerals. Review of the physician's orders [REDACTED]. [REDACTED]. Medical record review of resident #27's physician's orders [REDACTED]. Observation on January 14, 2010, 7:50 a.m., in the resident's room, revealed LPN #1 administered one [MEDICATION NAME] coated Aspirin 81 mg. Medical record review of the physician's orders [REDACTED]. [REDACTED]. | 2014-03-01 | ||
| 14225 | 14225 | BRIDGE AT SOUTH PITTSBURG, THE | 445343 | 201 EAST 10TH STREET | SOUTH PITTSBURG | TN | 37380 | 2010-01-13 | 312 | D | ZTTU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nail care for one resident (#2) of twenty seven reviewed residents. The findings included: Resident # 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Minimum Data Set, dated dated dated [DATE], revealed the resident was totally dependent on staff for hygiene including nail care. Medical record review of the Nursing Assistant Care Plan currently in use revealed nail care checked as being provided by the nursing assistant. Observation of the resident's finger nails on January 11, 2010, at 10:00 a.m.; January 12, 2010, at 1:00 p.m.; and January 13, 2010, at 9:00 a.m., revealed the fingernails long, and soiled with brown debris. Interview with the Director of Nursing at the resident's bedside and at the 200 Hall nursing station, on January 13, 2010, at 9:10 a.m., confirmed the resident's finger nails were long, soiled with brown debris and required trimming and cleaning. | 2014-03-01 | ||
| 14226 | 14226 | BRIDGE AT SOUTH PITTSBURG, THE | 445343 | 201 EAST 10TH STREET | SOUTH PITTSBURG | TN | 37380 | 2010-01-13 | 252 | D | ZTTU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide a homelike environment for one resident (#16) of twenty-seven residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, had difficulty making self understood, and required assistance with all activities of daily living. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) dated December 4, 2009, revealed the resident has adequate vision and hearing; makes noises and communicates some needs non-verbally; and requires sensory stimulation. Observation on January 11, 2010, at 9:30 a.m., and January 12, 2010, at 3:00 p.m., of the resident's room revealed no personal items, ie: pictures, television, radio, magazines etc. Interview on January 12, 2010, at 4:00 p.m., in the conference room, with the Director of Nurses confirmed the resident did not have any personal items in the room, and the room was not homelike. | 2014-03-01 | ||
| 14227 | 14227 | BRIDGE AT SOUTH PITTSBURG, THE | 445343 | 201 EAST 10TH STREET | SOUTH PITTSBURG | TN | 37380 | 2010-01-13 | 248 | D | ZTTU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide activities of interest for one resident (#16) of twenty-seven residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident's activity interests were music and watching television. Medical record review of the MDS dated [DATE], revealed the resident had impaired short and long term memory, had difficulty making self understood, and required assistance with all activities of daily living. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) dated December 4, 2009, revealed the resident has "...adequate vision and hearing...makes noises and communicates some needs non-verbally...requires sensory stimulation..." Observation on January 11, 2010, at 9:30 a.m., and January 12, 2010, at 3:00 p.m., of the resident's room revealed no personal items, ie: pictures, television, radio, magazines etc. Interview on January 12, 2010, at 4:30 p.m., with the activity assistant in the busy bee activity room revealed the resident did not like crowds, did not come to the activity room very often, and had not been assessed for like or dislikes for sensory toys, stuffed animals, simple puzzles, or other sensory items. | 2014-03-01 | ||
| 14228 | 14228 | BRIDGE AT SOUTH PITTSBURG, THE | 445343 | 201 EAST 10TH STREET | SOUTH PITTSBURG | TN | 37380 | 2010-01-13 | 241 | D | ZTTU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide dignity for one resident (#16) of twenty-seven residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, had difficulty making self understood, and required assistance with all activities of daily living. Observation on January 12, 2010, at 3:00 p.m., of the resident ambulating in the hallway revealed the resident's pants fell down exposing the buttocks. Observation continued to the therapy room where the pants fell to the resident's feet, exposing the perianal area, and several residents of the opposite sex laughed. Interview on January 12, 2010, at 3:15 p.m., with the Registered Nurse for Staff Development (present when the pants fell down) in the therapy room, confirmed dignity was not provided for the resident. | 2014-03-01 | ||
| 14229 | 14229 | BRIDGE AT SOUTH PITTSBURG, THE | 445343 | 201 EAST 10TH STREET | SOUTH PITTSBURG | TN | 37380 | 2010-01-13 | 250 | D | ZTTU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide social services to maintain the psychosocial well-being for one resident (#16) of twenty-seven residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory, had difficulty making self understood, and required assistance with all activities of daily living. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) dated December 4, 2009, revealed the resident has adequate vision and hearing; makes noises and communicates some needs non-verbally; and requires sensory stimulation. Observation on January 11, 2010, at 9:30 a.m., of the resident's room revealed no personal items, such as pictures, books, magazines, toys, television, or radio. Observation and interview on January 12, 2010, at 3:15 p.m., in the resident's room with Certified Nurse Assistant (CNA) #1 revealed several old pairs of pants and shirts in the closet. Interview with the CNA revealed the clothing had been obtained from discharged residents that had donated clothing and did not fit this resident. Review of the resident's Ledger Card revealed the resident had over $500.00 in the resident's trust fund account. Interview with the Social Worker (SW) on January 12, 2010, at 4:10 p.m., in the conference room, confirmed the resident on admission to the facility had arrived with no personal items, and had no family to bring or purchase personal items including clothing. Interview revealed the SW was aware the resident did not have personal items in the room or clothing that fit adequately, and the resident had over $500.00 in the trust account. Continued interview with the SW revealed the resident was on a waiting list for two facilities that specialize in care for Mental Retard… | 2014-03-01 | ||
| 14230 | 14230 | BRIDGE AT SOUTH PITTSBURG, THE | 445343 | 201 EAST 10TH STREET | SOUTH PITTSBURG | TN | 37380 | 2010-01-13 | 323 | D | ZTTU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, observation, and interview, the facility failed to ensure a safety device was functional for one resident (#4) of twenty-seven residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory problems, did not walk, and required extensive assistance with transfers. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the Care Plan, reviewed on September 8, 2009, revealed " ...At risk for fall related injury...Bed/chair alarm..." Medical record review of the Interdisciplinary Progress Notes dated September 24, 2009, at 12:15 a.m., revealed "Resident found sitting on bottom in floor...@ (at) end of...bed going thru...chest drawers. Tells nurse...fell ...denies pain, discomfort. Assessed for injuries. None apparent..." Review of the investigatio, provided by the facility revealed the bed alarm did not sound at the time of the resident's fall on September 24, 2009. Telephone interview on January 12, 2010, at 1:55 p.m., with Licensed Practical Nurse (LPN) #2, (LPN responsible for the resident's care on September 24, 2009) revealed the bed alarm did not sound at the time of the resident's fall, and the alarm was replaced. Interview on January 12, 2010, at 2:20 p.m., with the Director of Nursing, in the hallway, revealed at the time of the resident's fall on September 24, 2009, there was no system in place to check the functioning of the safety alarm, and it was unknown when the safety alarm had been checked prior to the resident's fall on September 24, 2009. | 2014-03-01 | ||
| 14277 | 14277 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 315 | D | NRDI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility policy, observation, and interview, the facility failed to complete a bladder training assessment for one (#20) of thirty-three residents reviewed. The findings included: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory problems, no long term memory problems, and moderately impaired cognitive skills for daily decision making. Medical record review of a physician's order dated October 20, 2009, revealed, "...D/C (discontinue) foley (catheter to drain bladder)...timed toileting program ... " Medical record review of the urinary incontinence questionnaire (undated) revealed, "...Bladder: Are you incontinent Occasionally..." Medical record review of the Assessment for Bowel and Bladder Training dated December 31, 2009, revealed, "...Mentally aware of toileting needs ...sometimes ...(total score of 14) ...7-14 Candidate for toileting, timed or scheduled voiding ... " Medical record review of a urinary incontinence assessment (undated) revealed, " ...Perform a 3 day Bladder Flow Record to assist with choice of Program ...scheduled toileting ...scheduled toileting at regular intervals on a planned basis to match the resident's voiding habits ..." Review of the facility policy, Guidelines to Assessment, revealed, "...complete the Assessment for Bowel and Bladder training if the resident is incontinent to determine if the resident is a candidate for individual training or timed/scheduled toileting...the resident will be placed in a bladder program appropriate for the resident ..." Observation on January 13, 2010, at 7:55 a.m., revealed the resident lying in the bed. Interview on January 13, 2010, at 12:30 p.m., with the Director of Nursing, at the nursing station, confirmed no documentation a three day voiding pattern had been completed. | 2014-02-01 | ||
| 14278 | 14278 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 323 | D | NRDI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility investigation, observation, and interview, the facility failed to ensure a safety device was in place for one (#4) of thirty-three residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, with severely impaired cognitive skills for daily decision making. Medical record review of the fall risk evaluation dated November 2, 2009, revealed the resident was at risk for falls. Medical record review of the nurse's note dated November 14, 2009, revealed, " ...Resident's self-release chair alarm is not working correctly ..." Medical record review of a physician's orders [REDACTED]. Review of the facility investigation dated November 15, 2009, revealed, "...found resident sitting in floor of BR (bathroom) (with) SR (self-release) belt off (no) injury ..." Medical record review of a physician's orders [REDACTED]. Observation on January 12, 2010, at 8:25 a.m., revealed the resident sitting in the wheelchair, in front of the nursing station, with a self release chair alarm in place. Interview on January 13, 2010, at 12:30 p.m., with the Director of Nursing, at the nursing station, confirmed the safety device was not in place at the time of the fall on November 15, 2009. | 2014-02-01 | ||
| 14279 | 14279 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 431 | D | NRDI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of current Individual Patient's Controlled Substances Record, review of facility policy, and interview, the facility and licensed pharmacist failed to establish a system of records of disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for seven (Resident #29,#30,#31,#32,#17,#11,#33) of thirty-three sampled residents. The findings included: Review of Facility Policy "Clinical Services Policies & Procedures, Nursing Volume l Policies for Medication Administration, Chapter 12" Controlled Drugs...Standard...A " controlled drugs proof of use sheet" is accurately maintained on all residents requiring controlled medications. Strict control of narcotics is always maintained...Policy ...Appropriate storage, recording, and use of controlled drugs are always maintained on all units. Narcotic proof of use sheet is accurately maintained on all residents requiring such medication...Procedure...4. The nurse signs off each dose of the controlled drug given by documenting: a. Date. b. Hour. c. Resident name d. Physician. e. Amount dispensed. f. Signature of nurse. g. Balance after subtracting amount dispensed...5. The nurse handling the controlled drug must follow the procedure in the event a dose is broken, partially used, discarded, or lost. a. The nurse records broken, partially used, or lost dose on the "proof of use sheet. b. The nurse and another nurse co-sign the " proof of use sheet." c. Two licensed nurses must witness the destruction of a controlled substance ...7. Narcotics are counted at the change of each shift by the off-going and the on-coming nurse and both sign the Change of Shift Count Record...c. If the count is incorrect, notify the supervisor and pharmacist...NOTE: The nurse remains on duty until the count is reconciled or the s… | 2014-02-01 | ||
| 14280 | 14280 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 441 | D | NRDI11 | Based on observation, policy review, and interview, the facility failed to ensure staff washed the hands after direct resident contact for one (#22) of thirty-three residents reviewed. The findings included: Observation on January 12, 2010, at 9:00 a.m., in the one hundred hallway, revealed CNA #1 (certified nursing assistant) adjusted resident #14's wheelchair footrest. CNA #1 after adjusting the footrest proceeded to pick up a breakfast tray from the meal cart. Further observation revealed CNA#1 took the breakfast tray into resident #22's room; placed the tray on the table; donned gloves; adjusted the resident to the upright position; proceeded to cut resident #22's food; and fed the resident. Review of the Handwashing Information-Handout #2, revealed ...the single most important factor in preventing and controlling infections is that of handwashing. ...Washing Your Hands ...6.Before serving food ....9. After handling the resident's belongings. Interview with the CNA #1 on January 12, 2010, at 9:10 a.m., in the hallway, confirmed the hands were not washed after adjusting the footrest on resident's wheelchair. Interview with the R.N. (registered nurse) supervisor unit #1, on January 12, 2010, at 10:15 a.m., in the hallway, confirmed staff hands are to be washed or disinfected between each resident. | 2014-02-01 | ||
| 14281 | 14281 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 281 | D | NRDI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the care plan for two residents (#16) of thirty-three residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with Diabetes, End Stage [MEDICAL CONDITION], Hypertension, and [MEDICAL CONDITION]. Medical record review of the physician notes dated January 2010, revealed the resident had a [MEDICAL TREATMENT] access (fistula) (access to use for [MEDICAL TREATMENT]) on the left arm and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan updated October 2009, revealed the care plan did not address the resident's [MEDICAL TREATMENT] access located on the resident's left arm or the practice which requires no needle sticks or blood pressures checks in the arm of the access. Interview with the ADON on January 13, 2010, at 8:05 a.m., at the second unit nurses' station, confirmed the care plan did not address the care of the access for [MEDICAL TREATMENT]. | 2014-02-01 | ||
| 14155 | 14155 | LIFE CARE CENTER OF HIXSON | 445380 | 5798 HIXSON HOME PLACE | HIXSON | TN | 37343 | 2010-01-21 | 281 | D | P3CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the [MEDICAL TREATMENT] contract, and interview, the facility failed to communicate to the [MEDICAL TREATMENT] center the assessment of a resident, and medication the resident received prior to the resident's visit to the [MEDICAL TREATMENT] center for one (#8) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, with modified independence in cognitive skills for daily decision making. Medical record review of the nursing note dated August 26, 2009, revealed, "...Res. (resident) refused to go for [MEDICAL TREATMENT], called to NP (nurse practitioner). [MEDICATION NAME] (medication for anxiety) 1 mg (milligram) IM (injection)...PT (prior to) [MEDICAL TREATMENT]...Res. Left (at) 06:20 (a.m.)..." Review of the Long Term Care Facility [MEDICAL TREATMENT] Services Agreement dated February 20, 2002, revealed, "...Responsibilities of Facility...The appropriate healthcare staff at Facility will make an assessment of the patient's physical condition and determine whether the patient is stable enough to be dialyzed on an outpatient basis...This assessment and communication will occur prior to each and every transfer of a patient to...for [MEDICAL TREATMENT] on an outpatient basis..." Interview on January 20, 2010, at 3:30 p.m., with the Social Service Director, at the nursing station, confirmed the resident was anxious about going to [MEDICAL TREATMENT] on August 26, 2009, but after the anti-anxiety medication was given, the resident agreed to go to [MEDICAL TREATMENT]. Interview on January 21, 2010, at 10:15 a.m., with the Director of Nursing, in the nursing office, confirmed no documentation of the assessment of the resident or the administration of the [MEDICATION NAME] was communicated prior to the … | 2014-04-01 | ||
| 14156 | 14156 | LIFE CARE CENTER OF HIXSON | 445380 | 5798 HIXSON HOME PLACE | HIXSON | TN | 37343 | 2010-01-21 | 315 | D | P3CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to provide a bladder training program for one (#5) resident of fifteen residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long term memory problems; had independent cognitive skills for daily decision making; and was usually continent of bladder. Medical record review of the assessment form for bowel and bladder training dated December 21, 2009, revealed the resident scored a ten, indicating the resident was a candidate for toileting, timed or scheduled voiding. Medical record review of the interim care plan dated December 21, 2009, revealed "...initiate bladder observation for patterning..." Medical record review of a urinary incontinence assessment dated [DATE], revealed "...scheduled toileting...at regular intervals on a planned basis to match the resident's voiding habits...scheduled toileting includes timed voiding with the interval based on the resident's usual voiding pattern or usually every three to four hours while awake..." Medical record review revealed no documentation the resident's usual voiding pattern was assessed or timed voiding was completed. Observation and interview on January 20, 2010, at 2:35 p.m. revealed the resident in a wheelchair. Interview with the resident revealed when asked if the resident was aware of the need to go to the bathroom, the resident stated "...I know when I have to go when I'm awake but not when I'm asleep..." Interview with the restorative nurse and the director of nursing on January 20, 2010, at 3:30 p.m., in the Director of Nursing's office confirmed the facility had failed to complete the voiding pattern assessment or the timed voiding. | 2014-04-01 | ||
| 14157 | 14157 | LIFE CARE CENTER OF HIXSON | 445380 | 5798 HIXSON HOME PLACE | HIXSON | TN | 37343 | 2010-01-21 | 502 | D | P3CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to obtain laboratory services for one resident (#5) of fifteen residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission physician orders [REDACTED]. Medical record review of a clarification physician order [REDACTED]. Observation on January 20, 2010, at 8:35 a.m., revealed the resident in a wheelchair for breakfast. Observation revealed the resident with no bruising or bleeding noted. Interview with licensed practical nurse (LPN #1) on January 20, 2010, at 10:00 a.m., in the conference room, confirmed the facility had failed to obtain the PTT as ordered by the physician. | 2014-04-01 | ||
| 14317 | 14317 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 157 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to update family contact information for one (#10) of fifteen residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes revealed the licensed nurse attempted to call the resident's brother on October 29, 2009, after the resident fell , and the brother's phone number was disconnected. Continued review revealed resident #10 fell again on November 12, 2009, and no contact number was available, so the resident's brother was not notified of the fall. Interview with the Social Services Director (SSD) and Case Manager (CM) #1 on January 21, 2010, at 9:35 a..m, in the Social Services Director's office, revealed the SSD and CM #1 were unaware the resident's brother's phone had been disconnected, and confirmed updated contact information was not available until January 21, 2010, at 1:00 p.m. | 2014-01-01 | ||
| 14318 | 14318 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 441 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, and interview, the staff failed to wash the hands, during a dressing change for two (#8, #1) of fifteen residents reviewed. The findings included: Observation on January 19, 2010, at 2:01 p.m., revealed Licensed Practical Nurse (LPN) #4 providing wound care to resident #8. Observation revealed LPN #4 donned gloves and removed soiled dressings from the right and left lower legs. Observation revealed without changing the gloves or washing the hands, LPN #4 cleansed two open wounds on the right lower leg, and three wounds on the left leg, with wound cleanser and gauze pads. Continued observation revealed without changing the gloves or washing the hands, LPN #4 applied Triple Antibiotic Ointment to each of LPN #4's gloved fingers, and then used each of the five fingers to individually apply the Triple Antibiotic Ointment to the five wounds on the lower legs. Continued observation revealed without changing the gloves or washing the hands, LPN #4 applied dressings to the five wounds. Review of the facility's policy Skin Integrity Program revealed "...Put on gloves...Remove soiled dressing...Cleanse wound with wound cleanser...Remove gloves and complete hand hygiene...Put on new gloves...Apply prescribed ointments if indicated...If you are dressing more than one site on a resident, hand hygiene must be done between each site..." Interview on January 20, 2010, at 11:10 a.m., with LPN #4, in the Assistant Director of Nursing's office, confirmed the gloves were not changed and the hands were not washed during the wound care provided to resident #8 on January 19, 2010, at 2:01 p.m. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on January 20, 2010, at 9:20 a.m., in resident #1's room, of LPN #4 provide treatment to a open wound on the resident's right fifth toe. Observation revealed: LPN #4 applied gloves; removed the resident's sock; a Certified Nurse Assistant en… | 2014-01-01 | ||
| 14319 | 14319 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 505 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to notify the physician of laboratory results for two (#8, #7) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the December 2009, physician's recapitulation orders revealed the resident was receiving [MEDICATION NAME] (anticoagulant) 4mg (milligrams) daily, and a PT/INR (laboratory test to measure blood coagulation) was to be completed every month. Medical record review of a PT/INR laboratory report dated December 22, 2009, revealed PT 25.1 (reference range 11.9-14.4) and INR 2.2 (reference range 2.0-3.5). Medical record review of the same PT/INR laboratory report revealed the laboratory report was faxed to the physician on December 23, 2009, however, medical record review revealed no documentation the physician had received/reviewed the laboratory report. Interview on January 21, 2010, at 9:35 a.m., with the Assistant Director of Nursing, in the conference room, confirmed there was no documentation the physician was notified of the results of the laboratory report. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapulation orders revealed: "...December 24, 2008, [MEDICATION NAME] level every 3 months ...March 24, 2009, PT/INR (measures how fast blood clots), Potassium, Liver Function every month ...August 21, 2009, BMP (Basic Metabolic Function) HEP (liver) function once a month ..." Medical record review of the laboratory report dated September 10, 2009, revealed "[MEDICATION NAME] 0.1 (L) (reference range 0.8-2.0 ng/mg) faxed...9/11/09 ..." Medical record review revealed no documentation the physician had received/reviewed the laboratory report. Medical record review of the laboratory report dated September 22, 2009, revealed Hepatic Function Panel Total Protein 5.2 (L)...(reference range 6.2-… | 2014-01-01 | ||
| 14320 | 14320 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 280 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the care plan was revised when a behavior modification program was initated for one (#14) of fifteen residents reviewed. The findings included: Resident # 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes revealed a Weekly Summary, dated July 10, 2009, "Resident allowed to use...personal cell phone if meds taken as scheduled. Resident likes to call...sister (name) on...cell phone." Medical record review of the current care plan, revealed the use of the cell phone to modify the resident's behavior was not addressed on the care plan. Interview with the Social Services Director and Case Manager #1 on January 21, 2010, at 9:10 a.m., in the SSD's office, revealed the resident was allowed to use the cell phone, if...took medications as scheduled, at the request of the resident's conservator. Continued interview confirmed the use of the cell phone was utilized to encourage the resident to take medications as scheduled, and confirmed the cell phone program was not addressed on the comprehensive care plan. | 2014-01-01 | ||
| 14321 | 14321 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 514 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the medical record was accurate for two (#12, #14) of fifteen residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Consultant Pharmacist Communication to the Physician dated July 15, 2009, revealed "...Antipsychotic Gradual Dose Reduction (GDR) [MEDICATION NAME] (antipsychotic) 4mg (milligrams) qHS (every hour of sleep)...Based on a review of the MDS (Minimum Data Set), progress notes and nursing record, it was felt by this reviewer that a GDR could be attempted. Please consider the following trial dose reduction: decrease [MEDICATION NAME] to 3mg qHS..." Medical record review of a physician's orders [REDACTED]. Medical record review of the Mental Health Notes, completed by the Psychiatric Nurse Practitioner, dated August 4, 2009, September 21, 2009, November 30, 2009, and January 18, 2010, revealed the Psychiatric Nurse Practitioner documented the resident continued to receive [MEDICATION NAME] 4mg at hour of sleep, after the [MEDICATION NAME] was decreased to 3mg on July 20, 2009. Interview on January 21, 2010, at 11:20 a.m., with the Director of Nursing (DON), in the DON's office, confirmed the Mental Health Notes/medical record was not accurate. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Mental Health Notes, completed by the Psychiatric Nurse Practitioner, dated August 24, 2009, revealed the resident received [MEDICATION NAME] (antipsychotic) 5 mg one time a day. Medical record review of physician's orders [REDACTED]. Medical record review of the Mental Health Notes, completed by the Psychiatric Nurse Practitioner, dated July 27, 2009, revealed the resident received [MEDICATION NAME] 5 mg 1 every day. Medical record review of the physician's orders [REDACTED]. Interview with the Director of Nursing in th… | 2014-01-01 | ||
| 14322 | 14322 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 323 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent a fall for one (#8) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had moderately impaired cognitive skills, required extensive assistance with transfers/ambulation, and had fallen in the past thirty days. Medical record review of the Fall Risk assessment dated [DATE], and December 14, 2009, revealed the resident was at high risk for falls. Medical record review of a nursing note dated November 18, 2009, at 8:00 a.m., revealed "This res (resident) found sitting in floor at...bedside. Assessment revealed (no) injuries...Fall was unwitnessed..." Medical record review of a Fall Care Plan dated November 18, 2009, revealed "...Resident will not be left in hallway or alone in room in w/c (wheelchair). Take resident from dining room directly to...room & assist to bed. " Medical record review of a nursing note dated November 22, 2009, at 1:40 p.m., revealed "Attempted to get into bed et slid into floor. (no) injuries noted..." Observation on January 20, 2010, at 8:13 a.m., revealed the resident lying on the bed. Interview on January 20, 2010, at 11:45 a.m., with the Director of Nursing, in the conference room, confirmed the resident was unattended at the time of the fall on November 22, 2009, and the Fall Care Plan was not followed. | 2014-01-01 | ||
| 14323 | 14323 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 309 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure physician's orders were followed for two (#14, #1) of fifteen residents reviewed. The findings included: Resident #14 was admitted to the facility on December 22, 2008, with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged to another facility on November 13, 2009. Medical record review of physician's orders revealed a telephone order, dated January 13, 2009, for [MEDICATION NAME] (antipsychotic) 5 mg (milligrams) one every morning and 5 mg one at bedtime "may give IM (intramuscular) if won't take PO (orally)". Continued review of physician's orders revealed when the [MEDICATION NAME] was increased to 10 mg 1 po bid (twice a day) "may give IM if refuses PO." Medical record review of physician's orders revealed the [MEDICATION NAME] was discontinued on August 19, 2009. Medical record review of nurse's notes revealed resident #14 spit out meds as follows March 5, 2009 at 1000; March 24, 2009, at 0730; April 28, 2009, at 0830; and July 27, 2009, at 2100, "spit out meds in BR (bathroom)." Medical record review of nurse's notes and the Mediaction Administration Records (MARS) from March, 2009, thru July, 2009, revealed the resident did not receive Zyprex via injection, as ordered, on any of the above dates. Medical record review of physician's orders and MARS from March, 2009, thru July, 2009, revealed on March 1, 2009, resident #14 was receiving [MEDICATION NAME] 5 mg every morning and 10 mg at bedtime (total of 15 mg). Continued review revealed on July 1, 2009, [MEDICATION NAME] was increased to 10 mg twice a day (total of 20 mg). Medical record review of physician's orders and MARS for July, 2009, revealed the [MEDICATION NAME] was again increased, with a 2:00 p.m., dose of 5 mg added (total of 25 mg). Interview with the Assistant Director of Nursing, in the conference room, on January 21, 2010, at 11:30 a.m., revealed the injection was to… | 2014-01-01 | ||
| 14324 | 14324 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 508 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure radiology services were obtained as ordered for one (#4) of fifteen residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of physician's progress notes revealed on November 23, 2009, a chest xray was obtained due to resident #4's complaints of congestion and wheezing. Continued review revealed the physician ordered [MEDICATION NAME] (antibiotic) once a day for seven days, and a repeat chest xray in three weeks. Medical record review of radiology reports revealed a repeat chest xray was not obtained until January 20, 2010. Interview with the Assistant Director of Nursing on January 20, 2010, at 2:10 p.m., in the conference room, confirmed the physician's orders [REDACTED]. | 2014-01-01 | ||
| 13972 | 13972 | MARTIN HEALTH CARE | 445249 | 158 MT PELIA RD | MARTIN | TN | 38237 | 2010-01-27 | 280 | E | 1 | 0 | J15E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 783 Based on medical record review, observation and interview, it was determined the facility failed to ensure the comprehensive care plans were revised to reflect the resident's current status for changes in diets, constipation/impaction, living arrangement, change to feeding tube, amputation and/or care of emergency bleeding for 5 of 22 (Residents #1, 2, 12, 13 and 14) sampled residents. The findings included: 1. Medical record review for Resident #1 documented and admission date of [DATE] with [DIAGNOSES REDACTED]. The physicians's order dated [DATE] stated, "DIET: PUREED W (WITH) NECTAR THICK LIQUIDS". The care plan dated [DATE] stated "pureed diet with thin liquids". The care plan was not revised with the physicians's order for the change in diet in regard to liquids. 2. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A [DATE] Kidney, Ureter and Bladder xray (KUB) documented, "...Probable fecal impaction." A [DATE] xray documented, "...HISTORY: FOLLOW UP FECAL IMPACTION... Formed rectal stool ball possibly related to fecal impaction..." A [DATE] physician's orders [REDACTED].#2's impaction or gout diet During an interview in the Minimum Data Set (MDS) office on [DATE] at 1:55 PM, Nurse #1 confirmed the care plan had not been updated to reflect Resident #2 had an impaction or being placed on a gout diet. 3. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] nursing care plan documented, "Problem... Altered psychosocial well being... Approaches: MARRIED. RESIDES IN ROOM AS WITH HUSBAND..." The care plan was not revised to reflect Resident 12's spouse had died . Observations of Resident #12 on [DATE] at 2:20 PM, revealed Resident #12 did not have a roommate. During an interview in the MDS office on [DATE] at 2:15 PM, Nurse #1 stated, "...her husband has expired..." 4. Medical record review for Reside… | 2014-07-01 |
| 14271 | 14271 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 508 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure an x-ray was completed for one (#6) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted the facility on August 3, 2009, with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated December 30, 2009, revealed "Resident noted to have very congested cough with thick yellow sputum...order obtained for chest x-ray..." Medical record review of a chest x-ray dated December 30, 2009, revealed "Impression:...probable left pleural effusion and left retrocardiac opacity that may represent atelectasis versus infiltrate." Medical record review of a physician's orders [REDACTED]." Medical record review revealed no documentation a repeat chest x-ray had been completed after December 30, 2009. Interview on January 25, 2010, at 2:25 p.m., with the Director of Nursing, in the conference room, confirmed the repeat chest x-ray ordered on December 30, 2009, was not completed. | 2014-02-01 | ||
| 14272 | 14272 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 281 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to discontinue a medication as ordered by the physician for one (#6), and failed to ensure a fluid restriction was followed for one (#24) of twenty-nine residents reviewed. The Findings included: Resident #6 was admitted the facility on August 3, 2009, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems and moderately impaired cognitive skills. Medical record review of a physician's orders [REDACTED]. Observation on January 26, 2010, at 2:20 p.m., revealed the resident lying on the bed, receiving oxygen at two liters per minute via a nasal cannula. Interview with the resident, at the time of the observation, revealed the resident was not experiencing any pain. Interview on January 25, 2010, at 1:10 p.m., with the Director of Nursing, in the conference room, confirmed the [MEDICATION NAME] was not discontinued as ordered by the physician. Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]...1000 ML (milliliter) Fluid Restriction: Dietary to send 120 ML w/Ea (with each) meal...100 ML to be given at HS (bedtime) w/snack...Nursing to use 540 ML: 90 ML w/ea med pass (medication administration)." Medical record review of the Intake and Output Records dated September 1, 2009, through January 27, 2010, revealed "...12/9/09 24 HR. (hour) Total PO (by mouth) intake 1160...12/11/09 Total PO intake 1220...12/15/09 Total PO intake 1280...12/22/09 Total PO intake 1210...1/4/10 Total PO intake 1130...1/7/10 PO intake 220 plus 600 plus 240 Total 860 (Corrected total amount 1060)...1/19/10 Total PO intake 450 plus 870 Total 1020 (Corrected total amount 1320)...1/20/10 Total PO intake 1280...1/21/10 Total PO intake 1310...1/25/10 Total PO intake 1240..." Interview on January 27, 2010, at 12:45 p.… | 2014-02-01 | ||
| 14273 | 14273 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 502 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain laboratory studies for three ( #1, #2, #10) of twenty-nine residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the January 2010 Physician's Recapitulation Orders revealed an order initiated June 30, 2009, for a lab study of CBC (Complete Blood Count) to be done every 6 months (June and December). Medical record review of the laboratory results revealed no documentation of the CBC analysis for December 2009. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the January 2010 Physician's Recapitulation Orders revealed an order initiated February 22, 2008, for a lab study of Hemoglobin A1C (to monitor diabetic therapy) to be done every 3 months (February/May/August/November). Medical record review of the laboratory results revealed no documentation of the Hemoglobin A1C analysis for November 2009. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the January 2010 Physician's Recapitulation Orders revealed an order for [REDACTED]. Interview with the Unit Manager at the 200 Hall Nurses station on January 25, 2010, at 1:25 p.m., confirmed the facility failed to obtain the laboratory studies for residents #1, #2, and #10 as ordered by the physician. | 2014-02-01 | ||
| 14274 | 14274 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 323 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were functional or in the lowest position for three (#6, #13, #14) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, moderately impaired cognitive skills, required extensive assistance with transfers/ambulation, and had fallen in the past ,[DATE] days. Medical record review of the current Care Plan reviewed on [DATE], revealed "...Resident is at risk for falls...alarms to bed/chair..." Observation on [DATE], at 9:00 a.m., revealed the resident lying on the bed with a pressure pad alarm in place, however, the alarm box was not activated. Observation and interview, on [DATE], at 9:15 a.m., with Licensed Practical Nurse (LPN) #1 revealed the resident lying on the bed, with a pressure pad alarm in place, and confirmed the alarm was not turned on/activated. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, and moderately impaired cognitive skills for daily decision making. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the physician's recapitulation orders dated [DATE], revealed, " ...Pressure Alarm On When Resident in Bed... " Medical record review of the Care Plan dated [DATE], revealed, "...pp (pressure pad) alarm in bed..." Observation on [DATE], at 1:50 p.m., revealed the resident entered the bathroom and closed the door. Continued observation with RN #2 revealed a pressure pad alarm on the bed, but not sounding. Further observation of the pressure pad alarm revealed, " Six month t… | 2014-02-01 | ||
| 14275 | 14275 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 176 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for self-administration of medications for one (#6) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems and moderately impaired cognitive skills. Medical record review of the January 2010, physician's recapitulation orders revealed the resident was to receive [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) and Atrovent ([MEDICATION NAME][MEDICATION NAME]) by a nebulizer treatment. Medical record review revealed no documentation the resident had been assessed for self-administration of medications. Observation on January 25, 2010, at 9:00 a.m., revealed the resident lying on the bed, unattended, with a mask over the nose and mouth, receiving a nebulizer treatment. Continued observation revealed the resident used the left hand to try to remove the mask. Observation and interview on January 25, 2010, at 9:15 a.m., with Licensed Practical Nurse (LPN) #1 revealed the resident lying on the bed receiving the nebulizer treatment, and confirmed LPN #1 had initiated the nebulizer treatment then left the resident unattended. Interview on January 25, 2010, at 1:10 p.m., with the Director of Nursing, in the conference room, confirmed the resident had not been assessed for self-administration of medications. | 2014-02-01 | ||
| 14276 | 14276 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 514 | E | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, observation and interview, the facility failed to maintain complete documentation of fluid intake for five (#15, #23, #24, #27, #28,) of 29 sampled residents. The finding included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed physician's orders [REDACTED]. Observation in the resident's room, on January 25, 2010, at 10:30 a.m., revealed a posted sign indicating fluid restriction. Review of the facility's policy for fluid intake and output revealed that intake and output measurements are to be recorded for residents if there is a physician's orders [REDACTED]. Interview with the Director of Nursing on January 25, 2009, on the D Hall, confirmed the fluid intake records were incomplete. Resident #23 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Medical record review revealed physician's orders [REDACTED]. Review of the "Comprehensive Intake and Output Record" revealed incomplete documentation of fluid intake for sixty days from October 19, 2009, through December 28, 2009. Interview with the Director of Nursing on January 27, 2010, on the D Hall, confirmed the fluid intake records were incomplete. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Telephone Orders dated November 13, 2009, revealed an order to increase fluid restriction to 1500 ml per day. Medical record review of the Comprehensive Intake-Output Records revealed no documentation of the fluid intake from November 16, 2009, until December 1, 2009. Interview at the nurses' station on January 26, 2010, at 4:10 p.m., with the 200 Hall Unit Manager, revealed the "intake should be recorded each day," and verified there was no documentation of the the resident's intake for the 15 day period from November 16 - December 1, 2009. Continued interview confirmed the facility failed… | 2014-02-01 | ||
| 13970 | 13970 | MARTIN HEALTH CARE | 445249 | 158 MT PELIA RD | MARTIN | TN | 38237 | 2010-01-28 | 309 | D | 1 | 0 | FQO111 | **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 followed for [MEDICAL TREATMENT] and failed to obtain orders for treatment of [REDACTED].#4 and 14) sampled residents and 1 of 16 Random Resident (RR #16). The findings included: 1. Medical record review for Resident #4 documented an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a list of residents being assessed for head lice dated for 9/16/09 documented Resident #4 was treated for [REDACTED].#4's physician's orders had no documented order for the treatment of [REDACTED]. During an interview in the Director of Nurses (DON) office on 1/27/10 at 11:45 AM, the Assistant Director of Nurses (ADON) stated, "I can't find it (orders for treatment of [REDACTED]." 2. Medical record review for Resident #14 documented an admitted 9/1/00 and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 1/14/10 did not include orders for [MEDICAL TREATMENT] treatment. During an interview in the conference room on 1/27/10 at 2:10 PM, the Minimum Data Set (MDS) nurse stated, "Should have order for [MEDICAL TREATMENT]." 3. Medical record review for RR #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Documentation in RR #16's medical record documented that RR #16 had head lice on 9/16/09. Review of RR #16's physician's orders had no documented orders for the treatment of [REDACTED]. During an interview in the DON's office on 1/27/10 at 11:45 AM, the ADON stated, "I can't find it (orders for treatment of [REDACTED]." | 2014-07-01 |
| 13971 | 13971 | MARTIN HEALTH CARE | 445249 | 158 MT PELIA RD | MARTIN | TN | 38237 | 2010-01-28 | 514 | D | 1 | 0 | FQO111 | **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 clinical records were complete and accurately documented for 2 of 22 (Residents #2 and 4) sampled residents and 1 of 17 Random Residents (RR #16). The findings included: 1. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of 12/4/09 physician's orders [REDACTED]." Review of a 12/11/09 physician's orders [REDACTED]." Review of the Medication Administration Records (MAR) revealed there was no documentation of Resident #2 having BMs before, during or after the above dates. During an interview in the conference room on 1/26/10 at 11:40 AM, the Assistant Director of Nursing stated, "...they (bms) should be documented on the MARs..." 2. Medical record review for Resident #4 documented an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of documentation in the medical record dated 9/16/09 revealed Resident #4 was treated for [REDACTED]. During an interview in the Director of Nurse's (DON) office on 1/27/10 at 11:45 AM, the Assistant Director of Nurses (ADON) stated, "I can't find it (order for the treatment of [REDACTED]." 3. Medical record review for RR #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of documentation in RR #16's medical record revealed RR #16 was treated for [REDACTED]. Review of the physician's orders [REDACTED]. During an interview in the DON's office on 1/27/10 at 11:45 AM, the ADON stated, "I can't find it (order for treatment of [REDACTED]." | 2014-07-01 |
| 14259 | 14259 | NHC HEALTHCARE, MCMINNVILLE | 445076 | 928 OLD SMITHVILLE RD | MC MINNVILLE | TN | 37110 | 2010-01-28 | 315 | D | VI5B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interview, the facility failed to provide incontinence care for one incontinent resident (#17) of seven incontinent residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had short term memory deficits with moderately impaired cognitive skills for daily decision making. Continued review revealed the resident required extensive assistance for transfers, was dependent on staff for personal hygiene and bathing and was incontinent of bowel and bladder. Observation on January 27, 2010, at 8:50 a.m., in the resident's room revealed Certified Nurse's Aide (CNA) #1 provided incontinence care to the resident after the resident had voided. Observation revealed CNA #1 positioned the resident on the left side, sprayed peri-wash on the resident's buttocks, and wiped the area with a dry towel. Observation revealed CNA #1 changed the incontinence pad, repositioned the resident in a supine position, and covered the resident with the sheet and blanket. Review of the facility policy, Perineal Care, revealed,"Purpose: Perineal cleansing will be done after incontinent episodes ..." Interview with CNA #1 on January 27, 2010, at 9:00 a.m., in the resident's bathroom, confirmed the resident had not been cleansed from the front and the incontinence care was incomplete. Interview with the Corporate Nurse in the Director of Nurses office on January 28, 2010, at 8:30 a.m., confirmed the facility policy for providing incontinence care had not been followed. | 2014-02-01 | ||
| 14260 | 14260 | NHC HEALTHCARE, MCMINNVILLE | 445076 | 928 OLD SMITHVILLE RD | MC MINNVILLE | TN | 37110 | 2010-01-28 | 252 | D | VI5B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide an odor-free environment for two residents (#8, #17) of twenty-five residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had bowel and bladder incontinence daily, and required extensive assistance with personal hygiene and bathing. Review of the nurse's note dated January 5, 2010, revealed," ...Remains totally incontinent and urinates on each turn also - Has a constant dribble and foul smell to urine. Often with loose stools ..." Review of the nurse's note dated January 13, 2010, revealed," ...Foul odor to urine ..." Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance for transfers, and was dependent on staff for personal hygiene and bathing. Continued review of the same MDS revealed the resident was incontinent of bowel and bladder daily. Observation during the initial facility tour on January 26, 2010, at 10:20 a.m., revealed resident #8 and #17 were roommates. Observation at this time revealed a strong, stale, pungent, urine odor present in the residents' room. Observation on January 26, 2010, at 1:30 p.m., and January 27, 2010, at 8:50 a.m., revealed the strong, stale, urine odor remained. Observation on January 27, 2010, at 8:50 a.m., revealed resident #17 and resident #8 had breakfast trays on their over-bed tables. Observation revealed resident #17 complained twice about the odor stating, "It is not very appetizing trying to eat when it smells so bad." Interview with Licensed Practical Nurse #1 on January 27, 2010 at 9:30 a.m., at the 200 hall nurses station, confirmed the room of resident #8 and #17 had a chronic foul odor; sometimes worse t… | 2014-02-01 | ||
| 14261 | 14261 | NHC HEALTHCARE, MCMINNVILLE | 445076 | 928 OLD SMITHVILLE RD | MC MINNVILLE | TN | 37110 | 2010-01-28 | 312 | D | VI5B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nail care for one (#6) of twenty-five residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory and required assistance with all activities of daily living including nail care. Observation on January 26, 2010, at 10:30 a.m., in the resident's room revealed the resident in bed receiving a bed bath from a Certified Nurse Assistant. Observation on January 27, 2010, at 9:15 a.m., and 1:00 p.m., in the resident's room revealed the resident in bed, eyes closed, and scratching the nose with the right index fingernail. Observation revealed the fingernail was jagged and soiled with dark debris under the fingernail tip. Observation revealed the remaining fingernails on the right hand also had dark debris under the finger nails; the left hand was under the covers. Observation on January 28, 2010, at 12:15 p.m., in the resident's room revealed the resident in bed feeding self with the right hand using the fingers and a fork; the five right hand finger nails were soiled with dark debris; and the index finger nail was jagged; the left hand middle and thumb nails were soiled with dark debris. Interview on January 28, 2010, at 12:20 p.m., with Licensed Practical Nurse #2 in the resident's room confirmed the resident's finger nails were soiled with dark debris and required cleaning and trimming. | 2014-02-01 | ||
| 14285 | 14285 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 502 | D | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete laboratory studies for one #15, of twenty-four residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a laboratory report for a Complete Blood Count dated January 7, 2010, revealed the hemoglobin was 9.9 (reference range 12.1-15.5) and the hematocrit was 29.7 (reference range 36.1-46.0). Medical record review of the same laboratory report dated January 7, 2010, revealed an undated physician's orders [REDACTED]." Medical record review revealed no documentation the hemoccults had been completed. Interview on February 2, 2010, at 4:20 p.m., with the Director of Nursing (DON), in the DON's office, confirmed the hemoccults had not been completed. | 2014-02-01 | ||
| 14286 | 14286 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 333 | D | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to prevent a significant medication error one (#17) resident of twenty-four residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Diabetic Treatment Administration Record dated January, 2010, revealed the accucheck (finger stick) blood sugars ranged from 106 to 95 (normal blood sugar is 80-100). Medical record review of the Diabetic Treatment Administration Record dated February 2, 2010, revealed an accucheck blood sugar result of 202. Observation on February 2, 2010, at 8:45 a.m., revealed RN #1 administered [MEDICATION NAME] (insulin) 10 units subcutaneous (injection) in the right arm to resident #17. Interview on February 2, 2010, at 9:25 a.m., with RN #1, at the 200 nursing station, confirmed the resident did not receive 15 units of [MEDICATION NAME] as ordered by the physician. | 2014-02-01 | ||
| 14287 | 14287 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 281 | E | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to address dietary recommendations in a timely manner for two residents (#13, #18), failed to address Mental Health Provider recommendations in a timely manner for one resident (#8), and failed to initiate treatment for [REDACTED].#14) of twenty-four residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Registered Dietician note dated November 4, 2009, revealed "...1) D/C (discontinue) (name supplement...3) Continue (name protein supplement) but (decrease) to 1 pkt (packet) qd...(every day) x (times) 30 d (days)...5) weekly wt (weight)" Medical record review of the faxed order request/notification dated November 25, 2009, revealed the Physician noted the above recommendations on December 2, 2009, and the Physician response was not noted by the facility prior to December 9, 2009. Medical review of the Physician order [REDACTED]. Interview with the Director of Nursing and the Regional Director of Clinical Services on February 2, 2010, at 3:30 p.m. in the Director of Nursing office confirmed the Registered Dietician's recommendations made on November 24, 2009; the Physician signed the fax notification with a response to the recommendations on December 2, 2009, and the facility did not recieve the Physician's response to address the recommendations until December 9, 2009, resulting in a 12 day delay. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Registered Dietician note dated December 28, 2009, revealed "...3) 30 ml (milliliters) of (named supplement) x 30 d (days) for meeting protein needs..." Medical record review of the faxed order Request/Notification form dated December 30, 2009, revealed the Physician's response was dated January 5, 2010, and noted by the Facility on January 12, 2010. Medical record review of the Phy… | 2014-02-01 | ||
| 14288 | 14288 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 323 | D | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were in place or functional for two (#14, #3) of twenty-four residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, severely impaired cognitive skills, was totally dependent for transfers and did not walk. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of the Care Plan, reviewed by the facility on January 26, 2010, revealed "...Potential for injury related to falls...unmindful of safety...Pressure sensitive alarm to bed to alert staff of unassisted transfers..." Observation on February 1, 2010, at 4:12 p.m., revealed the resident lying on a low bed, and the pressure sensitive alarm was in place, however, the cord from the pressure sensitive alarm was not attached to the alarm box. Observation and interview on February 1, 2010, at 4:15 p.m., with Licensed Practical Nurse (LPN) #1, revealed the resident lying on the bed, with the cord from the pressure sensitive alarm lying on the floor, disconnected from the alarm box and confirmed the alarm was not functional. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had short and long term memory problems, severely impaired cognitive skills, required extensive assistance with transfers, and did not walk. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of the Care Plan, reviewed by the facility on February 1, 2010, revealed " ...Potential for falls ...unmindful of safety ...Place bed alarm in an unassessible area ..." … | 2014-02-01 | ||
| 14289 | 14289 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 314 | D | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a pressure relieving device was in place to promote healing of a pressure sore for one resident (#2) of twenty-four residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was admitted to the hospital September 13, 2009, and returned to the facility on [DATE], with a pressure sore to the left heel described on the Pressure Ulcer Status Record as, "Soft and Mushy", 3.0 (width) x 4.0 (lenght) cm (centimeters). Continued review of the Pressure Ulcer Status Record revealed the pressure area progressed to a brown/black area 5.0 x 3.5 cm, Stage IV on October 9, 2009. Medical record review of the plan of care updated January 11, 2010, revealed, "Apply synthetic wool heel protectors' bilateral (feet), and heels elevated off bed at all times." Observation on February 2, 2010, at 11:00 a.m., revealed the resident in the bed with an abduction pillow supporting the resident's knees; however, heel protectors were not on the resident's feet, and the feet were pressing directly onto the mattress. Continued observation on February 3, 2010, at 9:30 a.m., revealed the resident's left heel pressing directly onto the mattress, without heel protectors on the feet. Continued observation with LPN #5, on February 3, 2010, at 10:05 a.m., revealed the (clean) fleece/wool heel protectors were located in the resident's closet. Observation on February 3, 2010, at 1:25 p.m., with (wound care nurse) LPN #5, revealed the wound to the left heel was a healing Stage IV, presenting as a healing Stage II, approximately 2.5 x 1.5 cm., with a small to moderate amount of serous drainage. Interview with the Licensed Practical Nurse #4, on February 3, 2010, at 10:15 a.m., at the north nursing station, confirmed the facility failed to ensure heel … | 2014-02-01 | ||
| 14282 | 14282 | LIFE CARE CENTER OF EAST RIDGE | 445296 | 1500 FINCHER AVENUE | EAST RIDGE | TN | 37412 | 2010-02-10 | 309 | D | 1RJR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to follow the physician's orders for one (#23) of twenty-five residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short/long term memory problems, and was independent in cognitive skills for daily decision making. Medical record review of the hospital transfer physician's orders dated September 5, 2009, revealed, "[MEDICATION NAME] (blood pressure) 1 mg...po (by mouth) BT (bedtime)[MEDICATION NAME] XL (blood pressure)...90 mg po BT..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of a physician's order dated September 6, 2009, revealed, "...Clarification of med (medication) administration times per pt (patient) [MEDICATION NAME] XL 90 mg po daily (at) 9 p.m., [MEDICATION NAME] 1 mg po daily (at) 9 p.m..." Medical record review of the Vital Sign Flow Sheet dated September 5, 2009, revealed, "...2 p 165/71 (blood pressure)...(September 6, 2009) 3:15 a.m. 157/78..." Medical record review of a OT (Occupational Therapy) Progress Note dated September 6, 2009, revealed, "...Eval (Evaluation) complete and treatment initiated...OT took BP (blood pressure) which was high and notified nursing immediately. Nurse came and provided blood pressure medications before continuing with assessment ... " Medical record review of a nurse's note dated September 6, 2009, revealed, "...7:30 A Notified by therapy pt B/P was elevated to (space left blank in nursing notes to document the blood pressure). APN (Advanced Practice Nurse) gave...order [MEDICATION NAME] 160mg to be given now instead of 12n..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Interview on February 9, 201… | 2014-02-01 | ||
| 14283 | 14283 | LIFE CARE CENTER OF EAST RIDGE | 445296 | 1500 FINCHER AVENUE | EAST RIDGE | TN | 37412 | 2010-02-10 | 514 | D | 1RJR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure the medical record was complete and accurate for two (#23, #22) of twenty-five residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Hospital transfer orders dated September 5, 2009, revealed, "[MEDICATION NAME] 160 mg tablet...320mg po (by mouth) 1200 (noon)..." Medical record review of the Physician's Recapitulation Orders dated September, 2009, revealed, "[MEDICATION NAME] 160 mg 1 po daily..." Review of a (named drug store pharmacy receipt) dated September 5, 2009, at 9:04 p.m. revealed the facility received [MEDICATION NAME] 320 mg tablets, quanity 4. Medical record review of an OT (Occupational Therapy) Progress Note dated September 6, 2009, revealed, "...Eval (Evaluation) complete and treatment initiated. Upon entering room to assess patient, patient's daughter expressed concern regarding blood pressure. OT took BP (blood pressure) which was high and notified nursing immediately. Nurse came and provided blood pressure medications before continuing with assessment..." Medical record review of a nurse's note dated September 6, 2009, revealed, "...7:30 A Notified by therapy pt B/P was elevated to (space left blank in the nursing notes to document the blood pressure). APN (Advanced Practice Nurse) gave...order [MEDICATION NAME] 160 mg to be given now instead of 12n..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Interview on February 10, 2010, at 8:20 a.m., with the DON (Director of Nursing), in the DON's office confirmed the blood pressure was not documented by the Occupational Therapist or the Nurse, and the physician's orders [REDACTED]. c/o # | 2014-02-01 | ||
| 14284 | 14284 | LIFE CARE CENTER OF EAST RIDGE | 445296 | 1500 FINCHER AVENUE | EAST RIDGE | TN | 37412 | 2010-02-10 | 281 | D | 1RJR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow physician's orders for a medication for one (#24) of twenty-five residents reviewed. The findings included: Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Nurse's Notes revealed on July 5, 2009, the resident's daughter requested a [MEDICATION NAME] (pain medication) for the resident. Medical record review revealed the Nurse Practitioner (NP) was notified on July 5, 2009, at 5:30 p.m., and ordered the medication. Medical record review of Nurse's Notes revealed [MEDICATION NAME] (pain medication) 75 mg. and [MEDICATION NAME] (for nausea) 50 mg. was ordered and to be given until the [MEDICATION NAME] could be obtained. Medical record review of Nurse's Notes revealed the facility received the medication on July 5, 2009, at 11:30 p.m., but was not applied. Review of the Controlled Medication Utilization Record revealed the pain patch was not applied until July 6, 2009, at 11:00 a.m. Interview with the NP in the Assistant Director of Nursing's office on February 10, 2010, at 1:00 p.m., confirmed the medication was to have been applied when obtained. C/O # | 2014-02-01 | ||
| 14181 | 14181 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2010-02-17 | 226 | E | FOGM11 | Based on policy review, review of personnel files and interview, it was determined the facility failed to implement policies for the prevention of abuse, neglect, mistreatment and misappropriation of property by providing incomplete screening of 45 of 54 (Employees #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 44, 46, 47, 49, 50, 52, 53 and 54) sampled employees. The findings included: Review of the facility's "Prevention of Resident Abuse" policy documented, "...Before hiring, all applicants are screened by reviewing their applications, calling past employers for references... verify certification, background checks... Screening Components... references ...certification/license verification... criminal background checks..." Review of facility personnel files of employees hired since 6/1/2009 revealed the following information was not completed: a. License or certification verification - Employee #1, 2, 12, 14, 42 and 52. b. Documentation of reference checks - Employee #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 18, 19, 21, 22, 23, 24, 25, 26, 27, 29, 31, 33, 34, 35, 36, 44, 46, 47, 49, 50, 52, 53, and 54. c. Abuse registry checks - Employee #1, 2, 7, 12, 42, and 52. d. Criminal background checks - Employee #1, 2, 4, 5, 7, 9, 27, 28, 30, 31, 37, 38, 39, 40, 41, 42, 50, and 52. During an interview in the consultation room, on 2/17/10 at 8:30 AM, the Administrator confirmed the screening information was not documented as required. | 2014-03-01 | ||
| 14182 | 14182 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2010-02-17 | 323 | E | FOGM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to identify risk, and develop and implement interventions to prevent recurrent falls for 2 of 4 (Residents #5 and 10) sampled residents with falls. The findings included: 1. Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]." Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #5's cognitive skills were assessed as "SEVERELY IMPAIRED" and "SOMETIMES UNDERSTANDS" simple direct communication. Resident #5 required "EXTENSIVE ASSISTANCE" with transfers, did not ambulate and was assessed as "TOTAL DEPENDENCE" with wheelchair locomotion. Resident #5 fell in the past 31 to (-) 180 days and required a trunk restraint. Review of the Care Plan updated 10/19/09 identified Resident #5 as a "FALL RISK... POTENTIAL FOR INJURY Related to ...Unsteady Gait...Cognitive Deficit... Weakness... Impaired Vision (Blind)... As evidenced by... History of falls... APPROACHES... Labs (laboratory tests)/diagnostic work as ordered... for abnormal results... Move to room closer to nurse's station... Shoes well-fitting with non-slip soles... PT/OT (physical therapy/occupational therapy) eval (evaluation) or Restorative nursing for strength training, gait, or transfer... Side rails up x (times) 2... Maintain room and hall ways free of clutter..." and requiring "RESTRAINT... Related to use of...Non-accessible seatbelt... APPROACHES...Make sure restraint is applied properly... Provide verbal reminders to resident to call when needing assistance... Keep call light and most frequently used personal items within reach..." Review of the nurses' notes dated 11/23/09 documented, "Resident (#5) was found on the floor on his side with the w/c (wheelchair) almost on his side with his NASB (non-accessible seat belt) attached... All staff inservice (inserviced) about fall and saf… | 2014-03-01 | ||
| 13776 | 13776 | NHC HEALTHCARE, FRANKLIN | 445127 | 216 FAIRGROUND ST | FRANKLIN | TN | 37064 | 2010-02-18 | 514 | D | 1 | 0 | OH4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint investigation for TN 763 Based on medical record review and interview, it was determined the facility failed staff failed to document of change of health status in the nurses' notes for 1 of 16 (Resident #14) sampled residents. The findings included: Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's physician progress notes [REDACTED]. Temperature is 97.4 Pulse is 78. Respirations are 20. ...patient lying in bed in no acute distress. She is alert." Review of a Physical Therapy (PT) note dated 11/20/09 documented "Pt (patient) became unresponsive, sitting up in W/C (wheelchair) in PT room. Pulse 141 and drooling. Nursing Services Notified." Review of the Nurses Notes for 11/20/09 revealed no documentation of the Resident #14's change of condition. During an interview in the Director of Nurse's (DON) office on 2/18/10 at 2:30 PM, the DON stated, the documentation of what happened that day was not good. When I investigated the event, I had the nurse who cared for her (Resident #14) that day to write a summary of what happened. It's not a part of the (Resident #14's) record, but I do have a copy in my records. The DON confirmed the nurses' notes written on 11/20/09 did not document the change in Resident #14's status. | 2014-09-01 |
| 13952 | 13952 | WEST MEADE PLACE | 445203 | 1000 ST LUKE DRIVE | NASHVILLE | TN | 37205 | 2010-02-23 | 164 | D | 0 | 1 | CKMF11 | Based on observations, it was determined 1 of 10 (Nurse #9) medication nurses failed to maintain the privacy and confidentiality of a resident's Medication Administration Record [REDACTED] The findings included: Observations in the third floor North hall on 2/22/10 at 7:25 PM, revealed Nurse #9 left a resident's MAR indicated [REDACTED]. The resident's information could have been viewed by anyone who passed by. | 2014-07-01 |
| 13953 | 13953 | WEST MEADE PLACE | 445203 | 1000 ST LUKE DRIVE | NASHVILLE | TN | 37205 | 2010-02-23 | 225 | D | 0 | 1 | CKMF11 | **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 that a thorough investigation was completed for an injury of unknown origin for 1 of 19 (Resident #17) sampled residents. The findings included: Review of the facility's "Abuse Protection and Response Policy" documented "...Identification Issues: Policy: any patient event that is reported to any staff by patient, family, other staff or any other person will be considered as possible abuse if it meets any of the following criteria: Any indication of possible willful infliction of injury to include unexplained bruising... Procedure: Staff observing or hearing about such events will report event immediately, either verbally or in writing to their immediate supervisor. The supervisor will initiate action... Investigative Issues: Policy: Any partner having either direct or indirect knowledge of any event that might constitute abuse must report promptly. Procedure: Any partner having any knowledge of any of the above circumstances is required to report, either verbally or in writing, to their supervisor, to the center social worker, the Director of Nursing or the Administrator. Policy: All events reported as possible abuse will be investigated to determine whether abuse did or did not take place. Procedure: Supervisory staff will initiate investigative action... Policy: Trends of investigative findings will be analyzed and addressed by the QA (Quality Assessment)/QI (Quality Improvement) committee process. Procedure: An accurate summary reporting of all investigations conducted by the center will be maintained as a working document of the Quality Assessment/Quality Improvement Committee..." Medical record review for Resident #17 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's nurses' notes documented the following: a. 1/19/09 at 6:20 PM - "...CNT (Certified Nursing Technician) reported this AM (morn… | 2014-07-01 |
| 13954 | 13954 | WEST MEADE PLACE | 445203 | 1000 ST LUKE DRIVE | NASHVILLE | TN | 37205 | 2010-02-23 | 309 | D | 0 | 1 | CKMF11 | **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 [MEDICAL TREATMENT] for 1 of 19 (Resident #14) sampled residents. The findings included: Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's physician's orders dated 2/9/10 had no documented order for [MEDICAL TREATMENT] treatment. During an interview in the Care Plan Coordinator's Office on 2/22/10 at 5:25 PM, the Minimum Data Set Nurse #1, quoted the Assistant Director of Nurses, "Routinely, we don't write a order for [MEDICAL TREATMENT] that's done at the hospital." | 2014-07-01 |
| 13955 | 13955 | WEST MEADE PLACE | 445203 | 1000 ST LUKE DRIVE | NASHVILLE | TN | 37205 | 2010-02-23 | 323 | D | 0 | 1 | CKMF11 | **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 implement new interventions after falls to protect residents from potential injuries from further falls for 2 of 13 (Residents #11 and 16) sampled residents with multiple falls. The findings included: 1. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's nurses' notes documented the resident sustained [REDACTED]. The care plan dated 11/10/09 had no documentation of new interventions put into place to prevent falls. Observation in Resident #11's room on 2/22/10 at 10:10 AM, revealed Resident #11 sleeping in bed with the head of the bed elevated, side rails up times 2, a mat on the floor on the right side, call light in reach and the bed in a low position. During an interview at the 3rd floor nurse's station on 2/23/10 at 10:20 AM, Nurse #6 was asked about new fall interventions for Resident #11. Nurse #6 confirmed there was no new safety measures put into place. 2. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's nurses' notes documented the resident sustained [REDACTED]. The care plan dated 8/5/09 had no documentation of new interventions put into place to prevent falls. Observations in Resident #16's room on 2/22/10 at 7:05 PM, revealed Resident #16 in bed, with the bed in a low position, the call light was within reach and 1/4 length side rails were up times 2. 3. During an interview at the 3rd floor nurse's station on 2/23/10 at 10:20 AM, Nurse #6 was asked about fall interventions. Nurse #6 stated, "We have done all we can do. We are a restraint free facility. The only other option would be to send to another facility that uses restraints." | 2014-07-01 |
| 14299 | 14299 | MCKENDREE VILLAGE INC | 445491 | 4347 LEBANON ROAD | HERMITAGE | TN | 37076 | 2010-02-24 | 157 | D | ECRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to notify the physician for abnormal blood glucose levels for one resident (#24) of twenty-six residents reviewed. The findings included: Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a physician's note dated May 18, 2009, revealed "Very demented, delusional often. DM (Diabetes Mellitus) ?new diagnosis. On [MEDICATION NAME] XL; glucose 145 on lab (laboratory), start accu-checks (blood glucose monitoring). Review of the physician's Recapitulation Orders dated May 24, 2009, revealed "Sliding scale with [MEDICATION NAME] Insulin 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; greater than 400 = 10 units." Review of the Diabetic Monitoring Log for May 2009, revealed an entry dated May 20, 2009, at 4:00 p.m., of blood glucose of 418 but no documentation the physician was notified of the elevated abnormal result. Continued review of the medical record revealed an entry dated May 24, 2009 at 4:00 p.m., of blood glucose of 474 and an entry at 9:00 p.m., of blood glucose of 498 but no documentation the physician was notified of the elevated abnormal results recorded for 4:00 p.m. and 9:00 p.m.. Medical record review revealed an entry dated May 28, 2009, at 4:00 p.m., of blood glucose of 451, an entry dated May 29, 2009, at 11:00 a.m., of blood glucose of 437, and an entry dated May 30, 2009, at 9:00 p.m., of blood glucose of 595 but no documentation the physician was notified of the elevated abnormal blood glucose results. Review of the facility policy entitled "Insulin Administration" revealed "Physician to be notified of blood sugars below 60 or above 400 unless there is a specific order addressing blood sugars outside these ranges directing otherwise." Interview with the Director of Nursing (DON) on February 24, 2010, at 10:15 a.m., in the DON's office, confirmed there were six in… | 2014-02-01 | ||
| 14300 | 14300 | MCKENDREE VILLAGE INC | 445491 | 4347 LEBANON ROAD | HERMITAGE | TN | 37076 | 2010-02-24 | 281 | D | ECRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the care plan for two residents (#15, # 16 ) for the protection of a [MEDICAL TREATMENT] access for twenty-six residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a [MEDICAL TREATMENT] access (fistula) (access to use for [MEDICAL TREATMENT]) on the left arm, and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan updated February 16, 2010, revealed the care plan did not address the resident's [MEDICAL TREATMENT] access located on the resident's left arm or the practice which requires no needle sticks or blood pressures checks in the arm of the access. Interview with the Director of Nursing (DON) on February 23, 2010, at 3:30 p.m., in the north hallway, confirmed the care plan did not address the care of the access for [MEDICAL TREATMENT]. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a [MEDICAL TREATMENT] access (fistula) on the left arm and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan dated February 22, 2010, revealed the care plan did not address the resident's access located on the resident's left arm or the practice which requires no needle sticks or blood pressure checks in the arm of the access. Interview with the Director of Nursing on February 23, 2010, at 3:30 p.m., in the north hallway, confirmed the care plan did not address the care of the access for [MEDICAL TREATMENT]. | 2014-02-01 | ||
| 14301 | 14301 | MCKENDREE VILLAGE INC | 445491 | 4347 LEBANON ROAD | HERMITAGE | TN | 37076 | 2010-02-24 | 431 | D | ECRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the disposal of an expired medication from one of two medications carts. The findings included: Observation on February 23, 2010, at 11:20 a.m., of the A Medication Cart located in the 200 East Medication Room, revealed a one pint (473 ml) bottle of Guituss Syrup, approximately half-full, with a manufacture's expiration date of ,[DATE] on the label of the bottle. Interview with Licensed Practical Nurse (LPN) #1 and LPN #2 in the 200 East Medication Room on February 23, 2010, at 11:30 a.m., confirmed the Guituss Syrup in the A Medication Cart was expired and should have been removed from the cart and disposed of. | 2014-02-01 |
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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 );