cms_TN
Data source: Big Local News · About: big-local-datasette
14,361 rows sorted by standard
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard ▼ | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 14071 | 14071 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2010-05-05 | 431 | D | M4JO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to date a medication when opened and failed to discard expired supplies in three of five supply cabinets. The findings included: Observation on [DATE], at 10:30 a.m., with Licensed Practical Nurse (LPN) #2, of the 2 North supply cabinet revealed the following: Four, vacutainer tubes (used for blood specimens) available for resident use, with an expiration date of February, 2009. Two vacutainer tubes available for resident use, with an expiration date of November, 2009. Nine packages of suction swabs (active ingredient hydrogen peroxide 1.5%) available for resident use, with an expiration date of 2007. One 20 milliliter container of Lidocaine 1%, opened and undated. Interview on [DATE], at 10:30 a.m., with LPN #2, on the 2 North Hall confirmed the supplies had expired and the Lidocaine was opened and undated. Observation on [DATE], at 11:10 a.m., with LPN #3, of the 3rd floor supply cabinet revealed the following: Sixteen 40 milliliter containers of Bact/Alert (used for arterial blood gases) available for resident use with an expiration date of [DATE], and sixteen 40 milliliter containers of Bact/Alert available for resident use, with an expiration date of [DATE]. Interview on [DATE], at 11:10 a.m., with LPN #3, on the 3rd floor, confirmed the supplies had expired. Observation on [DATE], at 12:45 p.m., with LPN #4, of the 100 South supply cabinet revealed the following: Five vacutainer tubes available for resident use, with an expiration date of November, 2009. Interview on [DATE]. at 12:45 p.m., with LPN #4, on the 100 South Hall, confirmed the supplies had expired. | 2014-04-01 | ||
| 14072 | 14072 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2010-05-05 | 314 | D | M4JO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, manufacture recommendations, observation and interview, the facility failed to ensure the specialty mattress was set accurately for two residents (#11, #1) of twenty- five residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the residents weight dated May 3, 2010, was131 lbs (pounds). Medical record review of the physician's orders [REDACTED]. Review of the name brand manufacture recommendations revealed "...The comfort control LED displays the patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure levels depending on the patient weight..." Observation and interview with the Wound Care Nurse on May 5, 2010, at 11.00 a.m., revealed the resident lying supine in the bed on the specialty mattress. Continued observation revealed the control panel set on 5 (for weight of 175 to 210 lbs). Interview with the Wound Care Nurse at the time, confirmed the specialty mattress is set depending on the resident's weight, and the current setting of 5 was not accurate for the resident's current weight. Resident #1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Medical record review of the care plan dated March 25, 2010, revealed "...apply air mattress to bed..." related to the risk of impaired skin integrity due to impaired mobility and [MEDICAL CONDITION]. Medical record review of the Weight Chart dated May 1, 2010, revealed the resident's weight of one hundred seventy-six pounds. Observation on May 3, 2010, at 10:30 a.m., May 4, 2010, at 8:00 a.m., and May 5, 2010, at 7:45 a.m., revealed the resident lying in a bed equipped with a Low Air Loss and Alternating Pressure Mattress. Continued observation revealed a control pump, with a pressure adjust knob and markings to indicate the resident's weight in pounds. Further observation revealed the pr… | 2014-04-01 | ||
| 14073 | 14073 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2010-05-05 | 281 | D | M4JO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to follow a Physician's order for one resident (#16) of twenty five residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's order dated April 21, 2010, revealed clean skin tear area on top of L (left) forearm with normal saline and pat dry. Apply dressing and cover with gauze and change every other day. Medical record review of the Physician's order dated April 25, 2010, revealed clean skin tear on right forearm with normal saline cover with dressing and cover with gauze, change every other day. Observation on May 3, 2010, at 9:10 a.m. revealed the resident seated on the bed. Continued observation revealed dressings to the right and left forearm dated April 29, 2010. Both dressings had been in place for 5 days. Interview with the Wound Care Nurse on May 3, 2010, at 9:15 a.m., confirmed the dressings were dated April 29, 2010, and the Physician's order to change the dressings every other day had not been followed. | 2014-04-01 | ||
| 14074 | 14074 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2010-05-05 | 166 | D | M4JO11 | Based on review of the resident council minutes, and interviews, the facility failed to resolve grievances in a timely manner for three of three months reviewed. The findings included: Review of the resident council minutes dated February 5, 2010, March 5, 2010, and April 2, 2010, revealed "...doesn't receive meds in timely manner...once in awhile late on giving medications...medication/timing issue with shots...medicine is sometimes late...when I ask for pain pill I don't get them..." Further review, revealed no documentation of follow up addressing the grievances. Interview with the resident council on May 3, 2010, at 2:30 p.m., in the one-south dayroom, revealed three residents voiced grievances of medication not given in a timely manner. Interview on May 5, 2010, at 1:30 p.m., with the Director of Social Services in the ground level in-service room, confirmed, "...I agree. We need to be more proactive with follow ups...I understand we need something on paper stating how the grievances have been addressed..." Interview with the DON (Director of Nursing), on May 5, 2010 at 9:30 a.m., in the DON's office confirmed the facility failed to resolve grievances in a timely manner. | 2014-04-01 | ||
| 14075 | 14075 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2010-05-05 | 502 | D | M4JO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of medical record review, and interview, the facility failed to obtain laboratory services for one resident (#1) of twenty-five reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]." Medical record review of lab results revealed no documentation for a PT/INR completed on April 26, 2010, as ordered by the physician. Interview on May 5, 2010, at 8:30 a.m., with LPN (Licensed Practical Nurse) #4, at the nurse's station on one south, confirmed the facility failed to obtain the PT/INR as ordered by the physician. | 2014-04-01 | ||
| 14076 | 14076 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2010-07-21 | 441 | D | CKRK11 | Based on observation and interview, the facility staff failed to wash the hands during a dressing change for one (#12) of twenty-five residents reviewed. The findings included: Observation on July 20, 2010, at 2:02 p.m., revealed Licensed Practical Nurse (LPN) #1 providing wound care to resident #12. Observation revealed LPN #1 removed a dressing from resident #12's right hand, and described the wound on the right wrist as a Stage III pressure area with a small amount of serous drainage. Observation revealed LPN #1 cleansed the wound with wound cleanser, and without changing the gloves or washing the hands, applied ointment and a dressing to the wound. Interview on July 20, 2010, at 3:15 p.m., with the Director of Nursing, at the nursing station, revealed the hands were to be washed after cleansing a wound prior to applying ointment or a clean dressing. Interview on July 20, 2010, at 2:25 p.m., with LPN #1, in the hallway, confirmed the gloves were not changed and the hands were not washed after cleansing the wound prior to applying ointment and a clean dressing. | 2014-04-01 | ||
| 14077 | 14077 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2010-07-21 | 280 | D | CKRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to revise the care plan for one resident (#9) with a history of falls of twenty-five residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no problems with memory, required moderate assistance with decision making, and extensive assistance with transfers. Review of the medical record revealed the resident had a history of [REDACTED]. Review of the facility's documentation dated September 22, 2009, revealed, "PT (Resident) found lying in the floor beside of bed on fall mat...Intervention...Low Bed..." Review of the facility's documentation dated April 8, 2010, revealed."PT (Resident) was found lying on floor in room...Intervention...Up in Geri-chair as tolerated." Review of the current care plan dated November 4, 2009, revealed no documentation for the use of a Geri- chair or a low bed. Observation on July 19, 2010, at 9:30 a.m., 10:30 a.m., and on July 20, 2010, at 8:30 a.m., revealed the resident sitting in a Geri-chair, in the resident's room. Continued observation revealed a low bed in the resident's room. Interview with the unit one risk manager on July 20, 2010, at 10:05 a.m., in the conference room, confirmed the care plan had not been revised until July 19, 2010, to reflect the use of a low bed and a Geri-chair. | 2014-04-01 | ||
| 14078 | 14078 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2010-06-15 | 323 | D | 4BZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one (#20) resident of thirty-one residents reviewed. The findings included: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, moderately impaired cognitive skills for daily decision making, and required extensive assistance for transfers. Medical record review of the High Risk Patient Selection Form dated March 11, 2010, and May 27, 2010, revealed the resident had fallen in the past 30 days and the past 31-180 days. Medical record review of the post falls nursing assessment dated [DATE], revealed, "...fell from wheelchair...on floor with WC (wheelchair) on top of (resident) safety belt still hooked to (resident) ...What immediate interventions were initiated to prevent future falls?...Anti Tipper Bars to WC..." Medical record review of the post falls investigation dated April 19, 2010, revealed, "...Type of injury: Bruise Head...Anti Tip Bars ordered for w/c..." Observation with LPN #1 (Licensed Practical Nurse), in the resident's room, on June 15, 2010, at 9:25 a.m., revealed the resident seated in the wheelchair without the antitipper bars on the wheelchair. Interview with LPN #1, on June 15, 2010, at 9:30 a.m., in the nursing station, confirmed the anti tippers are to be on the wheelchair. | 2014-04-01 | ||
| 14079 | 14079 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2010-06-15 | 425 | D | 4BZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the pharmacy delivery record and interview, the facility failed to ensure medication was available to meet the needs for one (#4) resident and failed to document the administration of three doses of a narcotic for one resident (#15) of thirty-one residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's progress note dated April 21, 2010, revealed, " ...recurrent cystitis...resistant pseudomonas...Tx (treat) (with) Aztreonam (antibiotic) 1 gram IM (intramuscular) q (every) 12 (hours) x 7 days..." Medical record review of a physician's orders [REDACTED]. Medical record review of the MAR (Medication Administration Record) dated April 2010, revealed the Aztreonam was circled as not administered on April 22, 2010, at 9 a.m., and 9 p.m., April 23, 2010, at 9:00 a.m., April 24, 2010, at 9:00 a.m., and 9:00 p.m., April 29, 2010, at 9:00 p.m., and April 30, 2010, at 9:00 p.m. Medical record review of the Nurse's Medication Notes (back of MAR) revealed, "...4/22/10 9 p Aztreonam 1 g IM (not) available from pharmacy...4/23/10 9 A Aztreonam...(not) available from pharmacy ...4/24/10 9 pm Aztreonam...(not) available from pharmacy...4/29/10 9 pm Aztreonam...not available...4/30/10 9 pm Aztreonam...not available ..." Review of the pharmacy delivery record dated April 24, 2010, revealed the Aztreonam 1 Gram was delivered on April 24, 2010. Interview on June 14, 2010, with RN #1 (Registered Nurse) at 10:30 a.m., in the Charge Nurse's office, confirmed the medication was not available for the resident. Review of the Narcotic Tracking/Destruction Log for June 2010, for resident #15, revealed four doses of Oxycodone 5 mg. was signed out for June 6, 2010. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. signed out on June 6, 2010. Interview with head nurse #2 on June 15… | 2014-04-01 | ||
| 14080 | 14080 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2010-06-15 | 322 | D | 4BZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to properly position the head of bed for resident (#7); failed to provide nutritional support as ordered for resident (#27); and failed to ensure assigned responsible staff administered nutritional support for resident (#9) of thirty one residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated June 1, 2010, to June 30, 2010, revealed, "...GLUCERNA 1.5...75ML/HR (milliliters per hour) X (times)21 HRS...OFF AT 1PM - ON AT 4PM...ASPIRATION PRECAUTIONS: HOB (head of bed) > (greater than) 30 DEGREES WHILE TF (tube feeding) IN PROGRESS..." Observation in the resident's room on June 13, 2010, at 10:15 a.m., revealed the resident lying on a Clinitron bed with the tube feeding in progress and the head of the bed elevated 20 degrees. Continued observation on June 14, 2010, at 8:40 a.m., revealed the resident lying on the Clinitron bed with the tube feeding in progress and the head of the bed elevated 19 degrees. Interview with Registered Nurse (RN) #2 in the resident's room on June 14, 2010, at 9:00 a.m., confirmed the facility failed to properly elevate the head of the bed greater than 30 degrees as ordered. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated June 1, 2010, to June 30, 2010, revealed, "[MEDICATION NAME] 1.5 @ (at) 70ML/HR X 20 HR...(OFF 10AM-2PM)..." Observation in the resident's room on June 14, 2010, at 3:05 p.m., and 3:50 p.m., revealed the resident sitting in a recliner with the tube feeding pump positioned directly behind the resident and was not turned on. Interview with RN #2 in the resident's room on June 14, 2010, at 3:50 p.m., confirmed the facility failed to ensure the feeding pump was turned on as ordered. Resident #9 … | 2014-04-01 | ||
| 14081 | 14081 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2010-06-15 | 250 | D | 4BZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure resident's needs were met by providing social services for one resident (#6) of thirty one residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge summary dated November 19, 2009, revealed the resident was fifty years old, had a bilateral below the knee amputation. Continued review revealed the resident had left hand digit amputation (2-5), and on April 28, 2010, had a revision of the bilateral above the knee revision. Observation of the resident on June 13, 2010, at 3:25 p.m., revealed the resident sitting. Interview with the resident at the time of observation revealed the resident explained the removal of both legs, and partial removal of the digits on both hands. Medical record review of the social services notes revealed no documentation the social services had addressed the loss of the lower extremities and the digits (fingers). Interview with the Master Social Worker on June 14, 2010, at 11:30 a.m., in the unit manager's office, confirmed the issue of the amputations had not been addressed. . | 2014-04-01 | ||
| 14082 | 14082 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2010-06-15 | 280 | D | 4BZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to develop a care plan that addressed the psychosocial needs for one resident (#6) of thirty one residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge summary dated November 19, 2009, revealed the resident was fifty years old, had a bilateral [MEDICAL CONDITION]. Continued review revealed the resident had left hand digit amputation (2-5), and on April 28, 2010, had a revision of the bilateral above the knee revision. Observation of the resident on June 13, 2010, at 3:25 p.m., revealed the resident sitting in a wheel chair. Interview with the resident at time of observation revealed the resident explaining the removal of both legs, and partial removal of the digits on both hands. Medical record review of the care plan dated May 5, 2010, revealed the psychosocial needs following amputations had not been addressed. Interview with the Unit Manager of 500 Hall, on June 14, 2010, at 11:30 a.m., confirmed the care plan had not addressed the psychosocial needs of the resident have bilateral leg amputation and partial removal of fingers on both hands. | 2014-04-01 | ||
| 14083 | 14083 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2010-06-15 | 281 | D | 4BZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to provide medication requested by one (hospice) resident (#15), of thirty-one residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had difficulty with long and short term memory, moderate difficulty with decision making skills, usually understood, and usually understands verbal information content. Continued review of the MDS revealed the resident had [MEDICAL CONDITION]/change in usual sleep pattern, no verbal or social behaviors, no difficulty with perception or awareness of surroundings, and no problems with mental function over the course of the day. Continued review of the MDS revealed the resident required assistance of staff with all activities of daily living Interview with the resident on June 14, 2010, at 9:15 a.m., in the resident's room, revealed the resident alert and oriented x three (person, place and time), responded appropriately to questions and statements. Continued interview with the resident revealed a request was made at approximately 10:00 p.m., on June 13, 2010, for an [MEDICATION NAME], for complaints of anxiety/anxiousness. Continued interview revealed the resident stated, "I felt awful, I thought I would come out of my skin, and I woke up hurting." When asked if the resident received it, stated "no, I never received it all night." When asked if the resident received an explanation why it was not given then or later, the resident stated, "no". Continued interview with the resident revealed the understanding the night medication had been given earlier; however, the resident stated was having anxiety/anxiousness. Medical record review revealed physician's orders [REDACTED]. by mouth every 2 hours as needed for severe anxiety". Review of the Medication Administration Reco… | 2014-04-01 | ||
| 14084 | 14084 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2010-06-15 | 221 | D | 4BZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to assess for the use of a restraint for one (#8) resident, and failed to ensure the restraint for one (#20) resident was secured according to the manufacturer's recommendation, of thirty-one residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had difficulty with long and short term memory and difficulty with decision making skills. Continued review of the MDS revealed the resident was dependent on staff for all activities of daily living, including feeding. Observation on June 13, 2010, at 2:45, and 4:00 p.m., revealed the resident in the day room, on 2-E, seated in a Geri Chair with a lap tray attached. Observation on June 13, 2010, at 3:30 p.m., revealed the resident at the Nurses Station on 2-E, seated in a Geri Chair with a lap tray attached. Medical record review of the physician's orders [REDACTED]. Pt. (patient) non-ambulatory. Check q (every) 30 min. Release. Reposition q 2hrs. and toilet as needed." Review of the Physical Therapy notes dated June 2, and June 9, 2010, revealed the resident continues to receive Therapy, noting the resident was able to ambulate 300 - 800 feet with minimal to moderate assist and three sit and rests. Interview with Physical Therapy Assistant #1 on June 15, 2010, at 10:10 a.m., by phone, revealed the resident received Physical Therapy and confirmed the resident is transported to and from the Therapy Department by Geri Chair with the lap tray attached. Interview with Head Nurse #2, on June 14, 2010, at 8:55 a.m., in the resident's room, confirmed the resident's Geri Chair was used because the resident attempted to get out of the Geri Chair and confirmed the lap tray had not been assessed for use as a restraint. Resident #20 was admitted to the facility on [DATE], with [DIAG… | 2014-04-01 | ||
| 14085 | 14085 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2010-06-15 | 514 | D | 4BZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to maintain documentation of services provided for one resident (#30); and ensure accurate sliding scale orders were obtained for one resident (#19) of thirty one residents reviewed. The findings included: Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed no documentation resident had received a shower three times per week as per care plan. Interview with the DON (Director of Nursing) on June 14, 2010, at 10:20 a.m., in the conference room, confirmed no documentation to show resident received a shower as planned. Resident # 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the referring facility's physician's orders [REDACTED]. (patient) from...(referring facility) to (current facility)...Continue current MAR (Medication Administration Record) see Discharge MAR. Check BG (blood glucose) AC (before meals) & HS (at bedtime). Pt is on [MEDICATION NAME] Sliding (sliding scale insulin) see MAR..." Review of the referring facility's Medication Status record dated May 29, 2010, and faxed to the facility June 1, 2010 at 1:47 p.m., revealed, "[MEDICATION NAME] Subcutaneous Solution 100 Units/ML (milliliter) SS (sliding scale) coverage unit qid (four times per day) subcut.(subcutaneously). [MEDICATION NAME] per sliding scale: BG 111-150 I unit, BG 151-200 2 units, BG 201-250 3 units, BG 251-300 4 units, BG 301-350 6 units, BG 351-400 9 units, BG >(greater than) 400 9 units and call hospice MD; <(less than) 70 call hospice MD and titrate hypoglycemic protocol..." Review of the physician's orders [REDACTED].S. BID (two times per day): 111-150= 1U (unit); 151-200=2U; 201-250=3U; 251-300=4U; 301-350=6U; 351-400=9U; >400=9U and call MD..." Review of the facility Medication Record for June, 2010, revealed, "[MEDICATION NAME] 100U/1 ML Vial for Humalog-[MEDICATION NAME] Insulin S.S. BI… | 2014-04-01 | ||
| 14086 | 14086 | ALEXIAN VILLAGE OF TENNESSEE | 445123 | 671 ALEXIAN WAY | SIGNAL MOUNTAIN | TN | 37377 | 2010-12-02 | 226 | D | 0P9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility policies and investigations, and interview, the facility failed to implement policies and procedures to ensure freedom from abuse for one resident (#2) of six residents reviewed and for seven of nine sitters. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired memory and cognition, and required total assistance with all activities of daily living. Observation of the resident on November 23, 2010, at 9:00 a.m., revealed the resident was sitting in a chair in the hallway and made brief eye contact, but did not attempt any verbalizations. Medical record review of a Nursing Progress Note dated October 4, 2010, at 5:00 p.m., revealed, "CNA (certified nurse aide) came to nurse and said that volunteer was 'hitting (resident #2).' This nurse went immediately to res (resident) & took over feeding. Res had no obvious injury or emotional distress. CNA states that vol (volunteer) 'smacked (resident #2's) hand and that (resident #2) attempted to hit (volunteer) back.' When (resident #2) swung at vol...again 'smacked (resident #2's) hand' and said if you hit me, I will hit you back...RN (registered nurse) was immediately called and volunteer was removed from room. Res hands had no marks and were not red." Medical record review of a Nursing Progress Note dated October 5, 2010, at 11:00 a.m., revealed, "...Res continues to show no S&S (signs and symptoms) of any type distress related to the incident." Medical record review revealed documentation the resident was not showing any signs of distress on October 6, 2010, at 6:00 p.m., October 7, 2010, at 5:00 p.m., and October 8, 2010, at 8:30 a.m. Medical record review of the Quality of Life Progress Notes revealed: "10-5-10 SW (social worker) notified of situation that occurred on 10/4 with vol… | 2014-04-01 | ||
| 14087 | 14087 | NHC HEALTHCARE, SPARTA | 445130 | 34 GRACEY ST | SPARTA | TN | 38583 | 2010-08-19 | 221 | D | RVKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure one resident (#1) of twenty two residents remained restraint free. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physical Restraints RAP Narrative dated March 22, 2010, revealed "Resident will use side rail on left side of bed to pull and hold to." Medical record review of the comprehensive care plan dated May 6, 2010, revealed "...risk for falls...I have a history of attempting transfer unassisted...Assist me with my current task when I am attempting to transfer unassisted." Medical record review of the certified nurse assistant Patient Specific Information revealed, "...siderails...x1 (times one) to left side-fall risk." Medical record review of the quarterly minimun data set (MDS) dated [DATE], revealed no side rail of any type in use. Observation on August 18, 2010, at 7:30 a.m., revealed resident in bed with full side rails up on both sides of the bed. Interview on August 18, 2010 at 9:30 a.m., with the 300 Unit Manager revealed only one side rail should be up on the back (left side) of the resident's bed. | 2014-04-01 | ||
| 14088 | 14088 | NHC HEALTHCARE, SPARTA | 445130 | 34 GRACEY ST | SPARTA | TN | 38583 | 2010-08-19 | 250 | D | RVKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide medically related social services needed for two residents (#4 & #16) of twenty-two residents reviewed. The findings included: Resident #4 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated July 7, 2010, revealed the resident had a short term memory problem and had modified independence for decision making. Medical record review revealed the resident had received Speech Therapy from readmission, had a Modified Barium Swallow Study on June 10, 2010, and afterwards had the diet upgraded to Mechanical Soft with chopped meat, no straws. Medical record review of the physician's progress note of August 5, 2010, revealed, "...resident wanting PEG (percutaneous feeding tube) removed..." Medical record review of the physician's orders [REDACTED]. Medical record review of the social services notes dated August 12, 2010, revealed "Pt. will be staying long term...unable to go home because friends state...no where to go." Observation and interview of the resident at 1:30 p.m., in the resident's room on August 18, 2010, revealed the resident had finished eating lunch in bed. Interview revealed the resident was reluctant to be interviewed, but the resident verified a plan to eventually leave the nursing home and stated, "First, I need to get this tube out...I don't know how it got there..." Interview with the social services assistant (SSA) verified resident #4 would not be able to return to previous home due to it being sold. Interview revealed the SSA stated the resident was followed by "a psych nurse" and a licensed counselor/social worker (LCSW). Interview verified the SSA had not spoke with the resident, LCSW, or the psych nurse since the information in the social services note of August 12, 2010, was given to the SSA by the resident's friend. During interview, the SSA stated the psych nu… | 2014-04-01 | ||
| 14089 | 14089 | NHC HEALTHCARE, SPARTA | 445130 | 34 GRACEY ST | SPARTA | TN | 38583 | 2010-08-19 | 441 | E | RVKN11 | Based on observation and interview the facility failed to store linen in a manner to prevent the spread of infection. The findings included: Observation on August 17, 2010, at 9:30 a.m.; August 18, 2010, at 2 p.m.; and August 19, 2010, at 9:00 a.m., revealed linen on the floor in the 100 unit clean linen closet and on the floor in the 200 unit clean linen closet. Observation revealed those items to include blankets, sheets, and one Hoyer lift pad. Interview on August 19, 2010, at 9:00 a.m., with the maintance staff confirmed the linen should be stored off the floor. | 2014-04-01 | ||
| 14090 | 14090 | NHC HEALTHCARE, SPARTA | 445130 | 34 GRACEY ST | SPARTA | TN | 38583 | 2010-08-19 | 253 | E | RVKN11 | Based on observation and interview the facility failed to maintain a clean environment during the initial tour of the facility. The findings included: Observation during the initial tour of the facility on August 19, 2010, at 9:00 a.m., in the presence of maintenance staff, the following was revealed: 1. Air conditioner covering and vent dirty in room 210. 2. Personal fan dusty in room 223. 3. Over the bed tables soiled with dried substance in rooms 222, 223, 305, 317. 4. Feeding tube pole with dried substance on the pole bases in room 105 and room 218. Interview with the maintenance staff on August 19, 2010, at 9:30 a.m., confirmed the facility failed to maintain a clean resident environment. | 2014-04-01 | ||
| 14091 | 14091 | NHC HEALTHCARE, SPARTA | 445130 | 34 GRACEY ST | SPARTA | TN | 38583 | 2010-08-19 | 356 | D | RVKN11 | Based on observation and interview the facility failed to post the daily staffing in a prominent place, in a clear and readable format. The findings included: Observation on August 17, 2010, from 9:15 a.m., to 4:30 p.m., August 18, 2010, from 7:15 a.m., to 5:15 p.m., and on August 19, 2010, from 7:15 a.m., to 8:45 a.m., of the three main entrances to the facility revealed no posting of the daily staffing for the facility's three units. Interview on August 18, 2010, at 8:50 a.m., in the conference room with the administrator, revealed the administrator was unsure where the staffing was posted but believed it was on station 2. Observation and interview on August 19, 2010, at 8:55 a.m., with the administrator and the director of nursing on station 2 revealed a white piece of paper with the staffing printed, in a clear plastic sleeve taped to the medication room window. Interview with the administrator and the director of nursing at the time of the observation confirmed the public could not easily find and read the staffing posted on the medication room window. | 2014-04-01 | ||
| 14092 | 14092 | NHC HEALTHCARE, SPARTA | 445130 | 34 GRACEY ST | SPARTA | TN | 38583 | 2010-08-19 | 371 | F | RVKN11 | Based on observation and interview the facility failed to store, prepare and serve food under sanitary conditions in the main kitchen and on the 300 unit. The findings included: The following observations were made in the kitchen on August 18, 2010, at 11:00 a.m.: 1. Heavy dark substance build up on the dish rack caddy in the dishroom. 2. Dark substance around the opening of the ice machine. 3. Food Spillage in the reach in cooler. 4. Dried food spillage around the base of the steam table. 5. Dried food spillage on the condiment cart. 6. Grease and dust buildup on the exaust hood. 7. Grease and dust buildup between the convection oven and the range. Continued observation at 11:22 a.m., during the noon meal service on the 300 unit revealed the following: 1. Regular cottage cheese served at 49 degrees. 2. Pureed cottage cheese served at 54 degrees. 3. Mixed fruit served at 54 degrees. Interview with the dietary manager on August 18, 2010, at 2:00 p.m., confirmed the cold food was not served at the proper temperature of 40 degrees and that areas of the kitchen were not clean. Observation on August 17, 2010, at 9:35 a.m., of the unit three nutrition room revealed the ice machine had several areas of a dark substance on the serving area, water from the ice machine running onto the floor, around the rusting metal doorpost out onto the floor in the hallway, and dark substances on the shelf and wall near the ice machine. Observation and interview on August 19, 2010, at 1:30 p.m., of the unit three nutrition room with the unit three manager revealed the ice machine had several areas of a dark substance on the serving area, water from the ice machine running onto the floor and around the rusting metal doorpost out onto the floor in the hallway, and dark substances on the shelf and wall near the ice machine. Interview with the unit three manager confirmed the ice machine/nutrition room was not sanitary. | 2014-04-01 | ||
| 14093 | 14093 | NHC HEALTHCARE, SPARTA | 445130 | 34 GRACEY ST | SPARTA | TN | 38583 | 2010-08-19 | 279 | D | RVKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to develop a comprehensive care plan for one (#17) resident's AICD (automatic implantable cardio-defibrillator) of twenty-two residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's [DIAGNOSES REDACTED]. Observation and interview with the resident on August 17, 2010, in the resident's room at 9:40 a.m., revealed the resident was alert, oriented, and able to converse and share recent medical history. Observation of the resident at 9:20 a.m., on August 19, 2010, revealed the resident up in the hall ambulating independently with a walker. Interview with LPN #1 on August 19, 2010, at 9:10 a.m., at the Station 1 nursing desk verified the resident's chart was not marked with an alert for the presence of an AICD. Interview confirmed LPN #1 had not previously been aware the resident had an implanted defibrillator. Interview confirmed the medical record did not define safety precautions due to the presence of the AICD and did not define whether the AICD included a pacemaker. Medical record review of the care plan with LPN #1 verified the AICD was not included in the resident's plan of care. Interview with LPN #1 at 10:00 a.m., on August 19, 2010, in the conference room, revealed the resident's cardiologist had been contacted within the last hour and LPN #1 was informed the resident had an appointment to see the heart doctor in September to have the AICD and pacemaker checked. During interview, LPN #1 stated the facility didn't have a defined procedure or protocol to address residents with an AICD and the LPN confirmed the assessment and care planning of the resident by the nursing staff had not included the AICD. | 2014-04-01 | ||
| 14094 | 14094 | NHC HEALTHCARE, SPARTA | 445130 | 34 GRACEY ST | SPARTA | TN | 38583 | 2010-08-19 | 246 | D | RVKN11 | Based on observation and interview the facility failed to provide a comfortable shower room for one shower room (unit 3) of three units in the facility. The findings included: Observation on August 19, 2010, at 9:00 a.m., in the unit 3 shower room revealed Certified Nurse Assistant (CNA) #1 assisted resident #6 with a shower. Observation revealed the room had no source of heat and the room was cool with cold air flowing from the vent in the ceiling, the resident complained frequently of being "cold", and the resident's hands and feet were a light blue color. Interview on August 19, 2010, at 9:05 a.m., with CNA #1 confirmed the shower room was cool with the cold air flowing from the ceiling vent; the staff had no means of warming the room for the resident's comfort; and the staff "just tries to hurry." Interview on August 19, 2010, at 10:15 a.m., in the conference room with the administrator confirmed the shower room on unit 3 was cool with the air conditioning in use and no source of heat for residents comfort during a shower. | 2014-04-01 | ||
| 14095 | 14095 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-08-10 | 431 | D | BD4V11 | Based on observation, and interview, the facility failed to discard expired medications and failed to date medications when opened in one of four medication rooms. The findings included: Observation on August 10, 2010, at 9:40 a.m., of the second floor medication room, with LPN (Licensed Practical Nurse) # 1 revealed the following in the medication refrigerator: three, ten milliliter bottles of Humalog Insulin, one approximately ? full, and two approximately 3/4 full, available for resident use, opened, and undated; two, ten milliliter bottles of Lantus Insulin, one approximately ? full, one approximately ? full, available for resident use, opened and undated; One, ten milliliter bottle of Novolin R Insulin, approximately1/2 full, with an opened date of July 3, 2010, and an expiration date of August 2, 2010; One, ten milliliter bottle of Novolin R Insulin, approximately ? full, with an opened date of July 2, 2010, and an expiration date of August 1, 2010. Interview on August 10, 2010, at 9:40 a.m., with LPN #1, in the second floor medication room, confirmed the insulin was available for resident use, the Humalog and Lantus Insulin was not dated when opened, and the Novolin R Insulin had expired. | 2014-04-01 | ||
| 14096 | 14096 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-08-10 | 456 | D | BD4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain equipment for one (#28) of thirty-seven residents reviewed. The findings included: Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on August 9, 2010, at 4:00 p.m., revealed the resident in the dining room, seated in a gerichair. Continued observation revealed the left arm on the gerichair was torn, with the wood and screws exposed. Observation with LPN (Licensed Practical Nurse) #1, on August 10, 2010, at 9:15 a.m., revealed the resident in the dining room, seated in a gerichair. Continued observation revealed the left arm of the gerichair torn, with the wood and screws exposed. Interview on August 10, 2010, at 9:15 a.m., with LPN #1, in the dining room, confirmed the gerichair was in need of repair. | 2014-04-01 | ||
| 14097 | 14097 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-08-10 | 157 | D | BD4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility policy, and interview, the facility failed to notify the physician timely for a change in condition for one (#27) of thirty-seven residents reviewed. The findings included: Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nurse's note dated January 23, 2010, revealed, "...P (pulse) 103...B/P (blood pressure) 76/40 5:30 A (a.m.) Resident unable to arouse to verbal stimuli-skin pale in color-resp (respirations) slow (and) shallow opens eyes to painful stimuli ...will continue to monitor...5:35 A Supervisor notified of (change) in condition...5:45 A Spoke (with) (named family member) (and) informed of decline in condition (named family member) request we send resident to (named hospital)...6:15 A T.O. (telephone order) received to transfer resident to...ER (emergency room )...6:30 A (ambulance) called to transport resident to...ER...4 p.m. Call placed to (hospital)-informed of admitting (diagnosis) MS (mental status) (change)[MEDICAL CONDITION]" Review of the facility policy "Change in a Resident's Condition or Status", revealed, "...The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been...A significant change in the resident's physical/emotional/mental condition...Except in medical emergencies, notifications will be made within twenty-four...hours of a change occurring in the resident's medical/mental condition or status..." Interview on August 10, 2010, at 12:45 p.m., in the lower level conference area, with the Director of Nursing, confirmed the physician was not notified timely of the change in the resident's status. | 2014-04-01 | ||
| 14098 | 14098 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-08-10 | 226 | D | BD4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, a review of facility investigations, and a review of the facility policy on abuse and neglect, the facility failed to promptly report an allegation of abuse for one resident (#19) and failed to thoroughly investigate an allegation of neglect for one resident (#11) of thirty-seven residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS), dated [DATE], revealed the resident had no short or long term memory impairment; required extensive assistance with transfers and dressing; was total care for hygiene and bathing; and was continent of bowel. Review of facility policy "Resident Abuse, Neglect and Misappropriation Prevention Program (RANMP)" revealed "Investigation--All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility...An immediate investigation into the alleged incident, during the shift it occurred on, is initiated as follows: 1. Interview the resident or other resident witnesses...The interview is to be dated, documented and signed by the nursing supervisor. A sampled 'Resident Interview Form' is attached...2. Interview the staff member implicated. Have the employee document their knowledge/version of the incident in a written narrative that is dated and signed. A (An) 'Employee/Witness Investigation Statement' is attached...3. Interview all staff on that unit, as well as other staff or other available witnesses. Witnesses are to document their knowledge of the incident in a written narrative, signed and dated, on the 'Employee/Witness Investigation Statement' form." Review of facility grievances revealed a "Concern/Comment Report", dated March 8, 2010, for the resident "Concern/Comment...only 1 sit to stand on floor, took 1 hour to take to bathroom and had BM (bowel movement) on self...Investigation Findings...There was only… | 2014-04-01 | ||
| 14099 | 14099 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-08-10 | 323 | D | BD4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure supervision while eating for one resident (#18) on aspiration precautions of thirty-seven residents reviewed. The findings included: Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the patient was sent to the hospital on July 31, 2010, and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Outpatient Modified Barium Swallow Study (MBSS) dated July 23, 2010, and signed by the Nurse Practitioner July 30, 2010, revealed, "...Moderate pharyngeal dysphagia...Mechanical Soft diet with regular liquids. No straws. Chin tuck with all liquids. Pt (patient) will require supervision and/or assist with all intake in order to complete chin tuck with each liquid swallow 2* (secondary to) impaired cognition...Spoke c/ (with) pt's RN (registered nurse)...re:(regarding) need for chin tuck to prevent aspiration..." Medical record review of a physician's orders [REDACTED]. Recommend nectar c/ chin tuck @ (at) this time..." Medical record review of a physician's orders [REDACTED]. Recommend assist/supervision @ meals...cue chin tuck c/ swallow." Medical record review of the hospital discharge orders dated August 5, 2010, revealed, "...Feed pt. Aspiration Precautions." Medical record review of the Care Plan dated January 18, 2010, and updated August 5, 2010, revealed, "...Aspiration Precautions." Medical record review of a physician's orders [REDACTED]. Medical record review of the Initial Care Plan dated August 5, 2010, revealed, "...Pt to be fed, Institute Aspiration Precautions..." Medical record review of the Initial Care Plan dated August 5, 2010, revealed a handwritten note, "Diet (change) 8-8-10 Puree texture w/assist/supervision (with assist/supervision) Nectar thick liquids." Observations of the resident, in the resident's room, on August 8, 2010, at 9:40 a.m., a… | 2014-04-01 | ||
| 14100 | 14100 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-08-10 | 514 | D | BD4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure an accurate medical record for one resident (#9) of thirty-seven residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated July 24, 2010, revealed, "Sitting in W.C. (wheelchair) in front of A building in the visitors parking lot...states 'I've got to get away from that idiot in my room.' 'I can't even (expletive) without (roommate) looking at me.' 'I'll be as crazy as (roommate) if I don't get away.' Updated elopement assessment, and supervisor, and (family member) made aware. Picture of this resident placed c/ (with) switchboard operator. Brought back to floor and directed to dining room c/ magazine away from roommate for the moment. Communication form completed." Medical record review, on August 8 and 9, 2010, of the Social Services notes and the Care Plan revealed no documentation Social Services had addressed the issues of attempted elopement or roommate conflict and compatibility. Medical record review, on August 10, 2010, at 10:30 a.m., revealed a Social Services note dated August 3, 2010, with the Social Services follow-up of the incident and "...Care Plan updated..." Further medical record review revealed the Care Plan had a handwritten update regarding the incident and was dated July 24, 2010. Medical record review and interview with Social Worker #1 on August 10, 2010, at 10:45 a.m., at the nursing station, confirmed the Social Worker had not documented in the medical record regarding the resident's attempted elopement and roommate conflict until the morning of August 10, 2010, and had inaccurately dated the Care Plan update as July 24, 2010, and the Social Services note as August 3, 2010. | 2014-04-01 | ||
| 14101 | 14101 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-08-10 | 281 | D | BD4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain clarification of a physician's order and follow the physician's order for one resident (#9) of thirty-seven residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was sent to the hospital on April 27, 2010, and returned to the facility on [DATE], following a repair of a fractured left hip. Medical record review of a medication prescription dated May 3, 2010, revealed the resident was to receive [MEDICATION NAME] (pain medication) 5 mg (milligrams) every 6 hours as needed for pain, and the prescription was for 20 tablets. Medical record review of the MAR (Medication Administration Record) for May 3, 2010, revealed the resident received 29 tablets of [MEDICATION NAME] May 4 through May 30, 2010. Medical record review of the MAR for June and July, 2010, revealed the resident received the [MEDICATION NAME] June 4, 8, 9, 10, 15, 18, and July 29. Medical record review of the MAR for August, 2010, revealed the resident did not receive any [MEDICATION NAME]. Medical record review of a progress note dated July 16, 2010, revealed, "[MEDICATION NAME] (pain medication) prescription was for 20 tab only & should have been dc'd (discontinued)..." Medical record review of a physician's order dated July 16, 2010, revealed, "...DC [MEDICATION NAME]" Medical record review of the physician's orders and MAR for July, 2010, revealed the resident was not receiving [MEDICATION NAME], but was still receiving [MEDICATION NAME]. Interview with LPN #3 (Licensed Practical Nurse) and review of the resident's medical record on August 10, 2010, at 10:35 a.m., at the nursing station, confirmed the resident did not have an active order for [MEDICATION NAME] on July 16, 2010; the hospital had written the [MEDICATION NAME] prescription for only 20 tablets; the resident had continued to receive … | 2014-04-01 | ||
| 14102 | 14102 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-08-10 | 246 | E | BD4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to serve meals according to resident preferences for four (#20, #21, #26, #29) of thirty-seven residents reviewed. The findings included: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated May 17, 2010, revealed the resident had no memory or cognitive impairments. Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had some short term memory problems, and no long term or cognitive impairments. Resident #26 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had no memory or cognitive impairments. Observation of the breakfast tray delivery on August 8, 2010, revealed the breakfast trays were delivered to residents #20, #21, #26, and #29 between 9:30 a.m., and 9:50 a.m. Interview with resident #20 on August 8, 2010, at 9:15 a.m., in the resident's room, revealed the only complaint the resident had was eating too late at night. Further interview revealed the evening meal sometimes does not arrive until 8:00 p.m., and "that is too late for old people." Further interview revealed the resident had complained to the nursing assistants on multiple occasions and was told "someone called off" and was the reason the trays were late. Further interview revealed the resident did not feel the excuse was reasonable. Interview with resident #21 on August 8, 2010, at 9:28 a.m., in the resident's room, revealed the resident's only complaint was evening meal trays were delivered too late. Further interview revealed the evening meal was usually around 7:30 p.m. Further interview revealed the resident did not like to eat that late and if the … | 2014-04-01 | ||
| 14103 | 14103 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-12-20 | 226 | D | T7FZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation documentation, review of facility policy, and interview, the facility failed to implement the abuse policy for one resident (#1) of six sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility documentation dated October 23, 2010 revealed, "At approximately 3 p (p.m.) today...talking with (certified nursing assistant - CNA #3)...(CNA #2) came up telling us about incident which occurred earlier in the day...As soon as I was relieved of my sitting job I reported this to my nurse (licensed practical nurse-LPN #1)." Review of facility investigation documentation dated October 23, 2010 at 5:00 p.m. and authored by LPN #2 revealed, "...physical/verbal contact...resident had brushed (certified nursing assistant- CNA#1's) breast with...hands...(CNA #1) knocked...hands away and said don't you grab my (breast) you sick (expletive deleted)...Both CNAs reported this to me..." Review of facility investigation documentation dated October 24, 2010 revealed, "...date of event 10-23-10 approximately 6:30 a.m..." Review of the facility's abuse policy revealed, "...Policy: Any complaint of, allegation of, observation of or suspicion of resident abuse...is to be thoroughly reported, investigated, and documented in a manner as detailed below...All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint...observation of, or suspicion of abuse...so that the resident's needs can be attended to immediately and investigation can be undertaken promptly..." Interview with the director of nursing on December 20, 2010 at 12:35 p.m. in a lower level classroom revealed a report of abuse alleged to have occurred before 7:00 a.m. on October 23, 2010 was not reported until late afternoon on October 23, 2010. Continued interview confirmed the facility failed to imp… | 2014-04-01 | ||
| 14104 | 14104 | BRIDGE AT ROCKWOOD, THE | 445143 | 5580 ROANE STATE HWY | ROCKWOOD | TN | 37854 | 2010-06-30 | 441 | D | WPTM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medicial record review, observation, and interview, the facility failed to provide a sanitary environment for one resident (#5) of twenty-four residents reviewed. The findings included: Resident #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required total assistance with all activities of daily living, had limited movement in all four extremities, and received all food and fluids via gastric tube. Observation on June 28, 2010, at 10:45 a.m., and 1:37 p.m., in the resident's room revealed 5-6 flies on the resident's floor, and on the resident's bed linens. Continued observation revealed light green colored secretions on the resident's tracheostomy and a dust covered fan blowing on the resident. Observation and interview on June 28, 2010, at 2:10 p.m., in the resident's room with the Director of Nursing confirmed the presence of flies and the dust covered fan in the resident's room. | 2014-04-01 | ||
| 14105 | 14105 | BRIDGE AT ROCKWOOD, THE | 445143 | 5580 ROANE STATE HWY | ROCKWOOD | TN | 37854 | 2010-06-30 | 323 | D | WPTM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were in place for one resident (#21) of twenty-four residents reviewed. The findings included: Resident #21 was readmitted to the facility November 21, 2007, with [DIAGNOSES REDACTED]. Medical record review of the Interdisciplinary Care Plan for Falls, dated May 15, 2010, revealed "...Body Alarm at all X's (times)..." Medical record review of a physician's orders [REDACTED].@ (at) all X's..." Observation on June 28, 2010, at 10:20 a.m., revealed the resident in bed, asleep, without the body alarm attached. Continued observation on June 29, 2010, at 4:15 p.m., and 4:40 p.m., revealed the resident asleep in bed with the body alarm clip attached to the bottom bed sheet. Interview with LPN (Licensed Practical Nurse) #1, on June 29, 2010, at 4:45 p.m., at the resident's bedside, confirmed the resident's body alarm was not attached to the resident. | 2014-04-01 | ||
| 14106 | 14106 | BRIDGE AT ROCKWOOD, THE | 445143 | 5580 ROANE STATE HWY | ROCKWOOD | TN | 37854 | 2010-06-30 | 514 | D | WPTM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to maintain a complete and accurate clinical record for three residents (#10, #11, #12) of twenty-four residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated April 26, 2010, revealed the resident required extensive assistance with transfers, dressing, personal hygiene, toileting, and bathing. Medical record review of the CNA (Certified Nursing Assistant) ADL (Activities of Daily Living) Tracking Form for May 2010, and June 2010, revealed no documentation of ADL's provided by the CNA on the following: 7 a.m.-3 p.m., shift on May 4, 10, 15, 23, 28, June 6, 20, 22, 24; 3 p.m.-11 p.m., shift on May 17, 18, 19, 23, 28, 31, June 1, 2, 3, 4, 8, 9, 20, 21; 11 p.m.-7 a.m., shift on May 5, 17, 18, 25, 29, June 5, and 9, 2010. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident required assistance with transfers, bed mobility, hygiene, bathing, and was incontinent of bowel and bladder. Medical record review of the CNA ADL Tracking Form for May 2010, and June 2010, revealed no documentation of ADL's provided by the CNA on the following: 7 a.m.-3 p.m., shift on May 4, 10, 15, 23, 28, and June 6, 20, 24; p.m.-11 p.m., shift on May 17, 18, 19, 23, 28, 31, and June 1, 2, 3, 4, 8, 9; 11 p.m.-7 a.m., shift on May 17, 18, 25, and June 5, and 9, 2010. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident required assistance with transfers, personal hygiene, bathing, dressing, toileting, and was incontinent of bowel and bladder. Medical record review of the CNA ADL Tracking Form for May 2010, and June 2010, revealed no documentation of ADL's being provided by the CNA on the following: 7 … | 2014-04-01 | ||
| 14107 | 14107 | MANOR HOUSE OF DOVER | 445155 | 537 SPRING STREET, PO BOX 399 | DOVER | TN | 37058 | 2010-04-29 | 441 | D | ZB4Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #TN 454 Based on policy review, medical record review and interview, it was determined the facility failed to ensure respiratory isolation was implemented to prevent the transmission of infection for 1 of 14 (Resident #3) sampled residents. The findings included: 1. Review of the "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting" policy documented "...RESPIRATORY INFECTIONS... Potential Pathogens... M. ([DIAGNOSES REDACTED]) [DIAGNOSES REDACTED], Respiratory viruses, S. (Staphylococci) pneumoniae, S. aureus (MSSA (Methicillin-Susceptible Staphylococcus Aureus) or MRSA (Methicillin Resistant Staphylococcus Aureus))... Emperic Precautions... Airborne Precautions plus Contact precautions." 2. Medical record review for Resident #3 documented an admission date of [DATE] at 7:20 PM with [DIAGNOSES REDACTED]. Review of the "Patient Transfer Form" dated 3/25/10 documented the resident was positive for MRSA of the sputum. Review of the hospital laboratory final report dated 3/25/10 for a sputum culture documented results of "Staphylococcus Aureus ...Note Methicillin Resistance..." Review of physician's orders [REDACTED]. During an interview in the conference room/office on 4/27/10 at 10:30 AM, the Director of Nursing stated the hospital staff had informed her 3 days prior to admission (3/22/10) to the facility that Resident #3 had MRSA in the nares and it had colonized. During an interview in the conference room/office on 4/27/10 at 11:00 AM, the Registered Nurse Unit Supervisor stated she had received the physician's orders [REDACTED]. During an interview in the conference room/office on 4/17/10 at 2:30 PM, Licensed Practical Nurse #3 stated the laboratory report for the positive MRSA culture of the sputum was found upon chart review on 3/29/10 and Resident #3 was placed in respiratory isolation. The facility failed to place Resident #3 in respiratory isolation on admission. | 2014-04-01 | ||
| 14108 | 14108 | LAUREL MANOR HEALTH CARE | 445156 | 902 BUCHANAN RD | NEW TAZEWELL | TN | 37825 | 2010-06-23 | 332 | D | SEOE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to administer medications correctly in three of forty opportunities observed. The facility's failure resulted in a seven percent medication error rate. The findings included: Observation on June 22, 2010, at 7:45 a.m., revealed licensed practical nurse (LPN #3) administered Multivitamin with minerals to resident #23. Medical record review revealed a physician's orders [REDACTED]. Interview with LPN #3 in the 200 hallway on June 22, 2010, at 8:00 a.m., confirmed the resident did not receive the correct vitamin as ordered by the physician. Observation on June 22, 2010, at 8:05 a.m., revealed LPN #2 administered Multivitamin with minerals to resident #24. Medical record review revealed a physician's orders [REDACTED]. Further review revealed a physician order [REDACTED]. Interview with LPN #2 on June 22, 2010, at 8:15 a.m., in the 200 hallway, confirmed the physician's orders [REDACTED]. | 2014-04-01 | ||
| 14109 | 14109 | LAUREL MANOR HEALTH CARE | 445156 | 902 BUCHANAN RD | NEW TAZEWELL | TN | 37825 | 2010-06-23 | 157 | D | SEOE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to record and update the legal representative's phone number for one (#11) of twenty-four sampled residents. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes revealed on May 25, 2010, at 5:30 p.m., resident #21 entered resident #11's room. Continued medical record review revealed when resident #11 told resident #21 to leave the room, resident #21 hit resident #11 in the face, across the nose. Medical record review of nurse's notes dated May 25, 2010, at 5:30 p.m., revealed "M.D. (medical doctor) notified and trying to reach (r/p--responsible party) (family member) (named). Phone number for (family member) states that the number is unavailable at this time. Will keep trying to reach r/p." Interview with LPN (licensed practical nurse) #4 on June 23, 2010, at 2:30 p.m., in the conference room, revealed the LPN attempted to contact the responsible party on June 22, 2010, and the telephone message revealed "the party was unavailable". Continued interview with LPN #4 confirmed the LPN did not document any attempts to reach the second contact person listed in the medical record between June 22 and June 25, 2010, when the altercation occurred. Interview with the Administrator on June 23, 2010, at 2:35 p.m., in the conference room, confirmed when the licensed nurse was unable to contact the responsible party after the altercation on May 25, 2010, no other documented attempts were made to attempt to reach the second contact person listed in the medical record, to inform the family of the altercation and resident #11's transfer to the emergency room . c/o # | 2014-04-01 | ||
| 14110 | 14110 | LAUREL MANOR HEALTH CARE | 445156 | 902 BUCHANAN RD | NEW TAZEWELL | TN | 37825 | 2010-06-23 | 280 | D | SEOE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to make revisions to the current Care Plan indicating the advanced directives code status for one (# 6) of twenty-four residents reviewed. The findings included: Resident # 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's current Care Plan dated February 23, 2010, revealed "...Do Not Resuscitate (DNR)..." Medical record review revealed a Physician order [REDACTED]. Medical record review, on [DATE], at 4:40 p.m., revealed the resident's Care Plan for code status to resuscitate (CPR) was updated on [DATE]. Interview on [DATE], at 12:19 p.m., with the Director of Nursing (DON) and Registered Nurse (RN) # 1, in the resident's room, revealed "...He's a DNR..." Interview on [DATE], at 4:20 p.m., with the DON and RN # 1, in the 100 Hall, revealed "...the resident is a full code...we were mistaken" Continued interview revealed, RN # 1 pointed to a blue, circular sticker "dot", beside the resident's name on the door, indicated the resident is full code (CPR) status. Interview with the Care Plan Coordinator, on [DATE], at 11:00 a.m., in the Care Plan Coordinator's office, revealed the resident's POST code status was changed on February 23, 2010 and the Care Plan was updated on [DATE] but not placed in resident's chart. Interview on [DATE], at 1:50 p.m., with the Social Services Director, in the conference room, revealed the Social Services Director is responsible for immediately updating Care Plan changes for code status and confirmed the facility failed to update the resident's current advanced directives code status on the Care Plan. | 2014-04-01 | ||
| 14111 | 14111 | LAUREL MANOR HEALTH CARE | 445156 | 902 BUCHANAN RD | NEW TAZEWELL | TN | 37825 | 2010-06-23 | 406 | D | SEOE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a system of communication amongst staff to ensure the accurate evaluation of behaviors, and accurate development of the behavior management program for one (#5) of twenty four sampled residents. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the PASARR (Pre Admission Screening and Annual Resident Review), dated August 12, 2008, revealed "...5. Developmental Needs:...History of uncooperativeness and disruptive behaviors...8. Rehabilitative Services (services of Lesser Intensity) Recommendations:..7. Behavior management (checked)...9. Recommendations and Rationale for Determination: Based on the information provided, (resident #5) continues to meet the target population definitions and needs DMRS (Division of Mental [MEDICAL CONDITION] Services) criteria for NF (nursing facility) placement due to (the resident's) dementia and multiple medical problems. While in the NF (the resident) will require a behavior management plan for (the resident's) uncooperativeness and disruptive behaviors..." Medical record review of psychotherapy progress notes revealed: May 5, 2010 "Focus of Session...We talked about how (the resident's) behaviors can affect how others respond to (the resident)...The patient has poor impulse control due to a mental handicap, however, (the resident) is able to acknowledge right from wrong and often engages in inappropriate behavior for attention. (The resident) should respond well to behavioral modification techniques." May 12, 2010 "The patient and I talked about an incident which occurred over the weekend which involved inappropriate touching...We also talked about the appropriate ways to interact with others and patient was encouraged to apologize for (the resident's) behavior." May 26, 2010 "The patient and I discussed (the resident's) recent changed behavior … | 2014-04-01 | ||
| 14112 | 14112 | LAUREL MANOR HEALTH CARE | 445156 | 902 BUCHANAN RD | NEW TAZEWELL | TN | 37825 | 2010-06-23 | 323 | D | SEOE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility investigation, and interview, the facility failed to provide adequate supervision to prevent a fall for two residents (# 3, #5) of twenty-four residents reviewed. The findings included: Resident # 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility document, dated July 10, 2009, revealed on July 9, 2009, at 12:30 p.m., the resident fell out of the wheelchair, with no injury. Continued review of the facility document, dated July 10, 2009, revealed "Additional Follow-Ups...Will use personal alarm both bed and chair to alert staff resd (resident) requires assistance." Medical record review of a Nurse's Note dated November 28, 2009, at 9:10 p.m., revealed "...Pt (patient) assisted to BR (bathroom) per CNA (Certified Nursing Assistant) et (and) instructed to pull call light. Pt up from toilet to bed, and fell on to tile floor...Noted approx 1 cm (centimeter) long superficial cut over right eye in eyebrow...sm (small) amt (amount) bleeding noted...noted 1 cm skin tear over right mid arm/elbow area and left hand noted less than 1 cm skin tear to 2 joint off middle finger...transport to ER (emergency room ) for evaluation..." Review of a facility investigation dated November 28, 2009, at 9:10 p.m., revealed "...Staff assisted resd (resident) to toilet and instructed resd to pull call light cord when finished. Resd did not pull cord, got up from toilet himself, attempted to walk back to bed and fell in floor hitting head..." Continued review of the investigation document revealed the post-fall interventions, "...Update fall program...Consult staff on not leaving a resd who is cognitively impaired in bathroom unattended..." Observation on June 22, 2010, at 2:23 p.m., revealed resident in wheelchair with belt across the resident's waist. Interview on June 23, 2010, at 9:55 a.m., with the Director of Nursing, Care Plan Coordinator, Social Services Direct… | 2014-04-01 | ||
| 14113 | 14113 | LAUREL MANOR HEALTH CARE | 445156 | 902 BUCHANAN RD | NEW TAZEWELL | TN | 37825 | 2010-06-23 | 441 | D | SEOE11 | Based on observation, and interview the facility failed to assure the ice scoop was handled to prevent contamination and the spread of infection. The findings included: Observation of the ice pass on the secure unit on June 21, 2010, at 2:15 p.m., revealed Certified Nursing Assistant (CNA) #2, with gloved hands, removed the lid to a resident water pitcher; lifted the lid of the ice cooler; reached in the cooler and removed the ice scoop from the ice; filled the resident water pitcher from the ice cooler in the hall; deposited the scoop in the ice; entered the resident room; placed the water pitcher on the resident's over bed table; positioned the over bed table; and without removing the gloves or washing the hands, exited the resident room. Continued observation revealed the CNA, without removing the gloves or washing the hands, entered another resident room; retrieved two different residents water pitchers; opened the resident bathroom door; emptied the water pitchers; returned to the hall; lifted the lid to the ice cooler; retrieved the scoop from the ice; filled the water pitchers; deposited the scoop in the ice; returned to the residents room; placed the water pitchers on the resident's over bed tables; and without removing the gloves and washing the hands, the CNA returned to the ice cooler. Interview in the hall of the secure unit with CNA #2 on June 21, 2010, at 2:18 p.m., confirmed the ice scoop was to be placed in a separate container and not deposited in the ice cooler and this was not done. Interview at the secure unit nurses station with the Unit Manager on June 21, 2010, at 2:25 p.m., confirmed the ice scoop was to be placed in a separate container and not deposited in the ice cooler. | 2014-04-01 | ||
| 14114 | 14114 | ASBURY PLACE AT JOHNSON CITY | 445162 | 105 WEST MYTRLE AVENUE | JOHNSON CITY | TN | 37604 | 2010-12-09 | 226 | D | L0CL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and interview, the facility failed to implement the abuse policy in a timely manner for one resident (#3) of five residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had long and short term memory problems and had severely impaired cognitive skills for daily decision making, was totally dependent on staff for feeding. Medical record review of the facility investigation dated October 8, 2010, revealed Certified Nursing Assistant #1 (CNA) allegedly force fed resident #3 and treated the resident roughly. Continue review revealed the incident occurred on October 4 or October 5, 2010, and was reported to Registered Nurse (RN) #1 on October 8, 2010, by CNA #3. Further review revealed CNA #4 witnessed CNA #1 "...trying to shove food in (resident's) mouth to make (resident) eat. (Resident) was begging (CNA #1) to stop ..." Further review revealed CNA #2 and CNA #4 at different times observed CNA #1 handle the resident roughly. Review of the facility abuse policy revealed "...all alleged violations involving abuse neglect, and injuries of unknown source (when both conditions are met) or misappropriation of resident's personal property will be reported to Nursing Supervisor or Director of Nursing immediately..." Interview with CNA #2 on December 8, 2010, at 2:10 p.m., in the conference room confirmed on October 4, 2010, CNA #2 did not observe CNA #1 feed the resident; however CNA #1 "bragged " that (CNA #1) got the resident to eat everything on (resident's) plate. Further interview confirmed later that night observed CNA #1 holding the resident up with elbow in the residents back while the resident was vomiting. Interview with CNA #3 on December 8, 2010, at 3:00 p.m. in the conference room, confirmed on October 5, 2010, during the night shift, C… | 2014-04-01 | ||
| 14115 | 14115 | KINDRED NURSING AND REHABILITATION-SMITH COUNTY | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2010-06-23 | 431 | D | RZXL11 | Based on observation, manufacturer's recommendations, and interview, the facility failed to assure biological are used or discarded prior to expiration for one of one medication rooms. The findings included: Observation of the refrigerator in the medication room on June 22, 2010, at 9:50 a.m., revealed one bottle of Tuberculin Purified Protein Derivative, ? full, opened and not dated. Review of the manufacturer's instructions revealed, "Once entered, vial should be discarded after 30 days." Interview with the Director of Nursing (DON) in the DON's office on June 23, 2010, at 9:30 a.m., confirmed the facility failed to discard or use the biological prior to expiration. | 2014-04-01 | ||
| 14116 | 14116 | KINDRED NURSING AND REHABILITATION-SMITH COUNTY | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2010-06-23 | 332 | D | RZXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of professional reference, and interview, the facility failed to appropriately administer medications in four of forty opportunities resulting in an error rate of ten percent. The findings included: Observation and interview of Licensed Practical Nurse (LPN #1) on hall 600 on June 22, at 8:45 a.m., 2010, revealed the nurse preparing medications at the medication cart. Observation included LPN #1 gathered the following oral medications for resident # 23: 1. [MEDICATION NAME] 20 mg (milligrams) (medication to decrease gastric acid secretion); 2. [MEDICATION NAME] 0.4 mg (to increase urination); 3. Multivitamin with Minerals (supplement); 4. [MEDICATION NAME] 100 mg (stool softener); 5. Potassium 20 millequivalents (replacement); 6. [MEDICATION NAME] 5 mg (steroid); 7. [MEDICATION NAME] 40 mg (diuretic); 8. [MEDICATION NAME] 25 mg (antihypertensive); and 9. [MEDICATION NAME] 40 mg (Anti-depressant). Continued observation revealed LPN #1 entered resident #23's room and placed the cup of medications on the table in front of the resident sitting in the chair. Continued observation and interview with resident #23 in the room on June 22, 2010, at 8:38 a.m., confirmed the breakfast meal had been served, consumed, and the tray had been removed from the room. Medical record review of the recapitulation of the Physician order [REDACTED]. Medical record review of the recapitulation of the Physician order [REDACTED]. Review of the medication book located at the nurses' station (2010 Pharmerica Specialized Long-term care nursing drug handbook) revealed the administration of [MEDICATION NAME] is "Best if administered before breakfast." Interview with LPN #1 at the nurses' station on June 22, 2010, at 9:00 a.m., verified the [MEDICATION NAME] was omitted and the [MEDICATION NAME] was administered after the meal. Observation on June 22, 2010, at 11:05 a.m., revealed Licensed Practical Nurse (LPN #2) preparing… | 2014-04-01 | ||
| 14117 | 14117 | KINDRED NURSING AND REHABILITATION-SMITH COUNTY | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2010-06-23 | 328 | D | RZXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview the facility failed to assure Nasal Cannula (type of oxygen delivery) tubing was changed timely for three resident's (#15, #16, #19) of twenty-seven residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Recapitulation Physician's Orders for June 2010, revealed, " ...O2 (oxygen) at 2L/MIN (two liters per minute) VIA (by) NASAL CANNULA..." Observation on June 21, 2010, at 9:35 a.m., in the resident room revealed, an oxygen concentrator in the on position delivering oxygen to the resident at 2L/MIN by nasal cannula. Continued observation at this time revealed no date on nasal cannula tubing. Interview with Charge Nurse # 1 on June 21, 2010, at 10:17 a.m., in the resident room confirmed, there was no date on the nasal cannula tubing to indicate when the tubing was last changed. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Medical record review of Recapitulation Physician's Orders for June 2010, revealed, " ...O2 (oxygen) at 2L/MIN (two liters per minute) PER (by) N/C (nasal cannula)PRN (as needed)..." Observation on June 21, 2010, at 9:48 a.m., in the resident room revealed, an oxygen concentrator in the on position delivering oxygen at 2L/MIN. Continued observation at this time revealed the nasal cannula tubing was dated June 11, 2010. Interview with Charge Nurse # 1 on June 21, 2010, at 10:15 a.m., in the resident room confirmed, the resident had recently received oxygen by nasal cannula (prior to breakfast this morning) and the nasal cannula tubing dated June 11, 2010, was not changed weekly as facility policy states. Resident # 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Recapitulation Physician's Orders for June 2010, revealed, " ...… | 2014-04-01 | ||
| 14118 | 14118 | KINDRED NURSING AND REHABILITATION-SMITH COUNTY | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2010-06-23 | 441 | D | RZXL11 | Based on observation and interview, the facility failed to change gloves during personal care for one (#2) of twenty-seven residents; and failed to administer medications in a sanitary manner. The findings included: Observation of resident #2 on June 21, 2010, at 2:10 p.m., included personal care performed by Certified Nursing Assistant (CNA #1). Continual observation revealed CNA #1 gathered supplies, manipulated the bed controls located on the upper side rail of the bed to lower the head of the bed, and applied gloves to both hands. CNA #1 removed the covers from the resident and pulled back the disposable brief; and wiped the front of the pubis and perineal area with a wet washcloth. CNA #1 assisted the resident to roll onto the right side and removed the disposable brief. CNA #1 cleaned the buttocks and rectal area with a wet washcloth removing a small amount of fecal material. CNA #1 walked from the bedside to the closet and without changing gloves opened the door and obtained a disposable brief and returned to the bedside. CNA #1 applied clean linen and the clean brief before assisting the resident to roll onto the left side. Without changing the gloves, CNA #1 positioned the clean brief, assisted the resident to lay on the back; secured the brief; pulled the covers from the foot of the bed up onto the resident; secured the nasal cannula into the nostrils; manipulated the bed controls to raise the head of the bed; left bedside and touched the interior door handle to open the door to get a plastic bag. With the same gloved hands, CNA #1 with one hand held the roll of plastic bags in the mounted basket and with the other hand pulled two plastic bags from the roll; touched the exterior door handle to open the door; pushed the door closed; and gathered the linens and garbage and placed in the plastic bags. Interview with CNA #1 in the hallway on June 21, 2010, at 2:21 p.m., verified the gloves were contaminated while performing personal care and were not changed before contaminating all the surfaces touched aft… | 2014-04-01 | ||
| 14119 | 14119 | SPRING CITY CARE AND REHABILITATION CENTER | 445209 | 331 HINCH STREET | SPRING CITY | TN | 37381 | 2011-01-25 | 309 | D | 2KET11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to catheterize one resident (#3) for residual urine as ordered by the physician of five residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with transfers, hygiene and bathing; required extensive assistance of two with toileting and was continent of bowel and bladder. Medical record review of a nurse's note dated October 7, 2010, revealed, " ...extreme urinary urgency but voids very little when taken to bathroom ..." Medical record review of a nurse's note dated November 21, 2010, revealed, " ...continent of B&B (bowel and bladder) (with) episodes of incontinence ..." Medical record review of a nurse's note dated December 7, 2010, revealed, "Res (resident) used bed pan output 400 ml (milliliters) straight cath for residual yielded 150 ml ..." Medical record review of a nurse's note dated January 5, 2011, revealed the resident was evaluated by a urologist on January 5, 2011. Medical record review of a urologist order dated January 5, 2011, revealed, "Have (resident) void then catheterize ...to check for post void residual." Medical record review of nurses' notes and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation on January 24, 2011, at 9:30 a.m., revealed the resident sitting in a chair at the bedside. The resident was alert and oriented and reported staff were "good" to take (resident) to the bathroom as needed. Interview on January 24, 2011, at 11:20 a.m., with Certified Nursing Assistant (CNA #1), who had been assigned to resident #3, confirmed the resident had urinary urgency. CNA #1 stated, "...We'll take (resident) to the bathroom...go down the hall a room or two to take care of other residents...(resident) has...light on again a… | 2014-04-01 | ||
| 14120 | 14120 | RAINTREE MANOR | 445216 | 415 PACE STREET | MC MINNVILLE | TN | 37110 | 2010-03-24 | 333 | D | DJM011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation of medication administration, facility policy review, and interview, the facility failed to ensure residents are free of significant medication errors for one resident (#26) of twenty-eight residents reviewed. The findings included: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation orders dated March 1 - 31, 2010, revealed "...K-Dur (potassium) 20 meq. (millequivalents) tablet SA (sustained action)...take one tablet by mouth daily...DO NOT CRUSH OR BREAK ABOVE MED..." Observation of the medication administration pass on March 23, 2010, at 8:35 a.m., on the 300 hall, revealed Licensed Practical Nurse (LPN #1) removed the resident's medications including a K-Dur tablet, placed the medications in a clear plastic envelope, and crushed the medications. Continued observation revealed LPN #1 placed the crushed medications into a clear plastic medication administration cup mixed with applesauce and administered to the resident. Review of facility policy Crushing Medications revealed "...The nursing staff and/or Consultant Pharmacist shall notify any Attending Physician who gives an order to crush a drug that the manufacturer states should not be crushed...The Attending Physician or Consultant Pharmacist must identify an alternative or the Attending Physician must document (or provide the nurses with a clinically pertinent reason to document) why crushing the medication will not adversely affect the resident..." Interview with LPN #1 on March 23, 2010, at 12:15 p.m., at the Nurses Station located at the end of the 300 hallway, confirmed the facility had failed to follow the policy for crushing medications and the physician order [REDACTED]. | 2014-04-01 | ||
| 14121 | 14121 | RAINTREE MANOR | 445216 | 415 PACE STREET | MC MINNVILLE | TN | 37110 | 2010-03-24 | 314 | D | DJM011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to apply heel protectors and float heels when in bed to prevent skin breakdown for one (#12) with a history of skin breakdown of twenty-eight residents reviewed. The findings included: Medical record review revealed resident #12 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on March 23, 2010, at 10:20 a.m., revealed resident #12 lying in bed without feet floating and no heel protectors were on. Further observation revealed the heel protectors were on the chair beside the resident's bed. Review of the nursing note dated January 9, 2010, revealed the resident was readmitted with "...stage one or greater to both heels..." Review of the Care Plan, with onset date on January 19, 2010, revealed the resident "...has Stage 2 to...right heel..." The care plan approaches included "float heel while in bed and apply bunny boots" (heel protectors). Review of the Skin Report dated March 22, 2010, revealed no open areas to the heel and the heel was slightly pink. Interview on March 23, 2010, at 10:23 a.m., in the resident's room with Certified Nurse Aide (CNA) #1 confirmed the resident was not wearing bunny boots and the heels were not floated. Interview with LPN #2, on March 23, 2010, at 2:49 p.m., in the hall outside of the Nursing Administration Office, revealed the heels were healed "last week with no open areas." Interview on March 23, 2010, at 3:00 p.m., with the Medicare Coordinator, in the Social Service Office, confirmed the facility failed to float the heels and apply the "bunny boots". | 2014-04-01 | ||
| 14122 | 14122 | RAINTREE MANOR | 445216 | 415 PACE STREET | MC MINNVILLE | TN | 37110 | 2010-03-24 | 514 | D | DJM011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure oxygen orders were accurate for one (#12) of twenty-eight residents reviewed. The findings included: Medical record review revealed resident #12 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital transfer orders dated January 9, 2010, revealed "O2 (oxygen) @ (at) 2 L/M (liters per minute) via nasal cannula." Review of the January 2010, February 2010, and March 2010, Recapitulation Orders revealed "O2 @ 2 L/M via N/C (nasal cannula)." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the February 2010 through March 23, 2010, MAR indicated [REDACTED] Observation on March 23, 2010, at 10:20 a.m., revealed resident #12 lying in bed, no oxygen alert was posted on the resident's entrance way, no oxygen concentrator was in the room, and no nasal cannula was placed on the resident. Interview on March 23, 2010, at 10:23 a.m., in the resident's room, with Certified Nurse Aide (CNA) #1, revealed "I think the O2 is PRN (as needed)." Continued interview confirmed there was no oxygen equipment in the room. Interview with Licensed Practical Nurse (LPN) #5 and the Quality Assurance Nurse, at the 100 hall nursing station, on March 23, 2010, at 2:52 p.m., confirmed the January 2010, readmission physician orders [REDACTED]. Continued interview confirmed the last nursing note addressing oxygen was dated January 23, 2010 and that January was the last time they recalled the resident with oxygen. Interview with the Quality Assurance Nurse, at the 100 hall nursing station, on March 23, 2010, at 3:15 p.m., revealed the physician was called and informed the SAT (oxygen saturation rate) was 95 per cent without oxygen and oxygen had not been provided since January. Continued interview revealed the physician discontinued the oxygen due to the… | 2014-04-01 | ||
| 14123 | 14123 | GLEN OAKS HEALTH AND REHABILITATION | 445234 | 1101 GLEN OAKS ROAD | SHELBYVILLE | TN | 37160 | 2009-03-24 | 363 | E | 8IYP11 | Complaint Investigation for TN 313 Based on review of the facility's menus, observation, and interview, it was determined the facility failed to follow the menu by serving smaller portions of pureed and ground meat for 31 of 83 diets served. The findings included: Review of the facility menu dated 2009, Week 4 Tuesday, documented, "... Lunch Beef Tips in Gravy ... grd/grvy (ground/gravy) (#10 scoop) (#10 scoop equals 2/5 cups), pur (pureed) (#8 scoop) (#8 scoop equals 1/2 cup)..." Observations in the kitchen on 3/24/09 at 11:15 AM, revealed the Cook served pureed meat with a #16 scoop and ground meat with a #16 scoop. A #16 scoop equals 1/4 cup. The Cook failed to follow the menu by not using #8 scoop for the pureed diet and not using the #10 scoop for ground meat. During an interview in the kitchen, on 3/24/09 at 12:15 PM, the Cook stated, "I've been here so long. The old one (menu) said 2 ounces and it's just a habit. If you get a bigger scoop, the food runs together." | 2014-04-01 | ||
| 14124 | 14124 | GLEN OAKS HEALTH AND REHABILITATION | 445234 | 1101 GLEN OAKS ROAD | SHELBYVILLE | TN | 37160 | 2009-03-24 | 517 | F | 8IYP11 | Based on review of the facility disaster menu plan, observation and interview, it was determined the facility failed to ensure there was an adequate food inventory for 3 of 3 days of the disaster menu. The findings included: Review of the facility's disaster menu plan, inventory needed for 100 beds, documented, "Fruits and Fruit Juices Apple Sauce 6/#10 cans, Apricots 6/#10 cans, Fruit Mix 6/#10 cans, Peaches 6/#10 cans, pears 6/#10 cans, Apple Juice 12/46 oz (ounces), Cranberry juice 12/46 oz, prune juice 12/46 oz, Orange juice 12/46 oz; Puree Fruits Peach 12/15 oz, Pear 12/15 oz, Thickened Orange juice, Thickened Apple juice, Thickened Cranberry juice; Milk and Puddings Evaporated Milk 6/#10 cans, Dry Milk 6/5 lb (pounds), Thickened Milk 12/32 oz, Chocolate Pudding 6/#10 cans, Vanilla Pudding 6/#10 cans; Vegetables Green Beans 6/#10 cans, Carrots 6/#10 cans, 3 Bean Salad 6/#10 cans, Stewed Tomatoes 6/#10 cans, Mixed Vegetables 6#10 cans, Corn 6/#10 cans, Potatoes diced/sliced 6/#10 cans, Sweet Potatoes/Yams 6/#10 cans; Puree Vegetables Peas 12/15 oz, carrots 12/15 oz, Green Beans 12/15/oz; Soups Cream of Tomato 12/50 oz, Chicken Noodle 12/50 oz; Starches Pinto Beans 6/#10 cans, Kidney Beans 6/#10 cans, Bran Flakes 4/35 oz, Corn Flakes 4/35 oz, Crispy Rice 4/35 oz, Toasted Oats 4/35 oz, Sandwich Cookies 120/2 ct (count), Vanilla Wafers 6/13 oz, Graham Crackers 200/2 ct, Saltine Crackers 500/2 ct, Unsalted Crackers 500/2 ct, Bread loaves 30 loaves; Protein and Mix Protein Beef Stew 6/#10 cans, Macaroni and Cheese 6/#10 cans, Chilli with Beans 6/#10 cans, Ravioli w (with)/Beef 6/#10 cans, Corned Beef Hash 6/#10 cans, Sausage Gravy 6/#10 cans, Tuna 6/cans, Peanut Butter 200/.75 oz, Cheese Sauce 6/#10 cans, Eggs 15 dozen, Puree Beef 12/ 15 oz, Puree Chicken 12/15 oz, Med Pass 2.0 6/32 oz; Other Iced Tea Bags 1/96 ct, Drink Mix SF (sugar free) 12/pkgs (packages), Jelly 6/32 oz, Mayo (mayonnaise)/Salad Dressing 500ct, Sugar 2000 ct, Salt 3000 ct, Pepper 3000 ct, Sweet/Low 2000 ct, Margarine". Observations in the food … | 2014-04-01 | ||
| 14125 | 14125 | GREYSTONE HEALTH CARE CENTER | 445242 | 181 DUNLAP ROAD | BLOUNTVILLE | TN | 37617 | 2010-06-30 | 241 | D | XE3911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to promote care that maintained or enhanced dignity during a meal for two residents (#26) and (#27) of twenty-seven residents reviewed. The findings included: Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident only required set up help for meals. Continued medical record review of the Care Plan dated May 13, 2010, revealed the resident feeds self with limited assistance. Observation in the 300 hall dining room on June 30, 2010, at 7:54 a.m., revealed resident sitting at a table with two other residents. Observation at this time revealed Certified Nursing Assistant (CNA) #1 feeding another resident #21 while resident # 26 watched. Continued observation in the 300 hall dining room on June 30, 2010, at 8:10 a.m., revealed facility staff setting up a tray for resident #26 (sixteen minutes) after resident #21 received tray. Interview with the Administrator on June 30, 2010, at 8:32 a.m., outside the administrator's office, confirmed the facility failed to maintain or enhance dignity during a meal for resident #26. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was total dependence for meals. Continued medical record review of the Care Plan dated March 25, 2010, revealed the resident is fed meals by staff. Observation in the 300 hall dining room on June 30, 2010, at 7:54 a.m., revealed resident sitting at a table with two other residents. Observation at this time revealed Certified Nursing Assistant (CNA) #1 feeding another resident #21 while resident # 27 watched. Continued observation in the 300 hall dining room on June 30, 2010, at 8:14 a.m., revealed facility staff setting up a tray to begin feeding resident #27 (twenty minutes) after resident… | 2014-04-01 | ||
| 14126 | 14126 | GREYSTONE HEALTH CARE CENTER | 445242 | 181 DUNLAP ROAD | BLOUNTVILLE | TN | 37617 | 2010-06-30 | 514 | D | XE3911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain an accurate clinical record for one resident (#6) of twenty-seven residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Order dated May 31, 2010, revealed, "[MEDICATION NAME] decreased to 375mg (milligrams) TID (three times daily)..." Medical record review of the monthly Recapitulation physician's orders [REDACTED]. Order dated May 31, 2010, to decrease the [MEDICATION NAME] to 375mg TID. Medical record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 at the Nurse's Station on June 29, 2010, at 8:50 a.m., confirmed the Recapitulation physician's orders [REDACTED]. | 2014-04-01 | ||
| 14127 | 14127 | SUMMIT VIEW OF LAKE CITY, LLC | 445259 | 204 INDUSTRIAL PARK RD | LAKE CITY | TN | 37769 | 2010-05-19 | 281 | D | M9X511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interview, the facility failed to follow physician's orders for one (#2) of twenty-four residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated May 1, 2010, revealed "...Chief Complaint: Congestion, progressive coughing, shortness of breath...Assessment and Plan: 1. Acute [MEDICAL CONDITION]...2. Pneumonia... " Medical record review of the Pharmacy Orders for Surgery or Transfer Patients (medication orders) signed by the hospital physician on May 11, 2010, revealed the resident was to receive [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) and Atrovent ([MEDICATION NAME][MEDICATION NAME]) via nebulizer (inhalation) every four hours while awake upon return to the facility. Medical record review of the May 13-18, 2010, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the Nurse's Medication Notes (located on the reverse side of the May 2010, MAR) revealed no documentation of why the [MEDICATION NAME] and Atrovent were not administered. Review of the facility's policy Administering Medication Guidelines revealed "...An explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at the scheduled time..." Observation on May 18, 2010, at 2:20 p.m., with Licensed Practical Nurse (LPN) #1, of the medication cart, revealed there were twenty-five doses of [MEDICATION NAME] and Atrovent, dispensed by the pharmacy on May 12, 2010, available to be administered to the resident. Observation on May 17, 2010, at 6:40 a.m., revealed the resident lying on the bed receiving oxygen via a nasal cannula, with no respiratory distress. Telephone interview on May 18, 2010, at 3:25 p.m., with the facility's pharmacist, co… | 2014-04-01 | ||
| 14128 | 14128 | SUMMIT VIEW OF LAKE CITY, LLC | 445259 | 204 INDUSTRIAL PARK RD | LAKE CITY | TN | 37769 | 2010-05-19 | 157 | D | M9X511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to notify the physician of medications not administered as ordered for one (#2) of twenty-four residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated May 1, 2010, revealed "...Chief Complaint: Congestion, progressive coughing, shortness of breath...Assessment and Plan: 1. Acute [MEDICAL CONDITION]...2. Pneumonia... " Medical record review of the Pharmacy Orders for Surgery or Transfer Patients (medication orders) signed by the hospital physician on May 11, 2010, revealed the resident was to receive [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) and Atrovent ([MEDICATION NAME][MEDICATION NAME]) via nebulizer (inhalation) every four hours while awake upon return to the facility. Medical record review of the May 13-18, 2010, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review revealed no documentation the physician was notified the [MEDICATION NAME] and Atrovent were not administered as ordered. Review of the facility's policy Administering Medication Guidelines revealed "...Attending physician must be notified when two (2) consecutive doses of a medication are refused or withheld..." Observation on May 18, 2010, at 2:20 p.m., with Licensed Practical Nurse (LPN) #1, of the medication cart, revealed there were twenty-five doses of [MEDICATION NAME] and Atrovent, dispensed by the pharmacy on May 12, 2010, available to be administered to the resident. Observation on May 17, 2010, at 6:40 a.m., revealed the resident lying on the bed, in no respiratory distress, receiving oxygen via a nasal cannula. Interview on May 19, 2010, at 7:55 a.m., with Registered Nurse (RN) #1, (nurse responsible for the administration of the [MEDICATION NAME] and Atrovent on May … | 2014-04-01 | ||
| 14129 | 14129 | SUMMIT VIEW OF LAKE CITY, LLC | 445259 | 204 INDUSTRIAL PARK RD | LAKE CITY | TN | 37769 | 2010-05-19 | 371 | F | M9X511 | Based on observation and interview, the facility failed to ensure the dietary employees working in the dish room properly cleaned and sanitized the dishes. The findings included: Observation on May 17, 2010, at 8:45 a.m., in the dish room, revealed one dietary employee on the clean side and one dietary employee on the dirty side of the dish machine. Further observation revealed the dietary employee from the clean side went to the dirty side, opened the dirty side of the dish machine door, pushed a rack of dirty dishes into the dish machine which came in contact with the rack of clean dishes inside the machine, and shoved the clean dishes out of the machine with the dirty dish rack, and shut the dirty side of the dish machine door. This employee then removed and disposed the gloves, went to the clean side of the dish machine, put on new gloves and started to store the dishes from the rack of dishes that had come in contact with the dirty dish rack. Interview on May 17, 2010, at 8:47 a.m., in the dish room, with the dietary employee on the clean side, confirmed the employee had gone from the clean side to the dirty side of the dish machine, opened the dirty side door of the dish machine, pushed a rack of dirty dishes into the rack of clean dishes inside the dish machine and shoved the rack of clean dishes out of the machine using the rack of dirty dishes. Further interview confirmed the employee had closed the dirty side door of the dish machine, took off and disposed the gloves, went to the clean side of the dish machine and put on new gloves and began storing dishes from the rack that had come in contact with the rack of dirty dishes. Further interview revealed "That's the way I've always done it..." Interview with the dietary supervisor on May 17, 2010, at 8:50 a.m., in the dish room, confirmed the observed process was the procedure in practice by the dietary department. | 2014-04-01 | ||
| 14130 | 14130 | SUMMIT VIEW OF LAKE CITY, LLC | 445259 | 204 INDUSTRIAL PARK RD | LAKE CITY | TN | 37769 | 2010-05-19 | 323 | D | M9X511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place or provide adequate supervision for four (#2, #9, #15, and #20) of twenty-four residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory deficits and moderately impaired cognitive skills. Medical record review of a Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the Plan of Care dated April 15, 2010, revealed "...Risk for falls...Safety alarm to alert staff to unassisted rising; check for functioning and placement..." Medical record review of the Nurse Progress Notes dated May 16, 2010, at 10:30 a.m., revealed "Called to resident room by CNA (Certified Nursing Assistant)...Resident laying on floor on left side of bed. Resident was laying on left side. Res (resident) voices no c/o (complaints of) pain at this time. R.O.M. (range of motion) WNL (within normal limits) for this resident. Neuro check WNL...red areas noted to left side & side of left knee. No bruising or swelling noted. Call light still attached to res blanket and within reach. Res. laying on blanket..." Medical record review revealed no documentation the safety alarm was in place at the time of the resident's fall on May 16, 2010. Observations on May 17, 2010, at 6:40 a.m., 8:35 a.m., 11:50 a.m., and 2:36 p.m., and on May 18, 2010, at 7:30 a.m., 8:52 a.m., and 1:10 p.m., revealed the resident lying on the bed with no safety alarm in place. Observation and interview on May 18. 2010, at 2:38 p.m., with the Director of Nursing, revealed the resident lying on the bed, and confirmed the safety alarm was not in place. Interview with the Director of Nursing, in the nursing station on May 19, 2010, at 7:36… | 2014-04-01 | ||
| 14131 | 14131 | SUMMIT VIEW OF LAKE CITY, LLC | 445259 | 204 INDUSTRIAL PARK RD | LAKE CITY | TN | 37769 | 2010-05-19 | 514 | D | M9X511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately document the administration of [MEDICATION NAME] for one (#18) of twenty-four resident reviewed. The findings included: Medical record review of resident #18 revealed facility admission on September 22, 2009, with [DIAGNOSES REDACTED]. Medical record review of a physician phone order dated October 16, 2009, revealed "1) Hold [MEDICATION NAME] x (times) 3 days 2) Decrease [MEDICATION NAME] to 3.5 mg (milligrams) daily 3) Recheck PT/INR in 10 days." Continued review of a physician phone order dated October 27, 2009, revealed "Change [MEDICATION NAME] to 4 mg M W F (Monday, Wednesday, Friday) and 3 1/2 mg on Tu Th Sat Sun (Tuesday, Thursday, Saturday, Sunday)." Review of the Medication Administration Record, [REDACTED]. Continued review revealed no documentation of the [MEDICATION NAME] was administered on October 19, 20, 22, 23, 24, 25 or 26, 2009. Review of the Emergency Box Record dated October 19, 2009, revealed two tablets of [MEDICATION NAME] 1 mg had been dispensed to resident #18. Interview with the pharmacist, on May 19, 2010, at 11:45 a.m., in the Director of Nursing Office, confirmed the pharmacy had dispensed, on October 19, 2009, fifteen doses of [MEDICATION NAME] 1.0 mg, and fifteen doses of [MEDICATION NAME] 2.5 mg with instruction of give one tab 1.0 mg with one tab 2.5 mg = 3.5 mg daily on October 19, 2009. Further interview revealed the resident had Medicare Part D insurance and the "unused doses would have been destroyed." Continued interview revealed the pharmacy would have no way of knowing if the medication had been administered since it had been destroyed and couldn't be counted for reimbursement. Interview with the Director of Nursing (DON), on May 19, 2010, at 10:30 a.m., in the DON Office, confirmed there was no documentation the [MEDICATION NAME] 3.5 mg was administered on October 19, 20, 22, 23, 24, 25, or 26, 2009. | 2014-04-01 | ||
| 14132 | 14132 | SUMMIT VIEW OF LAKE CITY, LLC | 445259 | 204 INDUSTRIAL PARK RD | LAKE CITY | TN | 37769 | 2010-05-19 | 502 | D | M9X511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to obtain laboratory test as ordered by the physician for one (#13) of twenty-four residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapitulation orders dated August, September, October, November, December, 2009, and January, February, March, and April, 2010, revealed, "...CBC (complete blood count)-BUN (blood, urea, nitrogen)-Creat (creatinine)-Na (sodium)-K (potassium)-ALT (liver test)-[MEDICATION NAME] every 4 months..." Medical record review of the lab reports revealed the BUN, Creat, Sodium, Potassium, ALT, and [MEDICATION NAME] was obtained in August, 2009, and the Complete Blood Count had not been obtained since March 2009. Interview on May 19, 2010, at 8:25 a.m., with the Director of Nursing, in the conference room, confirmed the labs had not been obtained every 4 months as ordered. | 2014-04-01 | ||
| 14133 | 14133 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2011-01-21 | 514 | D | UI8411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure the medical record was accurate for two residents (#1 #5) of eleven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Hospital discharge summary dated October 19, 2010, revealed the resident was admitted to the hospital on October 17, 2010 with a Urinary Tract Infection, and was discharged back to the facility on [DATE]. Medical record review of the Restorative Care Flow Record for the Month on October 2010, revealed ROM (range of motion) and application of braces to trunk and ankle were documented as provided on October 18, 2010. Interview with the Restorative Certified Nursing Assistant on January 19, 2011, at 2:00 p.m., in the conference room, confirmed services were documented on October 18, 2010 as provided, was not accurate and had intended to document on October 17, 2010 not on October 18, 2010. Interview with the Director of Nursing on January 19, 2011, at 3:00 p.m., in the conference room, confirmed the medical record was not accurate. Resident #5 was admitted to the facility on [DATE], and discharged on [DATE]. Medical record review of the Restorative Care Flow Sheet for the month of May 2010, revealed services were documented as provided on May 31, 2010 (after resident was discharged ). Interview with the Restorative Certified Nursing Assistant on January 19, 2011, at 2:00 p.m. in the conference room confirmed services were documented as provided on May 31, 2010, was not accurate and had intended to document on May 30, 2010, and not May 31, 2010. Interview with the Director of Nursing on January 19, 2011, at 3:00 p.m., in the conference room, confirmed the medical record was not accurate. c/o | 2014-04-01 | ||
| 14134 | 14134 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2011-01-21 | 314 | D | UI8411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete weekly skin assessments for one resident #8 with an area of shearing on the coccyx of eleven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Assessment for Pressure Sore Potential revealed dated January 1, 2010, March 1, 2010, June 29, 2010 and October 11, 2010, revealed the resident was high risk for developing pressure sores. Medical record review of the Physician order [REDACTED]. Medical record review of the weekly skin assessment dated [DATE], and December 6, 2010, revealed no documented skin problems. Medical record review of the wound care treatment note dated December 2, 2010, revealed "Coccyx intact cont (continue) (with) tx (treatment) as a precaution" Medical record review of the wound care treatment note dated December 9, 2010, revealed "Coccyx red yet blanchable cont (continue) (with) tx (treatment)." Medical record review of the weekly skin assessment dated [DATE], revealed " ...slight shearing pink area tx (treatment) in progress ..." Medical record review of the wound care treatment note dated December 22, 2010, revealed "Coccyx denuded abrasion noted cont (continue) (with) tx (treatment)." Medical record review of the next weekly skin assessment dated [DATE], revealed " ...shearing slight coccyx tx (treatment) in progress..." Interview with LPN #1 on January 19, 2011, at 1:00 p.m. in the conference room confirmed the area described on the December 13, 2010, weekly skin assessment was the Coccyx/Buttocks area. Interview with the Director of Nursing on January 19, 2011, at 2:15 p.m., in the conference room, confirmed per the skin assessment dated [DATE], the resident was noted with a shearing area to the coccyx and, no skin assessment was completed between December 13, 2010, until December 30, 2010 (17 days). c/o | 2014-04-01 | ||
| 14135 | 14135 | BROOKEWOOD NURSING CENTER, INC | 445278 | 332 RIVER ROAD | DECATUR | TN | 37322 | 2011-01-27 | 226 | D | BOSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation documentation, review of facility policy, personnel file review, and interview, the facility failed to implement the abuse policy for one resident (#5) of five sampled residents. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated August 30, 2010 at 10:30 p.m. revealed, "Pt. (patient) c/o (complained of) pain to neck. No s/s (signs/symptoms) bruising. No redness noted. Administrator in building et (et) aware." Medical record review revealed no nursing documentation dated August 30, 2010 before or after 10:30 p.m. Medical record review revealed the resident was discharged from the facility on September 1, 2010 and did not return to the facility. Review of facility investigation documentation dated August 30, 2010 revealed, "...confused...Physical restraint involved CNA (certified nursing assistant)...(resident) had outburst on 3rd shift CNA allegedly placed arm around res neck in choke hold position..." Continued review revealed no documentation regarding witnesses, location, or resident's condition. Review of facility documentation dated August 30, 2010 and signed by CNA #1 revealed, "...(Resident) took...foot rest off and pulled back as if...was going to throw the footrest. (CNA #2) was behind the wheelchair and put (resident) in a choke hold...kept (resident) in this hold pulling (resident) up out of the chair a little even after I got the footrest away from (resident)...I told CNA #2 three or four times that was enough until...finally let resident go." Review of facility investigation documentation dated August 30, 2010, and signed by licensed practical nurse (LPN) #1 revealed, "Pt had been irate et (and) needing care...1 CNA had taken a foot rest off pt's w/c (wheelchair) CNA #2 was behind pt...After the foot rest was removed, pt. complained of CNA #2 hurting...neck from pulling it… | 2014-04-01 | ||
| 14136 | 14136 | KINDRED NURSING AND REHABILITATION- FAIRPARK | 445286 | 307 N FIFTH ST BOX 5477 | MARYVILLE | TN | 37801 | 2010-09-09 | 312 | D | T4N211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide ADL care for a dependent resident for one resident (#9) of seventeen residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, severely impaired cognitive skills for daily decision making, and was totally dependent for hygiene and bathing. Medical record review of the care plan dated August 4, 2010, revealed, "...fingernail...care every Sunday..." Observation on September 8, 2010, at 10:30 a.m., with the Staff Development Coordinator, revealed the resident lying in the bed, both hands contracted with the fingernails on both hands extending approximately ? inch beyond the tips of the nail bed. Further observation revealed an odor from the hands when the Staff Development Coordinator opened the hands. Interview on September 8, 2010, at 10:30 a.m., with the Staff Development Coordinator, in the resident's room, confirmed the nails were long and needed to be trimmed and confirmed an odor from the hands. | 2014-04-01 | ||
| 14137 | 14137 | KINDRED NURSING AND REHABILITATION- FAIRPARK | 445286 | 307 N FIFTH ST BOX 5477 | MARYVILLE | TN | 37801 | 2010-09-09 | 441 | D | T4N211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility policy, and interview, the facility failed to follow infection control policies for one resident (#2) of seventeen residents reviewed. The findings included: Resident #2 was admitted to the facility June 18, 2010, with [DIAGNOSES REDACTED]. Medical record review of a Resident Progress Note dated September 4, 2010, at 9:25 a.m., revealed "...1 cm (centimeter) X (times) 1 cm round open area found to pt's (patient) R (right) medial heel. Pt. has history of pressure ulcers to heels...Open area is draining a small amount of serosanguinous drainage..." Medical record review of a Physician Telephone Order dated September 4, 2010, revealed "...Cx (culture) open area R medial heel, [MEDICATION NAME] BID (2 times a day) X 1 week to R medial heel. Call MD if + (positive) Cx for abx (antibiotic)..." Medical record review of a Laboratory Wound Culture Report dated September 6, 2010, revealed "...Right Heel...3+ Pseudomonas Aeruginosa (type of bacteria)...4+ Methicillin Resistant Staphylococcus Aureus (MRSA type of bacteria)..." Medical record review of a Physician Telephone Order dated September 6, 2010, revealed "...Dc (discontinue) [MEDICATION NAME]. [MEDICATION NAME] 2% Cream topically to right heel TID (3 times per day)[MEDICATION NAME] (antibiotic) 600 mg (milligram) PO (by mouth) BID X 14 days..." Observation on September 8, 2010, at 2:20 p.m., in the resident's room, with the Infection Control Nurse, revealed the right heel adhered to the bottom bed sheet. Continued observation revealed the nurse had to pull the sheet away from the heel. Further observation revealed yellow drainage on the bottom sheet, two open areas noted on the right medial and lateral heel. Review of a facility policy, Disease Specific Information (MRSA) revealed, "...Infected draining lesions/pressure ulcers. Limited to one or two areas; drainage completely contained by a secure dressing. Standard precautions durin… | 2014-04-01 | ||
| 14138 | 14138 | HUNTSVILLE MANOR | 445288 | 287 BAKER STREET | HUNTSVILLE | TN | 37756 | 2010-12-16 | 312 | D | HRD111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide oral care for one (#5) of twenty-eight residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required limited assistance with hygiene and received greater than 50% (percent) of nutrition through a feeding tube. Observation on December 7, 2010, at 1:30 p.m., revealed the resident lying in bed with tube feeding at 70 ml (milliliters) per hour. Observation revealed the resident's lips and mouth were dry and mucus streamed from the resident's upper lip to the lower lip. Observation of the resident and interview with the Licensed Practical Nurse (LPN #1) and Certified Nursing Assistants (CNA #1 and #2) on December 7, 2010, at 1:43 p.m., confirmed the resident was in need of oral care and confirmed oral care had not been provided on December 7, 2010. Observation of the resident and interview on December 7, 2010, at 1:47 p.m., with CNA #3 and at 1:50 p.m., with CNA #4 confirmed oral care had not been provided on December 7, 2010. CO # | 2014-04-01 | ||
| 14139 | 14139 | HUNTSVILLE MANOR | 445288 | 287 BAKER STREET | HUNTSVILLE | TN | 37756 | 2010-12-16 | 278 | D | HRD111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess one resident (#17) with Pressure Ulcers of twenty-eight residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a "Resident Admission (readmission) Body Audit" dated June 24 and 25, 2010, revealed the resident had two stage 4 Pressure Ulcers on the heels and two stage 2 Pressure Ulcers on the buttocks. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had no Pressure Ulcers. Interview on December 9, 2010, at 10:20 a.m., in the conference room, with the Licensed Practical Nurse (Treatment Nurse) confirmed the resident had two stage 4 Pressure Ulcers on the heels and two stage 2 Pressure Ulcers on the buttocks at the time of the body assessment dated [DATE] (by the former Treatment Nurse). Continued interview with the Treatment Nurse confirmed the wounds did not heal prior to the resident's death (September 16, 2010). Medical record review and interview on December 9, 2010, at 10:40 a.m., in the conference room, with Licensed Practical Nurse #4/MDS Coordinator confirmed the MDS dated [DATE], was not correct and failed to reflect the stage 4 Pressure Ulcers to the heels and the stage 2 Pressure Ulcers to the buttocks. C/O # , # | 2014-04-01 | ||
| 14140 | 14140 | HUNTSVILLE MANOR | 445288 | 287 BAKER STREET | HUNTSVILLE | TN | 37756 | 2010-12-16 | 456 | E | HRD111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident equipment was maintained for six (#22, #23, #24, #25, #26 and #27) of twenty-eight residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident required limited assistance with bed mobility and transfers and required extensive assistance with ambulation. Observation on December 8, 2010, at 11:35 a.m., revealed the resident was being transported in a wheelchair on the 100 hall by the Physical Therapy Technician (#1). Observation revealed the vinyl material on the right arm rest of the wheelchair was torn and had jagged edges with foam protruding from the armrest. Observation revealed the tear was four inches in length. Observation revealed the resident had no skin tears or reddened areas near the location of the torn armrest. Observation and interview on December 8, 2010, at 11:35 a.m., on the 100 hall, with the Physical Therapy Technician (#1) confirmed the armrest of the wheelchair was in need of repair. Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident was totally dependent on staff for all activities of daily living and was not ambulatory (able to walk). Observation on December 8, 2010, at 1:40 p.m., revealed the resident sitting in the wheelchair. Observation revealed the vinyl covering on both armrests was torn with foam exposed. Observation revealed the right armrest was missing one inch of foam padding with the metal frame exposed. Observation and interview on December 8, 2010, at 1:40 p.m., with Licensed Practical Nurse (LPN) #3 confirmed the wheelchair was in need of repair. Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the res… | 2014-04-01 | ||
| 14141 | 14141 | ERWIN HEALTH CARE CENTER | 445291 | 100 STALLING LANE | ERWIN | TN | 37650 | 2010-12-02 | 160 | F | P5CL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of resident fund records and interview, the facility failed to convey funds within thirty days of death for five (#1, #2, #3, #4, #5) of five residents with funds managed by the facility. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Record revealed the resident expired in the facility on [DATE]. Review of records related to the facility's management of the resident's personal funds revealed conveyance of the balance of the resident's funds in the amount of $301.58 was not issued to the family until [DATE], (two-and one-half months after the resident's death). Interview on [DATE], at 12:35 p.m., in the conference room, with the Assistant to the Administrator confirmed the resident expired in the facility on [DATE]. Continued interview with the Assistant to the Administrator confirmed the balance of the resident's funds in the amount of $301.58 was not conveyed to the family within thirty days of the resident's death and was not conveyed to the family until [DATE]. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Record revealed the resident expired in the facility on [DATE]. Review of records related to the facility's management of the resident's personal funds revealed conveyance to the estate of the balance of the resident's funds in the amount of $413.83 was not issued until [DATE]. Interview on [DATE], at 12:20 p.m., in the conference room, with the Assistant to the Administrator confirmed the resident expired in the facility on [DATE]. Continued interview with the Assistant to the Administrator confirmed the balance of the resident's funds in the amount of $413.83 was not conveyed to the resident's estate within thirty days of the resident's death and was not conveyed to the estate until [DATE]. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSE… | 2014-04-01 | ||
| 14142 | 14142 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2010-07-08 | 514 | D | F7WP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain complete fluid intake/output documentations for two (#4 and #23) of twenty five residents reviewed. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Continued record review revealed a physician's admission order for "[MEDICATION NAME] 1.2 by peg (feeding) tube per pump 115 ml (milliliters) 9:00 p.m. and stop at 5:00 a.m., flush with 30 ml water before and after feeding and flush peg tube with 300 ml each shift." Review of comprehensive care plan dated May 7, 2010 revealed interventions for Nutrition/Hydration included "Intake and Output". Review of the facility Intake and Output Record for fluids for the month of May 2010, reveal documentation for the 300 ml water flush incomplete on 17 of 30 days and the "24 hour totals" incomplete on 28 of 30 days. Interview with the Director of Nursing on July 8, 2010, at 10:15 a.m., at the nurse's station confirmed the fluid intakes were incomplete. Resident # 23 was admitted to the facility February 19, 2010 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]." Review of the facility Minimun data set dated [DATE], under special treatments/procedures and programs indicate Intake/Output to be monitored. Review of the facility Intake and Output Record for fluid from February 19, 2010, to discharge date on March 1, 2010, revealed the 100 ml water flushes, the 250 ml bolus feedings and the "24 hour totals" incomplete for 17 of 20 days. Interview with the Director of Nursing on July 8, 2010, at 10:15 a.m., at the nurse's station, confirmed the fluid intakes were incomplete. | 2014-04-01 | ||
| 14143 | 14143 | WYNDRIDGE HEALTH AND REHAB CTR | 445304 | 456 WAYNE AVENUE | CROSSVILLE | TN | 38555 | 2010-06-09 | 332 | D | V6Z311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility protocol review, and interview, the facility failed to maintain a medication error rate of less than five percent for two (#22, #23) of twenty-six residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the monthly recapitulation physician orders' dated June 2010, revealed "[MEDICATION NAME] (blood pressure medication) 10 mg (milligrams) po (by mouth) qd (every day)...Hold for SBP (systolic blood pressure) less 105 and DBP (diastolic blood pressure) less than 65..." Observation during the medication pass on June 8, 2010, at 8:48 a.m., revealed Charge Nurse # 1 obtained medications including [MEDICATION NAME] for the resident, entered the residents room and administered the medication to resident #22. Continued observation and record review of a Pulse and Blood Pressure document revealed the diastolic blood pressure of 58. Interview with charge nurse #1 at the 200 hall nurse's desk on June 8, 2010, at 10:42 a.m., confirmed the [MEDICATION NAME] had not been held for the resident's diastolic blood pressure of 58. Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the monthly recapitulation physician orders' dated June 2010, revealed "[MEDICATION NAME] Diskus ([MEDICATION NAME][MEDICATION NAME]) 1 (one) puff bid (twice a day)[MEDICATION NAME] 18 mcg (micrograms) inhalation qd (every day)..." Observation during medication pass inside the resident's room on June 8, 2010, at 7:40 a.m., revealed Charge Nurse #2 administered [MEDICATION NAME] Diskus one puff followed by [MEDICATION NAME] one puff and failed to wait one minute between each medication. Review of the facility's Inhaled Medication protocol for spacing and proper sequence revealed "...If more than one inhaler is used...wait 1-2 (one to two) minutes before administering the next medication..."… | 2014-04-01 | ||
| 14144 | 14144 | WYNDRIDGE HEALTH AND REHAB CTR | 445304 | 456 WAYNE AVENUE | CROSSVILLE | TN | 38555 | 2010-06-09 | 281 | D | V6Z311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow physician orders [REDACTED]. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated May 2010, revealed, "[MEDICATION NAME] XL (medication used to decrease elevated blood pressure) 12.5 MG (milligrams) PO (by mouth) QD (every day) with Apical Pulse x (times) I (one) minute and B/P (blood pressure)***Hold for SBP (systolic blood pressure) < (less than) 105 or DBP (diastolic blood pressure) < 65 or pulse < [MEDICATION NAME] (medication used to decrease elevated blood pressure) 10 MG PO at 8 AM and 8 PM with B/P***Hold for SPB <105 or DBP <65..." Medical record review of the MAR (Medication Administration Record) dated May 2010, revealed the following 8:00 a.m., diastolic blood pressures less than 65: May 4, 62; May 5, 60; May 6, 58; May 7, 60; May 8, 62; May 9, 62; May 10, 64; May 11, 64; May 12, 54; May 19, 56; May 20, 64; May 21, 60; May 24, 60. Continued review of the MAR indicated [REDACTED]. Further review of the MAR revealed the [MEDICATION NAME] XL and [MEDICATION NAME] had not been held on fifteen occasions when the diastolic blood pressure was below 65. Interview with the DON (Director of Nursing) on June 8, 2010 at 10:15 a.m., in the DON's office, confirmed the [MEDICATION NAME] and [MEDICATION NAME] were not held according to the parameters ordered by the Physician. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the May 2010, Physician Recapitulation Orders and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] Monoitrate ([MEDICATION NAME]) 20mg PO (by mouth) QD (daily), hold for SBP (systolic blood pressure) < (less than) 105 or DBP (diastolic blood pressure) <[MEDICATION NAME] 50mg PO QD, hold for SBP (systolic blood pressure) < (less … | 2014-04-01 | ||
| 14145 | 14145 | LIFE CARE CENTER OF MORRISTOWN | 445314 | 501 WEST ECONOMY ROAD | MORRISTOWN | TN | 37814 | 2010-12-02 | 356 | D | DH0I11 | Based on observation and interview, the facility failed to post staffing data on a daily basis. The findings included: Observation on December 1, 2010, at 8:30 a.m., 11:30 a.m., and 12:35 p.m., revealed the facility had not posted the daily staffing data for December 1, 2010, including the resident census and the number of Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants on duty. Interview on December 1, 2010, at 12:35 p.m., with the Administrator, in the lobby, confirmed the staffing information for December 1, 2010, had not been posted. C/O # | 2014-04-01 | ||
| 14146 | 14146 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2009-12-08 | 323 | D | 3VQT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 419 Based on medical record, observation and interview, it was determined the facility failed to follow interventions to prevent falls for 2 of 15 (Residents #8 and 12) sampled residents. The findings included: 1. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set ((MDS) dated [DATE] documented that Resident #8 was in need of full staff performance of daily activities. The significant change MDS dated [DATE] and the quarterly assessment of 6/15/09 documented Resident #8 was totally dependent for transfers for two person assist and totally dependent for ambulation requiring two person transfer. Review of Resident #8's care plan dated 3/5/09 documented the resident "At risk for injury/falls... and assist with transfer of 2." The care plan dated 4/1/09 documented "At risk for injury/falls related to impaired mobility hx (history) of falls... Approach Assist with transfers 2." An additional intervention included a body alarm on 12/6/09. Observation in Resident #8's room on 12/8/09 at 3:30 PM, revealed Resident #8 sitting in a wheelchair (w/c) with a body alarm clipped to the back of her shirt to the w/c. During an interview in Resident #8's room on 12/8/09 at 3:30 PM, Resident #8 stated, "Told (Certified Nursing Assistant (CNA) #3) there suppose to be 2 persons. She just picked me up and put me in bed and the rail fell ." The CNA failed to use two people for transfers as care planned. 2. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]." Review of the care plan dated 11/11/09 documented under the heading of problems was: Potential for falls and or injuries secondary to shuffling gait, confusion and history of falls. Under the heading of interventions, #3 intervention was: bed/chair alarm at all times. Observations in Resident #12's room on 12/8/09 … | 2014-04-01 | ||
| 14147 | 14147 | WOOD PRESBYTERIAN HOME | 445322 | 520 OLD HIGHWAY 68 | SWEETWATER | TN | 37874 | 2009-12-08 | 323 | D | R02I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 306 Based on medical record review, observation, and interview, the facility failed to provide supervision to prevent a fall for one (#1) resident of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, modified independence in cognitive skills for daily decision making, required extensive assistance with one person physical assistance for transfers, toilet use, and was continent of bowel and bladder. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the care plan dated February 24, 2009, revealed, " ...provide ext (extensive) assist x 1 for hygiene, dressing, toileting and bathing ..." Medical record review of the Resident Assessment Protocol dated February 24, 2009, revealed, " ...Most ADL's (activities of daily living) require the ext (extensive) assist of one ..." Medical record review of the investigation of unusual occurrence dated April 2, 2009, revealed, " ...Family reported CNA took ...to bathroom (and) left ...on toilet to use bathroom ...did not pull light and tried to get up without help and fell in floor ...Raised hematoma to back of head ...Changes to Care Plan: Staff to stay with ...when using bathroom ..." Observation on December 7, 2009, at 10:15 a.m., in the resident's room, revealed the resident in the wheelchair with a pressure sensitive pad alarm on the wheelchair. Interview on December 7, 2009, at 12:20 p.m., in the conference room, with the Director of Nursing, confirmed the resident was not to be left alone in the bathroom. | 2014-04-01 | ||
| 14148 | 14148 | WOOD PRESBYTERIAN HOME | 445322 | 520 OLD HIGHWAY 68 | SWEETWATER | TN | 37874 | 2010-08-26 | 226 | D | PUVW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation documentation, observation, and interview, the facility failed to implement the abuse policy for one resident (#1) of nine sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory impairment and was moderately impaired with decision-making skills. Continued review revealed the resident was frequently incontinent of bladder and needed extensive to total assistance with mobility, toileting, and hygiene/bathing. Medical record review of a nurse's note dated July 14, 2010, at 11:15 a.m., revealed, "...was approached by CNA (certified nursing assistant #1)...yesterday @ (at) approx (approximately) 5 pm...when (CNA #1) went into (resident's) room...a young boy was @...bedside...(CNA #1) stated upon...arrival, the boy took his hand from elder's brief area et (hurriedly pulled covers up. He then left the room..." Medical record review of a physician's progress note dated July 14, 2010, revealed, "Allegedly sexually abused [MEDICAL CONDITION] (partial or total loss of the ability to express ideas, resulting from brain damage)...no obvious tears, sores, or bleeding..." Review of facility investigation documentation (signed by CNA #1) dated July 13, 2010, revealed, "Today I witnessed a young man in (resident's) room, he had his hand under...blanket on the lower half of...body...I then went and told the nurse..." Review of facility policy revealed, "Abuse Prevention Policy and Procedure...Employees will be trained...about...preventing abuse and intervention techniques for aggressive or catastrophic behaviors...will identify and intervene..." Observation and interview with the resident on July 16, 2010, at 2:07 p.m., revealed the resident in bed in the room and requested the blinds be closed by use of gestures. … | 2014-04-01 | ||
| 14149 | 14149 | WOOD PRESBYTERIAN HOME | 445322 | 520 OLD HIGHWAY 68 | SWEETWATER | TN | 37874 | 2010-08-26 | 323 | D | PUVW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation documentation, observation, and interview, the facility failed to provide adequate supervision to prevent falls for one resident (#8) of nine sampled residents. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was impaired with decision-making skills, was non-ambulatory, and depended on staff for transfers. Medical record review of a fall risk assessment dated [DATE], revealed the resident required assist of two people for ambulation. Medical record review of a care plan dated February 11, 2010, revealed the risk for falls was addressed, and included, "...chooses not to ambulate and needs sit to stand lift to transfer at times...stay with...(resident) when...in toilet..." Medical record review of a nurse's note dated April 3, 2010, at 6:15 a.m., revealed the resident was found in the floor in the room, and included, "...thinks fell asleep in chair." Review of facility investigation documentation dated April 3, 2010, revealed, "...usually early riser...to sit in observable area when up early." Medical record review of a mental health note dated June 20, 2010, revealed, "O x 4 (oriented to person, place, time, situation) Insight impaired..." Medical record review of a nurse's note dated July 8, 2010, at 4:15 a.m., revealed, "...upon entering room...lying on floor in front of wheelchair...complaining of LUE (left upper extremity) pain...hematoma on the Lt. (left) side of...forehead..." Medical record review of a nurse's note dated July 8, 2010, at 4:30 a.m., revealed the resident was transported to a hospital. Medical record review of a nurse's note dated July 8, 2010, at 6:55 a.m., revealed, "return from ER (emergency room )...shoulder immobilizer to L (left) shoulder..." Medical record review of a fax to the physician dated July 11, 2… | 2014-04-01 | ||
| 14150 | 14150 | HOLSTON HEALTH & REHABILITATION CENTER | 445344 | 3916 BOYDS BRIDGE PIKE | KNOXVILLE | TN | 37914 | 2010-09-09 | 441 | D | YDLM11 | Based on observation, facility policy review, and interview, the facility failed to ensure hand hygiene and infection control practices were followed during ice pass on two of six halls, and failed to maintain infection control practices during incontinence care for one (#1) of eighteen residents reviewed. The findings included: Observation of the hydration aide on September 8, 2010, from 2:35 p.m., until 2:55 p.m., revealed the hydration aide dispensing ice to multiple residents from a rolling cart with a large cooler filled with ice, without gloves on the hands or available on the cart. Continued observation revealed the hydration aide entered one resident's room; returned to the ice cooler in the hall with a clear plastic cup full of tea; held the cup of tea over the ice cooler and filled the cup of tea with ice; and took the tea cup back to the resident's room. Continued observation revealed, without performing hand hygiene, the hydration aide went to the next resident room, brought a large cup out of the room, held it over the cooler of ice, filled it with ice, and returned to the resident's room. Continued observation revealed the hydration aide entered a total of 13 rooms on two halls, filling containers of ice by holding the individual residents' cups over the cooler of ice, and returning the cups to the residents' rooms. Continued observation revealed the hydration aide was touching items in residents' rooms, wiping off over bed tables, and touching residents, and did not wear gloves or perform hand hygiene between residents or resident rooms. Interview with the hydration aide on September 8, 2010, at 2:53 p.m., on the 500 hall, confirmed the hydration aide performed hand hygiene prior to starting the ice pass, but did not perform hand hygiene during the ice pass or between residents. Review of the facility's policy Handwashing revised October 1, 2008, revealed, "Wash hands before and after contact with each patient..." Interview with LPN (licensed practical nurse) #1 on September 8, 2010, at 2:45 p.m., … | 2014-04-01 | ||
| 14151 | 14151 | HOLSTON HEALTH & REHABILITATION CENTER | 445344 | 3916 BOYDS BRIDGE PIKE | KNOXVILLE | TN | 37914 | 2010-09-09 | 226 | D | YDLM11 | Based on review of personnel files, policy review, and interview, the facility failed to provide documentation of an abuse registry check for one (#1) of five employees reviewed. The findings included: Review of the personnel files on September 9, 2010, revealed Staff #1 had a hire date of August 25, 2010. Continued review of the file revealed the Abuse Registry was not checked until September 7, 2010, a two week delay after the hire date. Review of the facility policy for Abuse Protection & Response Policy...revealed: "...The center will not employ individuals who: Are currently listed on the State Nurse Aide Registry or any other State employee screening or disqualification list for Abuse, Neglect or Misappropriation of Patient Property." Interview with the Director of Nursing on September 9, 2010, at 1:55 p.m., at the west wing nursing station, confirmed no documentation the Abuse Registry was checked prior to employment for Staff #1. | 2014-04-01 | ||
| 14152 | 14152 | ROGERSVILLE CARE & REHABILITATION CENTER | 445359 | 109 HWY 70 NORTH | ROGERSVILLE | TN | 37857 | 2010-05-13 | 441 | D | 7ZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility policy, and interview, the facility failed to follow the infection control policy and failed to maintain a clean technique, for one resident (#19), of twenty seven residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had difficulty with long and short term memory and severe difficulty with decision making skills. Observation of a dressing change on May 12, 2010, at 10:25 a.m., revealed Licensed Practical Nurse (LPN #1) gathered the supplies, placed the supplies on the over-bed table, positioned the resident on the right side, exposing the buttocks and a dressing covering the pressure sore. Continued observation revealed LPN #1 washed the hands, donned gloves, removed the soiled dressing, and placed it in the biohazard bag. Continued observation revealed LPN #1 cleaned the pressure sore with a 3 x 3 gauze, and wound cleanser, then patted dry with a 3 x 3 gauze. Continued observation revealed LPN #1 removed the gloves, washed the hands and donned gloves; applied Silver Sorb and dry dressing; removed the gloves, washed the hands and donned gloves. Continued observation revealed LPN #1 failed to remove the gloves after removing the soiled dressing and before cleaning the wound. Interview with LPN #1 on May 12, 2010, at 12:45 p.m., on the 200 hall, confirmed the gloves were not removed after removing the soiled dressing and before applying the clean dressing. Review of the Dressing Procedures (for) Clean Technique revealed, "...Always change gloves after removing soiled dressing(s)." Interview with the Director of Nursing on May 12, 2010, at 2:50 p.m., in the administrator's office confirmed the policy was not followed. | 2014-04-01 | ||
| 14153 | 14153 | ROGERSVILLE CARE & REHABILITATION CENTER | 445359 | 109 HWY 70 NORTH | ROGERSVILLE | TN | 37857 | 2010-05-13 | 279 | D | 7ZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to revise the comprehensive care plan to include comfort measures for one resident (# 7) of twenty-seven residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Interview with the Director of Nursing (DON) and the Minimum Data Set (MDS) coordinator on May 12, 2010, at 10:05 a.m., in the MDS office confirmed the resident was on comfort measures and the facility had failed to revise the care plan to reflect the comfort measures. | 2014-04-01 | ||
| 14154 | 14154 | ROGERSVILLE CARE & REHABILITATION CENTER | 445359 | 109 HWY 70 NORTH | ROGERSVILLE | TN | 37857 | 2010-05-13 | 328 | D | 7ZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to assure oxygen was administered as ordered for one resident (#7) of twenty-seven residents reviewed. The findings included: Resident # 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED]. Observation on May 11, 2010, at 9:53 a.m., and 11:15 a.m., in the resident's room, revealed the resident in bed with nasal cannula (extension of oxygen delivery system) not in place for resident to receive oxygen. Observation with unit manager # 1 on May 12, 2010, at 9:28 a.m., in the resident's room, revealed the resident sitting up in a Geri chair (type of wheelchair) with the oxygen concentrator (oxygen delivery device) in the off position and the nasal cannula placed on the resident bed not in reach of resident. Interview with unit manager # 1 on May 12, 2010, at 9:30 a.m., at the North hall nurse's desk confirmed the resident was to have oxygen administered continuously at two liters by nasal cannula. | 2014-04-01 | ||
| 14155 | 14155 | LIFE CARE CENTER OF HIXSON | 445380 | 5798 HIXSON HOME PLACE | HIXSON | TN | 37343 | 2010-01-21 | 281 | D | P3CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the [MEDICAL TREATMENT] contract, and interview, the facility failed to communicate to the [MEDICAL TREATMENT] center the assessment of a resident, and medication the resident received prior to the resident's visit to the [MEDICAL TREATMENT] center for one (#8) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, with modified independence in cognitive skills for daily decision making. Medical record review of the nursing note dated August 26, 2009, revealed, "...Res. (resident) refused to go for [MEDICAL TREATMENT], called to NP (nurse practitioner). [MEDICATION NAME] (medication for anxiety) 1 mg (milligram) IM (injection)...PT (prior to) [MEDICAL TREATMENT]...Res. Left (at) 06:20 (a.m.)..." Review of the Long Term Care Facility [MEDICAL TREATMENT] Services Agreement dated February 20, 2002, revealed, "...Responsibilities of Facility...The appropriate healthcare staff at Facility will make an assessment of the patient's physical condition and determine whether the patient is stable enough to be dialyzed on an outpatient basis...This assessment and communication will occur prior to each and every transfer of a patient to...for [MEDICAL TREATMENT] on an outpatient basis..." Interview on January 20, 2010, at 3:30 p.m., with the Social Service Director, at the nursing station, confirmed the resident was anxious about going to [MEDICAL TREATMENT] on August 26, 2009, but after the anti-anxiety medication was given, the resident agreed to go to [MEDICAL TREATMENT]. Interview on January 21, 2010, at 10:15 a.m., with the Director of Nursing, in the nursing office, confirmed no documentation of the assessment of the resident or the administration of the [MEDICATION NAME] was communicated prior to the … | 2014-04-01 | ||
| 14156 | 14156 | LIFE CARE CENTER OF HIXSON | 445380 | 5798 HIXSON HOME PLACE | HIXSON | TN | 37343 | 2010-01-21 | 315 | D | P3CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to provide a bladder training program for one (#5) resident of fifteen residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long term memory problems; had independent cognitive skills for daily decision making; and was usually continent of bladder. Medical record review of the assessment form for bowel and bladder training dated December 21, 2009, revealed the resident scored a ten, indicating the resident was a candidate for toileting, timed or scheduled voiding. Medical record review of the interim care plan dated December 21, 2009, revealed "...initiate bladder observation for patterning..." Medical record review of a urinary incontinence assessment dated [DATE], revealed "...scheduled toileting...at regular intervals on a planned basis to match the resident's voiding habits...scheduled toileting includes timed voiding with the interval based on the resident's usual voiding pattern or usually every three to four hours while awake..." Medical record review revealed no documentation the resident's usual voiding pattern was assessed or timed voiding was completed. Observation and interview on January 20, 2010, at 2:35 p.m. revealed the resident in a wheelchair. Interview with the resident revealed when asked if the resident was aware of the need to go to the bathroom, the resident stated "...I know when I have to go when I'm awake but not when I'm asleep..." Interview with the restorative nurse and the director of nursing on January 20, 2010, at 3:30 p.m., in the Director of Nursing's office confirmed the facility had failed to complete the voiding pattern assessment or the timed voiding. | 2014-04-01 | ||
| 14157 | 14157 | LIFE CARE CENTER OF HIXSON | 445380 | 5798 HIXSON HOME PLACE | HIXSON | TN | 37343 | 2010-01-21 | 502 | D | P3CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to obtain laboratory services for one resident (#5) of fifteen residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission physician orders [REDACTED]. Medical record review of a clarification physician order [REDACTED]. Observation on January 20, 2010, at 8:35 a.m., revealed the resident in a wheelchair for breakfast. Observation revealed the resident with no bruising or bleeding noted. Interview with licensed practical nurse (LPN #1) on January 20, 2010, at 10:00 a.m., in the conference room, confirmed the facility had failed to obtain the PTT as ordered by the physician. | 2014-04-01 | ||
| 14158 | 14158 | MAURY REGIONAL HOSPITAL SNU | 445398 | 1224 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2011-02-08 | 241 | D | 2EK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the "Medication Guide for the Long-Term Care Nurse" and observations, it was determined 2 of 2 (Nurse #1 and 2) nurses failed to maintain residents' dignity and respect by entering residents' rooms without knocking or gaining permission to enter. The findings included: 1. Review of the "Medication Guide for the Long-Term Care Nurse," Sixth Edition, page 68, documented, "Medication Administration in Nursing Facilities ...11. The nurse should knock on the resident's door before entering..." 2. Observations outside room [ROOM NUMBER] on 2/7/11 at 11:35 AM, Nurse #1 entered Resident #5's room without knocking or gaining permission to enter. Observations outside room [ROOM NUMBER] on 2/7/11 at 6:20 PM, Nurse #1 entered Resident #1's room without knocking or gaining permission to enter. 3. Observations outside room [ROOM NUMBER] on 2/8/11 at 12:05 PM, Nurse #2 entered Resident #2's room without knocking or gaining permission to enter. | 2014-04-01 | ||
| 14159 | 14159 | MAURY REGIONAL HOSPITAL SNU | 445398 | 1224 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2011-02-08 | 431 | D | 2EK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined the facility failed to ensure medications were not left unattended in 1 of 10 (room [ROOM NUMBER]) resident rooms. The findings included: Review of the facility's medication storage policy documented "...assure the proper safe handling, security, and storage of medications... Procedure: 1. Keep medications in the automated dispensing machine or designated medication room of the patient care area." Observations in room [ROOM NUMBER] on 2/7/11 at 10:45 AM, revealed a medication cup with an orange liquid substance on the bedside table in room [ROOM NUMBER]. During an interview outside of resident room [ROOM NUMBER] on 2/7/11 at 10:45 AM, Nurse #1 stated the orange liquid substance was "resident's (Resident #3's) Lactulose. Tried to give it to her earlier. I did not mean to leave that (Lactulose medication) there." | 2014-04-01 | ||
| 14160 | 14160 | MAURY REGIONAL HOSPITAL SNU | 445398 | 1224 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2011-02-08 | 371 | D | 2EK511 | Based on policy review, observations and interviews, it was determined the facility failed to ensure dietary staff members prepared and served food under sanitary conditions as evidenced by not ensuring their hair or beards were covered on 2 of 2 (2/7/11 and 2/8/11) days of the survey. The findings included: 1. Review of the facility's "FOOD & (and) NUTRITION" policy documented, "...Wear the approved hair restraint when on duty... Long facial hair must be covered with a surgical mask and/or hood..." 2. Observations in the kitchen on 2/7/11 at 10:46 AM, Dietary Staff Member (DSM) #1 and #2 were working at the steam table wearing a cap, that did not completely cover their hair. DSM #3 and the Dietary Manager (DM) were walking throughout the kitchen wearing a cap, that did not completely cover their hair. DSM #4 was walking throughout the kitchen wearing a cap, that did not completed his hair nor was his beard covered. 3. Observations in the kitchen on 2/7/11 at 2:25 PM, DSM #3 and #5 were walking throughout the kitchen wearing a cap, that did not completely cover their hair. DSM #4 was walking throughout the kitchen with his hair and beard not covered. 4. Observations in the kitchen on 2/8/11 at 11:25 AM, DSM #6 was obtaining food temperatures wearing a chef hat. DSM #6's hair and beard were not covered. The DM was walking throughout the kitchen with a cap on that did not completely cover his hair. 5. During an interview in the kitchen on 2/7/11 at 2:35 PM, DSM #5 stated, "We routinely wear baseball caps and not hair covers. Will fix this immediately." During an interview in the kitchen on 2/8/11 at 11:45 AM, the DM stated, "...we have always worn ball caps. Will be a big change (completely covering hair and beards) for us..." | 2014-04-01 | ||
| 14161 | 14161 | MAURY REGIONAL HOSPITAL SNU | 445398 | 1224 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2011-02-08 | 441 | D | 2EK511 | Based on review of the "Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach" and observations, it was determined 1 of 2 (Nurse #1) nurses failed to prevent the potential development or transmission of an infection by failing to wash her hands and turned the water off with her bare hands. The findings included: Review of the "Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach", Third Edition, page 518 through (-) 519, documented "Handwashing... 7. Thoroughly dry hands with paper towel. 8. Unless foot or knee control are being used, use paper towel to turn off water faucet." Observations in Random Resident #1's room on 2/7/11 at 10:35 AM, Nurse #1 did not wash her hands or use hand sanitizer before administering medications. Observations in Resident #5's room on 2/7/11 at 11:35 AM, Nurse #1 cleaned the accucheck machine, washed her hands and turned the faucet off with her bare hands. After obtaining the residents blood, Nurse #1 removed her gloves, washed her hands and turned the faucet off with her bare hands. | 2014-04-01 | ||
| 14162 | 14162 | COMMUNITY CARE OF RUTHERFORD | 445406 | 901 COUNTY FARM RD | MURFREESBORO | TN | 37127 | 2010-05-12 | 323 | G | 5DZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility document review, and staff interview, the facility failed to ensure, on two occasions, to provide the required assistance and use the appropriate equipment for one resident (#21) of twenty-five records reviewed. The failure of the staff not providing the necessary assistance and using the appropriate equipment resulted in a fractured right hip to resident #21. The findings included: Medical record review revealed resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's care plan initiated September, 2009, revealed the resident was at high risk for falls. Continued review revealed the care plan was updated December 17, 2009, with the intervention "...assist (resident) 1-2 (one to two persons) using gait belt..." Continued review of the care plan revealed the intervention was updated March 17, 2010, to "...2 people with gait belt..." Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was totally dependent with two plus person physical assistance for transfers; extensive assistance with two plus persons physical assistance for bed mobility; and extensive assistance with one person physical assistance for toilet use, personal hygiene and bathing. Medical record review of the nursing note dated February 6, 2010, revealed "...was called in resident's room...was informed resident slid down w/c (wheelchair) while transferring from toilet to w/c...Tech helped...slide to floor and went for help." Two staff members "helped...to get to...electric w/c with gait belt...informed resident had skin tear on right lower leg...denies pain." Review of a facility investigation revealed on February 6, 2010, at 3:25 p.m., the resident had fallen. Further review revealed "1-2 person assist needed to transfer and/or ambulate...resident slid off w/c (wheelchair) while transferring from the toilet to w/c (electric)...Found a… | 2014-04-01 | ||
| 14163 | 14163 | IVY HALL NURSING HOME | 445469 | 301 WATAUGA AVE | ELIZABETHTON | TN | 37643 | 2010-05-12 | 323 | D | 1WJ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interviews, the facility failed to ensure a safety device was in place for one resident (#3) of twenty-six residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Medical record review of a Plan of Care, dated February 10, 2010, revealed, the resident had a history of [REDACTED]. Medical record review of facility documentation dated, May 3, 2010, revealed, "...Notified by CNA (Certified Nursing Assistant) to res. (resident) room. Res. up in W/C (wheelchair) @ (at) this time...Skin tear observed 3 in. (inch) long on top (R) forearm..." Continued review of facility documentation revealed, "...Plan: Educate staff to ensure geri-sleeve is worn to (R) arm." Interview with CNA #1 (on duty at the time of the skin tear) and the Director of Nursing, on May 11, 2010, at 10:05 a.m., in the 400 hall nurse's station, confirmed the geri-sleeve was not in place on May 3, 2010, when the resident sustained [REDACTED]. | 2014-04-01 | ||
| 14164 | 14164 | LAKESHORE HEARTLAND | 44A114 | 3025 FERNBROOK LANE | NASHVILLE | TN | 37214 | 2010-06-23 | 327 | D | 9JGX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain proper hydration for one resident (#9) of sixteen residents reviewed. The findings included: Resident #9 was originally admitted to the facility November 14, 2007, with [DIAGNOSES REDACTED]. Medical record review of the facility's Admission Evaluation and Interim Care Plan revealed the resident had readmitted to the facility from a hospital stay on May 22, 2010, with [DIAGNOSES REDACTED]. Further medical record review of the Admission Evaluation revealed the resident was dependent on staff for bed mobility and transfer. Medical record review of the Medical Nutrition Therapy Assessment revealed "potential for dehydration due to leaving 25% (of meals) having UTI (Urinary Tract Infection) and poor cognition." Continued medical record review of the nurse's notes revealed the resident had poor meal and fluid intake. Medical record review of the comprehensive care plan dated November 16, 2009, under the problem of alteration in nutrition revealed there were no specific approaches to keep the resident hydrated. Observation of the resident in bed on June 21, 2010, at 6:45 p.m., 7:40 p.m., June 22, 2010, at 9:44 a.m., and June 23, 201 0, at 7:26 a.m., and 10:45 a.m., revealed the water pitcher out of the reach of the resident. During the above observations, the water pitcher was positioned on a table at the foot of the resident's bed. Observation on June 23, 2010, at 7:26 a.m., revealed the resident in bed feeding self breakfast. Interview with the administrator on June 23, 2010, at 11:00 a.m., in the administrator's office confirmed the facility had failed to provide hydration for the resident. | 2014-04-01 | ||
| 14165 | 14165 | LAKESHORE HEARTLAND | 44A114 | 3025 FERNBROOK LANE | NASHVILLE | TN | 37214 | 2010-06-23 | 176 | D | 9JGX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for self administration of medications for two residents (#2, #16) of sixteen residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had intact short and long term memory, and required assistance with activities of daily living. Observation on June 23, 2010, at 7:45 a.m., with Licensed Practical Nurse (LPN) #1 in the resident's room revealed 12 Gas-X capsules and one 0.41 fluid ounce, 7/8 full bottle of Walgreen's Oral [MEDICATION NAME] with [MEDICATION NAME] (local anesthetic) on the resident's over the bed table. Interview with the resident on June 23, 2010, at 7:47 a.m., revealed the resident used both medications as needed, did not record or report to the nurses when used, and had not been assessed for self administration of medications. Interview on June 23, 2010, at 7:48 a.m., with LPN #1 confirmed the LPN was unaware if the resident had been assessed for self administration of medications and there had been no physician order to allow the resident to self administer medications. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had intact short and long term memory, required assistance with activities of daily living, and limited range of motion (ability to move) with one arm. Observation and interview on June 21, 2010, at 6:50 p.m., in the resident's room revealed one 96 count bottle, ? full of Tums on the resident's over the bed table. Interview with the resident revealed the resident took the Tums as needed, did not record when used or reported to the nurses when used, and was unsure if had been assessed for self administration of medications. Interview on June 21, 2010, at 6:55 p.m., with LPN #… | 2014-04-01 | ||
| 14166 | 14166 | LAKESHORE HEARTLAND | 44A114 | 3025 FERNBROOK LANE | NASHVILLE | TN | 37214 | 2010-06-23 | 431 | D | 9JGX11 | Based on observation, review of facility policy, and interview, the facility failed to ensure only licensed personnel had access to the medication room. The findings included: Observation on June 23, 2010, at 9:35 a.m., of the third floor medication room revealed Licensed Practical Nurse (LPN) #1 opened the medication room door and allowed the central supply clerk to enter the medication room unsupervised. Continued observation revealed LPN #1 walked down the hallway and out of visual supervision of the medication room. Continued observation revealed the central supply clerk was in the medication room unsupervised for ten minutes. Interview on June 23, 2010, at 9:45 a.m., with the central supply clerk revealed "they let me in when I stock the medication room and no one stays with me." Review of the facility's Storage of Medications policy revealed "...Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys..." Interview on June 23, 2010, at 10:15 a.m., in the conference room with the Director of Nursing confirmed unlicensed personnel must be supervised when in the medication room. | 2014-04-01 | ||
| 14167 | 14167 | LAKESHORE HEARTLAND | 44A114 | 3025 FERNBROOK LANE | NASHVILLE | TN | 37214 | 2010-06-23 | 441 | D | 9JGX11 | Based on observation and interview the facility failed to handle clean linens so as to prevent the spread of infection. The findings included: Observation on June 23, 2010, at 10:00 a.m., in the facility laundry revealed one employee handling soiled linen then folding clean linen while wearing the same uniform. Further observation revealed no physical separation between the soiled linen side of the laundry area and the clean. Interview with the Environment Manager and the Administrator on June 23, at 11:00 a.m., confirmed the soiled linen must be processed separate from the clean linen to minimize aerosolization of waste products and staff handling soiled linen should remove outer uniform covering before handling clean linen. | 2014-04-01 | ||
| 14168 | 14168 | BLEDSOE COUNTY NURSING HOME | 4.4e+233 | 107 WHEELERTOWN AVENUE | PIKEVILLE | TN | 37367 | 2010-09-07 | 281 | D | C2K711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interview, the facility failed to follow physician's orders for frequency of wound care for two (#2, #3) of five residents reviewed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the resident was moderately cognitively impaired with short and long-term memory deficits; was totally dependent for ADLs; was incontinent of bowel and bladder; ate <75% of diet of pureed with nectar-thick liquids. Review of the Weekly Pressure Ulcer Progress Report dated September 2, 2010, reveled the resident had a stage II decubitus ulcer to the coccyx, which measured 3 cm by 1 cm with partial depth. Continued review of the Progress Report revealed the ulcer bed was red and had no odor or drainage. Further review of the Progress Report revealed the resident also had a 6 cm by 3 cm circular black area on the left heel. Observation of wound care on September 7, 2010, at 3:00 p.m., revealed no dressing on the coccyx ulcer when the resident's diaper was removed. Continued observation revealed the wound measurements to be correct with the wound bed red as well as wound edges, and no odor or drainage. Observation of the resident's left heel revealed almost the whole heel covered with black eschar. Observation of the resident revealed heel protectors were in place on both feet and the feet were elevated on pillows. Review of physician's orders dated August 5, 2010, revealed the ulcer was to be cleansed with normal saline; open area to be filled with Fibercal; surrounding areas painted with Hendrickson's cream; covered with [MEDICATION NAME] and [MEDICATION NAME]. Continued review of the orders revealed the dressing was to be changed every three days and as needed. Review of the Treatment Record revealed the dressing was to be changed on the 7:00 a.m. to 3:00 p.m. shift as w… | 2014-04-01 | ||
| 14169 | 14169 | BAPTIST HEALTH CARE CENTER | inf | 700 WILLIAMS FERRY RD | LENOIR CITY | TN | 37771 | 2010-09-09 | 281 | D | TB7211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to monitor pain for three (#8, #9, and #25) residents receiving routine pain medication of twenty-five residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE] revealed the resident experienced less than daily moderate pain in the back, joint, and soft tissue. Medical record review of a nursing note dated July 8, 2010, revealed "Resident c/o (complained of) pain in...back moderate to severe..." Medical record review of a physician's telephone order dated July 8, 2010, revealed "[MEDICATION NAME]/APAP 5/500 mg po q hs (by mouth every bedtime)...DX (diagnosis): Chronic Pain." Further medical record review of the physician orders revealed the [MEDICATION NAME] order remained current through September 8, 2010. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the Pain Assessment Notes, dated July 6, 2010 revealed "New order per Dr...to start [MEDICATION NAME] 5/500 mg one tab po q h.s." Medical record review of a Pain Assessment Form, signed by Licensed Practical Nurse (LPN) #1 on July 6, 2010, revealed "...mild back pain every day at bedtime." Review of the facility policy for pain assessment dated [DATE] and revised on July 2007 revealed the pain assessment "will be performed by a licensed nurse upon admission, when there is a significant change in the residents condition and with each MDS assessment identifying pain." Further policy review revealed "5. Ongoing Monitoring...Residents on a pain management program will be monitored for pain by the charge nurse. The findings, will be documented on a pain management flow sheet that will remain a part of the resident's record..." Interview with LPN #1 on September 8, 2010, at 8:55 a.m., … | 2014-04-01 | ||
| 14170 | 14170 | BAPTIST HEALTH CARE CENTER | inf | 700 WILLIAMS FERRY RD | LENOIR CITY | TN | 37771 | 2010-09-09 | 323 | D | TB7211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one resident (#7) of twenty-five residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had moderately impaired cognitive skills, was totally dependent for transfers, did not walk, and had fallen in the past thirty days. Medical record review of the Assessment for Risk of Falls dated June 8, 2010, revealed the resident was at high risk for falls. Medical record review of the Care Plan dated June 30, 2010, revealed "...Resident has hx (history) of fall...apply mobility monitor at all times...may get up daily in a...roll about reclining chair..." Medical record review of a nursing note dated September 7, 2010, revealed "late entry for 9/3/10. Res (resident) observed in upright sitting position @ (at) foot of rollabout chair...(no) injuries noted..." Observation on September 7, 2010, at 9:24 a.m., revealed the resident seated in the roll about chair with a mobility monitor in place. Interview on September 8, 2010, at 11:59 a.m., with Licensed Practical Nurse (LPN) #1, in the conference room, revealed LPN #1 had observed the resident at the time of the fall on September 3, 2010, and confirmed the mobility monitor was not in place at the time of the fall. | 2014-04-01 |
Advanced export
JSON shape: default, array, newline-delimited
CREATE TABLE [cms_TN] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );