cms_TN
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text ▼ | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 752 | 752 | THE WATERS OF SHELBYVILLE, LLC | 445171 | 835 UNION STREET | SHELBYVILLE | TN | 37160 | 2017-12-06 | 658 | D | 1 | 1 | BDXJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > AMENDED: Correction made to date for F658. The dates were: 12/24/17, 12/25/17, and 12/26/17. The correct dates are: 12/24/16, 12/25/16, and 12/26/16. Based on facility policy review, medical record review, and interview, the facility failed to follow physician orders [REDACTED].#439) of 14 residents reviewed. The findings included: Review of facility policy, Drug Administration General Guidelines, dated 11/2016 revealed, .Medications are administrated (administered) as prescribed, in accordance with good nursing principles and practices .At the end of each medication pass, the person administering the medications reviews the MAR (Medication Administration Record) to ascertain that all necessary doses were administered and all administered doses were documented . Medical record review revealed Resident #439 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Infuse 100 ml (900 mg) over 60 minutes at 100 ml/hr (per hour) every 24 hours times 2 weeks. Medical record review of the 12/2016 MAR indicated [REDACTED]. Medical record review of Physician's Telephone Orders dated 12/24/16 revealed, .[MEDICATION NAME] (antifungal medication) 150 mg po (by mouth) daily X (times) 3 days for yeast [MEDICAL CONDITION] . Medical record review of the 12/2016 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 12/4/17 at 6:00 PM in the conference room confirmed the facility failed to administer [MEDICATION NAME] and [MEDICATION NAME] as prescribed by the Physician for Resident #439. | 2020-09-01 |
| 66 | 66 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 550 | D | 1 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based facility policy review, facility investigation review, medical record review, observation and interview, the facility failed to provide timely personal care to 1 resident (#83) of 161 residents observed. The findings include: Review of the facility policy, Resident Rights, revised 8/16/18 revealed .The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness and dignity . Review of the facility investigation dated 2/14/19 revealed Resident #83 had emesis (vomit) on his clothes and the Certified Nurse Aide (CNA) #8, failed to provide care such as changing the resident's clothes. Medical record review revealed Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #83 was totally dependent on 2 people for dressing and mobility. Observation on 4/2/19 and 4/3/19 at 8:39 AM and 8:56 AM, respectively, in Resident #83's room revealed resident in bed, clean no signs and no symptoms of distress noted. Continued observation revealed Resident #83 had just finished eating breakfast and was assisted by staff. Record review of the facility investigation interview with the Chaplain on 2/15/19 revealed the Chaplain was in the dining room on the 4th floor at 2:00 PM and observed Resident #83 had emesis on him. Continued review revealed the Chaplain reported the observation to CNA #8. Record review of the facility investigation interview with CNA #8 on 2/14/19 revealed Resident #83 had vomited approximately 2:15 PM. Continued review revealed CNA #8 took Resident #83 to the room to provide care at 3:20 PM. Interview with the Administrator on 4/3/19 at 3:17 PM in her office revealed Resident #83 had vomited after lunch and the meal schedule for lunch on the 4th floor was from 11:30 PM to 12:30 PM. Continued interview revealed CNA #8 had remove… | 2020-09-01 |
| 5306 | 5306 | MAGNOLIA CREEK NURSING AND REHABILITATION | 445461 | 1992 HWY 51 S | COVINGTON | TN | 38019 | 2016-04-13 | 323 | E | 1 | 0 | 53WE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based of policy review, medical record review and interview, the facility failed to complete a fall risk assessment for 3 of 3 (Resident #1, 6 and 7) sampled residents reviewed for falls. The findings included: 1. The facility's Falls and Fall Risk, Managing policy documented, .When a resident falls, the following information should be recorded in the resident's medical record .Completion of a falls risk assessment . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility incident investigation dated 2/16/16 revealed the resident was found by staff on the floor of his room next to the bed. Medical record review revealed no fall risk assessment was completed following the resident's fall. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility incident investigation dated 3/17/16 revealed the resident was found by staff sitting on the floor in the resident's restroom. Medical record review revealed no fall risk assessment was completed following the resident's fall. 4. Medical record review revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of a facility fall investigation report dated 3/17/16 revealed Resident #7 was found in her room sitting on her knees on the floor. Medical record review revealed no fall risk assessment was completed following the resident's fall. 5. Interview with the Director of Nursing (DON) on 4/13/16 at 3:55 PM, in the Minimum Data Set office, when asked if a fall risk assessment should be completed following a resident fall, the DON stated, .When it's a fall, the nurse on the floor, is to do the fall risk assessment. | 2019-04-01 |
| 2538 | 2538 | MILLINGTON HEALTHCARE CENTER | 445425 | 5081 EASLEY AVENUE | MILLINGTON | TN | 38053 | 2019-01-27 | 658 | J | 1 | 0 | Q97T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Invacare Reliant 450 (mechanical) Lift (assistive transfer device) manufacturer recommendation review, Oxford University Hospitals Occupational Therapy manual review, Lippincott Manual of Nursing Practice 10th Edition review, Mobility Advisor Wheelchair Ramps review, policy review, medical record review, and interview, the facility failed to ensure staff provided care according to acceptable standards of clinical practice to prevent accidents for 2 of 7 (Resident #1 and #2) sampled residents reviewed for accidents. The facility failed to ensure safe transport was provided for Resident #1 who was transported without staff supervision by a transport company employee, fell out of the wheelchair, sustained facial injuries and a fractured nose which resulted in Immediate Jeopardy. The facility failed to ensure staff appropriately and safely transferred Resident #2 via mechanical lift . On 11/7/18 Resident #2 sustained cheek discoloration. On 12/12/18 after a staff member transferred Resident #2 using a mechanical lift without assistance of another staff member, Resident #2 sustained extensive facial bruising, swelling, swallowing difficulties and had a fractured mandible (jaw) which resulted in actual harm and Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 in the conference room. The facility was cited an Immediate Jeopardy at F658-[NAME] The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the Oxford University Hospitals Occupational Therapy A Guide to Using Your Manual Wheelchair Safely manual dated (MONTH) (YEAR) documented, .Going down a steep slope .It is safer if the wheelchair can be guided down a steep slope backwards by a … | 2020-09-01 |
| 2539 | 2539 | MILLINGTON HEALTHCARE CENTER | 445425 | 5081 EASLEY AVENUE | MILLINGTON | TN | 38053 | 2019-01-27 | 689 | J | 1 | 0 | Q97T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Invacare Reliant 450 Lift (mechanical assistive transfer device) manufacturer recommendation review, policy review, hospital medical record review, medical record review, observation and interview, the facility failed to provide 2 of 7 (Resident #1 and #2) sampled residents appropriate and adequate supervision and assistance that ensured an environment free of accident hazards. The facility failed to provide adequate staff supervision for Resident #1 during transportation to an outside appointment. Resident #1 had been assessed at high risk for falls, had a history of [REDACTED]. Resident #1 was placed in a wheelchair, pushed out the doors of the facility and down a ramp by an outside transportation employee, unaccompanied, unsupervised by facility staff, and had not been assessed for safe independent transport. Resident #1 fell face forward out of the wheelchair onto the parking lot, sustained lacerations to his face and a fractured nose which resulted in actual harm and Immediate Jeopardy. The facility failed to ensure appropriate and safe lift transfers were provided to Resident #2 who was paralyzed on the left side from a [MEDICAL CONDITION] (stroke), was assessed as cognitively impaired and required total assistance of 2 staff with mechanical lift transfers. Resident #2 was transferred via lift by 1 staff member and was found with a discoloration on the left cheek on 11/7/18 and sustained a facial injury of extensive bruising and swelling, swallowing difficulties and was diagnosed with [REDACTED].#2. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 at 9:00 AM in the conference room. The facility was cited an Immediate Jeopardy at F689-J which is Substandard Quality of Care. The Immediate Jeopardy is ongoing. An exte… | 2020-09-01 |
| 20 | 20 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 281 | D | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Lippincott Manual of Nursing Practice, facility staffing files, facility policy, medical record review, and interview, the facility employed one Licensed Practical Nurse (LPN #9) with an expired license who administered insulin to 3 diabetic residents (#5, #16, and #14) of 17 residents reviewed. The findings included: Review of Lippincott Manual of Nursing Practice, Ninth Edition, chapter 2, revealed, .Licensure is granted by an agency of state government and permits individuals accountable for the practice of professional nursing to engage in the practice of that profession, while prohibiting all others from doing so legally . Review of the facility staff certification documents on [DATE] revealed LPN #9's license to practice nursing expired on [DATE]. Review of the facility's staffing files revealed LPN was hired on [DATE]. Medical record review of the facility's Insulin Administration Policy revised (MONTH) 2010 revealed, .Procedure .check blood glucose per physician order [REDACTED]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED].(increase) chemsticks (blood sugar testing) to AC/HS (before meals and bedtime) . Medical record review of Physician order [REDACTED].Humalog (fast-acting insulin for diabetics) 6 (units) with lunch and supper .hold if (blood glucose) (less than) 150 . Medical record review of Resident #5's electronic Medication Administration Record [REDACTED]. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 15 times out of 62 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 16 times out of 54 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN… | 2020-09-01 |
| 132 | 132 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 842 | F | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Medical record review and interview the facility failed to maintain complete medical records for 12 (#1, #5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements and /or treatments. The findings include: Review of facility policy, BM (Bowel Movement) Regimen, reviewed 6/1/18, revealed .The facility will monitor and track residents to determine the need for dietary and or chemical intervention to treat chronic and/or acute episodes of constipation .If a resident has had no bowel movement for 3 days the resident will receive additional high fiber drink and/or food supplements .If the resident has had no BM for 3 days the resident will receive on the evening shift a designated laxative and if no BM by the following morning the resident will receive a suppository after breakfast and if no BM by the evening of the fourth day the resident will be given a Fleets enema . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing; required extensive assistance of 1 person with grooming; required limited assistance with transfers, dressing, and toileting; and was frequently incontinent of bowel and bladder. Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/12/19 had a small BM (bowel movement) 6/13/19 - 6/18/19 no documentation 6/19/19 no BM 6/20/19 - 6/24/19 no documentation 6/25/19 no BM 6/26/19 - 7/8/19 no documentation 7/9/19 no BM. Medical record review of the Nurse's Notes confirmed there were no Nursing Notes available from admission on 2/23/18 to discharge on 7/9/19 including the incident which precipitated he… | 2020-09-01 |
| 2020 | 2020 | GRACELAND REHABILITATION AND NURSING CARE CENTER | 445331 | 1250 FARROW ROAD | MEMPHIS | TN | 38116 | 2019-10-31 | 686 | G | 1 | 0 | UHXG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, policy review, closed medical record review, and interview, the facility failed to ensure identified changes in a resident's skin condition were assessed, reported, and a physician's orders [REDACTED].#1) sampled residents reviewed with in-house acquired pressure ulcers. This failure of the facility resulted in actual Harm for Resident #1. The findings include: The NPUAP quick reference guide, 2nd addition, published 2014, documented, .A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing .Stage 3 pressure ulcer .Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (moist devitalized tissue, can be cream, yellow, or tan in color) may be present but does not obscure the depth of tissue loss .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (non-viable black (dark) tissue) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined . The facility's Pressure Ulcer Risk Assessment policy dated 2/20/19 documented, .If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected .Routinely assess and document the condition of the resident's skin .for signs and symptoms of irritation or breakdown .Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated . The facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol policy date… | 2020-09-01 |
| 2019 | 2019 | GRACELAND REHABILITATION AND NURSING CARE CENTER | 445331 | 1250 FARROW ROAD | MEMPHIS | TN | 38116 | 2019-10-31 | 580 | G | 1 | 0 | UHXG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, policy review, closed medical record review, and interview, the facility failed to ensure identified changes in a resident's skin condition were reported to the physician and a physician's orders [REDACTED].#1) sampled residents reviewed with in-house acquired pressure ulcers. The failure of the facility to report identified skin condition changes to the physician and obtain treatment orders before deterioration to a Stage 3 pressure ulcer and an Unstageable pressure ulcer resulted in actual Harm for Resident #1. The findings include: The NPUAP quick reference guide, 2nd addition, published 2014, documented, .A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing .Stage 3 pressure ulcer .Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (moist devitalized tissue, can be cream, yellow, or tan in color) may be present but does not obscure the depth of tissue loss .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (non-viable black (dark) tissue) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined . The facility's Changes in a Resident's Condition or Status policy documented, .Our facility shall notify the resident, his or her Attending Physician, and representative sponsor of changes in the resident's medical condition and/or status .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A… | 2020-09-01 |
| 4271 | 4271 | MIDTOWN CENTER FOR HEALTH AND REHABILITATION | 445139 | 141 N MCLEAN BLVD | MEMPHIS | TN | 38104 | 2016-10-13 | 314 | G | 1 | 1 | LFXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on National Pressure Ulcer Advisory Panel (NPUAP) reference guide, policy review, medical record review, and interview, the facility failed to timely identify, accurately assess and/or treat pressure ulcers for 2 of 7 (Residents #2 and 53) sampled residents with pressure ulcers. The facility's failure to timely identify, accurately assess and/or treat pressure ulcers resulted in actual harm to Resident #2, and #53 when the pressure ulcers deteriorated. The findings included: 1. Review of the NPUAP quick reference guide defined a Stage II (2) pressure ulcer as, .Partial thickness loss of dermis, presenting as a shallow open ulcer with a red pink bed, without slough. (MONTH) also present as an intact or open/ruptured serum filled blister . Review of the NPUAP quick reference guide defined a Stage III (3) pressure ulcer as, .Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling . Review of the NPUAP quick reference guide defined a Stage IV (4) pressure ulcer as, .Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleous do not have (adipose) subcutaneous tissue and these ulcers can be shallow . Stage IV ulcers can extend into muscle and/or supporting structures . making osteo[DIAGNOSES REDACTED] (bone infection) or osteitis (bone inflammation) likely to occur. Exposed bone/muscle is visible or directly palpable . Review of the NPUAP quick reference guide defines an Unstageable wound as, .full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough s… | 2019-10-01 |
| 2183 | 2183 | HILLVIEW COMMUNITY LIVING CENTER | 445367 | 897 EVERGREEN STREET, PO BOX 769 | DRESDEN | TN | 38225 | 2019-06-05 | 686 | D | 1 | 0 | 9LDZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on National Pressure Ulcer Advisory Panel guidelines, policy review, medical record review, observations and interview the facility failed to provide care and services to promote healing of pressure ulcers for 1 of 2 (Resident #3) sampled residents reviewed for pressure ulcers. The findings include: 1. The NATIONAL PRESSURE ULCER ADVISORY PANEL dated (MONTH) (YEAR) documented partial-thickness loss of skin with exposed dermis .should not be used to describe moisture associated skin damage (MASD) .MASD basic guidelines: No slough or eschar . 2. The facility's SKIN CARE PR[NAME]ESS policy dated 1/17/18 documented, .It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur .Process Guidelines .4. If a wound is not showing signs of improvement within 2 weeks of treatment, a re-evaluation of the wound and change in treatment should be considered . 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].cleanse stage 3 pressure injury to right buttock with wound cleanser or NS (normal saline), pat dry with gauze, apply collagen powder to wound bed, cover with foam dressing and secure with transparent dressing every day shift for pressure injury . The Physician Telephone Order dated 5/16/19 documented, .clean MASD to right buttock with wound cleanser and dry, apply skin prep around edges and allow to dry, apply [MEDICATION NAME] dressing q (every) 3 days and prn (as needed) soilage, every 24 hours as needed for skin care . The Physician Telephone Order dated 6/5/19 documented, .Santyl Ointment 250 unit/GM (gram) ([MEDICATION NAME]) Apply to right buttock topically one time a day . Review of the Pressure Injury Report dated 5/13/19 documented, .right buttock Stage 3 wound with 7… | 2020-09-01 |
| 1247 | 1247 | SIGNATURE HEALTHCARE OF MEMPHIS | 445241 | 1150 DOVECREST RD | MEMPHIS | TN | 38134 | 2018-02-23 | 690 | D | 1 | 0 | 5S2X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a Certified Nursing Assistant (CNA) job description, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Resident #3) sampled residents who were incontinent of bladder received appropriate treatment and services to achieve or maintain as much normal bladder function as possible. The findings included: 1. A CNA JOB DESCRIPTION dated and signed by CNA #2 on 3/14/16 documented, .Essential Duties & Responsibilities .Provide personal care (I.e., grooming, bathing, dressing, oral care, etc.) of residents daily and as needed . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #3 was always incontinent of bowel and bladder and required extensive assistance with personal hygiene. A care plan dated 9/28/17 and reviewed 12/20/17 revealed, .Problem .Resident has ADL (Activities of Daily Living) Self Care Deficit .Approaches .Staff to provide only the amount of assistance/supervision to meet the Resident's needs for all ADLs .Refer to Therapy as needed to evaluate and treat as indicated . The personnel file for CNA #2 hired on 3/14/16 was reviewed and revealed 1 of 14 COACHING & COUNSELING SESSION forms dated 11/23/17 which documented, . (X) WRITTEN .(Named Random Resident's) call light was on. I answered it and she motioned that she needed to be changed. (Named CNA #2) was making her rounds and (Named Random Resident's) room was next. I left the light on and continued to pass my meds (medications). The light had being (been) sounding for a while. When I looked up or noted (Named CNA #2) had gone home leaving (Named Random Resident) in bed on urine saturated sheet and diaper and pad .Earlier .asked (Named CNA #2) to (Delta symbol meaning check) her. However, after notin… | 2020-09-01 |
| 3182 | 3182 | COLLIERVILLE NURSING AND REHABILITATION, LLC | 445495 | 490 WEST POPLAR AVENUE | COLLIERVILLE | TN | 38017 | 2019-07-11 | 677 | E | 1 | 0 | 3FM311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a complaint allegation review, shower schedule review, medical record review, observation, and interview, the facility failed to ensure scheduled bathing and/or showers for 3 of 3 (Resident #1, #2 and #3) were provided. The findings include: 1. Complaint intake information dated 7/2/19 documented, .The complainant alleges the resident (Resident #1) is not getting his showers as scheduled . 2. Review of the facility's Shower Schedule revealed all residents were scheduled to receive a shower or full bed bath three times a week on Monday, Wednesday and Friday or Tuesday, Thursday and Saturday. 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident had unclear speech, had severe cognitive impairment, was non-ambulatory and dependent on staff for all activities of daily living (ADL). Review of the comprehensive care plan dated 9/30/18 revealed Resident #1 was dependent on staff for bathing/showers. Review of Resident #1's ADL documentation revealed no bath/shower was given between 5/2/19 to 5/7/19 (4 days) and 5/30/19 to 6/3/19 (5 days). Observations in Resident #1's room on 7/8/19 at 1:15 PM, and on 7/9/19 at 10:35 AM and 12:20 PM, revealed the resident spoke no discernable words, had severe cognitive impairment without the ability to express his needs. He received a continuous feeding via Gastrostomy tube and was dependent on staff for all of his needs. 4. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] the resident was severely cognitively impaired, non-ambulatory and dependent on staff for all ADLs. Review of the comprehensive care plan dated 4/19/18 revealed the resident was dependent on staff for bathing/showers. Review of Resident #2's ADL documentation revealed a bath/shower was n… | 2020-09-01 |
| 5116 | 5116 | WYNDRIDGE HEALTH AND REHAB CTR | 445304 | 456 WAYNE AVENUE | CROSSVILLE | TN | 38555 | 2016-05-25 | 309 | D | 1 | 0 | G07I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a facility Admission Agreement, record review, observation, and interview, the facility failed to ensure incontinent briefs were reordered for 1 resident (#3) of 3 sampled residents. Resident #3 was without a reorder of incontinent supplies for approximately 11 months. The findings included: Review of facility, Admission Agreement, signed [DATE] by Resident #3's responsible party revealed the resident agrees to: Pay all of the fees and charges described in this contract upon the terms agreed to unless third party payor arrangements have been made. Provide proof of such third party payor arrangements. Provide or be responsible for personal items of clothing, toiletries, ect. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Incontinence Care Plan onset date [DATE] revealed the resident had a slight decline in bowel continence and was frequently incontinent of bladder. The updated care plan goal dated [DATE] revealed the resident would remain clean and dry. The approach included check for incontinence at regular intervals, use incontinent pads/brief as needed, change promptly when soiled. Review of the Interdisciplinary Care Plan dated [DATE] revealed the family was present and voiced concerns regarding the resident's incontinent briefs. Continued review of the Interdisciplinary Care Plan revealed the 200 Unit Manager (UM) ensured the family the incontinent supplies were ordered. Review of the facility's most recent insurance information dated [DATE] was the last yearly authorization (which expired in a year ,[DATE]) revealed the resident received briefs for a [DIAGNOSES REDACTED]. Observation of Resident #3 on [DATE] at 10:35 AM revealed the resident sitting in a wheelchair (w/c) wearing a geri-sleeve on the right lower arm, a Sensor tab alarm clipped to the back of the resident's clothing. Observation of the resident's shelf revealed four incontinent briefs. Observation of Resident #3 on [DA… | 2019-05-01 |
| 1246 | 1246 | SIGNATURE HEALTHCARE OF MEMPHIS | 445241 | 1150 DOVECREST RD | MEMPHIS | TN | 38134 | 2018-02-23 | 550 | D | 1 | 0 | 5S2X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a medical record review, observation, and interview, the facility failed to preserve the dignity for 1 of 3 (Resident #3) sampled residents observed for incontinence care. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #3 was always incontinent of bowel and bladder and required extensive assistance with personal hygiene. A care plan dated 9/28/17 and reviewed 12/20/17 revealed, .Problem .Resident has a potential for complications associated with incontinence of bowel and/or bladder .Goal .Resident's dignity will be maintained without embarrassment or fear through next review date . Interview with Resident #3 on 2/21/18 beginning at 1:40 PM, in Resident #3's room, She was asked if she was checked and changed timely. Resident #3 stated, . I like to be out (in the facility) and they won't come and find me and they don't change me .I have not been changed at all today . Resident #3 was asked if she has told the Certified Nursing Assistant (CNA) she needs changing. She stated, I see them but they say they ain't got me .I can get in and out (bed to wheelchair) myself, but I need a little assistance sometimes and when I ask for a little, they don't give me no assistance .They say I have an attitude .I tell them in meetings that they leave me soaking . Observations in Resident #3's room on 2/21/18 from 1:40 PM until 2:30 PM, revealed Resident #3 had an odor of urine. At 2:30 PM, the Activity Assistant came in and wheeled her to activities. Observations continued in the dining room from 2:30 PM until 3:30 PM. Resident #3 was not checked by staff during the time she was in the dining room. Interview with the Activity Director on 2/21/18 at 4:30 PM, in the Activity Office, she was … | 2020-09-01 |
| 2730 | 2730 | AHC DYERSBURG | 445446 | 1900 PARR AVENUE | DYERSBURG | TN | 38024 | 2017-10-06 | 501 | K | 1 | 1 | DRLB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on contract review, policy review, review of The Lippincott Manual of Nursing Practice, 10th Edition, review of job descriptions, [MEDICAL TREATMENT] contract review, medical record review, and interview, the facility failed to ensure the Medical Director assisted the facility with identifying, evaluating and addressing clinical concerns, coordinating the medical care and providing clinical guidance and oversight regarding the implementation of resident care policies and procedures that reflect the current standards of practice for the residents residing in the facility. The facility failed to ensure the Medical Director assisted with addressing clinical concerns and provided guidance regarding resident care of the residents residing in the facility by failing to ensure there was an effective process that monitored and addressed the potential for adverse consequences related accidents/falls during transportation for medical care outside the facility, and failed to ensure the facility investigated and implemented appropriate interventions after falls during transport, resulting in Immediate Jeopardy (IJ) for 1 of 4 (Resident #58) sampled residents, when Resident #58, who was blind in both eyes and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs) sustained a fall with a serious injury, a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during transport on [DATE]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE] with [DIAGNOSES REDACTED]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment or death for resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facili… | 2020-09-01 |
| 275 | 275 | TREVECCA CENTER FOR REHABILITATION AND HEALING LLC | 445112 | 329 MURFREESBORO RD | NASHVILLE | TN | 37210 | 2019-10-23 | 609 | D | 1 | 0 | 2B9Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility document review, medical record review, and interview, the facility failed to report an incident of misappropriation of resident property to the appropriate agency within the prescribed time frame. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #2 scored 15 on the Brief Interview for Mental Status indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was always continent of bowel and bladder. Review of a summary dated 8/9/19 by the Administrator revealed .(named Resident #2) came to my office today to let me know that she had misplaced $350 that her son brought her. She said that he brought her the money so that she could go to her pain clinic. I asked her why she had that much money and she said that the clinic only took cash. She said that she thought she put it in her drawer. I asked her to see if we could help her find it and she said that she needed the money asap. I told her that it was not the responsibility of the facility to reimburse monies that are lost. She was very upset because she did not have extra money for the doctor's office . Interview with the Administrator and DON on 10/23/19 at 11:40 AM in the conference room revealed the resident was talking loudly in the foyer about missing money so the Administrator asked the resident into her office. The resident stated she had lost her money she needed to pay the pain clinic. The resident had not spoken to Social Services. The resident said she initially put the money in her bra then into the locked top drawer of her bedside cabinet. The resident is the only one who has a key to the top drawer. The Administrator and DON looked a… | 2020-09-01 |
| 2108 | 2108 | LAUDERDALE COMMUNITY LIVING CENTER | 445354 | 215 LACKEY LANE | RIPLEY | TN | 38063 | 2017-05-05 | 224 | K | 1 | 0 | QMFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documents, grievance complaint, Investigation report, policy review, medical record review, observation and interview, the facility failed to ensure residents were free from abuse, neglect and mistreatment by facility staff for 5 of 13 (Residents #16, 45, 55, 57 and 61) residents reviewed in the stage 2 sample review. The failure of the facility to ensure residents were free from mistreatment and neglect resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents and resulted in IMMEDIATE JEOPARDY (IJ) to Residents #16, 45, 57 and 61 and psychological harm to Resident #55 as evidenced by a tearful, emotional response during interview. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing and Region One Nurse Consultant #1 were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F224-K, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy was effective [DATE], and is ongoing The findings included: 1. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, The resident has the right to be free from abuse, neglect .Resident must not be subjected to abuse by anyone .Abuse-The willful infliction of injury .intimidation or punishment with resulting physical harm, pain or mental anguish .Verbal abuse-The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents .Mental abuse-Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Psychosocial harm-Include but not limited to extreme embarrassment, ongoing humiliation, degradation as a human… | 2020-09-01 |
| 276 | 276 | TREVECCA CENTER FOR REHABILITATION AND HEALING LLC | 445112 | 329 MURFREESBORO RD | NASHVILLE | TN | 37210 | 2019-10-23 | 610 | D | 1 | 0 | 2B9Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documents, medical record review, and interview the facility failed to conduct a thorough investigation of an alleged misappropriation of resident property. The findings included: Review of facility policy, Abuse Prevention, revised 3/27/13, revealed .The facility has a zero tolerance for abuse .The resident will not be subjected to mistreatment, neglect, or misappropriation of property .A criminal background check shall be initiated on any potential employee .All new employees will receive training on Abuse Prevention policies and procedures during the initial orientation period .Existing employees will receive ongoing training regarding Abuse Prevention .Employees who have been accused of resident abuse will be suspended from resident care duties until the investigation has been completed .An individual observing an incident of Resident abuse or suspected Resident abuse must immediately report the incident to their supervisor . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #2 scored 15 on the Brief Interview for Mental Status indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was always continent of bowel and bladder. Review of a summary dated 8/9/19 by the Administrator revealed .(named Resident #2) came to my office today to let me know that she had misplaced $350 that her son brought her. She said that he brought her the money so that she could go to her pain clinic. I asked her why she had that much money and she said that the clinic only took cash. She said that she thought she put it in her drawer. I asked her to see if we could help her find it and she said that she needed the money asap. I told her… | 2020-09-01 |
| 2109 | 2109 | LAUDERDALE COMMUNITY LIVING CENTER | 445354 | 215 LACKEY LANE | RIPLEY | TN | 38063 | 2017-05-05 | 225 | K | 1 | 0 | QMFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documents, policy review, medical record review, observation, and interview, the facility failed to ensure all allegations involving death, abuse, neglect, mistreatment and injuries of unknown origin were thoroughly investigated; and the facility failed to prevent further potential abuse, neglect and mistreatment for 5 (Resident #s 16, 45, 55, 57, and 61) residents of the 13 residents reviewed for abuse or neglect. The facility failed to thoroughly investigate the incident of a resident found dead between the bed side rail and the mattress; and take immediate actions that would prevent potential entrapment deaths of other residents; and report the death to the State Survey Agency. The failure of the facility to investigate a death, prevent abuse and mistreatment, investigate all allegations of abuse and mistreatment, investigate injuries of unknown origin, and report appropriate investigations to the State Agency resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents and resulted in IMMEDIATE JEOPARDY (IJ) to Residents #16, 45, 61, and 57 and psychological harm to Resident #55. Immediate Jeopardy is a situation is which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing and Region One Nurse Consultant were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F 225-K, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy is effective [DATE], and is ongoing. The findings included: 1. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, The resident has the right to be free from abuse, neglect .Resident must not be subjected to abuse by anyone .Abuse-The wil… | 2020-09-01 |
| 4527 | 4527 | MANCHESTER HEALTH CARE CENTER | 445391 | 395 INTERSTATE DRIVE | MANCHESTER | TN | 37355 | 2016-09-15 | 223 | D | 1 | 0 | M0NV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility investigation review, medical record review, and interviews, the facility failed to ensure residents were free from abuse and mistreatment for 1 Resident (#6) of 6 residents reviewed for abuse. The findings included: Review of facility policy entitled Abuse Prevention Standard, revised 9/15, revealed .The purpose of this written Resident Abuse, Neglect, and Misappropriation Prevention Program is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect, and abuse of residents and the misappropriation of resident property, and to review those practices and omissions, which if allowed to go unchecked could lead to abuse .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agency service the resident, facility members, legal guardians, friends, or other individuals .Abuse is defined as the harmful treatment of [REDACTED]. Review of the policy entitled Resident Rights and Dignity Management dated 4/16, in the section on Accommodation of Needs, revealed .In order to accommodate individual resident needs and preferences, staff attitudes and behaviors must be directed toward assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the resident's wishes . Continued review of the section on Dignity revealed .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed . Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 s… | 2019-09-01 |
| 2644 | 2644 | MT JULIET HEALTH CARE CENTER | 445439 | 2650 NORTH MT JULIET ROAD | MOUNT JULIET | TN | 37122 | 2019-03-13 | 656 | D | 1 | 1 | O5E111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility investigation, medical record review and interview, the facility failed to follow a care plan for 1 of 8 residents (#68) reviewed for falls. The findings include: Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Continued interview revealed Resident #68 required total dependence with 2 people for transfers. Medical record review of the care plan dated 11/27/18 revealed Resident #68 required 2 people lift for transfers. Record review of the facility investigation dated 2/6/19 revealed Certified Nurse Aid tried to transferred Resident #68 to the wheelchair by herself which resulted in the CNA #4 sliding the resident to the floor. Interview with the Director of Nursing (DON) on 3/13/19 at 8:03 PM in the Administrators office confirmed the care plan was not followed which resulted in a fall. | 2020-09-01 |
| 5036 | 5036 | CREEKSIDE CENTER FOR REHABILITATION AND HEALING | 445516 | 306 W DUE WEST AVENUE | MADISON | TN | 37115 | 2016-06-16 | 314 | G | 1 | 0 | GZPX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy and protocol review, medical record review, interview, and hospital medical record review, the facility failed to timely identify, provide treatment and prevent deterioration of a pressure ulcer for 1 (Resident #1) resident of 12 residents reviewed for pressure ulcers. The facility's failure to timely identify, provide treatment and prevent deterioration of a pressure ulcer resulted in Actual Harm to Resident #1. The findings included: Review of the facility policy titled Skin Program Policy, undated, revealed, Skin problems are minimized to the greatest extent possible through an aggressive approach consisting of four components. They are: 1. Prevention, evaluation and screening 2. Ongoing surveillance 3. Treatment orders 4. Treatment protocol .Each resident is evaluated for .skin care at the time of admission .all residents receive a weekly skin integrity check performed by licensed personnel .all disciplines are alerted immediately if the resident .is at risk for the development of skin breakdown. The nursing department coordinates the response to the resident needs (in the area of skin integrity) by the following means .With an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk .The admitting nurse completes a Braden skin and Pressure risk assessment .shows the resident to be 'at risk' or prone to skin breakdown .the Pressure Ulcer Prevention Checklist is implemented. Protocols for prevention of skin breakdowns are included on the Pressure Ulcer Prevention Checklist that should be completed .With each dressing change or at least on a weekly assessment will be made addressing at least the following per policy and procedure. 1. Site 2. Stage I, II, III, IV, Deep Tissue Injury, Unstageable 3. Size, diameter, depth and edges 4. Presence or absence of drainage, undermining 5. Presence or absence of odor, {necrotic} tissue type or amount 6. Skin col… | 2019-06-01 |
| 959 | 959 | WEST MEADE PLACE | 445203 | 1000 ST LUKE DRIVE | NASHVILLE | TN | 37205 | 2019-12-11 | 609 | D | 1 | 1 | JMLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review and interview the facility failed to report an allegation of abuse timely for Resident #3. The findings include: Facility policy review Abuse, Neglect, Misappropriation of Funds, revised 9/28/19 revealed, .to establish a policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .the facility has a zero tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing .allegation of Abuse and/or Serious Bodily Injury-2 Hour Limit: if the events that cause the reasonable suspicion of abuse immediately, but not later than 2 hours after forming the suspicion . Review of the facility investigation dated 11/4/19 revealed a witnessed altercation between Resident #3 and Resident #56. Continued review revealed on 11/3/19 Resident #56 slapped Resident #3. Further review revealed the Director of Nursing (DON) was notified of the incident on 11/4/19. Continued review revealed the DON reported the incident to the state agency on 11/4/19. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's MDS dated [DATE] revealed the resident had a BIMS score of 99, indicating the resident was unable to complete the interview. Continued review revealed the resident exhibited verbal behaviors. Interview wit… | 2020-09-01 |
| 1469 | 1469 | AHC CUMBERLAND | 445262 | 4343 ASHLAND CITY HIGHWAY | NASHVILLE | TN | 37218 | 2017-09-13 | 225 | D | 1 | 0 | F0U711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review and interview, the facility failed to properly complete an investigation for 1 resident (#9) of 17 residents reviewed. The findings included: Review of facility policy, Investigation dated (MONTH) 2014 revealed .Request written statements from persons who may have knowledge of the incident . Medical record review revealed Resident #9 admitted to facility on 5/13/16 with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #9 had a Brief Interview of Mental Status of 15, indicating she was cognitively intact. Review of a facility completed abuse investigation revealed a list of staff interviewed on 9/6/17 by the Assistant Director of Nursing/Registered Nurse (RN) #2 and the Risk Manager/Licensed Practical Nurse (LPN) #4. There was a hand written list with staff names and short statements beside each name (8 total) all in the same handwriting. There were 8 individually hand written statements dated 9/6/17, all in the same handwriting but a different handwriting from the list. Interview with RN #2 on 9/12/17 at 3:15 PM in her office revealed she wrote the list of the staff names and what that staff told her located in the facility completed investigation. RN #2 confirmed she failed to obtain written statements from the staff for the investigation of abuse to Resident #9. Interview with LPN #4 on 9/12/17 at 3:43 PM in her office revealed she wrote the 8 hand written individual statements located the facility completed investigation. LPN #4 confirmed she failed to obtain written statements for the investigation of abuse to Resident #9. Interview with the Administrator on 9/12/17 at 3:50 PM in her office confirmed the facility failed to obtain written statements from the staff that were interviewed and Resident #9 in the investigation of abuse to Resident #9. | 2020-09-01 |
| 4044 | 4044 | AHC WEST TENNESSEE TRANSITIONAL CARE | 445187 | 597 WEST FOREST AVENUE | JACKSON | TN | 38301 | 2016-11-22 | 514 | D | 1 | 0 | IQ3911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, closed medical record review and interview, the facility failed to document a change in a resident's condition and failed to document the administration of as needed (prn) medications or follow-up on effectiveness of the medication for 1 of 3 (Resident #1) sampled residents reviewed. The findings included: 1. The facility's Documentation policy documented, .Accurate and complete documentation is a critical aspect of every operation within a long term care nursing facility. This facility's policy is to document information timely and consistent with all applicable professional, legal and established standards and guidelines .Problems or a change in condition that develops must have nursing documentation on every shift for 3 days/72 hours or until the problem is resolved. Examples of new problems which would require every shift documentation are .Nausea and vomiting . 2. The facility's PHYSICIAN ORDER [REDACTED].Physician standing orders or protocol-based orders are pre-authorized orders conditioned upon the occurrence of certain clinical events .After determining the medication is appropriate, the nurse must document the medication on the eMAR. Effectiveness of the medication should also be documented on the eMAR . 3. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the emergency medical services (EMS) Patient Care Report dated 8/7/16, revealed EMS received the call from the facility for transfer of Resident #1 to the hospital at 2:12 PM, EMS arrived at the bedside at 2:17 PM and reached the hospital at 2:39 PM. Review of the hospital emergency room (ER) records dated 8/7/16, revealed the resident arrived in the ER with decreased responsiveness, skin cool and pale. She had agonal respirations and runs of ventricular fibrillation (fast irregular heart rhythm), and quickly declined into an asystole (no heart beat). The resident was pro… | 2019-11-01 |
| 641 | 641 | DIVERSICARE OF SMYRNA | 445160 | 200 MAYFIELD DRIVE | SMYRNA | TN | 37167 | 2020-02-26 | 600 | D | 1 | 1 | T07H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to prevent abuse for 1 of 2 residents (Resident #42) involved in a resident to resident altercation. The findings include: Review of the facility policy, Abuse, dated June 2018, showed, .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing of the center. Review of the medical record, showed Resident #4 was admitted to the facility on [DATE], with readmission on 6/7/2019 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #4 had a Brief Interview for Mental Status (BI[CONDITION]) score of 11 indicating moderate cognitive impairment. Further review showed Resident #4 had verbal behavior symptoms directed toward others. Review of the medical record, showed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed Resident #42 was rarely/never understood. Further review showed the resident had no mood or behavioral symptoms. Review of the facility investigation dated 2/18/2020, showed a witnessed physical altercation between Resident #4 and Resident #42 in the Activity room while waiting for the activity to begin. Further review showed Resident #4 grabbed Resident #42's wrist, slapped and kicked her. During an interview conducted on 2/25/2020 at 7:30 AM, the Activity Director confirmed Resident #4 and Resident #42 had a physical altercation. Further interview she stated, When I walked into the Activity room I s… | 2020-09-01 |
| 746 | 746 | THE WATERS OF SHELBYVILLE, LLC | 445171 | 835 UNION STREET | SHELBYVILLE | TN | 37160 | 2019-11-06 | 689 | J | 1 | 1 | TEZO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility documentation review, medical record review, observation and interview the facility failed to provide adequate supervision to prevent elopement for 1 resident (#68) of 5 residents reviewed who were wander/elopement (Residents who have a history of leaving or trying to leave the facility, or have wandered or have the potential to wander into unsafe areas) risks resulting in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 11/5/19 at 6:50 PM in his office. An extended survey was conducted from 11/5/19 to 11/6/19. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/27/19 through 8/20/19. The facilities corrective action plan, which removed the IJ, was received and the corrective actions were validated onsite on 11/6/19 F-689 was cited at a scope and severity of J as past noncompliance. The facility is not required to submit a plan of correction for F-689 [NAME] The findings include: Review of the facility policy, Missing Residents and Elopement, dated 8/1/16 revealed .It is the policy of this facility that all residents are provided adequate supervision to meet each resident's personal care needs .All residents will be assessed for behaviors or conditions that put them at risk of elopement .All resident's assessed to be at risk of elopement will have this issue addressed in their plan of care .Residents that are at risk of elopement will be provided at least one of the following safety precautions: staff supervision of facility exits either directly or by video camera .door alarms on facility exits .a personal safety device that notifies facility staff when the resident has left the facility wit… | 2020-09-01 |
| 285 | 285 | WESTMORELAND HEALTH AND REHABILITATION CENTER | 445114 | 5837 LYONS VIEW PIKE | KNOXVILLE | TN | 37919 | 2018-07-14 | 835 | J | 1 | 0 | K2OF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, interview, and observation, the Administrator failed to ensure facility policies were implemented, physicians were notified timely of changes in condition, and residents were free from neglect, avoidable accidents, and pain. The Administrator's failure resulted in a resident having an avoidable accident and a delay in receiving services and treatment after a fall with fractures, with Resident #7 experiencing intense pain, and placing Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Fu… | 2020-09-01 |
| 1668 | 1668 | GRACE HEALTHCARE OF WHITES CREEK | 445281 | 3425 KNIGHT DRIVE | WHITES CREEK | TN | 37189 | 2019-06-18 | 600 | G | 1 | 0 | QRE111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, medical record review, and interview the facility failed to ensure the safety and well-being of a resident and failed to protect a resident from verbal abuse and threats of physical abuse for 1 (Resident #2) of 4 residents reviewed for abuse. This failure resulted in HARM to the resident. The findings included: Review of facility policy, Abuse Prevention, revised 2/26/18, revealed .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, or misappropriation of resident property by anyone .All alleged violations involving abuse, neglect, exploitation, or mistreatment and misappropriation are reported immediately to the Administrator and DON .Verbal abuse is any use of oral, written, or gestured language that willfully includes the disparaging and derogatory terms to residents or within hearing distance, regardless of age, ability to comprehend, or infirmities .A screening process will be completed on all new hires .Training on activities that constitute abuse, neglect, exploitation, and misappropriation will be held in new hire orientation and annual training .All allegations will be thoroughly investigated under the direction of the Administrator .The completed investigation will be forwarded to the Facility's Quality Assurance/Performance Improvement Committee for review . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was frequently incontinent of bowel an… | 2020-09-01 |
| 2087 | 2087 | SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE | 445343 | 201 EAST 10TH STREET | SOUTH PITTSBURG | TN | 37380 | 2017-10-11 | 223 | D | 1 | 0 | 9Q7R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, medical record review, and interview the facility failed to provide supervision to protect 2 residents (#2, #3) from the physical aggression of another resident of 5 residents reviewed for abuse on the secure unit. The findings included: Review of the facility's policy, Abuse, Neglect, and Misappropriation .revised 11/28/16, revealed, .C.Abuse Prevention and Protection .2. If a Stakeholder observes a resident exhibiting any form of abuse toward another resident, the Stakeholder will intervene immediately to interrupt the incident and remove and/or separate the residents involved and move them to an environment where the residents' safety can be assured. The charge nurse and/or Director of Nursing will ensure that the residents do not have access to one another until the circumstances of the incident can be determined . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission Information dated 1/27/17 revealed the resident exhibited the following behaviors: resists care, verbally abusive, physically abusive and inappropriate/disruptive. Continued review revealed .Elder arrived at facility by ambulance .is ambulating with unsteady gait, combative with care .hard to direct, incont (incontinent) B&B (bowel and bladder) . Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had been unable to complete a Brief Interview for Mental Status (BIMS), and was deemed to have short and long term memory deficits with severe cognitive impairment. Continued review of the MDS revealed Resident #1 had inattention and disorganized thinking behaviors. Continued review of the Behaviors section of the MDS revealed the resident had exhibited physical behaviors toward others 4 to 6 days out of 7, and had directed verbal behavior sy… | 2020-09-01 |
| 2814 | 2814 | MADISONVILLE HEALTH AND REHAB CENTER | 445457 | 465 ISBILL RD | MADISONVILLE | TN | 37354 | 2018-08-08 | 609 | D | 1 | 0 | J2VJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to report an allegation of abuse immediately to the Administrator and the State Survey Agency timely for 1 resident (#4) of 11 residents reviewed. The findings include: Review of facility policy Abuse Prevention/Reporting Policy and Procedure, dated 5/9/18 revealed .All reports whether from family, residents or staff will be reported immediately to the Administrator and Abuse Coordinator and/or D.O.N and the resident's Primary Health Care Provider .An Event Report will be initiated by the Charge Nurse upon discovery/allegation and the Administration (NHA and DON) will be notified immediately regardless of the time of discovery or allegation of Abuse .If the events that cause the allegation involve abuse and/or result in serious bodily injury, reporting must be within 2 hours of the allegation being made or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials . Review of a facility investigation dated 5/5/18 at 5:36 AM revealed on 5/4/18 at 11:30 PM Resident #5 entered Resident #4's room, sat down on Resident #4's bed, and attempted to pull Resident #4's pants off, yelled, and smacked him in an attempt to get Resident #5 out of bed. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 13 of 15 (cognitively intact). Medical record review revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Medical record review of the Admission MDS assessment dated [DATE] revealed the Resident #5 s… | 2020-09-01 |
| 2510 | 2510 | ETOWAH HEALTH CARE CENTER | 445422 | 409 GRADY ROAD, PO BOX 957 | ETOWAH | TN | 37331 | 2018-04-17 | 600 | D | 1 | 0 | R7QB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, medical record review, observations, and interviews, the facility failed to ensure 2 residents (#2 and #4) were free from abuse during resident to resident altercations of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect & Exploitation Policy & Procedures dated 4/26/16 revealed .Policy .Residents are not to be subjected to abuse, neglect, and/or exploitation by anyone, including but not limited to, facility staff, other residents, consultants or volunteers .Abuse means the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish . Review of a facility investigation dated 4/8/18 revealed a written statement by Certified Nursing Assistant (CNA) #1. Continued review revealed CNA #1 was walking up the hall and observed Resident #1 slapping Resident #2's right hand. Further review revealed CNA #1 told Resident #1 to stop and Resident #1 said .You stop . Continued review revealed Resident #1 then used her right foot to start kicking at Resident #2 but the CNA was unable to verify if the resident actually kicked Resident #2. Further review revealed Resident #2 did not have any injuries. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was severely cognitive impaired and was totally dependent on staff for bed mobility, transfer, dressing, eating, and personal hygiene. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #1 was severely cognitive impaired and required extensive assistance for transfer, dressing, and hygiene/bathing. Interview with CNA #1 on 4/16/18 at 2:25 PM, in the conference room, revea… | 2020-09-01 |
| 2645 | 2645 | MT JULIET HEALTH CARE CENTER | 445439 | 2650 NORTH MT JULIET ROAD | MOUNT JULIET | TN | 37122 | 2019-03-13 | 689 | D | 1 | 1 | O5E111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation, medical record review, and interview the facility failed to prevent a fall for 1 of 8 residents (#68) reviewed. The findings include: Record review of the facility policy Fall Risk assessment dated ,[DATE] revealed .Implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care nd current standards of practice in order to reduce the risk of a fall . Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Continued interview revealed Resident #68 required total dependence with 2 people for transfers. Record review of the facility investigation dated 2/6/19 Resident #68 slid from the wheelchair during a transfer by only 1 staff member. Record review of the facility investigation dated 2/6/19 revealed a witness statement from a Certified Nurse Aide #4 revealed Resident #68 told CNA #4 she was a 1 person transfer. Continued review revealed CNA #4 realized Resident #4 could not assist in the transfer and lowered Resident #68 to the floor. Interview with Resident #68 on 3/13/19 at 11:23 AM revealed staff member attempted to transfer the resident to the wheelchair but could not and the resident was then lowered to the floor. Interview with Registered Nurse #3 on 3/13/19 at 2:45 PM 100 hallway revealed, the tech was trying to transfer Resident #68 alone and could not so she lowered her to the floor. Continued interview revealed she could not remember who provided care to Resident #68. Interview with the Director of Nursing on 3/13/19 at 8:03 PM in the Administrators office confirmed Resident #68 was transfered by 1 staff member. Continued interview confirmed .I would expe… | 2020-09-01 |
| 122 | 122 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 558 | G | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility record review and interview, the facility failed to ensure reasonable accommodation of needs to prevent decline for 1 (#22) of 38 residents reviewed resulting in psychosocial and physical Harm for Resident #22. The findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #22 required extensive assistance of 1 staff member for bed mobility and 2 staff members for transfers. Medical record review of the Progress Notes Report dated 4/8/19 revealed .Maintenance man reported to this nurse, f/u (follow up) with resident regarding having his bed replaced. (named medical equipment provider) delivered bed for resident in the interim, so maintenance can work/replace the parts to the existing bed . Resident #22 was transferred to the rental bed at this time. Medical record review of the service document from the rental company dated 4/9/19 revealed the order requisition sheet for a rental bariatric bed. Continued review revealed .5/8/19 fixed . Medical record review of the Former Nurse Practitioner (NP) notes dated 4/25/19 revealed .Patient appears hemodynamically stable, afebrile, nontoxic, but presents with left lower extremity [MEDICAL CONDITION] (bacterial infection of the skin) in the setting of chronic [MEDICAL CONDITION] .Elevate extremities . Medical record review of the Former NP notes dated 5/19/19 revealed .As such, it is medically necessary that the bed be changed to one that will allow extremity elevation, as this patient is rather immobile and morbidly obese and does suffer from marginally compensated heart failure and chronic [MEDICAL CONDITION] now presenting with [MEDICA… | 2020-09-01 |
| 120 | 120 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2017-06-23 | 282 | G | 1 | 0 | Q80711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, manufacturer's instructions review, observation, medical record review and interview the facility failed to follow the resident's care plan to ensure safe transfer techniques were implemented for 1 resident (#1) of 9 residents reviewed for abuse of 11 residents sampled. The facility's failure resulted in harm to Resident #1. The findings included: Review of the facility's policy, Resident Lift, undated, revealed, .Residents who are unable to transfer themselves independently or with minimal assistance shall be transferred safely with a lift .Guideline .2. At least two (2) trained staff are needed to transfer a resident when using a lift .7. In order to lift safely, follow manufactures operational guidelines for lifting, positioning, and transfer .Note: Make sure to pull appropriate make and model manufacturer guidelines for the lift used and follow manufacturer's instructions. Review of the manufacturer's Safety Instructions for Intended use revealed, (Product name) is a mobile raising aid .intended to be used on a horizontal surface for raising to a standing position and short transfer of residents .where the resident has been clinically assessed to correspond to the following categories .Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on carer in most situations - Physically demanding for carer . Review of facility's assessment, Mechanical Lifts - Function Flow Chart dated [DATE], revealed .Can the resident bear weight on at least one leg? No .Total lift required for transfer . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating the resident's cognition was severely impaired. Continued review revealed the resident required extensive assistan… | 2020-09-01 |
| 121 | 121 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2017-06-23 | 323 | G | 1 | 0 | Q80711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, manufacturer's instructions review, observation, medical record review, and interview the facility failed to ensure safe transfer techniques were implemented for 1 resident (#1) of 1 resident reviewed for injury of unknown origin of 11 residents reviewed. The facility's failure resulted in harm to Resident #1. The findings included: Review of the facility's policy, Resident Lift, undated, revealed, .Residents who are unable to transfer themselves independently or with minimal assistance shall be transferred safely with a lift .Guideline .2. At least two (2) trained staff are needed to transfer a resident when using a lift .7. In order to lift safely, follow manufactures operational guidelines for lifting, positioning, and transfer .Note: Make sure to pull appropriate make and model manufacturer guidelines for the lift used and follow manufacturer's instructions. Review of the manufacturer's Safety Instructions for Intended use revealed, (Product name (sit to stand lift)) is a mobile raising aid .intended to be used on a horizontal surface for raising to a standing position and short transfer of residents .where the resident has been clinically assessed to correspond to the following categories .Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on carer (care giver) in most situations - Physically demanding for carer . Review of facility's assessment, Mechanical Lifts - Function Flow Chart dated [DATE], revealed .Can the resident bear weight on at least one leg? No .Total lift required for transfer . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating the resident's cognition was severely impaired. Continued review revealed the resident required … | 2020-09-01 |
| 1468 | 1468 | AHC CUMBERLAND | 445262 | 4343 ASHLAND CITY HIGHWAY | NASHVILLE | TN | 37218 | 2017-09-13 | 224 | E | 1 | 0 | F0U711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record reivew, facility investigation review, observation, and interview, the facility failed to prevent misappropriation of resident narcotic medication for 7 residents (#1, #2, #3, #4, #5, #8, #11) of 16 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, effective 7/2014, revealed .The facility practices the concept of zero tolerance for patient abuse. Nurse management must strive to ensure the patients are free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of property. ANY report of actual or suspected abuse MUST be acted upon immediately .Conduct a thorough investigation that is well documented . Review of facility policy, Controlled Medications, revealed .All nurses must be inserviced on the procedure for accountability for controlled drugs on hire and annually thereafter . Review of facility policy, Controlled Drug Accountability Procedure, effective 7/2014, revealed : .Each dose administered is to be signed out by the nurse on the controlled drug record and on the patient's eMAR (electronic Medication Administration Record). Follow-up documentation for effectiveness should be accomplished on the eMAR also .The count of each controlled substance must be audited at every shift change by the nurse coming on duty and the nurse going off duty. Visual checks of the entire medication card for missing medications and the record sheet must be done by both nurses .Both nurses must sign the Narcotic Control Record indicating the count has been completed; the date, time, number of medication cards, and the number of controlled drug record sheets must be documented .If the count is incorrect the Director of Nursing (DON) must be notified immediately. No exchange of med cart keys should be done and the off-going nurse should not leave the facility . Review of facility policy, Destruction of Medications, ef… | 2020-09-01 |
| 253 | 253 | NHC HEALTHCARE, MURFREESBORO | 445108 | 420 N UNIVERSITY ST | MURFREESBORO | TN | 37130 | 2019-05-07 | 760 | D | 1 | 0 | 8UMM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to administered the correct medications for 1 (#1) of 3 residents reviewed on 4/27/19 related to Licensed Practical Nurse #2 during the evening medication pass. The findings include: Review of the facility policy, Medication Administration--General Guidelines , effective 6/2016 revealed .medications are administered as prescribed in accordance with good nursing principles and practices .the five rights are applied for each medication being administered . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 7 indicating severe cognitive impairment Medical record review of a comprehensive care plan revised 4/9/19 revealed Resident #1 was monitored and assessed for functional potential, mobility and generalized weakness. Medical record review of the Physician's orders revealed medications given in error to Resident #1 included: Keflex for infection; [MEDICATION NAME] to relax the muscles; Requip for [MEDICAL CONDITION] or Restless Leg Syndrome; [MEDICATION NAME] for Constipation, [MEDICATION NAME] for Benign [MEDICAL CONDITION] of the Prostate; and [MEDICATION NAME] for depression and [MEDICAL CONDITION]. Medical record review of the SBAR (Situation, Background, Appearance, Review/Notify) form dated 4/27/19 revealed a med error occurred. Medical record review of a transfer form from the facility to the hospital dated 4/27/19 revealed the key reason for transfer was a possible allergic reaction with the primary reason for transfer being diagnostic testing, not admission. Continued review revealed a medication error involving Resident #1 had occurred. Interview with the Director of Nursing on 5/6/19 at 9:00 AM in the conference room confirmed LPN #2 made a me… | 2020-09-01 |
| 345 | 345 | THE WATERS OF GALLATIN, LLC | 445124 | 555 EAST BLEDSOE STREET | GALLATIN | TN | 37066 | 2019-12-18 | 600 | D | 1 | 1 | BPQR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to ensure 1 (#66) of 94 residents was free from abuse. Facility policy review Resident Rights & Facility Responsibilities, undated, revealed .The right to live in a caring environment free from abuse, mistreatment and neglect . Facility policy review Abuse Prevention Program, dated 1/19/17, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .This facility will not tolerate resident abuse or mistreatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals . Review of facility investigation initiated on 11/11/19 revealed Resident #24 was observed with his hand on Resident #66's torso. Continued review revealed Resident #24 was removed and placed on 1 on 1 supervision and both residents were assessed by staff with no skin issues noted. Resident #24 was sent to local hospital for further evaluation with medication adjustments made; upon return to facility the resident was moved to a different unit to a private room. Continued review revealed staff were educated on abuse from 11/11/19 through 11/22/19. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident received a [DIAGNOSES REDACTED]. Medical record review of Resident #24's Order Summary Report dated (MONTH) 2019 revealed .[MEDICATION NAME] Sprinkles 125 MG (milligram) give 1 tablet at bedtime for sexual impulsivity 11/15/19 .Flutamide 250 mg one time daily at bedtime for sexual inappropriate behaviors 11/12/19 . Medical record review of Resident #24's History and Physical dated 11/12/19 revealed .Pt (patient) is being seen per nursing request. Pt has had an episode of sexually inappropriate behavior with another resid… | 2020-09-01 |
| 127 | 127 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 656 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to have an updated care plan for 1 (#22) of 38 residents reviewed. The findings include: Review of the facility policy Comprehensive Care Plans revised 7/19/18 revealed .The Comprehensive Care Plan will be person-centered to include the discharge plans to meet the resident's preference and goals to address the resident's medical, physical, mental and psychosocial needs . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of the Physician's Order Sheet dated 5/19/19 revealed .TREATMENT/PR[NAME]EDURE .ELEVATE LEGS AT ALL TIMES . Medical record review of the care plan dated 6/18/19 and 7/4/19 revealed the care plan was not revised to reflect orders to elevate Resident #22's legs at all times. Interview with Resident #22 on 8/12/19 at 11:11 AM in his room revealed the he had [MEDICAL CONDITION] for [AGE] years. Further interview revealed Resident #22 stated .this (the bed) needed to be fixed . It would not elevate his legs. Interview with the Corporate Nurse on 8/21/19 at 12:53 PM in the Social Services office confirmed the facility failed to update Resident #22's care plan to include elevation of the legs. | 2020-09-01 |
| 443 | 443 | MIDTOWN CENTER FOR HEALTH AND REHABILITATION | 445139 | 141 N MCLEAN BLVD | MEMPHIS | TN | 38104 | 2018-08-03 | 686 | D | 1 | 0 | Q36011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to notify the physician of a new area of skin breakdown for 1 of 3 sampled residents (Resident #11) reviewed for pressure ulcer/injury to the skin. The findings include: The facility's Pressure Ulcer/Injury Risk Assessment policy revised (MONTH) (YEAR) documented, .Notify attending MD (medical doctor) if new skin alteration noted . The facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy revised (MONTH) 2014 documented, .The physician will authorize pertinent orders related to wound treatments .and application of topical agents if indicated for type of skin alteration . The facility's Pressure Ulcers/Injuries Overview policy revised (MONTH) (YEAR) documented, .Shearing occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was sometimes understood with a cognitive score of 3 of 15 indicating severe cognitive impairment and the presence of disorganized thinking; required extensive assistance of 2 staff for bed mobility; was dependent for toileting;and was always incontinent of bowel and bladder. Review of the comprehensive plan of care initiated following the admission MDS assessment dated [DATE] and updated 7/24/18 revealed appropriate care plan interventions were implemented for assessed problems and needs which included risk for skin impairment related to incontinence, immobility, combativeness, resistance and refusal of care during personal care. Review of the C.N.[NAME] (Certified Nursing Assistant (CNA)) SKIN CARE ALERT dated 7/19/18 revealed a new red area was identified on Resid… | 2020-09-01 |
| 130 | 130 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 755 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to obtain Physicians' Orders for a medicated solution and failed to ensure that only licensed personnel administered medications for 1 (#22) of 38 residents reviewed. The findings include: Record review of the facility policy Medication Administration General Guidelines revised 9/6/18 revealed .Medications are prepared and administered only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare and administer medications . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Medical record review of the Physicians' Order Sheets and Physician's Telephone Orders dated (MONTH) 2019 revealed no orders for Dakin's (a dilute hypochlorite (bleach) antibiotic solution. It kills the microorganisms but also harms healthy skin in all concentrations) solution for Resident #22. Interview with Resident #22 on 8/7/19 at 1:26 PM in his room revealed Certified Nurse Aide (CNA) #2 and CNA #3 began to cleanse the plaques and fissures by pouring a solution (Dakin's) on the area. Continued interview with Resident #22 revealed the Wound Care Nurse (LPN #1) gave t… | 2020-09-01 |
| 4679 | 4679 | GREENHILLS HEALTH AND REHABILITATION CENTER | 445267 | 3939 HILLSBORO CIRCLE | NASHVILLE | TN | 37215 | 2016-08-11 | 514 | D | 1 | 0 | NRXS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to provide complete and accurate documentation for 1 (Resident #3) resident of 4 resident's reviewed. The findings included: Review of a facility policy titled Enteral Nutrition revised 1/13 revealed, .Key documentation elements: Type, amount, rate of feeding formula; Patency; Tolerance; Condition of stoma site; and Oral hygiene . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission assessment dated [DATE] revealed the resident had short and long-term memory loss, and had difficulty being understood by others. He had a Gastrointestinal Tube (GT) in his abdomen for feedings and medication administration, and he was totally dependent on staff for all Activities of Daily Living (ADL's). Medical record review of an Admission Nursing assessment dated [DATE] revealed no documentation for an incision or staples present for Resident #3. Medical record review of a Nursing Daily Skilled Charting note dated 4/16/16 revealed lung sounds were not documented; Cardiac and circulation were not documented; Feeding tube assessment was left unanswered; Mood and behavior were not documented; and no documentation of an incision or staples was present for Resident #3. Medical record review of a Nursing Daily Skilled Charting note dated 4/17/16 at 4:04 PM revealed LPN #1 documented the resident had a barrel chest. Continued review revealed no documentation of lung sounds, respiratory rate, or oxygen saturation. Continued review revealed the presence of a GT was left blank. The skin assessment was left blank. A nurses note documented, .staples intact to abd (abdomen) . Further review revealed the Skilled and Additional Services section was left blank. Medical record review of Enteral Feed Orders dated 4/15/16 revealed: Feeding: Administer [MEDICATION NAME] 1.5… | 2019-08-01 |
| 1470 | 1470 | AHC CUMBERLAND | 445262 | 4343 ASHLAND CITY HIGHWAY | NASHVILLE | TN | 37218 | 2017-09-13 | 250 | D | 1 | 0 | F0U711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 resident (#10) of 17 residents reviewed. The findings included: Review of facility policy, Social Services, dated (MONTH) (YEAR) revealed .Social workers are to provide support to the patient and their families and other individuals involved with the patient's care. Social workers are to be the patient's advocate to ensure they receive appropriate care and treatment . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #10 had a Brief Interview for Mental Status of 4 indicating she was severely cognitively impaired. Further review revealed the resident had no impairment of the lower extremities and was not steady, only able to stabilize with staff assistance with moving from seated to standing position, moving on/off toilet and surface-to-surface transfer. Medical record review of a Clinical Note dated 5/18/17 revealed edema in right ankle. Resident #10 expressed facial grimaces when the nurse touched the ankle and declined to get out of bed. Medical record review of a Physician assessment dated [DATE] revealed .Pt's (patient's) rt (right) ankle swollen, erythemoatous, possible deformity noted. Very painful (with) palpitation. Pt doesn't recall any injury to ankle. Was called last night regarding pain to pts hip/ankle, ordered uric acid level for today which is (negative) will get xray . Medical record review of a Radiology Report dated 5/19/17 revealed .There are comminuted angulated and mildly displaced acute fractures of the distal tibia and distal fibula, well above the joint space. The bones are osteopenic. There appears to be narrowing of the ankle joint. No there a… | 2020-09-01 |
| 613 | 613 | CLAIBORNE AND HUGHES HLTH CNTR | 445157 | 200 STRAHL STREET | FRANKLIN | TN | 37064 | 2019-07-11 | 609 | D | 1 | 0 | CCNJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, it was determined the facility failed to report allegations of abuse within 2 hours for 2 of 2 (Resident #1 and #2) sampled residents reviewed for alleged abuse. The findings include: The facility's Abuse, Neglect and Exploitation policy documented, .Report allegations or suspected abuse, neglect or exploitation immediately to State Agencies . Medical record review revealed Resident #1 was admitted to facility 6/20/18 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment for decision making. Interview with Resident #1 on 7/9/19 at 11:00 AM, in the Social Service office, Resident #1 stated, He hit me in the back of the head two times so I let go of walker and his wheelchair fell backwards into the grass . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #2 scored 15 on the BIMS, which indicated no cognitive impairment for decision making. Review of the Occurrence Report dated 6/20/19 documented, .(Resident #2) was push (pushed) by another resident (#1) causing wheel (wheelchair) to go off pavement cause (causing) him (Resident #2) to fall . Interview with the Director of Nursing (DON) on 7/11/19 at 1:00 PM, in her office, the DON confirmed the date of the incident was 6/20/19 and was not reported until 6/22/19. The DON was asked if the alleged abuse was reported timely. The DON stated, Probably not. | 2020-09-01 |
| 814 | 814 | GALLATIN HEALTH CARE CENTER, LLC | 445183 | 438 NORTH WATER AVE | GALLATIN | TN | 37066 | 2018-02-23 | 656 | D | 1 | 0 | 42HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to develop a plan of care to address moods for 1 of 7 samples residents (Resident #6). Findings include: Review of the undated facility policy MDS/Care Plans revealed .The facility must develop a comprehensive care plan to meet a resident's .needs . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; Brief Interview for Mental Status (BIMS) was 13/15, indicating he was cognitively intact, and exhibited little interest, feeling down/depressed, tired, and change of appetite for 2-6 days of the review period. Medical review of the Quarterly MDS dated [DATE] revealed the BIMS score of 14/15; and exhibited feeling down/depressed for 2-6 days of the review period. Medical record review of the care plan with completion date of 11/30/17 and revised in 1/19/18 revealed feeling down/depressed and tired were not addressed. Interview with the Registered Nurse (RN) #1/ MDS Coordinator on 2/21/18 at 8:45 AM in the conference room confirmed the care plan with completion date of 11/30/17 failed to address the resident was down/depressed and tired. Further interview confirmed the care plan with the completion date of 1/19/18 failed to address feeling down/depressed. | 2020-09-01 |
| 846 | 846 | GALLATIN HEALTH CARE CENTER, LLC | 445183 | 438 NORTH WATER AVE | GALLATIN | TN | 37066 | 2019-09-25 | 626 | D | 1 | 0 | GEY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to document its inability to meet the resident's needs for 1 (#5) of 7 residents reviewed for Admission/Transfer/Discharge criteria. The findings include: Review of facility policy, Transfer Agreement, revised 3/2017, revealed .Our facility has a transfer agreement in place with a designated hospital should our residents need care that is beyond the scope of our available care and services .The agreement ensures that residents are transferred from the facility to the hospital and admitted in a timely manner in an emergency situation by another practitioner .The agreement specifies restrictions with respect to the types of services available and types of residents or health conditions that will not be accepted by the hospital or the facility .Inquiries related to the transfer agreement should be referred to the Administrator . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored 15 on the Brief Interview for Mental Status (BIMS) indicating he was alert, oriented, and able to make his needs known. Continued review of the MDS revealed Resident #5 was dependent on 2 people for transfers and bathing; required extensive assistance of 2 people with bed mobility, dressing, toileting, and grooming; and was frequently incontinent of bowel and bladder. Medical record review revealed multiple episodes of refusing care; yelling and cursing at staff; family trying to use a mechanical lift to transfer him without staff being present; and family bringing in medications and other materials not associated with his care. Medical record review revealed Resident #5 was sent to the hospital with unresponsiveness and the facility refused to allow him to return due to inability to meet his need… | 2020-09-01 |
| 4971 | 4971 | LIFE CARE CENTER OF MORRISTOWN | 445314 | 501 WEST ECONOMY ROAD | MORRISTOWN | TN | 37814 | 2016-06-15 | 333 | G | 1 | 0 | SVOA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to ensure 1 resident (#174) was free from significant medication errors, of 6 residents reviewed for medication administration of 27 residents reviewed. This failure resulted in Harm to Resident #174. The findings included: Review of Clinical Services Policies & Procedures, Nursing Volume 1, physician's orders [REDACTED].to ensure accurate delivery of medications .confirm that the order is correct . Medical record review revealed Resident #174 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (a test for cognitive ability) score of 14, indicating the resident was cognitively intact. Medical record review of Resident #174's admission orders [REDACTED]. Medical record review of a Physician/Prescriber order per fax dated 6/29/15 revealed .Glimiperide (oral diabetes medication) 1 mg (millegram) PO (by mouth) BID (twice a day) (Hold if FS (finger stick blood sugar reading by glucometer) = (less than or equal to) 100 . Medical record review of the Fax order request/notification form dated 6/29/15 revealed . OK (with) Glimiperide (Hold if FS = 100) . Medical record review of the Medication Administration Record (MAR) for 6/15 and 7/15 revealed, .Glimiperide 1 mg po BID start 6/29/15 9:00 AM 5:00 PM . Medical record review of the Sliding Scale Insulin Form, dated 7/15, on which the finger stick blood sugars were documented, revealed on 7/2/15 at 6:00 AM Resident #174 had a blood sugar of 91. Continued review revealed at 4:00 PM the resident's blood sugar was 74. Continue review revealed no documentation to hold Glimiperide 1 mg po if the finger stick blood sugars were 100 or less. Medical record review of Resident #174's Medication Administration Record (MAR) dated 6/15 and 7/15 revealed .Glimiperide 1 mg po BID start 6/29/15 9 a… | 2019-06-01 |
| 3341 | 3341 | LIFE CARE CENTER OF OLD HICKORY VILLAGE | 445509 | 1250 ROBINSON ROAD | OLD HICKORY | TN | 37138 | 2017-06-07 | 333 | E | 1 | 0 | RZM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to ensure 1 resident (#2) was free from significant medication errors, of 4 residents' records reviewed for accurate admission medication administration. The findings included: Review of Clinical Services Policies & Procedures, Nursing Volume 1, physician's orders [REDACTED].to ensure accurate delivery of medications .confirm that the order is correct . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission assessment Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (a test for cognitive ability) score of 13, indicating the resident was cognitively intact. Medical record review of Resident #2's Discharge Medications Orders from recent hospital admission and return to the facilty 3/18/17 revealed .[MEDICATION NAME] (TRADE NAME: [MEDICATION NAME]) 400 MG ORAL TWICE DAILY .[MEDICATION NAME] (TRADE NAME: [MEDICATION NAME]) 125 MCG ORAL DAILY .TRAVOPROST (TRADE NAME: [MEDICATION NAME] Z 0.004% Ophth Drops) 1 DROP EACH EYE BEDTIME . Medical record review of the Physician order [REDACTED].[MEDICATION NAME] (Trade name: [MEDICATION NAME]) 112 MCG .PO (oral) DAILY .[MEDICATION NAME] (Trade name: [MEDICATION NAME]) 2% - 0.5% ophth drops) Left eye only Intraocular daily . No orders noted for [MEDICATION NAME] (TRADE NAME: [MEDICATION NAME]) 400 MG ORAL TWICE DAILY, [MEDICATION NAME] (TRADE NAME: [MEDICATION NAME]) 125 MCG ORAL DAILY or TRAVOPROST (TRADE NAME: [MEDICATION NAME] Z 0.004% Ophth Drops) 1 DROP EACH EYE BEDTIME. Medical record review of the Medication Administation Record (MAR) 3/18/2017 2:04 PM revealed administration of [MEDICATION NAME] (Travoprost) Drops Left eye only Inraocular daily from 3/19/17 throught 3/24/17 and [MEDICATION NAME] ([MEDICATION NAME]) 112 mcg po daily. Medical record review of a laboratory report collect… | 2020-09-01 |
| 3468 | 3468 | CHRISTIAN CARE CENTER OF MEMPHIS | 445522 | 6500 KIRBY GATE BOULEVARD | MEMPHIS | TN | 38119 | 2018-04-02 | 760 | E | 1 | 0 | JLWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to ensure 2 of 3 (Resident #1 and 5) sampled residents with physician ordered anticoagulant medication were free from significant medication errors. The findings included: 1. The facility's Emergency Pharmacy Service policy documented, Emergency pharmaceutical service will be available on a 24-hour basis. Emergency needs for medication will be met by using the facility's approved emergency drug kit (EDK) or special order from the pharmacy supplier . 2. Medical record review revealed Resident #1 was admitted to the facility 3/9/18 with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (anticoagulant medication) 70 milligrams (mg) subcutaneously twice daily at 6:00 AM and 6:00 PM. Review of the Medication Administration Record [REDACTED]. The nurse documented, .Held due to not available. reordered (Reordered) from pharm (pharmacy) . Observations in Resident #1's room on 3/26/18 at 5:15 PM, revealed the resident was alert and oriented to person and place and had difficulty speaking clearly and fluidly due to [MEDICAL CONDITION]. Paresis (weakness or paralysis) was noted on the resident's right upper and lower extremities. A family member was present and assisted during the interview with the resident's permission. There was no evidence of a negative outcome due to the missed dose of [MEDICATION NAME]. Interview with Resident #1 and a family member in the resident's room on 3/26/18 at 5:15 PM, this Surveyor was informed the resident had missed her 6:00 AM (morning) dose of [MEDICATION NAME] because it was not available in the medication cart and had to be ordered from pharmacy. Interview with the Complainant in the conference room on 3/26/18 at 8:05 PM, this Surveyor was informed the missed AM dose of [MEDICATION NAME] had been available in the facility's EDK but the nurse had failed to use the emergency supply… | 2020-09-01 |
| 3342 | 3342 | LIFE CARE CENTER OF OLD HICKORY VILLAGE | 445509 | 1250 ROBINSON ROAD | OLD HICKORY | TN | 37138 | 2017-06-07 | 425 | D | 1 | 0 | RZM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to ensure procedures were in place to provide accurate medication transcription, for 1 resident (#2), of 4 residents reviewed for accurate medication administration. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Discharge Medications Orders from recent hospital admission and return to the facilty 3/18/17 revealed .AMIODARONE (TRADE NAME: Cordarone) 400 MG ORAL TWICE DAILY .LEVOTHYROXINE (TRADE NAME: Synthroid) 125 MCG ORAL DAILY .TRAVOPROST (TRADE NAME: Travatan Z 0.004% Ophth Drops) 1 DROP EACH EYE BEDTIME . Medical record review of the Physician order [REDACTED].LEVOTHYROXINE (Trade name: Synthroid) 112 MCG .PO (oral) DAILY .Cosopt (Trade name: Travatan) 2% - 0.5% ophth drops) Left eye only Intraocular daily . Continued review revealed no orders noted for AMIODARONE (TRADE NAME: Cordarone) 400 MG ORAL TWICE DAILY, LEVOTHYROXINE (TRADE NAME: Synthroid) 125 MCG ORAL DAILY or TRAVOPROST (TRADE NAME: Travatan Z 0.004% Ophth Drops) 1 DROP EACH EYE BEDTIME. Medical record review of the Medication Administation Record (MAR) 3/18/2017 2:04 PM revealed administration of Cosopt (Travoprost) Drops Left eye only Inraocular daily from 3/19/17 throught 3/24/17 and levothyroxine (Synthroid) 112 mcg po daily. Medical record review of a laboratory report collected 3/24/17 revealed TSH (thyroid stimulating hormone) 11.72 (H) (high) Reference Range 0.35 - 5.50. Medical record review of Physician order [REDACTED]. Medical record review of the physician's orders [REDACTED].Send only Brand Name Synthroid for Levothyroxine 125 cg PO QD .Travoprost (Travatan 0.004% opth) Administer 1 drop in each eye @ HS .Aminodarone 400 mg PO QD - hold HR Apical Medical record review of the Medication Administration Record [REDACTED].Amiodarone 400 mg po qd - Hold f… | 2020-09-01 |
| 1513 | 1513 | GREEN HILLS CENTER FOR REHABILITATION AND HEALING | 445267 | 3939 HILLSBORO CIRCLE | NASHVILLE | TN | 37215 | 2019-02-13 | 622 | D | 1 | 1 | 7IKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to facilitate a safe discharge to home for 1 of 3 residents (#288) reviewed for discharge. The findings include: Review of the facility policy, Transfer and Discharge Procedure, dated 12/2017 revealed .Transfer and discharge procedures must provide sufficient preparation and orientation of the resident to ensure a safe, orderly transfer or discharge from the facility . Medical record review revealed Resident #288 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #288 had a Brief Interview for Mental Status score of 13 indicating no cognitive impairment. Further review revealed the resident was on a mechanical altered diet, enteral feeding and required extensive assistance with two people for eating. Medical record review of the Physician Telephone Orders dated 10/30/18 revealed .Hospital bed with air mattress: DME (Durable Medical Equipment), [DIAGNOSES REDACTED].Discharge home on 11/2/18 Foley cath (catheter) by home health PRN (as needed) . Medical record review of the MDS dated [DATE] revealed Resident #288 was discharged to the community on 11/2/18. Medical record review of the Orders Only Report dated 11/3/18 revealed .presents to the ED (Emergency Department) complaining of not having all the equipment he needs to feed himself. Per EMS (Emergency Management Services) he was discharged yesterday from rehab (rehabilitation) with a peg tube in place, and his tube remains in place and he has the food he needs, however he doesn't have a pump for the tube .He states that his tube feeds come in bags which makes it impossible for him to use syringes to feed himself, requiring a pump that will arrive at his house on Monday . Telephone interview with the Care Manager on 2/11/19 at 3:09 PM revealed she had placed a call to Resident #288 fiance on 11… | 2020-09-01 |
| 4142 | 4142 | MT PLEASANT HEALTHCARE AND REHABILITATION | 445374 | 904 HIDDEN ACRES DR | MOUNT PLEASANT | TN | 38474 | 2016-11-03 | 226 | J | 1 | 0 | J51L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to implement the abuse policy when 3 Certified Nurse Aides were aware a swallow-impaired, aspiration-risk resident was force fed food and fluid by a syringe for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. F226 is Substandard Quality of Care The findings included: Review of policy, Abuse Prevention/Reporting Policy and Procedure, revised [DATE], revealed .Every resident has the right to be free from .neglect .Definitions 6. Negligence: Failing to properly care for a resident in a manner conducive to professional care standards. 7. Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .Abuse Prevention Procedures .Prevention 5. Staff will be provided with information regarding the process for reporting a witnessed abuse, suspected abuse .Staff will be provided through education .the process for reporting abuse to their immediate Supervisor, Abuse Coordinator, local authorities and State department of health . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the ,[DATE] score on the Brief Interview for Mental Sta… | 2019-11-01 |
| 1718 | 1718 | FAIRPARK HEALTH AND REHABILITATION | 445286 | 307 N FIFTH ST BOX 5477 | MARYVILLE | TN | 37801 | 2018-01-19 | 842 | F | 1 | 0 | 8BQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to maintain a complete and accurate medical record for 7 residents (#1, #2, #3, #5, #6, #7, and #8) of 8 residents reviewed for activities of daily living (ADLs). The findings included: Review of the facility policy Documentation of Resident's Health Status, Needs and Services dated [DATE] and updated [DATE] revealed, .Rationale .The resident's record is a continuing account of the resident's health status and needs .if care item is not completed for that day .document time, date, and reason the care was not given (e.g, resident refused shower etc.) including any re-attempts at care .record supportive documentation in the resident's progress notes . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #1 expired on [DATE]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of ,[DATE] indicating the resident was severely cognitively impaired. Continued review revealed Resident #1 required extensive assistance with 2 or more staff for bed mobility and physical help with 1 person in part of bathing activity. Medical record review of the ADL (Activities of Daily Living) Flow Record and Documentation Survey Report, both dated (MONTH) (YEAR), revealed Resident #1 received a bath on [DATE], [DATE] and [DATE]. Review of Resident #1's medical record from (MONTH) through (MONTH) (YEAR) revealed no further documentation regarding baths. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #2 had a BIMS score of ,[DATE] indicating the resident was cognitively intact. Continued review revealed Resident #2 was independent with 1 person physical assista… | 2020-09-01 |
| 719 | 719 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2019-01-08 | 842 | D | 1 | 0 | KGXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to maintain complete and accurate medical record for 1 resident (#1) of 3 records reviewed. The findings include: Review of the facility policy, Medication Administration, dated 1/15/12, revealed .Medications shall be administered .as prescribed .The individual administering the medication must initial the resident's Medication Administration Record (MAR) on the appropriate line after giving the medication . Medical record review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The resident was discharged to an acute hospital on [DATE]. Medical record review of Resident #1's Pain Tool form dated 12/6/18 revealed the location of pain in right and left knees (front), pain was relieved by Tylenol 650 milligrams, effected the resident's sleep, social and physical activities/mobility, and emotions; and pain was made worse with movement and weather change. Medical record review of Physician Orders dated 12/6/18 revealed .Aspirin 81 milligrams (mg) 1 time daily for pain related to fracture, Monitor pain every shift, and Tylenol 325 mg Give 2 tablets every 8 hours as needed (PRN) for pain/fever . Medical record review of the Pain Interview form dated 12/13/18 revealed Resident #1 had occasional pain in last 5 days; pain did not make it hard to sleep; pain did limit day-to-day activities in past 5 days; intensity of pain 5 out of 10; indicators of pain/possible pain-vocal complaints; frequency with which resident complains or shows evidence of pain or possible pain-3 to 4 days; .Treatment .Received PRN pain medication-[MEDICATION NAME] 325 mg (milligrams) give 2 tablets po (by mouth) every 8 hr (hours) as needed-effective .Receive non-pharmaceutical intervention-Repositioning, Dim Light/Quiet environment, sometimes not effective (12/9, 12/10); Comments - resident has moderately cognitive impairment which can affec… | 2020-09-01 |
| 4143 | 4143 | MT PLEASANT HEALTHCARE AND REHABILITATION | 445374 | 904 HIDDEN ACRES DR | MOUNT PLEASANT | TN | 38474 | 2016-11-03 | 241 | J | 1 | 0 | J51L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to maintain the dignity to a swallow-impaired, aspiration risk resident when a syringe was used to force feed food and liquids for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Review of facility policy, Quality of Life-Dignity, revised 12/11/15, revealed .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Policy Interpretation and Implementation .'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall keep the resident informed .Procedures shall be explained before they are performed .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed .Staff shall treat cognitively impaired residents with dignity and sensitively . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the 3/15 score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, and had no swallowing disorder. Inter… | 2019-11-01 |
| 1543 | 1543 | GREEN HILLS CENTER FOR REHABILITATION AND HEALING | 445267 | 3939 HILLSBORO CIRCLE | NASHVILLE | TN | 37215 | 2017-10-31 | 511 | J | 1 | 0 | EO0911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to notify the Physician or Nurse Practitioner of a [MEDICAL CONDITION] for 1 resident (#1) of 7 residents reviewed. This failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for the resident. The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. The findings included: Review of facility policy, Changes in Resident Condition, revised 2/2017 revealed, .Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility Medical record review of a Radiology Report for Resident #1 dated 8/2/17 at 5:57 PM eastern time (4:47 PM central time) revealed, .Acute fracture, left femoral neck . Continued review revealed the report was faxed to the facility on [DATE] at 6:01 PM eastern time (5:01 PM central time). Medical record review of a Medical Progress Note dated 8/3/17 revealed, .(Patient) seen at staff request regarding fall .last evening resulting in pain to left hip. X-ray of hip ordered and has returned .with (positive) left femoral neck fracture. (Patient) was recently hospitalized for [REDACTED].according to staff thought she could walk .got up without assistance and fell . No further details of events surrounding were known by the (Nurse Practitioner) at this time .General Appearance .Disheveled .(positive) pain with slight abduction (moving the leg away from the middle of the body) of (Left Lower Extremity) .… | 2020-09-01 |
| 3392 | 3392 | NASHVILLE CENTER FOR REHABILITATION AND HEALING LL | 445512 | 832 WEDGEWOOD AVENUE | NASHVILLE | TN | 37203 | 2019-11-26 | 580 | D | 1 | 0 | 133K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to notify the resident representative of 2 room changes for 1 resident (#2) of 4 residents reviewed with room changes. The findings included: Review of the facility policy, Transfer-Room to Room, revised on 10/2012, revealed .That his or her family and visitors will be informed of the room change .Documentation-The following information should be in the resident's medical record .the date and time the room transfer was made . Review of the facility policy, Transfers or Discharge Documentation, revised 8/2014, revealed .When a resident is transferred or discharged , the reason for the transfer or discharge will be documented in the medical record .Documentation .concerning all transfers or discharges must include .The reason for the transfer or discharge .That the appropriate notice was provided to the resident and/or representative .The date and time of the transfer or discharge . Medical record review revealed Resident #2 was admitted to the facility on [DATE]. On 12/12/17 he was discharged to the hospital for elevated blood sugar and readmitted to the facility on [DATE]. On 12/26/17 he was discharged to the hospital for having pulled out the tube feeding tubing and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #2 was severely cognitively impaired with a score of zero (0) on the Brief Interview for Mental Status (BIMS) and required extensive or total 2 person assistance for all activities of daily living Medical record review of the room location for Resident #2 revealed from 6/30/17 through 2/1/18 he was in room [ROOM NUMBER] B. On 8/8/19 he was moved to private room [ROOM NUMBER]. On 8/13/19 he was relocated to room [ROOM NUMBER] [NAME] On 8/16/19 he remained in the same room but changed bed location to 510 B where he currently resides. Medical record revie… | 2020-09-01 |
| 3607 | 3607 | NHC PLACE AT COOL SPRINGS | 445475 | 211 COOL SPRINGS BLVD | FRANKLIN | TN | 37067 | 2017-04-05 | 224 | D | 1 | 0 | BOVY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to prevent verbal abuse of one resident (#1) of 3 residents reviewed for abuse. The findings included: Review of facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 11/28/16, revealed .Abuse, Neglect, Misappropriation of Patient Property and exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property, or exploitation must report the event immediately .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, or misappropriation of property did or did not occur .The Administrator or Director of Nursing will determine the direction of the investigating once notified of the alleged incident . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed CNA #1 was overheard on 3/22/17 telling the resident she was dirty, stunk, and needed a bath. Continued review revealed CNA #3 reported to the facility Team Coordinator that CNAs were verbally and physically inappropriate during early morning residen… | 2020-08-01 |
| 3120 | 3120 | MCKENDREE VILLAGE | 445491 | 4347 LEBANON ROAD | HERMITAGE | TN | 37076 | 2019-06-19 | 600 | D | 1 | 1 | VV4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to protect Resident #130 from physical abuse by a facility Certified Nurse Technician (CNT). The findings include: Facility policy review, Abuse Prevention/Reporting Policy and Procedure, updated 5/9/18, revealed .Every resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents, physicians, consultants, volunteers, family members, legal guardians, friends or other individuals .the facility has developed and instituted policies and procedures for screening and training employees in regard to the protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment and misappropriation of property . Facility policy review, Resident Rights, revised (MONTH) (YEAR), revealed .Employees shall treat all residents with kindness, respect, and dignity . Review of the facility's investigation dated 6/1/19 revealed Licensed Practical Nurse (LPN) #3 witnessed CNT #5 slap the back of Resident #130's arms. Continued review revealed the facility conducted a thorough investigation resulting in suspension and termination of CNT #5 related to the allegation. Review of the Incident/Accident Report dated 6/1/19 revealed Resident #130 .skin unremarkable . Medical record review revealed Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #130 was rarely/never understood. Further review revealed Resident #130 required total assist with one person with bed mobility, dressing and personal hygiene. Medical record review of th… | 2020-09-01 |
| 1475 | 1475 | AHC CUMBERLAND | 445262 | 4343 ASHLAND CITY HIGHWAY | NASHVILLE | TN | 37218 | 2017-10-26 | 333 | E | 1 | 0 | ORE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, Administration History review, and interview, the facility failed to ensure significant medications were administered in a timely manner for 4 residents (#2, #4, #7, #8) of 8 residents reviewed for medication administration. The findings included: Review of facility policy, Medication Administration, revised 9/5/13, revealed .Safe and accurate drug administration requires proficiency with administration techniques, assessment skills, and knowledge of the drugs .Medications should not be administered 60 minutes earlier or later than the scheduled time of administration .Before meals means 15 to 30 minutes before a meal is served .With meals means medications are given during a meal or up to 30 minutes after a meal is eaten .Routine med administration should not occur in the dining room .The nurse must immediately chart the med given on the electronic Medication Administration Record [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Entry Minimum (MDS) data set [DATE] revealed Resident #2 was severely impaired cognitively. Review of the Administration History revealed medications administered to Resident #2 from 10/01/17 - 10/25/17 included: Humalog (insulin) sliding scale insulin: 10/3/17 due at 7:30 AM and given at 9:48 AM;10/5/17 due at 7:30 AM and given at 9:35 AM; 10/05/17 due at 9:00 PM and given at 1:20 AM; 10/10/17 due at 7:30 AM and given at 9:27 AM; 10/11/17 due at 5:30 PM and given at 12:43 AM; 10/14/17 due at 11:30 AM and given at 1:16 PM; 10/14/17 due at 5:30 PM and given at 10:42 PM; 10/14/17 due at 9:00 PM and given at 10:42 PM; 10/16/17 due at 7:30 AM and given at 10:28 AM; 10/17/17 due at 5:30 PM and given at 9:37 PM; 10/20/17 due at 5:30 PM and given at 10:15 PM; 10/21/17 due at 7:30 AM and given at 1:37 PM; 10/21/17 due at 11:30 AM and given at 1:37 PM; 10/21/17 due at 5… | 2020-09-01 |
| 125 | 125 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 609 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, State Survey Agency Facility Reported Incidents database review, and interview, the facility failed to report neglect to the State Survey Agency for 1 (#22) of 38 residents reviewed. The findings include: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revised 5/2019, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, and misappropriation of resident property .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .During orientation all new Stakeholders will be trained on abuse .Each Stakeholder will receive annual training on abuse and neglect policies .The Facility Administrator, or designee, will investigate all such allegations .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Telephone interview with CNA (Certified Nurse Aid) #3 on 8/8/19 at 12:14 PM revealed on 6/18/19 CNA #… | 2020-09-01 |
| 4678 | 4678 | GREENHILLS HEALTH AND REHABILITATION CENTER | 445267 | 3939 HILLSBORO CIRCLE | NASHVILLE | TN | 37215 | 2016-08-11 | 322 | D | 1 | 0 | NRXS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to check gastrostomy tube (GT) placement; failed to irrigate the GT before and after medication administration; failed to change the irrigation set and syringe every 24 hours; failed to monitor for hydration, fluid overload and aspiration; and failed to inspect the surrounding skin of the stoma for 1 (Resident #3) resident of 1 residents reviewed with tube feedings. The findings included: Review of a facility policy titled Enteral Nutrition revised 1/13 revealed, .A resident who is fed by .gastrostomy tube receives the appropriate treatment and services .The nurse checks .gastrostomy placement .periodically during continuous feeding, and prior to flushes and/or medication administration .The nurse irrigates the feeding tube with 30-60 cc (cubic centimeters) tap water before and after administration of medications and 5-10 cc in between administration of multiple medications (or as ordered by the physician), before initiating a feeding, or when there is an interruption of feeding .administration sets are changed every 24 hours .The irrigation syringe is changed every 24 hours .Nursing .routinely monitor the following factors for evaluation of therapeutic efficacy, adverse effects, and clinical changes .Hydration .The resident is evaluated for intolerance to the Enteral feeding regimen .The skin surrounding a gastrostomy .is kept clean and free from irritation and/or infections. The site is evaluated for signs of [DIAGNOSES REDACTED] (redness), Tenderness, Drainage .Key documentation elements: Type, amount, rate of feeding formula; Patency; Tolerance; Condition of stoma site; and Oral hygiene . Medical record review revealed Resident #3 was admitted to the facility on [DATE] at 4:55 PM, and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission assessment dated [DATE] revealed the resident had short and long-term memory los… | 2019-08-01 |
| 3279 | 3279 | THE WATERS OF SMYRNA, LLC | 445502 | 202 ENON SPRINGS ROAD EAST | SMYRNA | TN | 37167 | 2018-01-16 | 661 | D | 1 | 0 | POU411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge, and a post-discharge plan of care for 1 resident (#6) of 5 residents reviewed for transfer/discharge requirements. The findings included: Review of facility policy Transfer and Discharge Policy and Procedure, dated 1/1/17 revealed when a resident was discharged to home or another long-term care facility, staff were to Complete a Discharge Summary Form. Medical record review revealed Resident #6 was admitted to the facility on [DATE] for long term care with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS), 10/1/17 revealed the resident had severe cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 3/15. Continued review of the MDS revealed the resident had delusions, required supervision with ambulation, and wandered daily. Further review of the MDS revealed the resident's behavior of daily wandering did not place her at significant risk of getting to a potentially dangerous location, and did not significantly intrude on the privacy of others. Continued review of the Admission Minimum Data Set (MDS) dated revealed no discharge planning was in effect. Medical record review of the resident's nursing Progress Notes revealed the resident had multiple instances of removing her Wanderguard (personal alarm to notify staff a resident is wihin close proximity to an exit of a set perimeter) device which was worn to prevent elopement. The resident was also able to exit the building on 2 separate occasions - 10/14/17 and 10/18/17. Medical record review of a Discharge Planning/Discharge Progress Note, dated 10/31/17, revealed the facility contacted the family to inform them the resident was not a good fit due to safety concerns and would need to be… | 2020-09-01 |
| 4486 | 4486 | SUMMIT VIEW OF FARRAGUT, LLC | 445258 | 12823 KINGSTON PIKE | KNOXVILLE | TN | 37923 | 2016-09-20 | 309 | D | 1 | 0 | VQPS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to follow the physician's orders for 1 resident (#3) of 7 residents reviewed. The findings include: Review of the facility's job description titled, Treatment Nurse (2003 Med-Pass, Inc.) states, Duties and Responsibilities, Initiate requests for consultation or referral. Respond to requests from the resident, physician, or nursing staff. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. nervous system and sense organs, Personal history of other mental and behavioral disorders, Presence of Aortocoronary Bypass Graft. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 9 out of 10 on Brief Interview for Mental Status indicating the resident had moderate impaired cognition. Continued review revealed the resident required limited assistance of one person with bed mobility and transfers, was totally dependent of 1 person with locomotion on the unit and off the unit, toilet use and bathing, and needed extensive assistance of 1person with dressing and personal hygiene. Continued review revealed the resident received Occupational Therapy and Physical Therapy. Review of the Interdisciplinary Progress Notes (IDT) dated 1/29/16 (late entry) for the Admission entry on 1/27/16, revealed the resident had been admitted for Physical Therapy, had a history of [REDACTED]. Continued review revealed the resident had an AAA surgery pending in 4 to 8 weeks, was diabetic, and had surgical incisions in the right groin and right ankle area. Review of the document (discharge orders) titled, Tennova Healthcare External Skilled Nursing Facility Orders signed and dated by the facility 1/27/16 at 2:40 PM states .12. *Ask vascular surgery for [REDACTED]. Record review of the facility's admission orders [REDACTED]. Interview with the Director of Nursing (DON) and the Wound Care Nurse… | 2019-09-01 |
| 4159 | 4159 | ETOWAH HEALTH CARE CENTER | 445422 | 409 GRADY ROAD, PO BOX 957 | ETOWAH | TN | 37331 | 2016-11-23 | 226 | D | 1 | 0 | 2VL411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to follow their abuse policy for immediate suspension of an employee accused of abusive behavior toward 1 Resident (#1) of 5 residents reviewed. The findings included: Review of the facility policy, Abuse, Neglect & Exploitation Policy & Procedures dated 4/25/16 revealed .Immediately upon receiving an allegation of or when there is a suspicion of abuse, neglect, mistreatment, misappropriation or exploitation, the staff in charge at the facility will protect the resident from harm and conduct a preliminary investigation through interviews with the person alleging or expressing a suspension of abuse .In the event an employee has been identified as the potential perpetrator of the incident, the employee will be suspended from work pending the outcome of the investigation. This can be done by the supervisor of the employee relieving them of all duties pending the outcome of the investigation . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating Resident #1 had moderate cognitive impairment. Review of the staffing schedule dated 10/30/16 revealed Certified Nurse Aide (CNA) #1 was scheduled to work 8 hours on D hallway. Review of the employee time card dated 10/30/16 revealed CNA #1 worked 8.25 hours on D hallway. Review of the facility's investigation, Notice of Suspension, related to allegation of abuse, neglect, exploitation and/or misappropriation of resident property for CNA #1 dated 10/31/16 revealed, .Telephone notification 10/31/16 at 11:15 . Interview with Licensed Practical Nurse (LPN) #1 on 11/21/16 at 2:17 PM, in the conference room confirmed LPN #1 was on duty on 10/30/16. Further interview confirmed Resident #1 alleged CNA #1 had hit him. Continued inter… | 2019-11-01 |
| 3841 | 3841 | BETHESDA HEALTH CARE CENTER | 445427 | 444 ONE ELEVEN PLACE | COOKEVILLE | TN | 38501 | 2017-02-23 | 323 | D | 1 | 0 | DI9N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to implement an intervention to prevent a fall for 1 resident (#2) of 3 residents reviewed for falls of 10 residents reviewed. The findings included: Review of the facility policy, Fall Risk/ Fall Prevention Guidelines, dated 9/2014 revealed, .identifying potential risk factors can assist in preventing falls . our facility must strive to provide a safe environment with methods to reduce accidents . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 6, indicating the resident had severe cognitive impairment. Medical record review of the nurse's event note dated 2/18/17 revealed, . I pivot patient over to wheelchair and as patient bottom sat on wheelchair CNA (Certified Nursing Assistant) stated that patient's wheelchair wasn't locked and wheel chair rolled back . Review of the facility's investigation statement dated 2/18/17 revealed, .heard yelling from the nurse's station went to the end of 400 hall to observe pt (patient) sitting on bottom in bathroom floor . Interview with the ADON (Assistant Director of Nursing) on 2/23/17 at 10:22 AM, in the conference room, confirmed the resident was transferred to an unlocked wheelchair and the CNA's were to lock wheelchairs prior to transferring residents. Further interview confirmed the facility failed to ensure the wheelchair was locked resulting in a fall for Resident #2. | 2020-02-01 |
| 1067 | 1067 | RAINTREE MANOR | 445216 | 415 PACE STREET | MC MINNVILLE | TN | 37110 | 2019-09-25 | 600 | D | 1 | 0 | X6BC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to prevent abuse for 2 residents (#4 and #5) of 5 residents reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Policy and Procedure, revised 2/26/18 revealed, The scope of this program shall apply to the prevention of abuse committed by anyone, including but not limited to, staff, other residents .This facility shall not condone any acts of resident .physical and/or mental abuse .RESIDENT-TO-RESIDENT ABUSE POLICY .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical .abuse from other residents . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Care Plan dated 3/15/18 (active) revealed .(Resident #4) has agitation towards others, verbally abusive toward staff . Medical record review of Resident #4's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating Resident #4 was severely cognitively impaired. Medical record review of Resident #4's Nurse Note dated 9/17/19 revealed .ACCORDING TO RESIDENT (Resident #5) AT APPROXIMATELY 3PM (Resident #4) ENTERED HIS OLD ROOM AND ATTEMPTED TO GET IN HIS OLD BED WHEN (Resident #5) NOW IN THIS ROOM WAS LYIGN (lying) DOWN .(Resident #4) THEN PR[NAME]EEDED TO REMOVE THE BED COVERS AND YELL AT (Resident #5) TO GET OUT OF HIS BED .(Resident #5) DID NOT MOVE AND (Resident #4) BEGAN TO PULL ON HIS CLOTHING UNTIL HE RIPPED (Resident #5's) SHIRT .AT THAT TIME (Resident #5) HIT (Resident #4) IN THE GROIN AND (Resident #4) THEN STARTED TO EXIT ROOM .(Resident #5) CAME TO DOORWAY AND WAS ASKED WHAT HAPPENED TO HIS SHIRT WHEN HE REPORTED THE INCIDENT TO THE 100 HALL NURSE . Medical record review revealed Reside… | 2020-09-01 |
| 2803 | 2803 | SWEETWATER NURSING CENTER | 445456 | 978 HWY 11 SOUTH | SWEETWATER | TN | 37874 | 2017-08-16 | 157 | D | 1 | 0 | 5ODH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to provide notification for a change in health status for 1 resident (#1) of 3 residents reviewed for notification of change. The findings included: Review of the facility policy Changes in a Resident's Condition or Status Effective Date ,[DATE] Revised ,[DATE] revealed .Nursing Services shall be responsible for notifying the Resident and responsible party when: .there is a significant change in the Resident's physical, mental, or emotional status . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] where he subsequently expired. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview of Mental Status was unable to be completed .short term memory problem .long term memory problem .moderately impaired - decisions poor; cues/supervision required . Review of the Nurse Practitioner (NP) note dated [DATE] revealed, .nurse requested visit for decline .was walking when first admitted ; now not walking. On exam resident with respiratory distress, unresponsive .CNA's (certified nurse aides) report some coughing with intake. SLP (speech language pathologist) evaluated yesterday and unable to fully participate with exam .respiratory tachypnea (rapid breathing) . Review of a Physician's Order dated [DATE], revealed, .stat 2 view CXR (chest xray), [MEDICAL CONDITION]. [MEDICATION NAME] stat (now) q (every) 6 hrs (hours) .Respiratory therapy to evaluate .) Review of the Mobile Images (chest xray) report revealed, acute right lower lobe infiltrate . Review of the NP note dated [DATE] revealed, .visit requested by Respiratory Therapy. Resident with shortness of breath and rhonchi . Interview with the Regional Client Operations Consultant on [DATE] at 4:00 PM, in the conference room confirmed expectations were the families … | 2020-09-01 |
| 243 | 243 | NHC HEALTHCARE, MURFREESBORO | 445108 | 420 N UNIVERSITY ST | MURFREESBORO | TN | 37130 | 2020-02-20 | 657 | D | 1 | 1 | PNQL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to revise a care plan for 1 of 52 residents (Resident #47) reviewed for behaviors. The findings include: Review of the facility policy titled, Care Plan Development, revised 7/3/2008, showed care plans were updated as needed, and on quarterly basis within 7 days of completion of the Minimum Data Set (MDS) assessment. Review of the medical record, showed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record, Quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #47 had a Brief Interview for Mental Status score 99 indicating severe cognitive impairment. Continued review showed Resident #47 had behaviors of wandering, hitting, kicking, pushing, scratching, and grabbing others. Review of the care plan dated 7/1/2019, 1[DATE]19, and 11/7/2019 showed no new behavior interventions for Resident #47. Review of the facility investigation dated 1[DATE]19 showed Resident #47 was found in Resident #[AGE]'s room rearranging the sheets on Resident #[AGE]'s bed. Continued review showed the actions of Resident #47 scared Resident #[AGE] and she grabbed Resident #47's hands which caused a skin tear the right hand. Resident #[AGE] had an X-ray of the right 5th digit because of pain due to physical contact with Resident #47. During an interview conducted on 2/20/2020 at 4:40 PM, Social Worker #2 confirmed the behavioral care plan for Resident #47 was not updated to reflect behaviors prior to the resident to resident incident on 11/3/2019. | 2020-09-01 |
| 1348 | 1348 | HARTSVILLE CONVALESCENT CENTER | 445256 | 649 MCMURRY BLVD | HARTSVILLE | TN | 37074 | 2018-01-25 | 600 | D | 1 | 0 | YR5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to, prevent mental abuse for 1 resident (#3) of 3 residents reviewed. The findings included: Review of facility policy revealed Policy and Procedure Abuse, Neglect, Misappropriation of Property & Exploitation undated .the willful infliction of injury, unreasonable containment, intimidation, punishment with resulting physical harm, pain or mental anguish, also includes deprivation of goods/services that are necessary to attain or maintain physical, mental, psychosocial, wellbeing .MENTAL ABUSE- mental abuse includes, but not limited to humiliation, harassment, threats of punishment, or deprivation . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #3 on 1/24/18 at 11:25 AM in her room revealed Resident #3 could not recall what day the incident took place but recalled it was at night. Continued interview revealed Resident #3 stated, The first two women acted like lunatics from the asylum. They came through the door, and were talking together in a foreign tongue. They came together straight to my bed and came at me with their fingers up to my neck. Continued interview revealed Resident #3 stated the Certified Nurse Aide (CNA) stated I'm going to take you out Saturday night and we gonna drink whiskey and get drunk. Continued interview revealed Resident #3 expressed it concerned and scared her. Resident #3 stated she felt staff was making fun of an elderly person by hollering turn out that light. Further interview revealed Resident #3 stated They act like lunatics trying to inflict pain on someone. They were going to flip me and change my diaper, but I wouldn't let them. I'm scared of them. They have frightened me out of my mind. They don't need to be working in a nursing home, that's no way to treat a human being. Further interview revealed Resident #3 stated This has been … | 2020-09-01 |
| 1347 | 1347 | HARTSVILLE CONVALESCENT CENTER | 445256 | 649 MCMURRY BLVD | HARTSVILLE | TN | 37074 | 2018-01-25 | 550 | D | 1 | 0 | YR5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to, provide care in a dignified manner for 1 resident (#3) of 3 residents reviewed. The findings included: Review of facility policy revealed Policy and Procedure Abuse, Neglect, Misappropriation of Property & Exploitation undated .the willful infliction of injury, unreasonable containment, intimidation, punishment with resulting physical harm, pain or mental anguish, also includes deprivation of goods/services that are necessary to attain or maintain physical, mental, psychosocial, wellbeing . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #3 on 1/24/18 at 11:25 AM in her room revealed Resident #3 could not recall what day the incident took place but recalled it was at night. Continued interview revealed Resident #3 stated The first two women acted like lunatics from the asylum. They came through the door, and were talking together in a foreign tongue. They came together straight to my bed and came at me with their fingers up to my neck. Continued interview revealed Resident #3 stated the Certified Nurse Aide (CNA) stated I'm going to take you out Saturday night and we gonna drink whiskey and get drunk. Continued interview revealed Resident #3 expressed concerned and it scared her. Resident #3 stated she felt staff was making fun of an elderly person by hollering turn out that light. Further interview revealed Resident #3 stated They act like lunatics trying to inflict pain on someone. They were going to flip me and change my diaper, but I wouldn't let them. I'm scared of them. They have frightened me out of my mind. They don't need to be working in a nursing home, that's no way to treat a human being. Further interview revealed Resident #3 stated This has been so horrendous; I'm scared it's going to happen every night. Resident #3 informed Social Services Director (… | 2020-09-01 |
| 4716 | 4716 | OVERTON COUNTY HEALTH AND REHAB CENTER | 445419 | 318 BILBREY STREET | LIVINGSTON | TN | 38570 | 2016-08-18 | 314 | D | 1 | 0 | HM2S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to assess pressure ulcers accurately and measure ulcers in a consistent manner for 1 (Resident #4) of 6 residents reviewed. The findings included: Review of facility policy entitled Skin/Wound Management Protocols in the section on Unstageable Pressure Ulcer or Full Thickness Wounds with Eschar or Slough revealed unstageable is defined as .full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed . Topical wound management includes selecting a product that will promote moist wound healing properties. Dressing choice should be determined by wound characteristics such as size, depth, amount of drainage. If the wound does not progress within 2-4 weeks contact a physician for further evaluation For wound with dead space (craters) gently fill with dressing product but do not pack tightly as this will impede healing. Monitor patient for signs and symptoms of infection. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 4/15 on the Brief Interview for Mental Status indicating she was severely impaired cognitively. Continued review of the MDS revealed Resident #4 was totally dependent on 2 staff for transfers and bathing; was totally dependent on 1 person for eating; required extensive assistance of 2 people for dressing and grooming; had a Foley catheter in place; and was frequently incontinent of bowel. Medical record review of the Nursing Admission assessment dated [DATE] revealed Resident #4 had an excoriated area to the right anterior thigh, skin tear to left posterior shoulder, and a skin tear to the right inner thigh. Continued review revealed .Multiple pressure areas noted to buttoc… | 2019-08-01 |
| 4782 | 4782 | CLAIBORNE AND HUGHES HLTH CNTR | 445157 | 200 STRAHL STREET | FRANKLIN | TN | 37064 | 2016-07-14 | 514 | F | 1 | 0 | E5B511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to complete Activities of Daily Living (ADL) Flow Sheet Record forms on 5 (Resident #1, 8, 9, 10, 11) of 5 residents reviewed for pressure ulcers and on 1 (Resident #3) of 6 residents reviewed for ADLs; failed to complete the Diet Flow Sheet for 3 (Resident #2, 7, 10) of 5 residents reviewed for weight loss; and failed to document pressure ulcer care on the Treatment Administration Record (TAR) for 1 (Resident #9 ) of 5 residents reviewed for pressure ulcers. The findings included: Review of the facility policy entitled Turning and Positioning the Resident revealed .Proper positioning and regular repositioning helps to prevent pressure sores, contractures, and stagnation of respiratory secretions. Residents who are unable to reposition themselves should be turned and repositioned every 2 hours . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was dependent on one person for dressing, bathing, grooming, and eating; had a suprapubic (directly into bladder) catheter in place; and was always incontinent of bowel. Further review revealed Resident #1 received tube feeding of Nestle [MEDICATION NAME] at 95 milliliters (ml) per hour for 22 hours and water 60 ml 6 times a day. Medical record review of the Activities of Daily Living, (ADL) Flow Sheet Record (FSR) form revealed the form was completed daily on each shift for residents to depict the resident's performance in bed mobility, transfers, toileting, dressing, fluid intake, grooming, bathing, and bowel and bladder function. Continued review of the form revealed the amount of support provided was also to be documented, including setup, one or two person assist, or activity did not occur the entire shift. Medical record review… | 2019-07-01 |
| 608 | 608 | CLAIBORNE AND HUGHES HLTH CNTR | 445157 | 200 STRAHL STREET | FRANKLIN | TN | 37064 | 2017-05-10 | 280 | D | 1 | 0 | DC3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to complete a care plan within 7 days after the completion of the comprehensive assessment and failed to revise a care plan for behaviors involving hallucinations for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 10/2010 revealed .Our facility's Care Planning/Interdisciplinary Team .develops and maintains a comprehensive care plan .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set) .Assessments of the residents are ongoing and care plans are revised as information about the resident and the resident's condition change .The Care Planning/Interdisciplinary Team is responsible for the review and updating of the care plans . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #1's Brief Interview for Mental Status was 12/15 indicating she was moderately cognitively impaired; had no mood, psychotic episodes or behaviors; she could hear adequately, and she could make herself understood and understood others. Medical record review revealed the care plan following the comprehensive MDS was dated 3/3/17, exceeding the 7 days after the assessment. Medical record review of the nursing notes revealed on 3/9/17 Resident #1 had experienced .hallucinations . Further review of nursing notes revealed the resident was seeing 1 or more children in her room or in her bed. Medical record review of the Social Service progress note dated 3/31/17 revealed .Res (Resident) continues to verbalize hallucinations according to nursing staff . Interview with the MDS Coordinator on 5/8/17 at 4:15 PM in the conference room confirmed Resident #1 had been experiencing visual hallucinations since 3/9/17 and t… | 2020-09-01 |
| 3032 | 3032 | CORNERSTONE VILLAGE | 445483 | 2012 SHERWOOD DRIVE | JOHNSON CITY | TN | 37601 | 2017-05-17 | 314 | D | 1 | 1 | LW9W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to complete skin assessments weekly for 1 (#133) of 3 residents reviewed for pressure ulcers, of 46 residents reviewed. The findings included: Review of the facility policy Pressure Sores, undated, revealed .A licensed nurse will complete a skin assessment weekly . Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged on [DATE]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making, required extensive assistance of one for bed mobility, personal hygiene, and required one person physical assistance for bathing. Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated 1/13/17 revealed a score of 18, indicating mild risk. Medical record review of the Care Plan dated 1/13/17 revealed .Provide extensive assist with bed mobility, transfers and toilet use as needed .Check for incontinence routinely and prn (as needed). Pericare after incontinent episodes . Medical record review of a Dietician Communication/Order Form dated 1/18/17 revealed .Recommend FeSulfate (iron) 325mg (milligrams) and Vit (Vitamin) C 500mg for [MEDICAL CONDITION] . Medical record review of a Skin Evaluation Form dated 2/5/17 revealed .Skin warm and dry to touch with good turgor .Buttocks clear with no open areas and no redness. Bilateral heels are firm and intact . Medical record review revealed the next Skin Evaluation Form in the resident's chart was dated 3/1/17 and revealed .skin has poor turgor and is dusky in color .open area noted on coccyx, foul odor noted with wet brown eschar to wound bed. Immediate surrounding skin is pink and blanchable with butterfly shape. Wound measures 3.2 (centimeters) x (by) 3.3 (centimeters) depth is unknown. R… | 2020-09-01 |
| 759 | 759 | SMITH COUNTY HEALTH AND REHABILITATION | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2020-02-05 | 689 | D | 1 | 0 | 5CUG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to conduct a thorough investigation of falls for 2 (Resident #1 and #3) residents of 3 residents reviewed with falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed the corporation strived to maintain a hazard free environment, mitigate fall risk factors and the implementation of preventative measures. The definition of a fall was considered to be .an unintentional coming to rest on the ground, floor, or the lower level, but not as a result of an overwhelming external force .when a resident is found on the floor, a fall is considered to have occurred . The Procedure included the fall risk assessment as part of the admission, quarterly and when a fall occurred, the identified risk factors should have been evaluated for the contribution they may have to the resident's likelihood of falling and the care plan interventions should have been implemented that addressed the resident's risk factors. Further review revealed if the event the resident fell .the attending nurse shall complete a post fall assessment .includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and the appropriateness of the interventions .nursing staff will observe and document continued resident response and effectiveness of interventions for 72 hours . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION] DISORDER, [MEDICAL CONDITION]… | 2020-09-01 |
| 3396 | 3396 | NASHVILLE CENTER FOR REHABILITATION AND HEALING LL | 445512 | 832 WEDGEWOOD AVENUE | NASHVILLE | TN | 37203 | 2018-12-20 | 661 | D | 1 | 0 | E5NC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to ensure 3 of 11 residents reviewed (#10, #18, and #20) were provided a post discharge plan of care. Additionally, the facility failed to develop a discharge summary for Resident #18. See F622 (Discharge) and F660 (Discharge Planning), for additional information regarding Resident #10. The findings include: Review of facility policy, Discharge Planning, undated, .Development of Discharge Plan .Social Services/designee will coordinate the obtaining of the required information from the Care Plan Team members to include .Current functional status and needs (from each discipline) .Progress notes and any subsequent revisions to the Discharge Plan to be recorded by all disciplines .Social services/designee and the care plan team will make an evaluation of alternate levels of care available, outside support systems available, and factors impacting on the continuous, uninterrupted needs of the resident . The policy did not address the importance of the involvement of the resident and/or their representative in the development of a post discharge plan of care. Medical record review of the Admission Record, revealed Resident #10 was admitted to the facility on [DATE] with dianoses of Altered Mental Status, Metabolic [MEDICAL CONDITION] (abnormal levels of electrolytes, water, and vitamins that possibly affect brain function), muscle weakness, and difficulty walking. Review of the 14 day Admission (MDS) data set [DATE] revealed a Brief Interview for Mental Status score 3 of 15 indicating she was severely cognitively impaired. A comprehensive review of the medical records revealed there was no documented evidence Resident #10, or her representative was provided a post discharge plan of care that was developed with the resident and/or her representative. Interview with the Administrator, Director of Social Services, Rehabilitation Director #109 and the Physical T… | 2020-09-01 |
| 2193 | 2193 | HARRIMAN CARE & REHAB CENTER | 445368 | 240 HANNAH ROAD | HARRIMAN | TN | 37748 | 2018-04-11 | 609 | D | 1 | 0 | IG0J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to ensure an allegation of abuse was reported timely for 1 resident (#2) of 8 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect and Misappropriation of Property dated 11/16/17 revealed .(facility) policy .ensure that all alleged violations of federal or state laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident's property are investigated and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with the Federal and State laws .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made .all allegations and incidents of abuse or neglect, as defined in this policy, will be reported immediately . Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #2 scored a 9 (moderately cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive two staff assist for bed mobility, transfers, dressing, toileting, and personal hygiene. Continued review revealed the resident was frequently incontinent of bladder and always incontinent of bowel. Medical record review of a Nursing Note dated 3/1/18 at 7:14 PM revealed .Late Entry-Spoke with resident (Resident #2) RE (regarding) allegation that a staff member had treated (Resident #2) in an inappropriate manner yesterday .resident unable to recall any happenings . Interview with the Director of Nursing (DON) on 4/11/18 at 7:58 AM, in the conference room, confirmed the two Certified Nursing Assistant… | 2020-09-01 |
| 4432 | 4432 | CREEKSIDE CENTER FOR REHABILITATION AND HEALING | 445516 | 306 W DUE WEST AVENUE | MADISON | TN | 37115 | 2016-10-24 | 514 | L | 1 | 0 | CT4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to ensure medical records were complete and accurate for 7 (Resident #2, #3, #5, #6, #7,#8, #18) residents of 14 residents reviewed by failing to document physician notification of blood glucose results greater than 400; failing to document recheck of abnormal blood glucose values in 15 minutes; failing to document blood glucose monitoring and tube feedings as ordered by the physician; and failing to document tube feedings administered when a resident's meal intake was decreased. These failures resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) for all facility residents. The Administrator (NHA) was notified of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Review of facility policy, Change in a Resident's Condition or Status, undated, revealed, .To insure the proper and timely .documentation of any changes in a resident's condition or status .The nurse will record in the resident's medical record any changes in the resident's medical condition or status . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars) .document the treatment of [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD(Medical Doctor) .351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . Medical record review of the 6/2016 Medication Administration … | 2019-10-01 |
| 2501 | 2501 | NHC HEALTHCARE, FARRAGUT | 445415 | 120 CAVETT HILL LANE | KNOXVILLE | TN | 37922 | 2017-10-25 | 323 | D | 1 | 1 | 1WES11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to ensure the safety of 1 resident (#366) of 3 residents reviewed for accidents. The findings included: Review of the Facility Policy Falls revised 7/14/17, revealed, .Assessment and Recognition .As part of the initial assessment .identify individuals with history of falls and risk factors for subsequent falling .based on preceding assessment .identify pertinent interventions to try to prevent subsequent falls . Medical record review revealed Resident #366 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) 5 Day Scheduled assessment dated [DATE], revealed Resident #366 required extensive assistance with activities of daily living (ADLs) and 2 person physical assist for transfers. Medical record review of Resident #366's Completed Care Plan dated 8/30/17, revealed no documentation the resident required 2 person physical assist with transfers. Medical record review of the MDS 30 Day Scheduled assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, meaning the resident was cognitively intact. Continued review revealed Resident #366 required extensive assistance with ADLs and 2 person physical assist for transfers. Medical Record review of the MDS Unscheduled assessment dated [DATE] revealed Resident #366 required 2 person physical assist for transfers. Medical record review of the Post Falls assessment dated [DATE] at 10:00 PM, revealed, .transfer from recliner to wheelchair and patient was facing recliner with wheelchair behind her when patients knees seemed to buckle. Patient's legs gave out and patient started going down .gently lower patient to knees on the floor . Continued review revealed, .immediate interventions .2 person assist for all transfers . Further review revealed one staff person was present to assist during the transfer. Medical Record re… | 2020-09-01 |
| 1825 | 1825 | WYNDRIDGE HEALTH AND REHAB CTR | 445304 | 456 WAYNE AVENUE | CROSSVILLE | TN | 38555 | 2018-08-29 | 689 | G | 1 | 1 | 6O4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to ensure the safety of 2 residents (#19, #4) of 6 residents reviewed for accidents, of 31 sampled residents. The facility's failure to ensure a safe transfer resulted in actual Harm to Resident #19 when the resident received a fractured femur from an improper transfer. The findings include: Review of the Facility Policy, Falls Management, undated, revealed, .Policy: Residents at risk for falls are identified to prevent future falls and maintain maximum level of function through use of interventions, as appropriate. Procedures: 1. A fall assessment will be completed on admission, quarterly (following the MDS (Minimum Data Set) schedule) and as needed. 2. The Care Plan will reflect measures implemented to prevent falls as appropriate. 3.) The Committee members will maintain/monitor as indicated .New interventions to Care Plan . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #19's Significant Change of Status, MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired with decisions of daily care. Continued review revealed the resident required extensive assistance with activities of daily living (ADLs), and 2 person assist for transfers and toileting. Medical record review of Resident #19's care plan initiated 1/26/16 and revised 10/4/17, revealed an intervention for assistance for the resident of 1-2 persons with transfers as needed and the use of a gait belt. (A gait belt is a device used by caregivers to transfer care receivers with mobility issues from one position to another, from one location to another or while assistively ambulating patients who have problems with balance.) Medical record review of a Fall Risk assessment dated [DATE] revealed Resident #19 was a high r… | 2020-09-01 |
| 3389 | 3389 | NASHVILLE CENTER FOR REHABILITATION AND HEALING LL | 445512 | 832 WEDGEWOOD AVENUE | NASHVILLE | TN | 37203 | 2017-09-27 | 281 | D | 1 | 0 | 9IDG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to follow Physician order [REDACTED].#3) of 8 residents reviewed for medication administration. The findings included: Review of facility policy, Medication Administration, revealed .Nursing Care Center Pharmacy and Procedure Manual .Medications are administered in accordance with written orders of the prescriber . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED].[DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Medical record review of the Narcotic Sheet dated 5/15/17 revealed [MEDICATION NAME]-[MEDICATION NAME] 10-325, 1 tablet every 6 hours for pain were not signed out on 5/15/17 for the 12:00 AM dose or the 6:00 AM dose. Telephone interview on 9/27/17 at 2:00 PM with Licensed Practical Nurse (LPN) #15 revealed the resident had left the faciity on [DATE] with family and returned around 11:00 PM that night. Further interview revealed the day shift nurse had given the resident her night medication (which included her pain medication) to take with her because she wouldn't be back in the facility until later that night. Continued interview revealed the resident requested her night medication when she returned at 11:00 PM and LPN #15 told her she couldn't give her the night medication again because she had taken it with her when she left the facility and this would over medicate her. Further interview revealed the resident was told if she had any pain to let her know and she would ask her supervisor what she could do. Continued interview revealed she helped the resident use the bedside commode and get into bed and never heard anything else from the resident that night. Further interview revealed LPN #15 did not give the12:00 AM dose of her pain medication because… | 2020-09-01 |
| 1806 | 1806 | LIFE CARE CENTER OF ELIZABETHTON | 445302 | 1641 HIGHWAY 19E | ELIZABETHTON | TN | 37643 | 2017-11-01 | 309 | D | 1 | 1 | VBW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to follow a physician's order for [MEDICAL CONDITION] care and failed to process a physician's order for an antibiotic for 1 resident (Resident #138) of 25 residents reviewed. The findings included: Review of the facility policy, Administration of Medication not dated revealed, .medications are administered safely .appropriately .initial each medication in the correct box on the MAR (medication administration record) after the medication is given .circle initials on MAR indicated [REDACTED].check .drawers .if it was placed in the wrong drawer .call the pharmacy or supervisor to obtain the medication . Review of the facility policy [MEDICAL CONDITIONS], or [MEDICATION NAME], revised 11/28/16 revealed, .procedure developed to provide a safe standard method for the care and maintenance of a patient with a [MEDICAL CONDITION] .physician's order will be obtained for ostomy care .regarding appliance .barrier .skin care .documentation .time .initials of person doing treatment .develop the comprehensive person-centered careplan . Review of the facility policy Physician's Orders/Transcription revised 10/2004 revealed .proper channels of communication are used to ensure accurate delivery of medications and treatments .receiving an order .physician .must write order on order sheet .each time .nurse charts .physician orders section should be checked for new orders .sign .order sheet .indicating orders have been transcribed .draw line on order sheet below the order .send copy to pharmacy . Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #138 had a Brief Interview of Mental Status (BIMS) score of 12, indicating Resident #138 had moderate cognitive impairment. Continued review revealed Resident #138 required limited assistance of one person p… | 2020-09-01 |
| 4223 | 4223 | CREEKSIDE CENTER FOR REHABILITATION AND HEALING | 445516 | 306 W DUE WEST AVENUE | MADISON | TN | 37115 | 2016-12-14 | 281 | E | 1 | 0 | 0GRH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to follow physician's orders for medication administration for four residents (#15, #22, #25, #36) of 37 residents reviewed for medication administration, and failed to follow physician's orders for administration of tube feeding for 1 resident (#13) of 3 residents reviewed for tube feeding. The findings included: Review of facility policy, Identifying and Managing Medication Errors and Adverse Consequences, revised (MONTH) 2007, revealed .The staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. The staff and practitioner shall strive to minimize adverse consequences by: (a) following relevant clinical guidelines and manufacturer's specifications for use. (b) defining appropriate indications for use . Medical record review revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 was moderately impaired cognitively. Continued review of the MDS revealed Resident #15 required extensive assistance with transfers, dressing, and grooming; was dependent for feeding and bathing; and was always incontinent of bowel and bladder. Medical record review of physician's orders dated 12/6/16 revealed an order for [REDACTED]. which was documented as administered. Further review of physician's orders revealed Resident #15 was also being treated for [REDACTED]. Continued review of orders dated 12/7/16 revealed orders for .[MEDICATION NAME] 40 mg IM x1 . and .[MEDICATION NAME] 20 mg po (orally) daily for [MEDICAL CONDITIONS] . Medical record review of the Medication Administration Record (MAR) revealed one sheet with the [MEDICATION NAME] 40 mg IM documented as administered on 12/8/16 at 3:00 PM. Continu… | 2019-11-01 |
| 4812 | 4812 | GRACE HEALTHCARE OF WHITES CREEK | 445281 | 3425 KNIGHT DRIVE | WHITES CREEK | TN | 37189 | 2016-07-08 | 281 | E | 1 | 0 | TQUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to follow the facility policy on Intake and Output for 3 (Resident #1, 3, 4) of 3 residents reviewed; failed to document the use of [MEDICAL CONDITION] (Continuous Positive Airway Pressure) on the Medication Administration Record [REDACTED]. The findings included: Review of the facility policy entitled Intake and Output, Conditions Requiring, revealed .Recording of Intake and Output will be done with the goal of providing continuing assessment information, therefore the Physician and or the Director of Nursing/Nurse Managers may place a resident on Intake and Output or discontinue Intake and Output if the resident's clinical condition deems appropriate . 2. Residents with the following conditions and [DIAGNOSES REDACTED]. Residents with a Foley catheter .d. Residents on fluid restriction .3. Nursing staff will record Intake and Output per facility documentation protocols . Review of the facility policy entitled Fluids, Restricted revealed . It is the policy of this facility to safely provide to the resident the amounts of fluids indicated by the physician's order .Fluids will be provided upon request and at times designated . Fluids consumed by the resident are to be accurately measured and recorded. Intake record should be maintained during the time the resident is on restricted fluids . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 8 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #1 required extensive assist with transfers; was independent with eating; was incontinent of bowel; and had a Foley catheter in place. Medical record review revealed Resident #1 was admitted … | 2019-07-01 |
| 4715 | 4715 | OVERTON COUNTY HEALTH AND REHAB CENTER | 445419 | 318 BILBREY STREET | LIVINGSTON | TN | 38570 | 2016-08-18 | 281 | D | 1 | 0 | HM2S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to follow their policy to obtain urine cultures for residents with cloudy urine for 1 (Resident #4) of 6 residents reviewed. The findings included: Review of policy entitled Culture tests and confirmed by the DON on 8/16/16 at 3:30 PM as being the policy the facility currently follows, revealed .Urine cultures may be obtained by the Charge Nurse if a resident develops cloudy urine or other signs of urinary tract infection. An order from the physician must be obtained before the specimen is sent to the laboratory . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 4/15 on the Brief Interview for Mental Status indicating she was severely impaired cognitively. Continued review of the MDS revealed Resident #4 was totally dependent on 2 staff for transfers and bathing; was totally dependent on 1 person for eating; required extensive assistance of 2 people for dressing and grooming; had a Foley catheter in place; and was frequently incontinent of bowel. Medical record review of a communication with the physician dated 12/29/15 revealed .Family noted dark colored urine which they verbalized was indicative of a UTI (urinary tract infection). (MONTH) we obtain UA (urinalysis) to verify? . Continued review revealed the physician responded on 1/2/16 to obtain one by an in and out catheterization. Further review revealed a note from the physician's office dated 1/4/16 stating .do not obtain UA D/T (due to) ABT (antibiotics) in use . Medical record review of nursing notes dated 1/13/16 revealed Resident #4 had a Foley catheter which was draining cloudy urine with sediment. Continued review of notes dated 1/15/16 revealed the Foley catheter was draining cloudy yellow urine with moderate amount of sediment… | 2019-08-01 |
| 4843 | 4843 | NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C | 445373 | 202 EAST MTCS ROAD | MURFREESBORO | TN | 37130 | 2016-07-26 | 514 | D | 1 | 0 | AK2Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to have neurological assessments readily accessible for review during the survey for 1 (Resident #3) of 3 residents reviewed for falls. The findings included: Review of the facility policy Neurological Assessment, dated 9/2014, revealed .Falls that occur and a patient hits their head or if the fall is unobserved and the possibility is there that a patient may have hit their head, a neurological assessment must be conducted to evaluate for possible impairment . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Monthly Falls Tracking Form, the facility documentation of the event and/or the investigation, and review of the medical record of the physician orders and progress notes revealed Resident #3 had the following: 1.) On 1/6/16 at 7:30 AM had an unobserved fall, was an unassisted self transfer from the wheelchair and was found on the floor next to the wheel chair. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 1/6/16 revealed an order for [REDACTED]. 2.) On 1/15/16 at 9:00 AM had an unobserved fall, was found lying on the floor mat next to the resident's bed. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 1/15/16 revealed an order for [REDACTED]. 3.) On 1/29/16 at 7:00 AM had a witnessed fall from the wheelchair to the floor hitting her head. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 2/1/16 revealed an order for [REDACTED].F/U (follow-up) fall/laceration Fore head/ .neurochecks 4.) On 6/6/16 at 1:15 AM had an unwitnessed fall from the wheelchair to the floor. Review of the … | 2019-07-01 |
| 57 | 57 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2017-07-19 | 225 | D | 1 | 1 | 788Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to investigate injuries of unknown origin for 1 resident (#379) and failed to initiate an investigation in a timely manner for a missing pain patch for 1 resident (#168) of 35 residents reviewed in Stage II. The findings included: Review of facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property, and Exploitation, revised 11/28/16 revealed .abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .An injury should be classified as an injury of unknown source when both of the following conditions are met: (a) The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and (b) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property, or exploitation did or did not take place .The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident . Review of facility policy, Miscellaneous Special Situations, Discrepancies, Loss and or Diversion of Medications, dated 6/2016 revealed .All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed .Immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator, Director of Nursing (DON), Consultant Pharmacist and Director of Pharmacy are notified and an investigation co… | 2020-09-01 |
| 3309 | 3309 | NEWPORT HEALTH AND REHABILITATION CENTER | 445504 | 135 GENERATION DRIVE | NEWPORT | TN | 37821 | 2017-05-24 | 205 | F | 1 | 1 | 8GYB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to issue a written bed-hold policy to the resident and responsible party for 10 of 10 residents (#162, #142, #121, #85, #63, #54, #33, #30, #28 and #27) reviewed for admission, transfer, and discharge rights of 27 residents reviewed. The findings included: Review of Bed Hold/Leave of Absence policy revision date: (MONTH) (YEAR) '' .Upon admission or Leave of Absence, a facility designee will provide the resident and/or responsible party written information concerning the option to exercise the Bed Hold/Leave of Absence Policy .Upon leave of absence, a Bed Hold Authorization form is distributed to the resident and/or responsible party .'' Medical record review revealed resident #162 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) discharge records dated 11/23/16 and 1/17/17, revealed the resident was transferred to the hospital on [DATE] and on 1/17/17. Medical record review continued and revealed a written notice of the bed-hold policy was not issued. Medical record review revealed the following 9 residents were hospitalized without documentation of a bed-hold policy being issued: Resident #142 was hospitalized [DATE]-4/5/17; Resident #121 was hospitalized [DATE]-2/28/17; Resident #85 was hospitalized [DATE]-2/18/17; Resident #63 was hospitalized [DATE]-4/11/17; Resident #54 was hospitalized [DATE]-4/11/17; Resident #33 was hospitalized [DATE]-4/28/17; Resident #30 was hospitalized [DATE]-3/31/17; Resident #28 was hospitalized [DATE]-2/2/17; and Resident #27 was hospitalized [DATE]-1/24/17. Interview with the Director of Nursing (DON) on 5/24/17 at 10:40 AM, in the conference room, confirmed the facility had not provided written information concerning the bed-hold policy the 2 times Resident #162 was transferred to the hospital. Continued interview revealed, .I could not find anythi… | 2020-09-01 |
| 4813 | 4813 | GRACE HEALTHCARE OF WHITES CREEK | 445281 | 3425 KNIGHT DRIVE | WHITES CREEK | TN | 37189 | 2016-07-08 | 514 | E | 1 | 0 | TQUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to maintain a complete and accurate medical record for [MEDICAL CONDITION] (Continuous Positive Airway Pressure) use for 2 (Resident #1, 6) of 3 residents reviewed for [MEDICAL CONDITION] use; for fluid restriction for 3 (Resident #1, 3, 4) of 3 residents reviewed for fluid restriction; for physician orders for 1 (Resident #2) of 9 residents reviewed; and for transcription error for 1 (Resident #7) of 9 residents reviewed. The findings included: Review of the facility policy entitled [MEDICAL CONDITION]/[MEDICAL CONDITION] Support revealed .Documentation .General Assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; Time [MEDICAL CONDITION] was started; duration of the therapy; Mode and setting for the [MEDICAL CONDITION]/ .Oxygen concentration and flow, if used; How the resident tolerated the procedure; Oxygen saturation during therapy . Review of the facility policy entitled Intake and Output, Conditions Requiring, revealed .Recording of Intake and Output will be done with the goal of providing continuing assessment information . 2. Residents with the following conditions and [DIAGNOSES REDACTED]. Residents with a Foley catheter .d. Residents on fluid restriction .3. Nursing staff will record Intake and Output per facility documentation protocols . Review of the facility policy entitled Fluids, Restricted revealed . It is the policy of this facility to safely provide to the resident the amounts of fluids indicated by the physician's order .Fluids will be provided upon request and at times designated . Fluids consumed by the resident are to be accurately measured and recorded. Intake record should be maintained during the time the resident is on restricted fluids . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [D… | 2019-07-01 |
| 5334 | 5334 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2016-03-17 | 514 | D | 1 | 0 | RDMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to maintain accurate medical records for addressing allergies [REDACTED].#1 and #9) of 5 records reviewed for allergies [REDACTED].>The findings included: Review of the facility policy, reviewed 6/1/15, entitled allergies [REDACTED].Guidelines for Obtaining Information at Time of Admission: Obtain allergy information from the resident regarding past history of allergies [REDACTED].Record stated allergy information .On front of medical record cover . Medical record review revealed Resident #1 was admitted to the facility, from another nursing facility, on 6/12/15 with [DIAGNOSES REDACTED]. Continued record review of the transferring facility discharge physician orders revealed the resident was allergic to [MEDICATION NAME] and [MEDICATION NAME]. Medical record review of the Admitting Physician's Order Sheet dated 6/12/15 revealed .Drug allergies [REDACTED]. although the discharging facility physician orders documented the allergies [REDACTED]. Medical record review of the TB Screening and Immunization Record form, with the allergy section including .[MEDICATION NAME] and PCN ([MEDICATION NAME]) ., dated 6/13/15 revealed a TB test to the .R (right) forearm .Result of Test .+ (positive) .chest x-ray - (negative) .See EMAR (computerized Medication Administration Record) . Further review revealed the form included no documentation under the section addressing .Chest X-Ray .Results . Medical record review of the Nurse's Note dated 6/16/15 at 5:30 PM revealed .Daughter informed nurse today that her mother was allergic to [MEDICATION NAME] that she got red areas on her arm. Nurse noted raised areas to TB site. Daughter .stated I forgot to tell you, you all will have to cover that up to prevent mother from scratching. Area covered with bandage to prevent scratching. Allergy noted on E-ZMAR (computerized MAR/EMAR) per DON (Director of Nursing) instructions .Dau… | 2019-03-01 |
| 3326 | 3326 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2019-05-21 | 842 | D | 1 | 0 | T9UH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to maintain accurate medication administration record for 1 of 3 residents (#1) reviewed. The findings include: Review of the facility policy revised 2/2018, Protection of Residents: Reducing the Threat of Abuse and Neglect revealed .Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone .It is the policy of this facility to screen staff (as defined in this policy) for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit abuse, neglect, and exploitation of resident property .The deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongs or money without the resident's consent. Residents' property includes all residents' possessions, regardless of their apparent value to others since they may hold [MEDICATION NAME]'s value to the resident . Review of the facility policy revised 1/1/13, Inventory of Controlled Substances revealed .The facility should routinely reconcile the number of doses remaining in the packages to the number of remaining doses recorded on the controlled Substances Verification/Shift Count Sheet, to medication administration record . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment Medical record review of the care plan dated 4/26/19 revealed .Resident at risk of pain. Risk factors include: Pancreatitis (inflammation of the pancreas), pancreatic CA (cancer), kidney stones . Medical record review of the Discharge Patient Medication Report dated 4/25/19 revealed .[MEDICATION NAME]/apap ([MEDICATION NAME]) (pain m… | 2020-09-01 |
| 757 | 757 | SMITH COUNTY HEALTH AND REHABILITATION | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2020-02-05 | 580 | D | 1 | 0 | 5CUG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the Resident's Representative of a fall for 1 resident (Resident #3) of 3 residents reviewed for falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed .the responsible party should be notified . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING [MEDICAL CONDITION], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, and MAJOR [MEDICAL CONDITION]. Medical record review of the Face Sheet for Resident #3 revealed Family Member #3 was listed as the Contact/Emergency Contact #1. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. Medical record review revealed the following: On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5, revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (patient - (Resident #3) lying face down on the floor. there was a fair amount of blood on floor .pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek . On 1/10/2020, of the Post Fall Review, written by LPN #5, revealed Resident #3 had an unwitnessed fall on 1/9/2020 at 12:50 PM. Further review revealed the .Family/Responsible Party was notified on 1/9/2020 at 2:00 PM and named the specific family member. Further review revealed the specified family me… | 2020-09-01 |
| 5033 | 5033 | CREEKSIDE CENTER FOR REHABILITATION AND HEALING | 445516 | 306 W DUE WEST AVENUE | MADISON | TN | 37115 | 2016-06-16 | 157 | G | 1 | 0 | GZPX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician of a pressure ulcer for 1 (Resident #1) resident of 12 residents reviewed for pressure ulcers. The facility's failure to notify the physician of the pressure ulcer resulted in Actual Harm to Resident #1. The findings included: Facility policy review titled Wound Care Management, dated 3/13/15 revealed, .Notify the .physician .of the presence of the wound and if the resident .has a negative change in the wound appearance . Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15/15 indicating the resident was cognitively intact. Continued review of the MDS revealed the resident had no pressure ulcers and was always incontinent of urine and bowel. Medical record Review of the POS [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] at 4:27 AM by Licensed Practical Nurse (LPN) #1, revealed documentation of the presence of a Pressure Ulcer in the skin portion of the assessment for Resident #1. Medical record review of the Departmental Notes dated 3/17/16 at 10:39 AM, by LPN #2, documented .late entry for 3/16/16: resident also has noted open area on coccyx . Medical record review of the Skin Concerns Roster dated 3/17/16 at 5:27 PM by RN #1 revealed, Yes skin concern-nurse notified. Medical record review of the Skin Inspection Report for Resident #1 dated 2/15/16 through 5/4/16 revealed the following: 3/17/16 Skin Not Intact-Existing by LPN #3 4/22/16 Skin Not Intact-New by RN #2 4/27/16 Skin Not Intact-Existing by LPN #4 5/4/16 Skin Not Intact-Existing by LPN #4 Medical record review of the Wound Assessment Report by LPN #5… | 2019-06-01 |
| 4422 | 4422 | CREEKSIDE CENTER FOR REHABILITATION AND HEALING | 445516 | 306 W DUE WEST AVENUE | MADISON | TN | 37115 | 2016-10-24 | 157 | K | 1 | 0 | CT4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician of residents with a blood glucose greater than 400 for 5 (Resident #2, #6,#5, #7, #8) of 12 residents reviewed for Diabetes Mellitus. These failures placed all diabetic residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death or a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:15 PM in the Conference Room. The findings included: Review of facility policy, Change in Resident's Condition or Status, undated, revealed, .To insure the proper and timely reporting and documentation of any changes in a resident's condition or status .Nursing services will notify the resident's attending physician when .there is a significant change in the resident's physical, mental or psychosocial status .there is a need to alter the resident's treatment .Deemed necessary or appropriate in the best interest of the resident . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated revealed, .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter). The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD (Medical Doctor) .351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:… | 2019-10-01 |
| 604 | 604 | CLAIBORNE AND HUGHES HLTH CNTR | 445157 | 200 STRAHL STREET | FRANKLIN | TN | 37064 | 2017-05-10 | 157 | D | 1 | 0 | DC3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician the ordered urine analysis (U/A) and culture was not obtained for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Policy for MD/RP (Medical Doctor/Responsible Party) Notifications, undated revealed .PURPOSE: To keep the physician, who is in charge of the medical care .informed of the resident's medical condition .STANDARD: Notification of the physician .should occur promptly, according to federal regulations, when there is a change in the resident's condition . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].U/A + (and) culture . Medical record review of the Lab Log, with Licensed Practical Nurses (LPN's) #2 and #3 present, revealed the 3/23/17 U/A order was documented in the Lab Log to be obtained on 3/24/17. Further review revealed a written notation .Unable to Obtain . Interview with LPN's #2 and #3 on 5/9/17 at 3:00 PM at the 1 East nursing station confirmed the 3/23/17 U/A and culture order had been documented in the Lab Log and the facility was not able to obtain a specimen. When the LPN's were asked if the physician had been notified the U/A had not been obtained, the LPN's confirmed the facility failed to notify the physician until 5/8/17. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:25 PM in the Administrator's office confirmed the facility failed to notify the physician the U/A had not been obtained and seek further instructions. | 2020-09-01 |
| 609 | 609 | CLAIBORNE AND HUGHES HLTH CNTR | 445157 | 200 STRAHL STREET | FRANKLIN | TN | 37064 | 2017-05-10 | 281 | D | 1 | 0 | DC3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to obtain a physician order [REDACTED]. The findings included: Review of facility policy, Medication and Treatment Orders, revised 2/2014 revealed .Orders for medications and treatments will be consistent with principles of safe and effective order writing .shall be administered only upon the written order . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].DC (discontinue) zinc oxide cream (ointment for skin treatment) to buttock and groin q (every) shift and as needed . Further review revealed no physician signed telephone order or physician signed computerized order to initiate the the zinc oxide treatment. Medical record review of the 2/2017 and 3/2017 Treatment Administration Records revealed the zinc oxide treatment was administered from 2/15/17 to 3/13/17. Interview with Licensed Practical Nurse (LPN) #2 on 5/10/17 at 9:30 AM at 1 East nursing station confirmed she had written the 3/13/17 discontinuation of zinc oxide order. LPN #2 reviewed the telephone and computerized physician orders [REDACTED]. Interview with the Administrator on 5/10/17 at 10:45 AM in the conference room confirmed the facility failed to follow the facility policy to only administer medications and treatments after a physician order [REDACTED]. | 2020-09-01 |
| 114 | 114 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-01-15 | 690 | D | 1 | 1 | W7UH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to obtain physician orders [REDACTED].#25) of 39 residents reviewed. The findings include: Review of the undated facility policy, Physician Orders, revealed .orders given by Physician/Medical Practitioner .notification to family/POA (Power of Attorney) via telephone .New order documented in nursing notes that order was received and family notified . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #25's physician's orders [REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #25 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact. Medical record review of Resident #25's Daily Skilled Nurse's Notes for 12/1/18 thru 12/10/18 revealed no documentation regarding an order for [REDACTED].>Interview with Resident #25 on 1/13/19 at 9:24 AM in her room revealed she stated The head nurse (the former Director of Nursing (DON)) came to help put a catheter in one evening, not sure if there was an order or not. Continued interview revealed she reports there were several people in the room trying to help place the catheter. She stated the nurse, the one not here because she was fired, asked her if she could place the catheter to get a urine sample because she was sick. She stated the nurse told me she was worried about me. I told her she could go ahead and put the catheter in. Continued interview revealed she stated I asked her if she had an order and she said yes. Interview with the Nurse Practitioner on 1/13/19 at 11:29 AM in the West dining room confirmed an order was not obtained for Resident #25 to be catheterized. Interview with Registered Nurse (RN) #4 on 1/14/19 at 3:49 PM at the North hall nursing station revealed she assisted the former DON in performing an intermitte… | 2020-09-01 |
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CREATE TABLE [cms_TN] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );