cms_TN
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14,361 rows sorted by rowid descending
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| Link | rowid ▲ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 14361 | 14361 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 225 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to investigate and report 1 of 1 (Resident #25) sampled resident's allegation of abuse. The facility's failure to investigate and report the abuse allegation placed Resident #25 in immediate jeopardy as evidenced by her show of mental anguish by crying during an interview. The findings included: Review of the facility's abuse policy documented, "1. Defining... "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in "physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult... Reporting and Response Notify the Administrator and/or Director of Nursing immediately. Do not wait until "morning" ...An accident /Incident Report is completed as soon as possible after an allegation of abuse or neglect is made... Report all alleged violations and all substantiated incidents to official agencies as required by State law..." Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] documented, "...Section C Cognitive Patterns Brief Interview for Mental Status...C0500. Summary Score...15 (cognitively intact)..." Observations in Resident #25's room on 5/8/12 at 10:53 AM, Resident #25 began crying when talking about the way the staff treated her. During an interview in Resident #25's room on 5/8/12 10:53 AM, Resident #25 stated, "...they (staff) steal from you all time. Bloomer gone this morning, socks, magazines..." During an interview in Resident #25's room on 5/8/12 at 11:06 AM, Resident #25 was asked, "Has staff yelled or been rude to you?" Res… | 2014-01-01 | ||
| 14360 | 14360 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 520 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility's administrative staff failed to identify and address quality of care issues such as failure to ensure adequate supervision of residents; failure to ensure adequate interventions were developed to manage and prevent falls; failure to provide necessary care and services for the management and treatment of [REDACTED].#66) sampled residents reviewed in the Stage 2 review. The facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed to investigate the reported abuse for Resident #25. The facility failed to assess and address the care and prevention of pressure ulcers for 1 of 2 (Resident #138) sampled residents observed with pressure ulcers. The facility failed to ensure the facility's protocol for monitoring nutrition was followed for 1 of 7 (Resident #118) sampled residents for nutrition in the Stage 2 review. The failure of the Quality Assurance and Assessment (QAA) Committee to identify and address these concerns resulted in the potential cause of death for Resident #66 as evidenced by repeated falls, no treatment and services for repeated behaviors and no physician notification of his deteriorating conditions. The failure of the QAA Committee to investigate and report the alleged abuse reported to the facility by Resident #25 and the failure to ensure RR #1 and Residents #25 were free from mistreatment and neglect placed these residents in immediate jeopardy as evidenced by tearful emotional responses when interviewed. The findings included: 1. During an interview in the Assistant Director of Nursing's (ADON) office on 5/15/12 at 2:00 PM, the Administrator, who coordinated the QAA Committee, did… | 2014-01-01 | ||
| 14359 | 14359 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 516 | D | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and observation, it was determined the facility failed to maintain confidentiality of a resident's private healthcare information during 1 of 2 (Resident #89) dressing change observations. The findings included: Medical record review for Resident #89 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of a dressing change in Resident #89's room on 5/13/12 at 11:30 AM, revealed Resident #89 lying in bed on his left side, the head of bed was elevated 30 degrees and 150 cubic centimeters (cc) of water was infusing per feeding tube. Nurse #5 was observed to gather supplies, removed the old dressing, performed wound care as ordered and disposed the dressing in a red bag. Nurse #5 left the computer open to Resident #89's Treatment Administration Record (TAR) as he walked down the hall to the nurses' station. | 2014-01-01 | ||
| 14358 | 14358 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 490 | J | LH9611 | Based on policy review, review of residents' rights, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility failed to be administered in a manner that ensured the environment was as free as possible from accident hazards; failed to maintain the highest practicable physical, mental, and psychosocial well being and failed to notify the physician of condition changes for 1 of 32 (Resident #66) sampled residents in the Stage 1 and 2 review. The facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed to investigate the reported abuse for Resident #25. residents interviewed in the Stage 1. The findings included: 1. The facility administration failed to ensure the environment was free from possible accident hazards, failed to ensure the staff assessed, provided the necessary care and services to address mental and psychosocial adjustment difficulties for Resident #66 as evidenced by not reporting non-compliance with oxygen therapy, low oxygen saturation levels not reported to physician, abnormal lung sounds that worsened, did not report fever to the physician, no fall management / prevention of multiple falls and did not address or report to the physician the repeated behaviors displayed. The facility's failure to assess and provide the necessary care and services and notify the physician of these conditions placed Resident #66 in immediate jeopardy. Refer to F157, F309, F319, F323 and F328. 2. The facility administration failed to ensure Resident #25 and RR #1 were free from verbal abuse; failed to effectively monitor staff interaction with residents; facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed … | 2014-01-01 | ||
| 14357 | 14357 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 463 | D | LH9611 | Based on observation and interview, it was determined the facility failed to ensure the resident call system was functional for 1 of 32 (Resident #63) sampled residents reviewed in Stage 1 and Stage 2. The findings included: Observations in Resident #63's room (218 B) on 5/8/12 at 8:00 AM, revealed the call light was not functioning. Nurse #13 was observed to check the call light in room 218 B on 5/8/12 at 8:30 AM and confirmed it was not working. During an interview in room 218 B on 5/8/12 at 8:30 AM, Nurse #13 stated, "Will have to get maintenance to check (call light)..." Observations during an interview in room 218 on 5/8/12 at 9:25 AM, the Director of Maintenance replaced the call light cord and stated, "Light functioning." | 2014-01-01 | ||
| 14356 | 14356 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 456 | D | LH9611 | Based on policy review, observation and interview, it was determined the facility failed to ensure that essential medical equipment was properly maintained as evidenced by 3 of 3 gerichairs observed with torn upholstery. The findings included: 1. Review of the facility's clinical equipment policy documented, "Purpose: To provide clean clinical equipment and help promote sanitary environment. Policy: For all clinical equipment, the manufacturer's recommendations for cleaning or disinfecting are followed... geri-chairs and other specialty chairs are cleaned on a monthly schedule and as needed... are cleaned weekly and as needed using germicidal agent that is approved for housekeeping to use..." 2. Observations on 5/9/12 beginning at 3:50 PM revealed the following: a. Room 113 - The geri-chair in the room had tears in both arms. b. Room 114 - Both arms of the geri-chair were torn. Observations in the 300 hall shower room on 5/14/12 at 4:37 PM, revealed a gerichair with the head rest upholstery torn. During an interview in the Assistant Director of Nursing's office on 5/10/12 starting at 11:30 AM, the Director of Maintenance was asked how often he or the maintenance assistant was in the resident rooms and if he was aware of their appearance and condition. The Director of Maintenance stated that "he and/or the assistant were in each resident's room and the common areas at least monthly for scheduled maintenance and on top of that, for needed repairs that were reported to the maintenance department by staff or residents." | 2014-01-01 | ||
| 14355 | 14355 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 441 | E | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of infection control logs, observation and interview, it was determined the facility failed to establish and maintain an infection control program that provided a safe, sanitary and comfortable environment for the residents by failing to investigate and maintain records of incidents and corrective actions related to infections; failed to ensure that 2 of 5 (200 and 100 hall medication carts) medication carts and the treatment cart were clean; failed to ensure that 2 of 2 Random Residents (RR) #2 and #8) failed to clean feeding syringes; failed to prevent the catheter tubing and bag from dragging on the floor for 1 of 32 (Resident #98) sampled residents; failed to wash hands during 1 of 2 (noon meal on 5/7/12) dining observations or during medication administration on 3 or 4 (200, 300 and 400 halls) halls. The findings included: 1. Review of the facility's "Vanguard Healthcare Services Infection Control Surveillance" policy documented, "...The Infection Control Practitioner does surveillance of healthcare-associated infections by... Healthcare-associated infections are reported monthly... Surveillance documentation is maintained on the... ECS (Electronic Charting System) QA (quality assurance) /Infection Control Folder... Infection Control Report (line listing of resident infections)... Log of Employee Infections..." Review of 6 months of "Infection Control Log" documented, "...infection control November 10 reported infections..., December 6 reported URI's (upper respiratory infections) on second floor seasonal, 5 UTI's (urinary tract infections)..., January (Jan)... 13 residents received antibiotics in Jan... February (Feb)... 9 residents received antibiotics in Feb..., and March... 6 residents an ATB (antibiotic) all for UTI... There was no documentation to identify the residents or staff involved in the infections, type of infection, symptoms, cultures / labs (laboratory) results, treatment/other actions, or i… | 2014-01-01 | ||
| 14354 | 14354 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 431 | D | LH9611 | Based on observation and interview, it was determined the facility failed to ensure drugs were not stored past their expiration date in 1 of 6 (100 hall medication room) medication storage areas. The findings included: Review of the facility's medication storage policy documented, "...13. Outdated, contaminated, or deteriorated medications... are immediately removed from stock, disposed of according to procedures for medication destruction..." Observations in the 100 hall medication room on 5/13/12 at 3:50 PM, revealed the following drugs were stored past their expiration date: a. Three bottles of Enteric Coated (EC) Aspirin (ASA) 325 milligram (mg) tablets with an expiration date of 4/12. b. A bottle of Simethicone 80 mg tablets with an expiration date of 1/12. c. A bottle of Loperamide HCL 2 mg with an expiration date of 4/12. d. A bottle of Senna 8.6 mg with an expiration date of 4/12. e. A bottle of Promod Liquid Protein Fruit Punch with an expiration date of 12/1/11. f. A bottle of Geri Care Iron Supplement Elixir Ferrous Sulfate 220 mg with an expiration date of 11/11. g. Two Phenadoz Suppository with an expiration date of 4/6/12. During an interview in the first floor medication room on 5/13/12 at 3:50 PM, Nurse #5 was shown the medications as noted above and asked if the medications were out of date. Nurse #5 stated, "Yes." | 2014-01-01 | ||
| 14353 | 14353 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 425 | D | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure that pharmacy services were timely for 2 of 32 (Residents #33 and #100) sampled residents in Stage 1 and Stage 2. The findings included: 1. Medical record review for Resident #33 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].i.d. (twice daily) 0900 (9:00 AM) 2100 (9:00 PM) FOR: Pain..." Review of the April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation in the nurse's charting under the exception tab documented, "4/25/2012 09:49AM... Morphine Sulfate 15MG Tablet held med (medication) unavailable... 4/26/2012 09:03PM... Morphine Sulfate 15MG Tablet held REASON: Not available in Med Select 4/27/2012 10:09AM... Morphine Sulfate held med unavailable..." During an interview in the 200's hall on 5/9/12 at 8:20 PM, Resident #33 stated that she did get her pain medication and that her pain was relieved..." During an interview in the Assistant Director of Nursing's office on 5/14/12 at 9:00 AM, the Director of Nursing (DON) was asked what happened that the resident did not receive the Morphine Sulfate. The DON stated, "I don't know what happened. I couldn't even make a guess as to what happened." 2. Medical record review for Resident #100 documented a physician's orders [REDACTED].i.d..." Review of the nurse charting exception tab dated 4/25/12 documented, "...held REASON Medication not available." The facility failed to ensure that the pharmacy timely delivered medications for Resident #33 and 100. | 2014-01-01 | ||
| 14352 | 14352 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 412 | D | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of dental contract, medical record review, observation and interview, it was determined the facility failed to provide dental services for dental complaints and dental problems triggered on the Minimum Data Set (MDS) for 3 of 32 (Residents #19, #25 and #45) sampled residents of the 32 residents included in the Stage 2 sample. The findings included: 1. Review of the facility dental contract with Onecare Dental Solutions was signed on March 1, 2012. 2. Medical record review for Resident #19 admitted on [DATE] with [DIAGNOSES REDACTED]. The 14 day MDS dated [DATE] was blank in the dental area. The quarterly MDS dated [DATE] was blank in the dental area. During an interview in Resident #19's room on 5/8/12 at 10:23 AM, Resident #19 stated, "No problems, had teeth, dropped and broke them, would like to have teeth." Observation during that interview in Resident #19's room on 5/8/12 at 10:23 AM, confirmed Resident #19 was edentulous. During an interview in the Assistant Director of Nursing's (ADON) office on 5/8/12 at 10:40 AM, the Director of Nursing (DON) stated, "...would get a dental consult for that, we had a dentist that came here, no longer comes here, I believe they stopped coming in December (2011)." During an interview in the ADON's office on 5/8/12 at 4:40 PM, the DON stated, "Need to clarify, we did lose dentist but just signed a new contract with one last week, currently getting list of names for him (dentist) to see, to be here in 2 weeks. Have put (named Resident #19) on the list." 3. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] documented, "L0200 D. Obvious or likely cavity or broken natural teeth. There was no care plan for dental problems. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview in Resident #25's room on 5/8/12 at 6:59 AM, Resident #25 was asked ab… | 2014-01-01 | ||
| 14351 | 14351 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 371 | E | LH9611 | Based on recipe review, observation and interview, it was determined the facility failed to follow proper kitchen sanitation as evidence by food stored on the floor, juice connectors on the floor, mop and bucket in the clean dishwasher area, bread pudding not done, and staff touching the doors of the stove with mittens and gloves without changing prior to handling food and equipment on 4 of 9 days (5/7/12, 5/8/12, 5/10/12 and 5/12/12) of the survey. The findings included: 1. Review of the dietary service policy documented, "...Food must be stored above floor level and away form walls. All staple food should be stored in a clean dry place 8" (inches) to 12" off the floor on food dollies or shelves... Food preparation: Use a sanitized thermometer to evaluate food temperatures... Food Service Using a properly sanitized thermometer, check the temperatures of hot and cold food prior to serving... Observe food storage rooms and food storage in the kitchen... Do staff handle and cook potentially hazardous foods..." 2. Observations in the kitchen on 5/7/12 revealed the following: a. At 10:45 AM - boxes of canned good and elbow macaroni on the floor. b. At 10:49 AM - dispenser connector on the floor. c. At 11:42 AM - the backdoor had dirt all over it and the lock had a hole in it. Observations in the dining room on 5/7/12 revealed the following: a. At 11:45 AM - water in front of the ice machine coming from the dishwasher room. b. At 11:50 AM - the door to the dishwasher room with dirty brown material on the wall and rust by the edge of the door next to the floor. c. At 11:51 AM - the door to the kitchen had paint peeling and a crack in the wall. 3. Observation in dishwasher room on 5/8/12 at 5:00 PM, revealed a mop bucket and mop against the clean dish area which held clean dishes and a large trash can was sitting beside the mop bucket. During an interview in the dishwasher room on 5/8/12 at 5:00 PM, the dietary manager stated, "I know they're (mop and mop bucket) not supposed to be there..." Observations in the kitchen … | 2014-01-01 | ||
| 14350 | 14350 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 364 | E | LH9611 | Based on recipe review, observation and interview, it was determine the facility failed to ensure food was done and palatability during 2 of 2 (5/7/12 and 5/9/12) dining observations. The findings included: 1. Observations in the second floor dining room during the noon meal on 5/7/12 at 12:05 PM and during the supper meal on 5/9/12 at 5:00 PM, revealed no ice in any of the glasses. During an interview in the second floor dining room on 5/9/12 at 5:15 PM, Certified Nursing Assistant #1 stated, "Never any ice in glasses, don't know why?" 2. Review of the recipe for Bread Pudding documented, "Bake in oven at 325 (sign for degrees) F (Fahrenheit), or until inserted knife comes out clean. Observations in the kitchen on 5/9/12 at 12:15 PM, revealed the bread pudding that was placed into cups to be served was noted to be runny. During an interview in the kitchen on 5/9/12 at 12:30 PM, the dietary manager confirmed the bread pudding was not done. 3. Observations in the kitchen on 5/9/12 at 12:15 PM, revealed there was no ice in the glasses of tea. Observations in the kitchen on 5/9/12 at 5:10 PM, revealed no ice in drinks. | 2014-01-01 | ||
| 14349 | 14349 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 333 | D | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the "GERIATRIC MEDICATION HANDBOOK", medical record review, observation and interview, it was determined the facility failed to ensure that residents were free of significant medication errors. The nursing staff failed to administer insulin within the proper time frame related to meals for 2 of 6 (Random Residents (RR) #6 and RR #7) and failed to prepare the correct dose of insulin for 1 of 6 (Resident #53) residents receiving insulin injections. The findings included: 1. Review of the "GERIATRIC MEDICATION HANDBOOK" tenth edition, page 41 documented, "DIABETES: INJECTABLE MEDICATIONS... Humalog... Rapid-Acting Insulin Analog... ONSET... 15 min (minutes)... TYPICAL ADMINISTRATION / COMMENTS 15 minutes prior to meals or immediately after eating..." 2. Medical record review for Random Resident (RR) #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].d. (four times a day) 0800 1200 1600 and 2000... 241- (to) 300 (blood sugar) = (amount of insulin to be administered) 9units..." Observations in RR #6's room on 5/13/12 at 11:55 AM, Nurse #2 administered 9 units of Humalog insulin to RR #6. RR #6 did not get up to go to the dining room at lunch time and was not offered a tray or a substantial snack by the nurse until 1:30 PM. The administration of the insulin 1 hour and 35 minutes before a lunch tray or snack was served resulted in a significant medication error. During an interview in the 100 hall on 5/13/12 at 1:30 PM, Nurse #2 was asked if RR #6 had been served a meal tray or had a snack. Nurse #2 stated, "No. He'll get up and go to the dining room and get what he wants to eat. That's how he does..." 3. Medical record review for RR #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].d 0800 1200 1600 2000...61-180 blood sugar = 5 units..." Observations in RR #7's room on 5/7/12 at 11:30 AM, Nurse #11 administ… | 2014-01-01 | ||
| 14348 | 14348 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 332 | E | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the "GERIATRIC MEDICATION HANDBOOK", medical record review, observation and interview, it was determined the facility failed to ensure that 3 of 4 (Nurses #2, 6 and 11) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 51 opportunities for error, resulting in a medication error rate of 5.9%. The findings included: 1. Review of the "GERIATRIC MEDICATION HANDBOOK" tenth edition, page 41 documented, "DIABETES: INJECTABLE MEDICATIONS... Humalog... Rapid-Acting Insulin Analog... ONSET... 15 min (minutes)... TYPICAL ADMINISTRATION / COMMENTS 15 minutes prior to meals or immediately after eating..." 2. Medical record review for Random Resident (RR) #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].d. (four times a day) 0800 1200 1600 and 2000... 241- (to) 300 = (amount of insulin to be administered) 9units..." Observations in RR #6's room on 5/13/12 at 11:55 AM, Nurse #2 administered 9 units of Humalog insulin to RR #6. RR #6 did not get up to go to the dining room at lunch time and was not offered a tray or a substantial snack by the nurse until 1:30 PM. The administration of the insulin 1 hour and 35 minutes before a lunch tray or snack was served resulted in medication error #1. During an interview in the 100 hall on 5/13/12 at 1:30 PM, Nurse #2 was asked if RR #6 had been served a meal tray or had a snack. Nurse #2 stated, "No. He'll get up and go to the dining room and get what he wants to eat. That's how he does..." 3. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physicians orders dated 5/2012 documented, "...HumaLOG 100UNIT/ML Solution injection sub-Q per sliding scale q.i.d. 0800 1200 1630 2100 ...181-210 = 6 units..." Observations in the 200 hall on 5/9/12 at 5:30 PM, Nurse #6 prepared the insulin for adminis… | 2014-01-01 | ||
| 14347 | 14347 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 328 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure that proper respiratory treatment and services were provided for 2 of 32 (Residents #66 and #138) sampled residents of the 32 residents included in Stage 1 and Stage 2. The facility failed to adequately assess and notify the physician of behaviors, anxiety, agitation, repeatedly low oxygen saturation results and resident's noncompliance with using the oxygen placed Resident #66 in immediate jeopardy. The findings included: 1. Review of the facility's "Oxygen, Administration" policy documented, "...To provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident... Document all appropriate information in the clinical record... Oxygen is a drug and, as such, there must be a physician's orders [REDACTED]. Review of the facility's "Pulse Oximetry, Monitoring of Residents" policy documented, "...Obtain physician order [REDACTED]. Review of the facility's "Change in Condition" policy documented, "...A resident's physician and legal representative or responsible party must be notified of a change in the resident's condition... Documentation of the Change in Condition will be made in the appropriate condition system folder in the Electronic Medical Record... Situations in which a physician... should be notified Immediately of a change in a resident's condition include... significant and unexpected change/decline in a resident physical, mental and/or psychosocial status..." Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses' notes documented the following: a. [DATE] at 3:50 AM - " [MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..." [DATE] at 4:45 - 02 (oxygen) Saturation: 84% (percent) on 02." b. [DATE] at 7:47 AM - "..Resident … | 2014-01-01 | ||
| 14346 | 14346 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 325 | G | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to timely implement interventions recommended by the Registered Dietician (RD) for 1 of 7 (Resident #118) sampled residents experiencing a significant weight loss of the 32 sampled residents in Stage 1 and Stage 2. The facility failed to timely implement weight loss recommendations which resulted in a significant weight loss causing actual harm to Resident #118. The findings included: Review of the facility's "Weight Loss / Underweight" policy documented, "...Residents who have a significant, unchanged weight loss or who are 20% (percent) or more below their IBW (ideal body weight) or UBW (usual body weight) are considered to be at nutrition risk. Significant unchanged weight loss... should be addressed on the care plan... The resident's physician and the consultant dietitian are notified... include high calorie foods such as large portions, fortified cereals, and juices, house supplements in the diet.... consider requesting a physician order [REDACTED]. Medical record review for Resident #118 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Monthly Weights" for Resident #118 documented a weight of 134.6 pounds (#) on 3/21/12, a weight of 129.4 # on 4/11/12 and a weight of 125.6 # on 5/7/12, resulting in a significant weight loss of 7.5 percent in 2 months. Review of the RD assessments documented the following: a. 3/30/12 - "weight 133 lbs... nutrition intake... requires assist with d/t (due to) [MEDICAL CONDITION] RD RECOMMENDATIONS: add MVI with minerals daily, add fortified food with breakfast." b. 4/25/12 - "...weight loss... 129lbs... RD RECOMMENDATIONS: add house supp (supplement) 4 oz (ounces) bid (twice a day), add fortified foods with meals, cont (continue) weekly wts (weights) x (for) 4 weeks, add MVI with min (minerals) daily." A physician's orders [REDACTED]. The order was documented as "M… | 2014-01-01 | ||
| 14345 | 14345 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 319 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of material safety data sheets (MSDS), medical record review and interview, it was determined the facility failed to assess, notify the physician and provide appropriate treatment and services to address mental and psychosocial adjustment difficulties for 1 of 32 (Resident #66) sampled residents in Stage 1 and Stage 2. Failure of the facility to assess, implement interventions, adequately supervise and notify the physician of behaviors placed Resident #66 in immediate jeopardy. The findings included: Review of the facility's "Behavior Management Plan" policy documented, "The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... The following four-step plan provides the methods of problem solving needed to deal with behavioral symptoms in a quick and consistent way... 1. Immediate Action to control a threatening or dangerous behavioral symptom. 2. Behavior assessment to observe and describe the behavior. 3. Medical evaluation to look for medical or other causes of the behavioral symptom that need treatment... Psychiatric evaluation may be needed. 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the administrator, and the mental health consultant... Residents will be immediately transported to a designated or requested acute care facility for evaluation..." Review of the facility's "Change in Condition" policy… | 2014-01-01 | ||
| 14344 | 14344 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 318 | D | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to provide appropriate treatment and services to ensure that a resident maintained the highest level of range of motion (ROM) for 1 of 1 (Resident #3) sampled residents with ROM needs in Stage 1 and Stage 2. The findings included: Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented in Section G that the resident was assessed with [REDACTED]. Review of the care plan dated 2/9/12 did not include ROM exercises. Observations in Resident #3's room on 5/9/12 at 7:41 AM, revealed Resident #3 had left sided contractures. He held his left arm up bent at the elbow against his chest and his left foot pedal of his wheelchair was elevated and extended and supported his left foot and leg. During an interview in Resident #3's room on 5/8/12 at 9:53 AM, Nurse #8 confirmed Resident #3 had contractures on his left side on both the upper and lower extremities. During an interview at the second floor nurses' station on 5/14/12 at 2:35 PM, the restorative certified nursing technician (CNT) #2 was asked if Resident #3 had a restorative plan of care and did he received ROM exercises. CNT #2 stated, "...He is not in the restorative program at the time... the nursing staff on the unit are responsible for his care and treatment..." During an interview on the 200 hall on 5/14/12 at 2:40 PM, CNT #3 (who was assigned to care for Resident #3) was asked if she performed scheduled ROM exercises or ROM exercises with the resident while giving his daily personal care. CNT #3 stated, "No." | 2014-01-01 | ||
| 14343 | 14343 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 314 | G | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to provide assessments and treatments to pressure ulcers for 1 of 2 (Resident #138) sampled residents with pressure ulcers in Stage 1 and Stage 2. Failure of the facility to assess and provide care and treatments resulted in actual harm when Resident #138's pressure ulcers deteriorated. The findings included: Review of the facility's "Wounds Care/Treatment Guidelines" policy documented, "...weekly assessment is completed on all wounds. This should include measurement and a description... The door must be closed and the curtains pulled... There must be a specific order for the treatment. Documentation of the treatment should be done immediately after the treatment..." Medical record review for Resident #138 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A nurses note dated 4/27/12 documented pressure ulcer to "right heel - unstageable, 2x (by) 3cm (centimeters), painful to touch, left heel - unstageable, 4.25x7.25cm, painful to touch, abdominal incision 21x< (less than) 1cm surgical wound, and coccyx- stage 1, reddened, 4x4cm." The initial Minimum Data Set ((MDS) dated [DATE] documented the resident as cognitive - 3 severely impaired, had no behaviors, had 2 unstageable pressure sores, had a surgical wound. The 14 day MDS dated [DATE] documented the resident as cognitive - 3 severely impaired, had no behaviors, inaccurately documented the resident had a stage 4- that measured 0.2x0.3x0.6cm pressure ulcer, had a surgical wound, and inaccurately documented the resident had [MEDICAL CONDITION]. A nurses note dated 4/27/12 documented the physician assessed the resident and sent him to the hospital on [DATE] and he returned back to the facility on [DATE]. A nurses note dated 5/8/12 documented the resident dislodged a tube and was sent back to the hospital on [DATE] and returned to the facility on [DATE]. The medical rec… | 2014-01-01 | ||
| 14342 | 14342 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 312 | D | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to provide grooming for 1 of 26 (Resident #64) sampled residents observed in Stage 1 and Stage 2. The findings included: Medical record review for Resident #64 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview Mental Status (BIMS) 0, indicating cognitive impairment and total care for hygiene. Observations in Resident #64's room on 5/7/12 at 4:12 PM and on 5/9/12 at 4:15 PM, revealed Resident #6 with chin hair present. During an interview at second floor nursing station on 5/11/12 at 5:30 PM, Certified Nursing Assistant #2 stated, "Residents get shower every other day, suppose to shave chin hair on those days..." | 2014-01-01 | ||
| 14341 | 14341 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 309 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for 2 of 32 (Residents #66 and #106) sampled residents in Stage 1 and Stage 2. The facility was unable to provide documentation of the physician being notified of the resident's repeated behaviors, anxiety, agitation, repeatedly low oxygen saturation results, resident's noncompliance with using the oxygen, symptoms of swelling, dyspnea, coolness, paleness, abnormal lung sounds and elevated temperature. There was no documentation that the physician was notified of the resident eating the moisture barrier cream. Failure of the facility to assess the residents status, notify the physician of these conditions and implement a plan of care placed Resident #66 in immediate jeopardy. The findings included: 1. Review of the facility's "Behavior Management Plan" policy documented, "The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... The following four-step plan provides the methods of problem solving needed to deal with behavioral symptoms in a quick and consistent way... 1. Immediate Action to control a threatening or dangerous behavioral symptom. 2. Behavior assessment to observe and describe the behavior. 3. Medical evaluation to look for medical or other causes of the behavioral symptom that need treatment... Psychiatric evaluation may be needed. 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying men… | 2014-01-01 | ||
| 14340 | 14340 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 282 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to provide care according to the care plan for 1 of 32 (Resident #66) sampled residents in Stage 1 and Stage 2. The failure of the facility to provide care according to the care plan to address behaviors and falls resulted in immediate jeopardy to Resident #66. The findings included: Review of the facility's "Behavior Management Plan" policy documented, "The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the administrator, and the mental health consultant... Residents will be immediately transported to a designated or requested acute care facility for evaluation..." Review of the facility's "Accidents/ Incidents/ Unusual Circumstances" policy documented, "It is the policy of this facility to provide residents with adequate supervision to minimize the risk of accidents... The facility will identify residents at risk for falls and implement interventions to minimize the occurrence of falls for those at risk... Residents will be assessed for Fall Risk routinely on admission, quarterly, following a fall and with a significant change... Based on assessment findings, appropriate interventions are identified and implemented... Care plans are updated and revised at every fall or incident..." Me… | 2014-01-01 | ||
| 14339 | 14339 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 280 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of dental contract, medical record review, observation and interview, it was determined the facility failed to revise the comprehensive care plan for 9 of 32 (Residents #66, #138, #118, #19, #64, #89, #100, #106 and #128) sampled residents in Stage 1 and Stage 2. The failure of the facility to accurately and completely assess and revise the care plan to address behaviors, falls, accident hazards, oxygen therapy and change in condition placed Resident #66 in an immediate jeopardy. The failure of the facility to assess and provide treatments resulted in deterioration of pressure ulcers resulting in actual harm to Resident #138. The failure of the facility to implement recommendations resulted in actual harm when Resident #118 sustained a significant weight loss. The findings included: 1. Review of the facility's "Behavior Management Plan" policy documented, "The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... " Review of the facility's "Accidents/ Incidents/ Unusual Circumstances" policy documented, "It is the policy of this facility to provide residents with adequate supervision to minimize the risk of accidents... Care plans are updated and revised at every fall or incident..." Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses note documented the following: a. [DATE] - "Resident scratches himself and has scabs all over body. Hospital staff stated this is his behavior... resident's decisions are poor; cues/supervision required.… | 2014-01-01 | ||
| 14338 | 14338 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 279 | E | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of dental contract, medical record review, observation and interview, it was determined the facility failed to develop a complete and accurate comprehensive care plan for 14 of 32 (Residents #3, #14, #19, #25, #33, #45, #64, #85, #106, #118, #121, #129, #137 and #138) sampled residents in Stage 1 and Stage 2. The findings included: 1. Review of the facility's "The Care Plan" policy documented, " The Comprehensive Care Plan is completed within seven (7) days after the MDS (minimum data set) is completed... and reviewed quarterly thereafter... If modification, deletions, additions are necessary, changes should be made at the time of the occurrence." Review of the facility's "Accidents/ Incidents/ Unusual Circumstances" policy documented, "It is the policy of this facility to provide residents with adequate supervision to minimize the risk of accidents... The facility will identify residents at risk for falls and implement interventions to minimize the occurrence of falls for those at risk... Care plans are updated and revised at every fall or incident..." 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented in Section G that the resident was assessed with [REDACTED]. Review of the care plan dated 2/9/12 did not include ROM exercises. Observations in Resident #3's room on 5/9/12 at 7:41 AM, revealed Resident #3 had left sided contractures. He held his left arm up bent at the elbow against his chest and his left foot pedal of his wheelchair was elevated and extended and supported his left foot and leg. During an interview in Resident #3's room on 5/8/12 at 9:53 AM, Nurse #8 confirmed Resident #3 had contractures on his left side on both the upper and lower extremities. During an interview at the second floor nurses' station on 5/14/12 at 2:35 PM, the restorativ… | 2014-01-01 | ||
| 14337 | 14337 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 272 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of dental contract, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility failed to ensure a complete and accurate assessment was completed for 6 of 32 (Residents #66, #138, #14, #19, #106 and #100) sampled residents reviewed in Stage 1 and Stage 2. The failure of the facility to accurately and completely assess behaviors, falls, accident hazards, oxygen therapy and change in conditions placed Resident #66 in an immediate jeopardy. The failure of the facility to assess and provide treatments to pressure ulcers resulted in actual harm to Resident #138. The findings included: 1. Review of the facility's "Behavior Management Plan" policy documented, "The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... The following four-step plan provides the methods of problem solving needed to deal with behavioral symptoms in a quick and consistent way... 1. Immediate Action to control a threatening or dangerous behavioral symptom. 2. Behavior assessment to observe and describe the behavior. 3. Medical evaluation to look for medical or other causes of the behavioral symptom that need treatment... Psychiatric evaluation may be needed. 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the administrator, and the mental health consultant... Residents wi… | 2014-01-01 | ||
| 14336 | 14336 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 253 | F | LH9611 | Based on policy review, observation and interview, it was determined the facility failed to provide effective maintenance and housekeeping services to maintain a sanitary, orderly and comfortable interior as evidenced by baseboards peeling from the wall, cracked and missing floor tiles, cracked and torn sheet rock, sheet rock in need of cleaning and/or painting, holes in the walls, air units that were not sealed and flush with the wall and/or with cracked and/or missing vent covers and a missing dial, privacy curtains missing pegs and/or dangling from the curtain's ceiling track, dirty floor tiles, blackened caulking at the base of toilets, a broken toilet seat, broken light fixture covers, a light socket behind a bed with the sheet rock cracked and busted leaving the socket box loose in the wall in 44 of 44 (Resident rooms #101, 102, 103, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 201, 202, 203, 204, 205, 206, 207, 208, 209, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223 and 224) resident rooms observed, 300 hall, 200 hall shower room, assisted bath, clean linen closet, physical therapy, nurses bathroom, front office, oxygen room, nurses clean utility room, 1st floor supply room, janitor closet, dining room, 100 hall, 200 hall, Director of Nursing's (DON) office, the Minimum Data Set office and 200 hall shower room. The facility's failure to provide effective maintenance and housekeeping services to maintain a sanitary, orderly and comfortable environment resulted in substandard quality of care. The findings included: 1. Review of the facility's clinical equipment policy documented, "Purpose: To provide clean clinical equipment and help promote sanitary environment. Policy: For all clinical equipment, the manufacturer's recommendations for cleaning or disinfecting are followed... Wheelchairs, geri-chairs and other specialty chairs are cleaned on a monthly schedule and as needed... IV (intravenous medication) poles... are cleaned weekly and as needed… | 2014-01-01 | ||
| 14335 | 14335 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 250 | D | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to document social progress notes and discharge planning for 1 of 3 (Resident #121) sampled residents in Stage 2. The findings included: Medical record review for Resident #121 documented an admission date of [DATE] from hospital with [DIAGNOSES REDACTED]. A social history completed on 1/23/12 documented the resident lived in an apartment with a friend prior to hospital stay due to a stroke. There were no social work progress notes in the medical record. There was no documentation of any discharge planning. The care plan did not address discharge planning. During an interview in the Assistant Director of Nursing's office on 5/12/12 at 9:10 AM, the Director of Nursing (DON) stated, "She (Resident #121) is currently getting restorative treatments, therapy has been discontinued." | 2014-01-01 | ||
| 14334 | 14334 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 242 | D | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure the right of residents to make choices about aspects of their life in the facility that are significant to them were respected for 2 of 10 (Resident #33 and Random Resident (RR) #5) sampled residents interviewed in Stage 1 and Stage 2. The findings included: 1. Medical record review for Resident #33 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] documented the resident's activity preferences that were very important to her such as books, newspapers, magazines, listen to music you like, keep up with the news, do things with groups of people, do your favorite activities, go outside and religious services/events. Review of the current care plan documented, "...Strength (Activities) content with her present activity choice, having no complaints about activity choices, staying busy with room activities of choice. Assess interests/strengths. Invite and assist to activities Avoid fatigue Activity..." The care plan did not include the individualized activities and preferences of Resident #33. Observations in Resident #33's room on 5/9/12 at 12:10 PM, revealed Resident #33 watching TV and a bible laying on the overbed table. Observations on the front porch on 5/9/12 at 2:40 PM, revealed Resident #33 seated outside smoking and visiting with other residents. Observations on the front porch on 5/12/12 at 2:00 PM, revealed Resident #33 sitting outside on porch with a group of other residents while smoking. During an interview in Resident #33's room on 5/8/12 at 8:50 PM, Resident #33 was asked if she could go outside if she liked. Resident #33 stated, "...No. I took up smoking so I could go outside..." 2. During an interview in RR #5's room on 5/10/12 at 9:00 AM, RR #5 was asked if the rights of residents were respected and encouraged. RR #5 stated, "most of time... we hav… | 2014-01-01 | ||
| 14333 | 14333 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 241 | G | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, medical record review, observation and interview, it was determined the facility failed to promote care for residents in a manner that maintained or enhanced each residents dignity and respect for 3 of 32 (Random Resident (RR) #1, Residents #25 and #118) sampled residents in Stage 1 and Stage 2 reviewed for dignity and respect; observations of residents (RR #2 and RR #6) during tour and the medication pass and during 1 of 2 (lunch meal on 5/7/12) dining observations. The facility's failure to ensure Resident #25 and RR #1 were treated with dignity and respect resulted in actual harm as evidenced by the residents being tearful when discussing abuse and mistreatment during interviews. The findings included: 1. Review of the facility's abuse protocol documented, "..."Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in "physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult. "...Verbal Abuse" is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or with their hearing distance, regardless of their age, ability to comprehend, or disability... "Mental abuse" includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation... "Neglect" means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... only a single incident is necessary for a determination of neglect..." 2. Review of the facility's "RESIDENT RIGHTS" statement documented, "...RESIDENT BEHAVIOR AND FACILITY PRACTICES... ABUSE... You have the right to be free… | 2014-01-01 | ||
| 14332 | 14332 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 226 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, medical record review, observation and interview, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed to investigate the reported abuse for Resident #25. The facility failed to implement procedures that protected RR #1 and Resident #25 from abuse or mistreatment, which resulted in immediate jeopardy as evidenced by displays of emotions due to mental anguish when both residents became tearful when discussing demeaning remarks and actions of staff related to their need for assistance with incontinent care. The findings included: 1. Review of the Abuse Protocol documented "1. Defining... "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in "physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult..." 2. Review of the facility's "RESIDENT RIGHTS" statement documented, "...RESIDENT BEHAVIOR AND FACILITY PRACTICES... ABUSE... You have the right to be free from verbal, sexual, physical or mental abuse... STAFF TREATMENT... The facility must implement procedures that protect you from abuse, neglect or mistreatment..." 3. Medical record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/30/12 documented, "...PROBLEM (ADL's (activity of daily living) /FUNCTIONAL): Self Care Deficit needs ext (extensive) Bed Mobility Transfers Toilet Use... RELATED TO: [MEDICAL CONDITION], Decreased mobility Muscle weakness... MANIFESTED BY: Loss of independe… | 2014-01-01 | ||
| 14331 | 14331 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 224 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, medical record review, observation and interview, it was determined the facility failed to ensure 1 of 10 (Random Resident (RR) #1) residents interviewed in the Stage 1 review was free from mistreatment and neglect by facility staff. RR #1 did not feel that she was treated with respect and dignity. RR #1 confirmed staff had yelled and been rude to her. The facility's failure to ensure that RR #1 was free from mistreatment and neglect placed RR #1 in immediate jeopardy as evidenced by the tearful emotional responses during an interview. The findings included: Review of the facility's "Abuse Prevention" policy documented, "..."Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in "physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult..." Review of the facility's "RESIDENT RIGHTS" statement documented, "...RESIDENT BEHAVIOR AND FACILITY PRACTICES... ABUSE... You have the right to be free from verbal, sexual, physical or mental abuse... STAFF TREATMENT- The facility must implement procedures that protect your from abuse, neglect or mistreatment..." Medical record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/30/12 documented, "...PROBLEM (ADL's (activities of daily living) /FUNCTIONAL): Self Care Deficit needs ext (extensive) Bed Mobility Transfers Toilet Use... RELATED TO: [MEDICAL CONDITION], Decreased mobility Muscle weakness... MANIFESTED BY: Loss of independence, Incontinence... TOILETING: Extensive assist..." Observations during an interview in RR #1's room on 5/8/12 at 2:50 PM, RR #1 was asked, "Do you feel the staff t… | 2014-01-01 | ||
| 14330 | 14330 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 223 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, medical record review, observation and interview, it was determined the facility failed to ensure 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 were free from verbal abuse. RR #1 and Resident #25 did not feel they were treated with respect and dignity. RR #1 and Resident #25 confirmed facility staff had yelled and been rude to them. The facility's failure to ensure that residents were free from verbal abuse placed RR #1 and Resident #25 in immediate jeopardy as evidenced by tearful emotional responses during the interviews. The findings included: 1. Review of the facility's "Abuse Prevention" policy documented, "..."Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in "physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult..." 2. Review of the facility's "RESIDENT RIGHTS" statement documented, "...RESIDENT BEHAVIOR AND FACILITY PRACTICES... ABUSE... You have the right to be free from verbal, sexual, physical or mental abuse... STAFF TREATMENT... The facility must implement procedures that protect you from abuse, neglect or mistreatment..." 3. Medical record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/30/12 documented, "...PROBLEM (ADL's (activity of daily living) /FUNCTIONAL): Self Care Deficit needs ext (extensive) Bed Mobility Transfers Toilet Use... RELATED TO: [MEDICAL CONDITION], Decreased mobility Muscle weakness... MANIFESTED BY: Loss of independence, Incontinence... TOILETING: Extensive assist..." Observations during a resident interview in RR #1's room on 5/8/12 at 2:50… | 2014-01-01 | ||
| 14329 | 14329 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 170 | C | LH9611 | Based on policy review and interview, it was determined the facility failed to ensure that residents' mail was sent and promptly received for 1 of 10 Random Resident (RR #5) and sampled residents interviewed. This potential affects all residents mailing or receiving mail on weekends, since the facility has the post office to hold the mail until Monday due to no one is in the front office on weekends. The findings included: Review of the facility's "Resident Mail delivery and Distribution" policy documented, "...All resident mail is delivered unopened and postmarked (for outgoing mail) within 24 hours." During an interview in RR #5's room on 5/10/12 at 9:00 AM, RR #5 was asked about receiving mail in the facility. RR #5 stated, "Don't know if it (mail) is delivered on Saturdays." During an interview in the Assistant Director of Nursing's office on 5/11/12 at 8:45 AM, the Activities Director stated, "Mail is delivered Monday through Friday to front office, placed in our box and we deliver it to the residents. No mail delivery on weekends because there is no one in the front office. We are not able to get into front office on weekends. No mail delivery on Saturday, they (post office) wait till (until) Monday, Post office holds the mail till Monday because there is no one in the front office. Wished we could get it on weekends, have been incidents where residents have asked (on weekends) if they had any mail." | 2014-01-01 | ||
| 14328 | 14328 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 157 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of material safety data sheets (MSDS), medical record review and interview, it was determined the facility failed to notify the physician of a deterioration in health, mental and psychosocial status of the resident's repeated behaviors, anxiety, agitation, repeatedly low oxygen saturation results, resident's noncompliance with using oxygen, symptoms of swelling, dyspnea, coolness, paleness and abnormal lung sounds and elevated temperature for 1 of 32 (Resident #66) sampled residents in Stage 1 and Stage 2. Failure of the facility to assess the resident's status and notify the physician of these conditions placed Resident #66 in immediate jeopardy. The findings included: Review of the facility's "Pulse Oximetry, Monitoring of Residents" policy documented, "...Obtain physician order [REDACTED]. Review of the facility's "Change in Condition" policy documented, "...A resident's physician... must be notified of a change in the resident's condition... Documentation of the Change in Condition will be made in the appropriate condition system folder in the Electronic Medical Record... Situations in which a physician... should be notified Immediately of a change in a resident's condition include... any accident / incident with suspected or actual injury... significant and unexpected change/decline in a resident's physical, mental and/or psychosocial status..." Review of the MSDS sheets for the two moisture barrier creams used in the facility revealed the following: a. MSDS for [MEDICATION NAME] Extra Protective Cream "...ACUTE HEALTH HAZARDS... INGESTION... GASTROINTESTINAL IRRITATION. INGESTION OF LARGE QUANTITIES CAN BE HAZARDOUS. SYMPTOMS OF INTOXICATION... Contact a poison control center for instructions... After first aid, get appropriate in-plant, paramedic, or community medical support... EYES... may cause eye irritation... Avoid eye contact." b. MSDS for [MEDICATION NAME] Dimethicone Protectant "...ACUTE HEALTH HA… | 2014-01-01 | ||
| 14327 | 14327 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 156 | D | LH9611 | Based on record review and interview, it was determined the facility failed to provide 2 of 3 (Residents #9 and 105) residents with an advanced beneficiary notice as required by law. The findings included: Review of advanced beneficiary notices on 5/14/12 at 1:05 PM, the facility was unable to provide an advanced beneficiary notices for Residents #9 and #105. During an interview in the Assistant Director of Nursing's (ADON) office on 5/14/12 at 1:05 PM, the Social Worker stated, "We did not start giving them (advanced beneficiary notice) until April (2012)." | 2014-01-01 | ||
| 14326 | 14326 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 323 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility failed to ensure the environment was safe and free of accident hazards, residents received adequate supervision for behaviors and implement interventions to prevent falls for 4 of 32 (Residents #66, #118, #64 and 129) sampled residents in Stage 1 and Stage 2. The facility failed to adequately assess, implement interventions and supervision to ensure the environment was safe and free of accident hazards and notify the physician of conditions resulted in an immediate jeopardy when Resident #66 continued to exhibit behaviors, falls and deterioration of condition. The findings included: 1. Review of the facility's "Behavior Management Plan" policy documented, "The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... The following four-step plan provides the methods of problem solving needed to deal with behavioral symptoms in a quick and consistent way... 1. Immediate Action to control a threatening or dangerous behavioral symptom. 2. Behavior assessment to observe and describe the behavior. 3. Medical evaluation to look for medical or other causes of the behavioral symptom that need treatment... Psychiatric evaluation may be needed. 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the adminis… | 2014-01-01 | ||
| 14325 | 14325 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2013-11-20 | 246 | D | GOZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to maintain a call light within reach for one resident (#223) of twenty residents reviewed. The findings included: Resident #223 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated November 11, 2013, revealed the resident had a potential for falls/injury related to history of falls, decreased mobility, weakness, with the approach to keep the call light within reach. Observation and interview with the resident, on November 19, 2013, at 8:26 a.m. revealed the resident seated in a wheelchair in the resident's room with the breakfast tray on the over bed table in front of the resident. Further observation revealed the call light was on the bed side table directly behind the wheelchair and out of reach of the resident. Interview with the resident revealed the resident was not able to reach the call light. Interview on November 20, 2013, at 8:30 a.m., with the resident's direct care Certified Nurse Aide #1, in the resident's room, confirmed the resident was capable of using the call light. Further interview confirmed the call light was not in reach of the resident. | 2014-01-01 | ||
| 14324 | 14324 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 508 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure radiology services were obtained as ordered for one (#4) of fifteen residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of physician's progress notes revealed on November 23, 2009, a chest xray was obtained due to resident #4's complaints of congestion and wheezing. Continued review revealed the physician ordered [MEDICATION NAME] (antibiotic) once a day for seven days, and a repeat chest xray in three weeks. Medical record review of radiology reports revealed a repeat chest xray was not obtained until January 20, 2010. Interview with the Assistant Director of Nursing on January 20, 2010, at 2:10 p.m., in the conference room, confirmed the physician's orders [REDACTED]. | 2014-01-01 | ||
| 14323 | 14323 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 309 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure physician's orders were followed for two (#14, #1) of fifteen residents reviewed. The findings included: Resident #14 was admitted to the facility on December 22, 2008, with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged to another facility on November 13, 2009. Medical record review of physician's orders revealed a telephone order, dated January 13, 2009, for [MEDICATION NAME] (antipsychotic) 5 mg (milligrams) one every morning and 5 mg one at bedtime "may give IM (intramuscular) if won't take PO (orally)". Continued review of physician's orders revealed when the [MEDICATION NAME] was increased to 10 mg 1 po bid (twice a day) "may give IM if refuses PO." Medical record review of physician's orders revealed the [MEDICATION NAME] was discontinued on August 19, 2009. Medical record review of nurse's notes revealed resident #14 spit out meds as follows March 5, 2009 at 1000; March 24, 2009, at 0730; April 28, 2009, at 0830; and July 27, 2009, at 2100, "spit out meds in BR (bathroom)." Medical record review of nurse's notes and the Mediaction Administration Records (MARS) from March, 2009, thru July, 2009, revealed the resident did not receive Zyprex via injection, as ordered, on any of the above dates. Medical record review of physician's orders and MARS from March, 2009, thru July, 2009, revealed on March 1, 2009, resident #14 was receiving [MEDICATION NAME] 5 mg every morning and 10 mg at bedtime (total of 15 mg). Continued review revealed on July 1, 2009, [MEDICATION NAME] was increased to 10 mg twice a day (total of 20 mg). Medical record review of physician's orders and MARS for July, 2009, revealed the [MEDICATION NAME] was again increased, with a 2:00 p.m., dose of 5 mg added (total of 25 mg). Interview with the Assistant Director of Nursing, in the conference room, on January 21, 2010, at 11:30 a.m., revealed the injection was to… | 2014-01-01 | ||
| 14322 | 14322 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 323 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent a fall for one (#8) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had moderately impaired cognitive skills, required extensive assistance with transfers/ambulation, and had fallen in the past thirty days. Medical record review of the Fall Risk assessment dated [DATE], and December 14, 2009, revealed the resident was at high risk for falls. Medical record review of a nursing note dated November 18, 2009, at 8:00 a.m., revealed "This res (resident) found sitting in floor at...bedside. Assessment revealed (no) injuries...Fall was unwitnessed..." Medical record review of a Fall Care Plan dated November 18, 2009, revealed "...Resident will not be left in hallway or alone in room in w/c (wheelchair). Take resident from dining room directly to...room & assist to bed. " Medical record review of a nursing note dated November 22, 2009, at 1:40 p.m., revealed "Attempted to get into bed et slid into floor. (no) injuries noted..." Observation on January 20, 2010, at 8:13 a.m., revealed the resident lying on the bed. Interview on January 20, 2010, at 11:45 a.m., with the Director of Nursing, in the conference room, confirmed the resident was unattended at the time of the fall on November 22, 2009, and the Fall Care Plan was not followed. | 2014-01-01 | ||
| 14321 | 14321 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 514 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the medical record was accurate for two (#12, #14) of fifteen residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Consultant Pharmacist Communication to the Physician dated July 15, 2009, revealed "...Antipsychotic Gradual Dose Reduction (GDR) [MEDICATION NAME] (antipsychotic) 4mg (milligrams) qHS (every hour of sleep)...Based on a review of the MDS (Minimum Data Set), progress notes and nursing record, it was felt by this reviewer that a GDR could be attempted. Please consider the following trial dose reduction: decrease [MEDICATION NAME] to 3mg qHS..." Medical record review of a physician's orders [REDACTED]. Medical record review of the Mental Health Notes, completed by the Psychiatric Nurse Practitioner, dated August 4, 2009, September 21, 2009, November 30, 2009, and January 18, 2010, revealed the Psychiatric Nurse Practitioner documented the resident continued to receive [MEDICATION NAME] 4mg at hour of sleep, after the [MEDICATION NAME] was decreased to 3mg on July 20, 2009. Interview on January 21, 2010, at 11:20 a.m., with the Director of Nursing (DON), in the DON's office, confirmed the Mental Health Notes/medical record was not accurate. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Mental Health Notes, completed by the Psychiatric Nurse Practitioner, dated August 24, 2009, revealed the resident received [MEDICATION NAME] (antipsychotic) 5 mg one time a day. Medical record review of physician's orders [REDACTED]. Medical record review of the Mental Health Notes, completed by the Psychiatric Nurse Practitioner, dated July 27, 2009, revealed the resident received [MEDICATION NAME] 5 mg 1 every day. Medical record review of the physician's orders [REDACTED]. Interview with the Director of Nursing in th… | 2014-01-01 | ||
| 14320 | 14320 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 280 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the care plan was revised when a behavior modification program was initated for one (#14) of fifteen residents reviewed. The findings included: Resident # 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes revealed a Weekly Summary, dated July 10, 2009, "Resident allowed to use...personal cell phone if meds taken as scheduled. Resident likes to call...sister (name) on...cell phone." Medical record review of the current care plan, revealed the use of the cell phone to modify the resident's behavior was not addressed on the care plan. Interview with the Social Services Director and Case Manager #1 on January 21, 2010, at 9:10 a.m., in the SSD's office, revealed the resident was allowed to use the cell phone, if...took medications as scheduled, at the request of the resident's conservator. Continued interview confirmed the use of the cell phone was utilized to encourage the resident to take medications as scheduled, and confirmed the cell phone program was not addressed on the comprehensive care plan. | 2014-01-01 | ||
| 14319 | 14319 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 505 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to notify the physician of laboratory results for two (#8, #7) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the December 2009, physician's recapitulation orders revealed the resident was receiving [MEDICATION NAME] (anticoagulant) 4mg (milligrams) daily, and a PT/INR (laboratory test to measure blood coagulation) was to be completed every month. Medical record review of a PT/INR laboratory report dated December 22, 2009, revealed PT 25.1 (reference range 11.9-14.4) and INR 2.2 (reference range 2.0-3.5). Medical record review of the same PT/INR laboratory report revealed the laboratory report was faxed to the physician on December 23, 2009, however, medical record review revealed no documentation the physician had received/reviewed the laboratory report. Interview on January 21, 2010, at 9:35 a.m., with the Assistant Director of Nursing, in the conference room, confirmed there was no documentation the physician was notified of the results of the laboratory report. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapulation orders revealed: "...December 24, 2008, [MEDICATION NAME] level every 3 months ...March 24, 2009, PT/INR (measures how fast blood clots), Potassium, Liver Function every month ...August 21, 2009, BMP (Basic Metabolic Function) HEP (liver) function once a month ..." Medical record review of the laboratory report dated September 10, 2009, revealed "[MEDICATION NAME] 0.1 (L) (reference range 0.8-2.0 ng/mg) faxed...9/11/09 ..." Medical record review revealed no documentation the physician had received/reviewed the laboratory report. Medical record review of the laboratory report dated September 22, 2009, revealed Hepatic Function Panel Total Protein 5.2 (L)...(reference range 6.2-… | 2014-01-01 | ||
| 14318 | 14318 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 441 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, and interview, the staff failed to wash the hands, during a dressing change for two (#8, #1) of fifteen residents reviewed. The findings included: Observation on January 19, 2010, at 2:01 p.m., revealed Licensed Practical Nurse (LPN) #4 providing wound care to resident #8. Observation revealed LPN #4 donned gloves and removed soiled dressings from the right and left lower legs. Observation revealed without changing the gloves or washing the hands, LPN #4 cleansed two open wounds on the right lower leg, and three wounds on the left leg, with wound cleanser and gauze pads. Continued observation revealed without changing the gloves or washing the hands, LPN #4 applied Triple Antibiotic Ointment to each of LPN #4's gloved fingers, and then used each of the five fingers to individually apply the Triple Antibiotic Ointment to the five wounds on the lower legs. Continued observation revealed without changing the gloves or washing the hands, LPN #4 applied dressings to the five wounds. Review of the facility's policy Skin Integrity Program revealed "...Put on gloves...Remove soiled dressing...Cleanse wound with wound cleanser...Remove gloves and complete hand hygiene...Put on new gloves...Apply prescribed ointments if indicated...If you are dressing more than one site on a resident, hand hygiene must be done between each site..." Interview on January 20, 2010, at 11:10 a.m., with LPN #4, in the Assistant Director of Nursing's office, confirmed the gloves were not changed and the hands were not washed during the wound care provided to resident #8 on January 19, 2010, at 2:01 p.m. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on January 20, 2010, at 9:20 a.m., in resident #1's room, of LPN #4 provide treatment to a open wound on the resident's right fifth toe. Observation revealed: LPN #4 applied gloves; removed the resident's sock; a Certified Nurse Assistant en… | 2014-01-01 | ||
| 14317 | 14317 | GENERATIONS CENTER OF SPENCER | 445388 | 87 GENERATIONS DRIVE | SPENCER | TN | 38585 | 2010-01-21 | 157 | D | IMBG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to update family contact information for one (#10) of fifteen residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes revealed the licensed nurse attempted to call the resident's brother on October 29, 2009, after the resident fell , and the brother's phone number was disconnected. Continued review revealed resident #10 fell again on November 12, 2009, and no contact number was available, so the resident's brother was not notified of the fall. Interview with the Social Services Director (SSD) and Case Manager (CM) #1 on January 21, 2010, at 9:35 a..m, in the Social Services Director's office, revealed the SSD and CM #1 were unaware the resident's brother's phone had been disconnected, and confirmed updated contact information was not available until January 21, 2010, at 1:00 p.m. | 2014-01-01 | ||
| 14316 | 14316 | WILLOWS AT WINCHESTER CARE & REHABILITATION CENTER | 445319 | 32 MEMORIAL DRIVE | WINCHESTER | TN | 37398 | 2010-09-29 | 281 | D | 6R7P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to follow the care plan for one resident (#5); and failed to follow physician's orders for one resident (#8) of eleven 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 was "...total dependence..." for transfers. Medical record review of the Care Plan dated June 4, 2010, revealed "...use lift for transfers with assistance of two." Review of a facility investigation dated July 16, 2010, revealed "...manually lifted resident to shower chair..." Interview on September 28, 2010, at 12:30 p.m., with Certified Nursing Assistant #1, at the nurse's station, revealed "...lifted resident manually with help...did not use the full lift..." Interview on September 28, 2010, at 2:30 p.m., with the ADON (Assistant Director of Nursing) in the ADON's office, confirmed the facility failed to follow the care plan for proper transfer of the resident. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's order revealed the resident was to have a weekly BMP (Basic Metabolic Panel) . Review of the laboratory report revealed the last BMP lab was completed August 17, 2009. Interview with Director of Nursing on [DATE], at 2:50 p.m., in the conference room, confirmed the last BMP lab was August 17, 2009. | 2014-01-01 | ||
| 14315 | 14315 | WILLOWS AT WINCHESTER CARE & REHABILITATION CENTER | 445319 | 32 MEMORIAL DRIVE | WINCHESTER | TN | 37398 | 2010-09-29 | 323 | D | 6R7P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to supervise to ensure staff used a proper transfer device when transferring one resident (#9) of eleven 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 term memory deficit, required extensive assist for transfers and was non ambulatory. Medical record review of the care plan dated October 6, 2009, revealed the resident was to be transferred using the sit to stand mechanical lift. Review of a facility investigation dated December 9, 2009, revealed the resident was manually transferred to a bedside commode on November 23, 2009, and after staff members placed resident back in bed, the resident complained of leg pain. Continued review of the facility's investigation revealed the resident continued to complain of pain and pain medication was given through out the night. Medical record review revealed the resident was sent to the local hospital on November 24, 2009 and an Xray revealed a fracture of right femur. Interview with CNA#2 (one of the CNAs who were involved in transferring the resident on November 23, 2009) on September 28, 2010 at 12:45 p.m. in the conference room, revealed two CNAs transferred the resident to the bedside commode without using the mechanical lift but the resident did not fall or hurt their leg during this transfer. The CNA stated they stayed with the resident while the resident was on the commode and the resident did not specifically say their leg was hurting until the resident was assisted back to the bed. The CNA stated the resident's voiced pain was reported to the nurse. Interview with LPN #1 (Licensed Practical Nurse) on September 28, 2010, at 1:00 p.m., in the conference room, revealed the nurse had assessed the resident the evening of November 23, 2009, and had not noticed … | 2014-01-01 | ||
| 14314 | 14314 | TRI STATE HEALTH AND REHABILITATION CENTER | 445263 | 600 SHAWANEE RD | HARROGATE | TN | 37752 | 2010-03-31 | 164 | D | J54J11 | **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 ensure privacy was provided during personal care for one resident (#13) of twenty-three residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident had short and long term memory deficits; had severely impaired judgment; was incontinent of bowel and bladder; and required total staff assistance with all activities of daily living. Observation in the resident's room on March 30, 2010, at 8:45 a.m., revealed, upon opening the door 6 inches after knocking, Certified Nursing Assistant (CNA) #1 and CNA #2 were providing incontinence care to the resident. Continued observation revealed the resident was in the bed on the far side of the room; the privacy curtain was not pulled and the resident's genitals were visible from the door and the resident's roommate was in a wheelchair eating breakfast by the bed closest to the door. Interview in the resident's room on March 30, 2010, at 8:50 a.m., with CNA #1 and CNA #2 confirmed the privacy curtain was not in use to provide for the resident's privacy during incontinence care; the resident was not covered to provide for the resident's privacy; and the roommate and anyone entering the room had full view of the exposed resident while the CNA's were providing incontinence care. Review of the facility policy Resident's Rights revealed "...9. Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and care in his personal..." Interview with the Administrator in the office of the Administrator on March 30, 2010, at 3:10 p.m., confirmed the privacy of the residents is to be protected by utilizing the privacy curtain to prevent exposure during personal care. | 2014-01-01 | ||
| 14313 | 14313 | TRI STATE HEALTH AND REHABILITATION CENTER | 445263 | 600 SHAWANEE RD | HARROGATE | TN | 37752 | 2010-03-31 | 272 | D | J54J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to complete a side rail assessment for one (#12) of twenty-three residents reviewed. The finding's included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation and interview on March 29, 2010, at 11:45 a.m., and March 30, 2010, at 8:15 a.m., in the resident's room revealed the resident awake and resting in bed with bilateral half side rails in the down position. Continued observation and interview with resident on these dates revealed, the resident wished to have the side rails up for increased safety but had been told by Licensed Practical Nurse (LPN) #1 that side rails in the up position were illegal. Medical record review of a Side Rail assessment dated [DATE], revealed the Side Rail Assessment had not been completed. Interview on March 30, 2010, at 8:45 a.m., with the facility Risk Manager, in the Risk Manager office confirmed, the facility failed to assure the assessment for side rails was completed to determine the necessity of side rails. | 2014-01-01 | ||
| 14312 | 14312 | TRI STATE HEALTH AND REHABILITATION CENTER | 445263 | 600 SHAWANEE RD | HARROGATE | TN | 37752 | 2010-03-31 | 151 | D | J54J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to honor the rights of one resident (#12) of twenty-three residents reviewed. The finding's included: Resident # 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was independent in decision making and had no short or long term memory problems. Observation and interview on March 29, 2010, at 11:45 a.m., and March 30, 2010, at 8:15 a.m., in the resident's room revealed the resident awake and resting in bed with bilateral half side rails in the down position. Continued observation and interview with resident on these dates revealed, the resident wished to have the side rails up for increased safety but had been told by Licensed Practical Nurse (LPN) #1 that side rails in the up position were illegal. Interview on March 30, 2010, at 8:20 a.m., in the resident's room, with LPN #2 confirmed it was the resident right to have side rails in the up position. Interview on March 30, 2010, at 8:32 a.m., with LPN #1 on the 200 hall revealed, LPN #1 told the resident that, side rails could be up when Certified Nursing Assistants (CNA's) were in the room but side rails were to be down when staff were not in the room. Continued interview with LPN #1 revealed, the facility's Risk Manager had informed LPN #1 of the above. Interview on March 30, 2010, at 8:45 a.m., with the facility's Risk Manager, in the Risk Manager's office revealed, the Risk Manager had told LPN #1 that the resident was to have side rails when CNA's were in the room to assist in turning; but was not to have the side rails in place in the up position when staff was not in room. Continued interview confirmed, that it was the resident right to have side rails in the up position. | 2014-01-01 | ||
| 14311 | 14311 | SUMMIT VIEW OF FARRAGUT, LLC | 445258 | 12823 KINGSTON PIKE | KNOXVILLE | TN | 37923 | 2009-12-16 | 281 | D | 4T7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow the physician's order [REDACTED]. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the Daily Skilled Nurse ' s Notes revealed the following blood pressure readings: on December 9, 2009, 101/62; (normal 120/80); on December 11, 2009, 102/62; and on December 13, 2009, 110/54. Interview with the Director of Nursing on December 15, 2009, at 10:15 a.m., in the Director of Nursing 's office confirmed, per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order dated December 9, 2009, for decreasing [MEDICATION NAME] to 2.5 mg was not followed. | 2014-01-01 | ||
| 14310 | 14310 | SUMMIT VIEW OF FARRAGUT, LLC | 445258 | 12823 KINGSTON PIKE | KNOXVILLE | TN | 37923 | 2009-12-16 | 314 | D | 4T7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow dietary recommendations and obtain physician orders for a pressure area for one (#1) of twenty-three residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems with severely impaired cognitive skills and required assistance with all activities of daily living. Medical record review revealed the resident was receiving daily treatment for [REDACTED]. Medical record review of a dietary recommendation dated November 24, 2009, revealed, "Recommend, Restart Prostat 30 ml. BID (twice daily)." Medical record review revealed the Nurse Practitioner signed the recommendation on November 24, 2009, but no physician's order was written. Observation with the Unit Manager while performing a dressing change, in the resident's room, on December 15, 2009, at 12:30 p.m., revealed a healing Stage II pressure area 2.0 x (by) 2.0 x less than 0.1 cm. on the resident's left buttock. Interview with the Nurse Practitioner in the nursing office on December 16, 2009, at 10:30 a.m., confirmed the recommendation were noted however, the Nurse Practitioner failed to write a physician's order. | 2014-01-01 | ||
| 14309 | 14309 | WEXFORD HOUSE, THE | 445207 | 2421 JOHN B DENNIS HIGHWAY | KINGSPORT | TN | 37660 | 2010-09-02 | 157 | D | 3DE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify the physician of a recommendation by the Dietary Manager for a speech evaluation for one (#1) of eighteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living; had no chewing or swallowing problems and had no weight loss. Medical record review of documentation by the Speech Therapist dated June 16, 2010, revealed, "...Eval (Evaluation) not indicated...No report or C/O (complaint) pt (resident) having difficulty...swallowing. Deficits in self-feeding reported to OT (Occupational Therapy)..." Review of documentation of a "Post Admit Meeting" with the resident's Power of Attorney (POA-family member), dated June 22, 2010, revealed, "...Softer foods...POA says (resident) having trouble eating/speech to eval...Discussed current diet. Resident choking. Recommend ST (Speech Therapy) to evaluate..." Medical record review revealed no documentation speech therapy re-evaluated the resident after the POA reported the resident was having swallowing difficulty. Review of the POS [REDACTED]. Continued interview with the Dietary Manager confirmed on June 22, 2010, the Dietary Manager recommended the resident be re-evaluated by the Speech Therapist due to the report by the POA the resident was choking. Interview on August 24, 2010, at 1:05 p.m., in the office, with the Director of Nursing confirmed the facility failed to "follow up" with the physician on the recommendation made by the Dietary Manager on June 22, 2010, for speech therapy to evaluate the resident. C/O # | 2014-01-01 | ||
| 14308 | 14308 | WEXFORD HOUSE, THE | 445207 | 2421 JOHN B DENNIS HIGHWAY | KINGSPORT | TN | 37660 | 2010-09-02 | 514 | D | 3DE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow facility policy for documentation related to skin tears for one resident (#1) of eighteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills. Medical record review of a physician's orders [REDACTED]. Medical record review of nurses' notes dated June 15, 2010, (admission) through July 8, 2010 (date of discharge from the facility) and the treatment record dated July 2010, revealed no documentation as to when the skin tears developed and no documentation of the size of the skin tears, drainage, condition of the surrounding skin or the cause of the skin tears. Review of the facility's policy for skin tears revealed, "...The following information should be recorded in the resident's medical record:...site and description of the skin tear or wound...date and time the skin tear was discovered...All assessment data...bleeding, size of wound...obtained when inspecting the wound..." Interview on August 24, 2010, at 10:45 a.m., in the office, with the Registered Nurse/Treatment Nurse confirmed the resident had two skin tears on the right leg. Interview on August 26, 2010, at 9:10 a.m., in the office, with the Treatment Nurse confirmed no documentation of the size of the skin tears and no documentation related to drainage or the condition of the skin surrounding the skin tears. Continued interview with the Treatment Nurse confirmed the facility's policy for documentation of skin tears was not followed. C/O # | 2014-01-01 | ||
| 14307 | 14307 | WEXFORD HOUSE, THE | 445207 | 2421 JOHN B DENNIS HIGHWAY | KINGSPORT | TN | 37660 | 2010-09-02 | 309 | D | 3DE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to assess and investigate the cause of skin tears for one (#1) of eighteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; had periods of restlessness and repetitive physical movements; had physically abusive behavioral symptoms and resisted care; was totally dependent on staff for all activities of daily living; and had no skin tears. Medical record review of a weekly skin assessment dated [DATE], revealed, "...Scratch on (R) (right) (lower) extremity..." Medical record review of a weekly skin assessment dated [DATE], revealed, "...Scratch to RLE (right lower extremity)..." Medical record review of a physician's orders [REDACTED]. Medical record review of nurses' notes dated June 15, 2010, (admission) through July 8, 2010, (date of discharge from the facility) and the treatment record dated July 2010, revealed no documentation as to when the skin tears developed and no documentation of the size of the skin tears, drainage, condition of the surrounding skin or the cause of the skin tears. Review of the facility's policy for skin tears revealed, "...When a skin tear is discovered, complete an incident report...Evaluate possible cause and determine preventive measures...The following information should be recorded in the resident's medical record:...site and description of the skin tear or wound...date and time the skin tear was discovered...All assessment data...bleeding, size of wound...obtained when inspecting the wound..." Interview on August 24, 2010, at 10:45 a.m., in the office, with the Registered Nurse/Treatment Nurse confirmed the resident had skin tears on the right leg which "wasn't healing." Continued interview wit… | 2014-01-01 | ||
| 14306 | 14306 | WEXFORD HOUSE, THE | 445207 | 2421 JOHN B DENNIS HIGHWAY | KINGSPORT | TN | 37660 | 2010-09-02 | 365 | D | 3DE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to honor a dietary request for soft food and failed to follow through with a speech therapy evaluation for one (#1) of eighteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living; had no chewing or swallowing problems and had no weight loss. Medical record review of documentation by the Speech Therapist dated June 16, 2010, revealed, "...Eval (Evaluation) not indicated...No report or C/O (complaint) pt (resident) having difficulty...swallowing. Deficits in self-feeding reported to OT (Occupational Therapy)..." Medical record review of a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Review of documentation of a "Post Admit Meeting" with the resident's Power of Attorney (POA-family member), dated June 22, 2010, revealed, "...Softer foods...POA says (resident) having trouble eating/speech to eval...Discussed current diet. Resident choking. Recommend ST (Speech Therapy) to evaluate..." Medical record review revealed no documentation soft food was provided to the resident as requested by the resident's POA on June 22, 2010,and revealed no documentation speech therapy evaluated the resident after the POA reported the resident was having swallowing difficulty. Review of the Post-Admit Meeting documentation dated June 22, 2010, and interview on August 24, 2010, at 10:35 a.m., in the office, with the Dietary Manager, revealed the Speech Therapist had evaluated the resident prior to the meeting on June 22, 2010. Continued interview with the Dietary Manager confirmed on June 22, 2010, the Dietary Manager recommended the resident be … | 2014-01-01 | ||
| 14305 | 14305 | WEXFORD HOUSE, THE | 445207 | 2421 JOHN B DENNIS HIGHWAY | KINGSPORT | TN | 37660 | 2010-09-02 | 322 | D | 3DE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure tube feeding was disconnected and reconnected by licensed staff, which had been trained in the procedure, for one (#6) of eighteen residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living; and was fed via a feeding tube. Medical record review of the physician's recapitulation orders dated August 1-31, 2010, revealed ? strength Glucerna was administered at eighty milliliters each hour for twenty-three hours each day. Review of a statement written by Certified Nursing Assistant (CNA) #1, related to an allegation CNA #1 had abused resident #6 on August 5, 2010, (unsubstantiated) revealed, "...saw (CNA #2)...asked (CNA #2) to help me put (resident) to bed...took (resident) to...room and helped me undress (resident). Then I put...gown on and changed...brief...hooked (resident) back up to...feeding tube...raised...head. Interview on August 23, 2010, at 11:10 a.m., in the office with the Director of Nursing (DON) confirmed CNAs were not authorized to disconnect and reconnect tube feedings. Interview on August 24, 2010, at 8:05 a.m., in the office with CNA #1 confirmed on August 5, 2010, CNA #1 disconnected the tube feeding for resident #6; showered the resident; reconnected the tube feeding; and turned on the tube feeding pump "to keep the same rate flowing." Continued interview with CNA #1 confirmed CNA #1 had turned off the pump and disconnected the tube feeding on other occasions "to get (resident) ready to go to the shower" and had reconnected the tube feeding and turned on the pump after the resident's shower. C/O # | 2014-01-01 | ||
| 14304 | 14304 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-09-24 | 406 | D | B9UY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide occupational therapy services for one resident (#2) of five sampled residents. The findings included: Resident #2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had decreased range of motion and partial loss of movement on one hand. Medical record review of the MDS dated [DATE] revealed the resident was severely impaired with decision-making skills and totally dependent on staff for all activities of daily living. Continued review revealed the resident had decreased range of motion and partial loss of movement on one hand. Medical record review of the care plan dated September 16, 2010 revealed, "PT/OT to eval & tx (physical therapy/occupational therapy to evaluate and treat)." Medical record review of a physician's orders [REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED].(joint) contractures ...pulls away from this therapist on attempts at PROM (passive range of motion) but ultimately allowed gentle PROM ...and application of palmar rolls ..." Observation on September 23, 2010 at 10:55 a.m. revealed the resident in bed and without any contracture preventive device in either hand. Observation on September 24, 2010 at 10:35 a.m. revealed the resident in a geri-chair in the room and hand rolls in the right and left hands. Interview with OT #1 on September 24, 2010 at 10:58 a.m. in a lower level conference room revealed a communication error had occurred regarding the physician's orders [REDACTED].#2. C/O: # | 2014-01-01 | ||
| 14303 | 14303 | BEVERLY PARK PLACE HEALTH AND REHAB | 445131 | 5321 BEVERLY PARK CIRCLE | KNOXVILLE | TN | 37918 | 2010-09-24 | 312 | D | B9UY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nail care for one (#3) of five sampled residents. 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 was impaired with decision-making skills and dependent on staff for mobility and hygiene/grooming. Continued review revealed the resident had decreased range of motion of the right and left hands. Medical record review of the care plan effective through November 11, 2010 revealed, "...nail care as needed..." Observation on September 23, 2010 at 10:33 a.m. revealed the fingers of the resident's left hand clenched into the palm, and the resident used the right hand to open up the fingers of the left hand. Continued observation revealed the fingernails extended past the fingertips and left red indentions in the palm of the hand. Observation and interview with RN #1 on September 23, 2010 at 10:35 a.m. revealed the nurse obtained the resident's permission to trim the nails, and confirmed the facility had failed to provide nail care for Resident #3. C/O: # | 2014-01-01 | ||
| 14302 | 14302 | MCKENDREE VILLAGE INC | 445491 | 4347 LEBANON ROAD | HERMITAGE | TN | 37076 | 2010-02-24 | 441 | D | ECRM11 | Based on observation, facility policy review, and interview, the facility failed to ensure a sanitary environment to help prevent the development and transmission of disease and infection for one of two ice machines and two of three shower rooms. The findings included: Observation on February 23, 2010, at 10:40 a.m., in the 200 East Nurse's Pantry, revealed employee #1 took a Styrofoam cup from the counter beside the sink, placed it in the sink basin, then removed it from the sink basin, walked over to the ice machine and scooped through the ice twice using the same Styrofoam cup. Observation on February 23, 2010, at 11:00 a.m., revealed a dried dark brown substance on four of four walls in the 200 East shower room; a dark brown substance on the floor of the 200 East shower room; and a dried dark brown substance on the floor of the 200 North shower room. Review on February 23, 2010, of the policy and procedure dated 4/2003 for Ice Safety revealed "...Use a clean, sanitized container (ice bucket designed for this purpose is ideal) and ice scoop to transfer ice from an ice machine to other containers..." Review on February 23, 2010, of the policy and procedure for Shower Rooms revealed "...2. In the event of an accident occurring in the shower room requiring disinfecting and cleaning, the nurse aide will notify environmental services as soon as possible, with resident care, safety, and privacy taking precedence..." Interview with the Director of Nursing (DON) at the Nurse's Station on February 23, 2010, at 3:05 p.m., confirmed an ice scoop is to be used to transfer ice from the ice machine and Environmental Services should have been notified to clean the dried, dark- brown substance from the shower rooms. Interview with the Director of Environmental Services in the Conference Room on February 24, 2010 at 10:20 a.m., confirmed "... was not notified of the condition of the shower rooms ". | 2014-02-01 | ||
| 14301 | 14301 | MCKENDREE VILLAGE INC | 445491 | 4347 LEBANON ROAD | HERMITAGE | TN | 37076 | 2010-02-24 | 431 | D | ECRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the disposal of an expired medication from one of two medications carts. The findings included: Observation on February 23, 2010, at 11:20 a.m., of the A Medication Cart located in the 200 East Medication Room, revealed a one pint (473 ml) bottle of Guituss Syrup, approximately half-full, with a manufacture's expiration date of ,[DATE] on the label of the bottle. Interview with Licensed Practical Nurse (LPN) #1 and LPN #2 in the 200 East Medication Room on February 23, 2010, at 11:30 a.m., confirmed the Guituss Syrup in the A Medication Cart was expired and should have been removed from the cart and disposed of. | 2014-02-01 | ||
| 14300 | 14300 | MCKENDREE VILLAGE INC | 445491 | 4347 LEBANON ROAD | HERMITAGE | TN | 37076 | 2010-02-24 | 281 | D | ECRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the care plan for two residents (#15, # 16 ) for the protection of a [MEDICAL TREATMENT] access for twenty-six residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a [MEDICAL TREATMENT] access (fistula) (access to use for [MEDICAL TREATMENT]) on the left arm, and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan updated February 16, 2010, revealed the care plan did not address the resident's [MEDICAL TREATMENT] access located on the resident's left arm or the practice which requires no needle sticks or blood pressures checks in the arm of the access. Interview with the Director of Nursing (DON) on February 23, 2010, at 3:30 p.m., in the north hallway, confirmed the care plan did not address the care of the access for [MEDICAL TREATMENT]. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a [MEDICAL TREATMENT] access (fistula) on the left arm and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan dated February 22, 2010, revealed the care plan did not address the resident's access located on the resident's left arm or the practice which requires no needle sticks or blood pressure checks in the arm of the access. Interview with the Director of Nursing on February 23, 2010, at 3:30 p.m., in the north hallway, confirmed the care plan did not address the care of the access for [MEDICAL TREATMENT]. | 2014-02-01 | ||
| 14299 | 14299 | MCKENDREE VILLAGE INC | 445491 | 4347 LEBANON ROAD | HERMITAGE | TN | 37076 | 2010-02-24 | 157 | D | ECRM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to notify the physician for abnormal blood glucose levels for one resident (#24) of twenty-six residents reviewed. The findings included: Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a physician's note dated May 18, 2009, revealed "Very demented, delusional often. DM (Diabetes Mellitus) ?new diagnosis. On [MEDICATION NAME] XL; glucose 145 on lab (laboratory), start accu-checks (blood glucose monitoring). Review of the physician's Recapitulation Orders dated May 24, 2009, revealed "Sliding scale with [MEDICATION NAME] Insulin 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; greater than 400 = 10 units." Review of the Diabetic Monitoring Log for May 2009, revealed an entry dated May 20, 2009, at 4:00 p.m., of blood glucose of 418 but no documentation the physician was notified of the elevated abnormal result. Continued review of the medical record revealed an entry dated May 24, 2009 at 4:00 p.m., of blood glucose of 474 and an entry at 9:00 p.m., of blood glucose of 498 but no documentation the physician was notified of the elevated abnormal results recorded for 4:00 p.m. and 9:00 p.m.. Medical record review revealed an entry dated May 28, 2009, at 4:00 p.m., of blood glucose of 451, an entry dated May 29, 2009, at 11:00 a.m., of blood glucose of 437, and an entry dated May 30, 2009, at 9:00 p.m., of blood glucose of 595 but no documentation the physician was notified of the elevated abnormal blood glucose results. Review of the facility policy entitled "Insulin Administration" revealed "Physician to be notified of blood sugars below 60 or above 400 unless there is a specific order addressing blood sugars outside these ranges directing otherwise." Interview with the Director of Nursing (DON) on February 24, 2010, at 10:15 a.m., in the DON's office, confirmed there were six in… | 2014-02-01 | ||
| 14298 | 14298 | RIDGETOP HAVEN HEALTH CARE CENTER | 445486 | 2002 GREER ROAD | RIDGETOP | TN | 37152 | 2010-04-29 | 323 | D | RTKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent resident to resident incidents for three residents (#7, #8, # 18) of eighteen residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory deficit, moderately impaired decision making skills, with wandering behavior that occurred daily and the behavior was not easily altered. Medical record review of the nurse's notes dated April 11, 2010, revealed "resident wandering up and down hallways today and into other resident's rooms. As a result of this (resident #7) was hit (L)(left) jaw area by another resident (#8). No injuries on (resident #7) will monitor." Continued review revealed April 14, 2010, "(resident #7) had altercation with resident (#8) in the common front hallway and the two residents had an argument over a chair, resident (#8) punched resident (#7)." "No injuries found...will monitor " was redirected. Nurse's notes dated April 20, 2010, revealed, "resident continues to wandering into rooms of other residents, frequent reorientation and assistance given to move to commons area, communication verbalized is confused and intelligible." Observation on April 27, 2010, at 2:30 p.m., revealed, resident #7 in the dining room attempting to interfere with the task of housekeeping; after several attempts to redirect staff was able to walk resident out of the dining room. Continued observation revealed resident #7 was escorted out of room #5 (room #5 occupied by female residents) by DON (Director of Nursing). Continued observation revealed resident #7 entered resident #14's room and stand in front of the resident. (Resident #14 was observed sitting in a rock-n-go chair.) Resident #7 entered adjoining room of resident #18. Resident #18 was a… | 2014-02-01 | ||
| 14297 | 14297 | RIDGETOP HAVEN HEALTH CARE CENTER | 445486 | 2002 GREER ROAD | RIDGETOP | TN | 37152 | 2010-04-29 | 281 | D | RTKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to assess one resident's (#5) blood glucose level after the resident developed [MEDICAL CONDITION], of eighteen residents reviewed. The findings included: Medical record review revealed resident #5 was admitted to the facility in September 2005, with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Record review revealed on January 30, 2010, the resident had blood glucose checks with an accompanying sliding scale for insulin administration ordered before each meal and at bedtime. Medical record review of the Diabetic Record revealed on February 10, 2010, the resident received 12 units of [MEDICATION NAME](a fast acting insulin) at 4:00 p.m., for a blood glucose level of 351. Medical record review revealed an untimed entry in the Nurse's Notes on February 10, 2010, "...CNA (certified nurse aide)...noted resident unresponsive...this nurse noted resident having [MEDICAL CONDITION]. Called 911...had other nurse stay with resident...resident having [MEDICAL CONDITION] activity about every 30 seconds. Around 6:45 EMS here to transport." Medical record review of the history and physical examination ...The patient apparently was having [MEDICAL CONDITION] for over 15-20 minutes and EMS arrived and checked the blood sugar. The blood sugar was 26...given D50 (an IV solution with 50% [MEDICATION NAME]). After which...more awake and alert, but still very confused and sleepy. Blood sugar after initial improvement came back down to 66...CT of the head reported as negative...being admitted to the intensive care unit for close observation for the follow up of the blood sugars." Further review of the H & P revealed, "IMPRESSION: 1. [MEDICAL CONDITION] activity related to most likely [DIAGNOSES REDACTED] (low blood glucose level)." Medical record review revealed the resident was readmitted to the nursing home the following day, February 12, 2010. Obs… | 2014-02-01 | ||
| 14296 | 14296 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2010-06-03 | 323 | D | JRLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure a safety device was in place for one resident (#5) of twenty-six 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 was "...total dependence..." and required "...two + (plus) persons physical assist..." for transfers. Medical record review of a Plan of Care, dated November 2, 2009, revealed the resident was at risk for falls and was to use a "...Sit to Stand (used for transfers) lift for all transfers..." Medical record review of facility documentation dated, December 26, 2009, revealed, " ...CNA (Certified Nursing Assistant) who was assisting res (resident) with transfer was loosing safe grip. Res was safely lowered to floor to prevent fall..." Continued review of facility documentation revealed, "...Comments/Conclusion: Use lift for transfers, Two person transfers..." Interview with CNA #1 (on duty at the time of the fall) and the Director of Nursing, on June 2, 2010, at 9:40 a.m., in the Director of Nursing's office, confirmed the Sit to Stand lift was not in use on December 26, 2009, when the resident sustained [REDACTED]. | 2014-02-01 | ||
| 14295 | 14295 | ISLAND HOME PARK HEALTH AND REHAB | 445476 | 1758 HILLWOOD DRIVE | KNOXVILLE | TN | 37920 | 2010-10-28 | 226 | D | 4S8L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility investigation, and interview, the facility failed to notify the State Agency of an allegation of abuse within the required time frame for one resident (#1) of six 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 with no loss in short or long term memory and required only supervision with cognitive skills for daily decision making. Review of a facility investigation dated May 6, 2010, revealed " ...Notified by Regional nurse that pt. (patient) felt afraid of staff member...Pt notified another staff member of feeling afraid ..." Continued review of the facility investigation revealed the facility completed interviews with the resident, staff, and the alleged perpetrator and had been unable to substantiate any abuse had occurred. Review of the facility investigation revealed the facility reported the allegation of abuse to the state agency on May 25, 2010. Interview with the Administrator and DON (Director of Nursing) on October 27, 2010, at 3:15p.m., in the conference room, confirmed the facility failed to report the allegation of abuse to the state agency in the required time frame as required. | 2014-02-01 | ||
| 14294 | 14294 | ISLAND HOME PARK HEALTH AND REHAB | 445476 | 1758 HILLWOOD DRIVE | KNOXVILLE | TN | 37920 | 2010-10-28 | 514 | D | 4S8L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain accurate clinical records for two residents (#3, #5) of six residents reviewed. The findings included: Resident #5 was admitted to the facility September 5, 2007, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, was totally dependent for activities of daily living, had no indications of depression, anxiety, or sad mood, and had exhibited no behavior symptoms or psychosocial deficits. Medical record review of the social services notes dated August 28, 2008 through May 17, 2010, revealed " ...no mood or behavior problems ..." Medical record review of a psychiatric consultant Nurse Practitioner Progress notes dated January 10, 2010 through October 22, 2010, revealed "recent exac (exacerbation) of sexually inappropriate behaviors ...seen for E&M (evaluation and management) of DAT (dementia) c (with) [MEDICAL CONDITION] and beh (behavior) sxs (symptoms) including sexual inappropriateness & physical aggressive ..." Observation on October 27, 2010, at 9:30 a.m., in the dining room with the resident revealed the resident sitting in a wheelchair, smiling, alert, oriented to person and time, pleasant, and socially appropriate. Interview with the Administrator and Director of Nursing (DON) October 27, 2010, at 10:45 a.m., in the conference room, confirmed the resident had no current behavioral issues. Further interview with the Administrator and the DON confirmed the resident's medical record was inaccurately documented in describing the problem behaviors as "current" and/or "recent" rather than "history of." Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a notorized document dated June 27, 2010, revealed " ...Appointment of Healthcare Agent ..." with one daughter listed as the Agent and no alternate l… | 2014-02-01 | ||
| 14293 | 14293 | HILLVIEW HEALTH CENTER | 445464 | 1666 HILLVIEW DRIVE | ELIZABETHTON | TN | 37643 | 2010-07-29 | 323 | D | R51U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide supervision to prevent accidents and ensure safety devices were in place for one resident (#10) of fifteen sampled residents reviewed. The findings include: Resident #10 was admitted to the facility September 22, 2008, with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set ) dated March 7, 2010, revealed the resident had short and long term memory loss, moderately impaired cognitive skills for daily decision making and was independent with ambulation. Medical record review of the MDS dated [DATE], revealed the resident had short and long term memory loss, severely impaired cognitive skills for daily decision making, was totally dependent for transfer and locomotion on unit, required a wheelchair for mobility, and had a history of [REDACTED]. Medical record review of Falls Risk Assessments dated September 22, 2008, through June 19, 2010, revealed the resident to be at high risk for falls. Medical record review of the nurse's notes and facility documents dated March 27, 2010, through July 20, 2010, revealed the resident had a history of [REDACTED]. Medical record review of the care plan updated May 22, 2010, following a fall on that date, revealed a planned new approach "...mats placed on left side of bed ..." Medical record review of a facility document dated May 25, 2010, revealed "...resident lying in floor beside of bed..." "Immediate intervention implemented: placed non-skid socks on resident." Further review revealed no documentation the safety mat was in place at the time of the fall. Interview with the Director of Nursing, (DON) July 29, 2010, at 9:15 a.m., in the conference room, confirmed there was no documentation of the mat being in place at the resident's bedside at the time of the fall. Medical record review of the care plan dated June 10, 2010, revealed approaches listed: "...Mats on floor at bedside and bed alarm use… | 2014-02-01 | ||
| 14292 | 14292 | HORIZON HEALTH AND REHAB CENTER | 445383 | 811 KEYLON STREET | MANCHESTER | TN | 37355 | 2010-06-09 | 224 | D | M3K711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Controlled Substances records, facility policy review, and interview, the facility failed to prevent misappropriation of medications for two (#10, #11) of sixteen residents reviewed. The findings included: Review of the Controlled Substances record for resident #10 revealed thirty tablets of [MEDICATION NAME]-Apap (pain medication) 5-325 tablets were dispensed by the pharmacy to the facility on [DATE]. Continued review of the Controlled Substances record revealed one tablet of the [MEDICATION NAME]-Apap 5-325 was administered to another resident on May 26, 2010. Review of the Controlled Substances record for resident #11 revealed thirty [MEDICATION NAME] (antianxiety medication) 0.5 mg. (milligrams), with instructions to take 1/2 tablet by mouth once daily, were dispensed by the pharmacy to the facility on [DATE]. Continued review of the Controlled Substances record revealed the [MEDICATION NAME] was administered to another resident on the following days: May 31, 2010, June 2, 3, 4, and 7, 2010. Review of a second Controlled Substances record for resident #11 revealed thirty [MEDICATION NAME] 0.5 mg., with instructions to take one tablet by mouth daily, were dispensed by the pharmacy to the facility on [DATE]. Continued review of the Controlled Substances record revealed the [MEDICATION NAME] was administered to another resident on the following days: June 2, 3, 4, 6, and 7, 2010. Review of the facility's policy Borrowing Narcotic Medications revealed "It is the policy of United Regional Medical Center to assure that residents receive their medications in a timely manner. Although borrowing narcotic medications from resident to resident is strongly discouraged...when all other possible options have been exhausted the following procedure is to be utilized: If all options have been exhausted, and the medication in question cannot be acquired for the resident in a timely manner...then and only then should the facility borrow a… | 2014-02-01 | ||
| 14291 | 14291 | HARRIMAN CARE & REHAB CENTER | 445368 | 240 HANNAH ROAD | HARRIMAN | TN | 37748 | 2010-10-27 | 322 | D | K55Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, review of the facility policy "Gastrostomy Feedings #G-3" and review of manufacturer's directions, the facility failed to ensure staff provided appropriate care for a feeding tube for one resident (#4) of seven residents reviewed. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident was alert and oriented only to recent events; had problems with decision making skills; was total assist with all activities of daily living; and was receiving nourishment via jejunostomy (tube used for feeding, surgically inserted into the lower stomach) tube feeding. Medical record review of the Physician's Order's, dated July 21, 2010, no time noted, revealed "...(named tube feeding solution) at 80 ml (milliliters) per hr (hour) ...on 4 (hours), off 2 (hours)...Flush a/ (before) and p/ (after feeding with 30 ml H2O (water)..." Observation with Licensed Practical Nurse (LPN) #4 of the resident in the resident's room on September 7, 2010, at 1:05 p.m., revealed the resident in a semi-seated position in the bed with a tube feeding running via pump at 80 ml/hr. Continued observation revealed, hanging from the tube feeding pump was an 18 inch guide wire in an open plastic sleeve. Continued observation revealed the tip of the guide wire was covered in a crusted yellow substance. Interview with LPN #4 in the resident's room on September 7, 2010, at 1:05 p.m., revealed the guide wire is utilized to "unclog" a feeding tube; the guide wire is reusable; and the tip of the guide wire was covered in a crusted yellow substance. Interview revealed the LPN had not been inserviced on the use of the guide wire to unclog the feeding tube. Interview at the Nurses' Station with the Nurse Practitioner on September 8, 2010, at 4:00 p.m., revealed there had been no symptoms related to the reuse of the guide wire to u… | 2014-02-01 | ||
| 14290 | 14290 | HARRIMAN CARE & REHAB CENTER | 445368 | 240 HANNAH ROAD | HARRIMAN | TN | 37748 | 2010-10-27 | 224 | D | K55Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, facility investigation report review, and interview, the facility failed to prevent the misappropriation of narcotic medications for one resident (#1) of seven 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 [DATE], revealed the resident was alert and oriented in all areas; had no problems with decision making skills; and experienced moderate pain less than daily. Medical record review of the Physician's Order, dated December 3, 2009, revealed "[MEDICATION NAME] ([MEDICATION NAME]-APAP, a [MEDICATION NAME] based controlled narcotic [MEDICATION NAME]) 5/500 mg (5 milligrams [MEDICATION NAME] and 500 milligrams [MEDICATION NAME]) 2 tabs (tablets) po (by mouth) q (every) 4 hrs (hours) prn (as needed) for pain..." Medical record review of the Care Plan, dated December 15, 2009, revealed the resident had been identified as being at risk for pain with interventions to include "...prn pain medication..." Medical record review of resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued review of the MAR indicated [REDACTED]. Review of the controlled substance count sheet (record of number of controlled medications administered and number of controlled medications remaining) for resident #1's [MEDICATION NAME] 5/500 mg tablets, dated December 3 - 31, 2009, revealed the resident had 30 doses administered with LPN #1 signing out for 28 of the 30 doses. Review of a facility investigation report, dated December 30, 2009, at 2:15 p.m., revealed the Director of Nursing (DON) was informed by Licensed Practical Nurse (LPN) #2 that a shift count controlled substance ([MEDICATION NAME] 5/500 mg) record sheet for resident #1 was missing and the 28 doses of [MEDICATION NAME] 5/500 mg was not present. Continued review revealed… | 2014-02-01 | ||
| 14289 | 14289 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 314 | D | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a pressure relieving device was in place to promote healing of a pressure sore for one resident (#2) of twenty-four residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was admitted to the hospital September 13, 2009, and returned to the facility on [DATE], with a pressure sore to the left heel described on the Pressure Ulcer Status Record as, "Soft and Mushy", 3.0 (width) x 4.0 (lenght) cm (centimeters). Continued review of the Pressure Ulcer Status Record revealed the pressure area progressed to a brown/black area 5.0 x 3.5 cm, Stage IV on October 9, 2009. Medical record review of the plan of care updated January 11, 2010, revealed, "Apply synthetic wool heel protectors' bilateral (feet), and heels elevated off bed at all times." Observation on February 2, 2010, at 11:00 a.m., revealed the resident in the bed with an abduction pillow supporting the resident's knees; however, heel protectors were not on the resident's feet, and the feet were pressing directly onto the mattress. Continued observation on February 3, 2010, at 9:30 a.m., revealed the resident's left heel pressing directly onto the mattress, without heel protectors on the feet. Continued observation with LPN #5, on February 3, 2010, at 10:05 a.m., revealed the (clean) fleece/wool heel protectors were located in the resident's closet. Observation on February 3, 2010, at 1:25 p.m., with (wound care nurse) LPN #5, revealed the wound to the left heel was a healing Stage IV, presenting as a healing Stage II, approximately 2.5 x 1.5 cm., with a small to moderate amount of serous drainage. Interview with the Licensed Practical Nurse #4, on February 3, 2010, at 10:15 a.m., at the north nursing station, confirmed the facility failed to ensure heel … | 2014-02-01 | ||
| 14288 | 14288 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 323 | D | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were in place or functional for two (#14, #3) of twenty-four residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, severely impaired cognitive skills, was totally dependent for transfers and did not walk. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of the Care Plan, reviewed by the facility on January 26, 2010, revealed "...Potential for injury related to falls...unmindful of safety...Pressure sensitive alarm to bed to alert staff of unassisted transfers..." Observation on February 1, 2010, at 4:12 p.m., revealed the resident lying on a low bed, and the pressure sensitive alarm was in place, however, the cord from the pressure sensitive alarm was not attached to the alarm box. Observation and interview on February 1, 2010, at 4:15 p.m., with Licensed Practical Nurse (LPN) #1, revealed the resident lying on the bed, with the cord from the pressure sensitive alarm lying on the floor, disconnected from the alarm box and confirmed the alarm was not functional. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had short and long term memory problems, severely impaired cognitive skills, required extensive assistance with transfers, and did not walk. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of the Care Plan, reviewed by the facility on February 1, 2010, revealed " ...Potential for falls ...unmindful of safety ...Place bed alarm in an unassessible area ..." … | 2014-02-01 | ||
| 14287 | 14287 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 281 | E | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to address dietary recommendations in a timely manner for two residents (#13, #18), failed to address Mental Health Provider recommendations in a timely manner for one resident (#8), and failed to initiate treatment for [REDACTED].#14) of twenty-four residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Registered Dietician note dated November 4, 2009, revealed "...1) D/C (discontinue) (name supplement...3) Continue (name protein supplement) but (decrease) to 1 pkt (packet) qd...(every day) x (times) 30 d (days)...5) weekly wt (weight)" Medical record review of the faxed order request/notification dated November 25, 2009, revealed the Physician noted the above recommendations on December 2, 2009, and the Physician response was not noted by the facility prior to December 9, 2009. Medical review of the Physician order [REDACTED]. Interview with the Director of Nursing and the Regional Director of Clinical Services on February 2, 2010, at 3:30 p.m. in the Director of Nursing office confirmed the Registered Dietician's recommendations made on November 24, 2009; the Physician signed the fax notification with a response to the recommendations on December 2, 2009, and the facility did not recieve the Physician's response to address the recommendations until December 9, 2009, resulting in a 12 day delay. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Registered Dietician note dated December 28, 2009, revealed "...3) 30 ml (milliliters) of (named supplement) x 30 d (days) for meeting protein needs..." Medical record review of the faxed order Request/Notification form dated December 30, 2009, revealed the Physician's response was dated January 5, 2010, and noted by the Facility on January 12, 2010. Medical record review of the Phy… | 2014-02-01 | ||
| 14286 | 14286 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 333 | D | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to prevent a significant medication error one (#17) resident of twenty-four residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Diabetic Treatment Administration Record dated January, 2010, revealed the accucheck (finger stick) blood sugars ranged from 106 to 95 (normal blood sugar is 80-100). Medical record review of the Diabetic Treatment Administration Record dated February 2, 2010, revealed an accucheck blood sugar result of 202. Observation on February 2, 2010, at 8:45 a.m., revealed RN #1 administered [MEDICATION NAME] (insulin) 10 units subcutaneous (injection) in the right arm to resident #17. Interview on February 2, 2010, at 9:25 a.m., with RN #1, at the 200 nursing station, confirmed the resident did not receive 15 units of [MEDICATION NAME] as ordered by the physician. | 2014-02-01 | ||
| 14285 | 14285 | LIFE CARE CENTER OF COPPER BASIN | 445310 | 166 COPPER BASIN INDUSTRIAL PARK PO BOX 518 | DUCKTOWN | TN | 37326 | 2010-02-03 | 502 | D | NCHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete laboratory studies for one #15, of twenty-four residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a laboratory report for a Complete Blood Count dated January 7, 2010, revealed the hemoglobin was 9.9 (reference range 12.1-15.5) and the hematocrit was 29.7 (reference range 36.1-46.0). Medical record review of the same laboratory report dated January 7, 2010, revealed an undated physician's orders [REDACTED]." Medical record review revealed no documentation the hemoccults had been completed. Interview on February 2, 2010, at 4:20 p.m., with the Director of Nursing (DON), in the DON's office, confirmed the hemoccults had not been completed. | 2014-02-01 | ||
| 14284 | 14284 | LIFE CARE CENTER OF EAST RIDGE | 445296 | 1500 FINCHER AVENUE | EAST RIDGE | TN | 37412 | 2010-02-10 | 281 | D | 1RJR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow physician's orders for a medication for one (#24) of twenty-five residents reviewed. The findings included: Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Nurse's Notes revealed on July 5, 2009, the resident's daughter requested a [MEDICATION NAME] (pain medication) for the resident. Medical record review revealed the Nurse Practitioner (NP) was notified on July 5, 2009, at 5:30 p.m., and ordered the medication. Medical record review of Nurse's Notes revealed [MEDICATION NAME] (pain medication) 75 mg. and [MEDICATION NAME] (for nausea) 50 mg. was ordered and to be given until the [MEDICATION NAME] could be obtained. Medical record review of Nurse's Notes revealed the facility received the medication on July 5, 2009, at 11:30 p.m., but was not applied. Review of the Controlled Medication Utilization Record revealed the pain patch was not applied until July 6, 2009, at 11:00 a.m. Interview with the NP in the Assistant Director of Nursing's office on February 10, 2010, at 1:00 p.m., confirmed the medication was to have been applied when obtained. C/O # | 2014-02-01 | ||
| 14283 | 14283 | LIFE CARE CENTER OF EAST RIDGE | 445296 | 1500 FINCHER AVENUE | EAST RIDGE | TN | 37412 | 2010-02-10 | 514 | D | 1RJR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure the medical record was complete and accurate for two (#23, #22) of twenty-five residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Hospital transfer orders dated September 5, 2009, revealed, "[MEDICATION NAME] 160 mg tablet...320mg po (by mouth) 1200 (noon)..." Medical record review of the Physician's Recapitulation Orders dated September, 2009, revealed, "[MEDICATION NAME] 160 mg 1 po daily..." Review of a (named drug store pharmacy receipt) dated September 5, 2009, at 9:04 p.m. revealed the facility received [MEDICATION NAME] 320 mg tablets, quanity 4. Medical record review of an OT (Occupational Therapy) Progress Note dated September 6, 2009, revealed, "...Eval (Evaluation) complete and treatment initiated. Upon entering room to assess patient, patient's daughter expressed concern regarding blood pressure. OT took BP (blood pressure) which was high and notified nursing immediately. Nurse came and provided blood pressure medications before continuing with assessment..." Medical record review of a nurse's note dated September 6, 2009, revealed, "...7:30 A Notified by therapy pt B/P was elevated to (space left blank in the nursing notes to document the blood pressure). APN (Advanced Practice Nurse) gave...order [MEDICATION NAME] 160 mg to be given now instead of 12n..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Interview on February 10, 2010, at 8:20 a.m., with the DON (Director of Nursing), in the DON's office confirmed the blood pressure was not documented by the Occupational Therapist or the Nurse, and the physician's orders [REDACTED]. c/o # | 2014-02-01 | ||
| 14282 | 14282 | LIFE CARE CENTER OF EAST RIDGE | 445296 | 1500 FINCHER AVENUE | EAST RIDGE | TN | 37412 | 2010-02-10 | 309 | D | 1RJR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to follow the physician's orders for one (#23) of twenty-five residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short/long term memory problems, and was independent in cognitive skills for daily decision making. Medical record review of the hospital transfer physician's orders dated September 5, 2009, revealed, "[MEDICATION NAME] (blood pressure) 1 mg...po (by mouth) BT (bedtime)[MEDICATION NAME] XL (blood pressure)...90 mg po BT..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of a physician's order dated September 6, 2009, revealed, "...Clarification of med (medication) administration times per pt (patient) [MEDICATION NAME] XL 90 mg po daily (at) 9 p.m., [MEDICATION NAME] 1 mg po daily (at) 9 p.m..." Medical record review of the Vital Sign Flow Sheet dated September 5, 2009, revealed, "...2 p 165/71 (blood pressure)...(September 6, 2009) 3:15 a.m. 157/78..." Medical record review of a OT (Occupational Therapy) Progress Note dated September 6, 2009, revealed, "...Eval (Evaluation) complete and treatment initiated...OT took BP (blood pressure) which was high and notified nursing immediately. Nurse came and provided blood pressure medications before continuing with assessment ... " Medical record review of a nurse's note dated September 6, 2009, revealed, "...7:30 A Notified by therapy pt B/P was elevated to (space left blank in nursing notes to document the blood pressure). APN (Advanced Practice Nurse) gave...order [MEDICATION NAME] 160mg to be given now instead of 12n..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Interview on February 9, 201… | 2014-02-01 | ||
| 14281 | 14281 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 281 | D | NRDI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the care plan for two residents (#16) of thirty-three residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with Diabetes, End Stage [MEDICAL CONDITION], Hypertension, and [MEDICAL CONDITION]. Medical record review of the physician notes dated January 2010, revealed the resident had a [MEDICAL TREATMENT] access (fistula) (access to use for [MEDICAL TREATMENT]) on the left arm and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan updated October 2009, revealed the care plan did not address the resident's [MEDICAL TREATMENT] access located on the resident's left arm or the practice which requires no needle sticks or blood pressures checks in the arm of the access. Interview with the ADON on January 13, 2010, at 8:05 a.m., at the second unit nurses' station, confirmed the care plan did not address the care of the access for [MEDICAL TREATMENT]. | 2014-02-01 | ||
| 14280 | 14280 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 441 | D | NRDI11 | Based on observation, policy review, and interview, the facility failed to ensure staff washed the hands after direct resident contact for one (#22) of thirty-three residents reviewed. The findings included: Observation on January 12, 2010, at 9:00 a.m., in the one hundred hallway, revealed CNA #1 (certified nursing assistant) adjusted resident #14's wheelchair footrest. CNA #1 after adjusting the footrest proceeded to pick up a breakfast tray from the meal cart. Further observation revealed CNA#1 took the breakfast tray into resident #22's room; placed the tray on the table; donned gloves; adjusted the resident to the upright position; proceeded to cut resident #22's food; and fed the resident. Review of the Handwashing Information-Handout #2, revealed ...the single most important factor in preventing and controlling infections is that of handwashing. ...Washing Your Hands ...6.Before serving food ....9. After handling the resident's belongings. Interview with the CNA #1 on January 12, 2010, at 9:10 a.m., in the hallway, confirmed the hands were not washed after adjusting the footrest on resident's wheelchair. Interview with the R.N. (registered nurse) supervisor unit #1, on January 12, 2010, at 10:15 a.m., in the hallway, confirmed staff hands are to be washed or disinfected between each resident. | 2014-02-01 | ||
| 14279 | 14279 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 431 | D | NRDI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of current Individual Patient's Controlled Substances Record, review of facility policy, and interview, the facility and licensed pharmacist failed to establish a system of records of disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for seven (Resident #29,#30,#31,#32,#17,#11,#33) of thirty-three sampled residents. The findings included: Review of Facility Policy "Clinical Services Policies & Procedures, Nursing Volume l Policies for Medication Administration, Chapter 12" Controlled Drugs...Standard...A " controlled drugs proof of use sheet" is accurately maintained on all residents requiring controlled medications. Strict control of narcotics is always maintained...Policy ...Appropriate storage, recording, and use of controlled drugs are always maintained on all units. Narcotic proof of use sheet is accurately maintained on all residents requiring such medication...Procedure...4. The nurse signs off each dose of the controlled drug given by documenting: a. Date. b. Hour. c. Resident name d. Physician. e. Amount dispensed. f. Signature of nurse. g. Balance after subtracting amount dispensed...5. The nurse handling the controlled drug must follow the procedure in the event a dose is broken, partially used, discarded, or lost. a. The nurse records broken, partially used, or lost dose on the "proof of use sheet. b. The nurse and another nurse co-sign the " proof of use sheet." c. Two licensed nurses must witness the destruction of a controlled substance ...7. Narcotics are counted at the change of each shift by the off-going and the on-coming nurse and both sign the Change of Shift Count Record...c. If the count is incorrect, notify the supervisor and pharmacist...NOTE: The nurse remains on duty until the count is reconciled or the s… | 2014-02-01 | ||
| 14278 | 14278 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 323 | D | NRDI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility investigation, observation, and interview, the facility failed to ensure a safety device was in place for one (#4) of thirty-three residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, with severely impaired cognitive skills for daily decision making. Medical record review of the fall risk evaluation dated November 2, 2009, revealed the resident was at risk for falls. Medical record review of the nurse's note dated November 14, 2009, revealed, " ...Resident's self-release chair alarm is not working correctly ..." Medical record review of a physician's orders [REDACTED]. Review of the facility investigation dated November 15, 2009, revealed, "...found resident sitting in floor of BR (bathroom) (with) SR (self-release) belt off (no) injury ..." Medical record review of a physician's orders [REDACTED]. Observation on January 12, 2010, at 8:25 a.m., revealed the resident sitting in the wheelchair, in front of the nursing station, with a self release chair alarm in place. Interview on January 13, 2010, at 12:30 p.m., with the Director of Nursing, at the nursing station, confirmed the safety device was not in place at the time of the fall on November 15, 2009. | 2014-02-01 | ||
| 14277 | 14277 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2010-01-13 | 315 | D | NRDI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility policy, observation, and interview, the facility failed to complete a bladder training assessment for one (#20) of thirty-three residents reviewed. The findings included: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory problems, no long term memory problems, and moderately impaired cognitive skills for daily decision making. Medical record review of a physician's order dated October 20, 2009, revealed, "...D/C (discontinue) foley (catheter to drain bladder)...timed toileting program ... " Medical record review of the urinary incontinence questionnaire (undated) revealed, "...Bladder: Are you incontinent Occasionally..." Medical record review of the Assessment for Bowel and Bladder Training dated December 31, 2009, revealed, "...Mentally aware of toileting needs ...sometimes ...(total score of 14) ...7-14 Candidate for toileting, timed or scheduled voiding ... " Medical record review of a urinary incontinence assessment (undated) revealed, " ...Perform a 3 day Bladder Flow Record to assist with choice of Program ...scheduled toileting ...scheduled toileting at regular intervals on a planned basis to match the resident's voiding habits ..." Review of the facility policy, Guidelines to Assessment, revealed, "...complete the Assessment for Bowel and Bladder training if the resident is incontinent to determine if the resident is a candidate for individual training or timed/scheduled toileting...the resident will be placed in a bladder program appropriate for the resident ..." Observation on January 13, 2010, at 7:55 a.m., revealed the resident lying in the bed. Interview on January 13, 2010, at 12:30 p.m., with the Director of Nursing, at the nursing station, confirmed no documentation a three day voiding pattern had been completed. | 2014-02-01 | ||
| 14276 | 14276 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 514 | E | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, observation and interview, the facility failed to maintain complete documentation of fluid intake for five (#15, #23, #24, #27, #28,) of 29 sampled residents. The finding included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed physician's orders [REDACTED]. Observation in the resident's room, on January 25, 2010, at 10:30 a.m., revealed a posted sign indicating fluid restriction. Review of the facility's policy for fluid intake and output revealed that intake and output measurements are to be recorded for residents if there is a physician's orders [REDACTED]. Interview with the Director of Nursing on January 25, 2009, on the D Hall, confirmed the fluid intake records were incomplete. Resident #23 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Medical record review revealed physician's orders [REDACTED]. Review of the "Comprehensive Intake and Output Record" revealed incomplete documentation of fluid intake for sixty days from October 19, 2009, through December 28, 2009. Interview with the Director of Nursing on January 27, 2010, on the D Hall, confirmed the fluid intake records were incomplete. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Telephone Orders dated November 13, 2009, revealed an order to increase fluid restriction to 1500 ml per day. Medical record review of the Comprehensive Intake-Output Records revealed no documentation of the fluid intake from November 16, 2009, until December 1, 2009. Interview at the nurses' station on January 26, 2010, at 4:10 p.m., with the 200 Hall Unit Manager, revealed the "intake should be recorded each day," and verified there was no documentation of the the resident's intake for the 15 day period from November 16 - December 1, 2009. Continued interview confirmed the facility failed… | 2014-02-01 | ||
| 14275 | 14275 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 176 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for self-administration of medications for one (#6) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems and moderately impaired cognitive skills. Medical record review of the January 2010, physician's recapitulation orders revealed the resident was to receive [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) and Atrovent ([MEDICATION NAME][MEDICATION NAME]) by a nebulizer treatment. Medical record review revealed no documentation the resident had been assessed for self-administration of medications. Observation on January 25, 2010, at 9:00 a.m., revealed the resident lying on the bed, unattended, with a mask over the nose and mouth, receiving a nebulizer treatment. Continued observation revealed the resident used the left hand to try to remove the mask. Observation and interview on January 25, 2010, at 9:15 a.m., with Licensed Practical Nurse (LPN) #1 revealed the resident lying on the bed receiving the nebulizer treatment, and confirmed LPN #1 had initiated the nebulizer treatment then left the resident unattended. Interview on January 25, 2010, at 1:10 p.m., with the Director of Nursing, in the conference room, confirmed the resident had not been assessed for self-administration of medications. | 2014-02-01 | ||
| 14274 | 14274 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 323 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were functional or in the lowest position for three (#6, #13, #14) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, moderately impaired cognitive skills, required extensive assistance with transfers/ambulation, and had fallen in the past ,[DATE] days. Medical record review of the current Care Plan reviewed on [DATE], revealed "...Resident is at risk for falls...alarms to bed/chair..." Observation on [DATE], at 9:00 a.m., revealed the resident lying on the bed with a pressure pad alarm in place, however, the alarm box was not activated. Observation and interview, on [DATE], at 9:15 a.m., with Licensed Practical Nurse (LPN) #1 revealed the resident lying on the bed, with a pressure pad alarm in place, and confirmed the alarm was not turned on/activated. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, and moderately impaired cognitive skills for daily decision making. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the physician's recapitulation orders dated [DATE], revealed, " ...Pressure Alarm On When Resident in Bed... " Medical record review of the Care Plan dated [DATE], revealed, "...pp (pressure pad) alarm in bed..." Observation on [DATE], at 1:50 p.m., revealed the resident entered the bathroom and closed the door. Continued observation with RN #2 revealed a pressure pad alarm on the bed, but not sounding. Further observation of the pressure pad alarm revealed, " Six month t… | 2014-02-01 | ||
| 14273 | 14273 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 502 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain laboratory studies for three ( #1, #2, #10) of twenty-nine residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the January 2010 Physician's Recapitulation Orders revealed an order initiated June 30, 2009, for a lab study of CBC (Complete Blood Count) to be done every 6 months (June and December). Medical record review of the laboratory results revealed no documentation of the CBC analysis for December 2009. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the January 2010 Physician's Recapitulation Orders revealed an order initiated February 22, 2008, for a lab study of Hemoglobin A1C (to monitor diabetic therapy) to be done every 3 months (February/May/August/November). Medical record review of the laboratory results revealed no documentation of the Hemoglobin A1C analysis for November 2009. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the January 2010 Physician's Recapitulation Orders revealed an order for [REDACTED]. Interview with the Unit Manager at the 200 Hall Nurses station on January 25, 2010, at 1:25 p.m., confirmed the facility failed to obtain the laboratory studies for residents #1, #2, and #10 as ordered by the physician. | 2014-02-01 | ||
| 14272 | 14272 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 281 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to discontinue a medication as ordered by the physician for one (#6), and failed to ensure a fluid restriction was followed for one (#24) of twenty-nine residents reviewed. The Findings included: Resident #6 was admitted the facility on August 3, 2009, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems and moderately impaired cognitive skills. Medical record review of a physician's orders [REDACTED]. Observation on January 26, 2010, at 2:20 p.m., revealed the resident lying on the bed, receiving oxygen at two liters per minute via a nasal cannula. Interview with the resident, at the time of the observation, revealed the resident was not experiencing any pain. Interview on January 25, 2010, at 1:10 p.m., with the Director of Nursing, in the conference room, confirmed the [MEDICATION NAME] was not discontinued as ordered by the physician. Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]...1000 ML (milliliter) Fluid Restriction: Dietary to send 120 ML w/Ea (with each) meal...100 ML to be given at HS (bedtime) w/snack...Nursing to use 540 ML: 90 ML w/ea med pass (medication administration)." Medical record review of the Intake and Output Records dated September 1, 2009, through January 27, 2010, revealed "...12/9/09 24 HR. (hour) Total PO (by mouth) intake 1160...12/11/09 Total PO intake 1220...12/15/09 Total PO intake 1280...12/22/09 Total PO intake 1210...1/4/10 Total PO intake 1130...1/7/10 PO intake 220 plus 600 plus 240 Total 860 (Corrected total amount 1060)...1/19/10 Total PO intake 450 plus 870 Total 1020 (Corrected total amount 1320)...1/20/10 Total PO intake 1280...1/21/10 Total PO intake 1310...1/25/10 Total PO intake 1240..." Interview on January 27, 2010, at 12:45 p.… | 2014-02-01 | ||
| 14271 | 14271 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 508 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure an x-ray was completed for one (#6) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted the facility on August 3, 2009, with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated December 30, 2009, revealed "Resident noted to have very congested cough with thick yellow sputum...order obtained for chest x-ray..." Medical record review of a chest x-ray dated December 30, 2009, revealed "Impression:...probable left pleural effusion and left retrocardiac opacity that may represent atelectasis versus infiltrate." Medical record review of a physician's orders [REDACTED]." Medical record review revealed no documentation a repeat chest x-ray had been completed after December 30, 2009. Interview on January 25, 2010, at 2:25 p.m., with the Director of Nursing, in the conference room, confirmed the repeat chest x-ray ordered on December 30, 2009, was not completed. | 2014-02-01 | ||
| 14270 | 14270 | KINDRED NURSING AND REHABILITATION-SMITH COUNTY | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2010-10-19 | 226 | D | HD6911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, facility policy review, and interview, the facility failed to complete a timely and thorough investigation of an injury of unknow source for one resident (#6) of eleven residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had moderately impaired cognition but could answer simple yes/no questions; was independent with Activities of Daily Living (ADLs); was independent with eating, transfers, and ambulation. Medical record review of a nursing note dated February 15, 2010, revealed "Heard loud noise outside res. (resident's) door. Res. slamming both fists on side table." Continued medical record review of a nursing note dated February 23, 2010, revealed "Hitting at bed and stomping feet." Medical record review of a Behavior Monitoring Log dated July 25, 2010, revealed "Hitting self and furniture in room with hands. Laying down on bed; picking up legs with hands on thighs and slamming legs on bed. When standing up, pounding on sides and buttocks. Was told to stop - that behavior was not acceptable and could cause harm. Then resident sat down on bed; grabbed both inner thighs; and slammed legs down on bed." Medical record review of a nursing note dated July 31, 2010, revealed "Multiple bruises to bilateral thigh area. Bruises appear to be healing. Attempted to notify brother. Message left." Review of a facility event report dated July 31, 2010, revealed "...Injury of unknow source...Injury to self...hits self...circumstances unknown..bruise...bilateral thigh..." Continued review revealed the DON was unaware of the bruising since the DON had been out of town from July 31, to August 3, 2010, and scheduled a meeting with the resident's brother for August 3, 2010, to review concerns expressed by the brother. Continued review revealed during the me… | 2014-02-01 | ||
| 14269 | 14269 | KINDRED NURSING AND REHABILITATION-SMITH COUNTY | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2010-10-19 | 279 | D | HD6911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to develop a comprehensive care plan based on data from the Minimum Data Set for one resident (#6) of eleven residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had moderately impaired cognition but could answer simple yes/no questions; was independent with Activities of Daily Living (ADLs); was independent with eating, transfers, and ambulation. Medical record review of the current care plan, dated July 7, 2010 revealed the resident required extensive assistance with bathing and limited assistance with dressing. Interview with two random Certified Nursing Assistants on October 4, 2010, at 3:30 p.m., revealed the resident was independent with all ADLs and able to walk all about the facility. Interview with the DON on October 5, 2010, at 3:30 p.m., revealed the DON was unaware the care plan stated the resident needed extensive assistance and confirmed the resident was independent in all ADLs. COMPLAINT # | 2014-02-01 | ||
| 14268 | 14268 | KINDRED NURSING AND REHABILITATION-SMITH COUNTY | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2010-10-19 | 280 | D | HD6911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to revise the care plan to include essential information to provide care for one resident (#1) of eleven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was severely impaired cognitively; required two people for transfer; required extensive assistance with Activities of Daily Living (ADLs); was fed; and was incontinent of bowel and bladder. Medical record review of a nurse's note dated July 14, 2010, July 15, 2010, July 20, 2010, August 1, 2010, and August 3, 2010, revealed "...up in geri chair..." and "..at nurse's station..." Medical record review of a nursing note dated August 24, 2010, revealed "Called to room by CNA (Certified Nursing Assistant). Resident on floor on left side, facing away from window. Laceration to center of forehead. Blood pressure 220/119. Pressure alarm sounding." Continued medical record review revealed the resident was transferred to the hospital for evaluation and treatment. Medical record review of a hospital discharge summary dated August 26, 2010, revealed the resident suffered a "C1 (first cervical vertebra) impaction fracture with mild displacement of left lateral mass." Continued medical record review of the hospital discharge summary revealed "...did not feel (resident) was a candidate for any further treatment in terms of...fracture...did feel it would be best to keep (resident) in a collar as best (resident) can tolerate...however, if the collar did become uncomfortable or started to cause pressure sores, it could be discontinued with the understanding that (resident) could wind up with a catastrophic spinal cord injury..." Medical record review revealed the resident was readmitted to the facility on [DATE]. Medical record review of the current care plan updated September 9, 2010, r… | 2014-02-01 | ||
| 14267 | 14267 | KINDRED NURSING AND REHABILITATION-SMITH COUNTY | 445172 | 112 HEALTH CARE DR | CARTHAGE | TN | 37030 | 2010-10-19 | 323 | G | HD6911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, observation, and interview, the facility failed to provide supervision and/or ensure safety devices were in place for two residents (#1 and #5) of eleven residents reviewed. The facility's failure resulted in harm to resident #1. 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 was severely impaired cognitively; required two people for transfer; required extensive assistance with Activities of Daily Living (ADLs); was fed; and was incontinent of bowel and bladder. Medical record review of a nurse's note dated August 24, 2010, revealed "Called to room by CNA (Certified Nursing Assistant). Resident on floor on left side, facing away from window. Laceration to center of forehead. Blood pressure 220/119. Pressure alarm sounding." Continued medical record review revealed the resident was transferred to the hospital for evaluation and treatment. Medical record review of a hospital discharge summary dated August 26, 2010, revealed the resident suffered a "C1 (first cervical vertebra) impaction fracture with mild displacement of left lateral mass." Continued medical record review of the hospital discharge summary revealed "...did not feel (resident) was a candidate for any further treatment in terms of...fracture...did feel it would be best to keep (resident) in a collar as best (resident) can tolerate...however, if the collar did become uncomfortable or started to cause pressure sores, it could be discontinued with the understanding that (resident) could wind up with a catastrophic spinal cord injury..." Medical record review revealed the resident was readmitted to the facility on [DATE]. Review of the facility investigation dated August 24, 2010, revealed an untimed interview with CNA #1 on August 24, 2010, "went into the room to get tray, res… | 2014-02-01 | ||
| 14266 | 14266 | NHC HEALTHCARE, COOKEVILLE | 445110 | 815 SOUTH WALNUT AVENUE | COOKEVILLE | TN | 38501 | 2010-05-26 | 323 | D | F3R311 | **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 alarm was in place for one resident (#3) of twenty-one residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory problems, moderately impaired cognitive skills for daily decision making, and required assistance with most activities of daily living. Medical record review of a Falls Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the Care Plan dated March 25, 2010, revealed "...alarms after supper to remind me to call for help..." Medical record review of a Post Falls Nursing assessment dated [DATE], 8:00 p.m., revealed "...Patient was found sitting on floor with call light in hand by bedside...was reaching for lotion on the bedside table when...slipped from bed to floor..." Review of a facility fall investigation form dated May 17, 2010, revealed "...no alarms on when the incident occurred..." Observation on May 24, 2010, at 8:15 p.m. revealed the resident in bed, the bed in the lowest position, pressure pad alarm on the bed and activated. Interview with LPN (Licensed Practical Nurse) #1, on May 26, 2010, at 10:25 a.m., confirmed the resident did not have the pressure pad alarm in place at the time of the fall on May 17, 2010. | 2014-02-01 | ||
| 14265 | 14265 | NHC HEALTHCARE, COOKEVILLE | 445110 | 815 SOUTH WALNUT AVENUE | COOKEVILLE | TN | 38501 | 2010-05-26 | 176 | D | F3R311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure assessment for self-administration of medications was completed for one resident (#10) of twenty-one residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation of a medication pass on May 24, 2010, at 8:20 p.m., with RN #1 (Registered Nurse), revealed the RN entered the resident's room and administered oral medications to the resident, applied an ointment to the resident's cheeks, and left a plastic medicine cup with [MEDICATION NAME] cream 0.01% setting on the resident's over bed table. Interview with RN #1 on May 24, 2010, at 8:40 p.m., on the 200 hall confirmed the [MEDICATION NAME] cream was left on the resident's over bed table for the resident to self-administer when ready. Interview with the Director of Nursing on May 24, 2010, at 9:05 p.m., at the 200 hall nursing station, confirmed the resident had not been assessed for self-administration of medications and medications were not to be left in the resident's room. | 2014-02-01 | ||
| 14264 | 14264 | NHC HEALTHCARE, COOKEVILLE | 445110 | 815 SOUTH WALNUT AVENUE | COOKEVILLE | TN | 38501 | 2010-05-26 | 157 | D | F3R311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and interview, the facility failed to notify the physician of low finger stick blood sugar (FSBS) levels and/or high FSBS for three residents (#2, #13, #10) of twenty-one sampled residents. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders For April and May of 2010, revealed, "...FSBS AC (before meals) and HS (at bedtime) ...Sliding scale insulin with [MEDICATION NAME] SQ (subcutaneous injection) as follows: 400=12 units and call MD..." Medical record review of the Diabetic Monitoring Log revealed the resident had a FSBS of 44 on April 10, 2010, at 5:30 p.m., a FSBS of 56 on April 11, 2010, at 7:00 a.m., a FSBS of 55 on April 11, 2010, at 5:30 p.m., a FSBS of 54 on April 12, 2010, at 5:30 p.m., and a FSBS of 54 on May 1, 2010 at 11:00 a.m. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders for April and May of 2010, revealed "...FSBS AC (before meals) and HS (at bedtime) ...Sliding scale insulin with [MEDICATION NAME] SQ (subcutaneous injection) as follows: 400=12 units and call MD...". Medical record review of the Diabetic Monitoring Log revealed the resident had a FSBS of 42 on April 2, 2010, at 4:20 a.m., a FSBS of 44 on April 8, 2010, at 1:20 a.m., and a FSBS of 56 on April 22, 2010, at 7:00 a.m. Review of facility policy Insulin Administration revealed "...5. Physician to be notified of blood sugars below 60 or above 200 unless there is a specific order addressing blood sugars outside these ranges or directing otherwise..." Interview with the DON (Director Of Nursing) in the DON office on May 25, 2010, at 3:00 p.m., confirmed the facility had failed to notify the physician of the low blood sugars. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. … | 2014-02-01 | ||
| 14263 | 14263 | NHC HEALTHCARE, COOKEVILLE | 445110 | 815 SOUTH WALNUT AVENUE | COOKEVILLE | TN | 38501 | 2010-05-26 | 246 | D | F3R311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to place the call light within reach for three residents (#16, #17, #18) of twenty-one residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated May 22, 2010, revealed "Risk for Falls" and "keep call light within my reach." Observation on May 24, 2010, at 6:10 p.m., revealed the resident in bed with the call light draped over a reclining chair near the bed and out of reach of the resident. Interview with the Director of Nursing on May 26, 2010, at 9:15 a.m., in the Administrator's office confirmed the call light is to be within reach of the resident. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated March 1, 2010, revealed "ADL's" (activities of daily living) and "Please keep my call light within my reach." Observation on May 24, 2010, at 6:15 p.m., revealed the resident in bed with the call light cord draped across the foot board of the bed and out of the resident's reach. Continued interview with the resident revealed the resident was unable to reach the cord and ask the surveyor to please move the cord near the resident's left side. Interview with the Director of Nursing on May 26, 2010, at 9:15 a.m., in the Administrator's office confirmed the call light is to be positioned within reach of the resident. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated February 24, 2010, revealed "ADL's" and "please keep call light within my reach." Observation on May 24, 2010, at 6:20 p.m., revealed the resident in bed with the call light cord draped across the foot board of the bed and out of the resident's reach. Interview with the Director of Nursing on May 26, 2010, at 9:15 a.m… | 2014-02-01 | ||
| 14262 | 14262 | NHC HEALTHCARE, COOKEVILLE | 445110 | 815 SOUTH WALNUT AVENUE | COOKEVILLE | TN | 38501 | 2010-05-26 | 431 | D | F3R311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure medications were dated when opened and failed to ensure expired biologicals were not available for resident use for one of four medication carts and one of two medication rooms. The findings included: Observation of the medication cart on the 300 hall on [DATE], at 8:00 a.m., with LPN #1 (Licensed Practical Nurse) revealed a drawer containing the following multiple stock medications, not dated when opened: Aspirin 325 mg 125 tablets, ,[DATE] full; Colace Stool Softener 100 tablets, ,[DATE] full; Tussin DM Sugar Free Cough medicine 4 ounces, ,[DATE] full; Aspirin 325 mg 100 tablets, ? full; Enulose one pint, ,[DATE] full; Pepto 8 ounces, ? full; Liquid Acetaminophen 16 ounces more than ? full; Docusate 16 ounces, more than ? full. Observation of a drawer on the cart revealed a glucometer kit (to check blood sugar) containing glucometer strips with an expiration date of March, 2010, and dated as opened [DATE]. Interview with LPN #1 on [DATE], at 8:00 a.m., on the 300 hall confirmed the stock medications had not been dated when opened and the glucometer strips were expired and had been used for a resident's blood sugar checks. Observation of the medication room on the 300 and 400 hall on [DATE], at 8:15 a.m., revealed the following expired biologicals and undated medications: Glucometer strips with an expiration date of March, 2010; Stomahesive (for ostomy bag changes) one ounce expired September, 2009; Hemoccult (to check for blood in stool) 15 mL expired March, 2009; and, in the refrigerator, one Humulin-R insulin ? full, not dated when opened. Interview with the wound care nurse on [DATE], at 8:15 a.m., in the 300 and 400 hall medication room, confirmed the biologicals had expired and were available for resident use. Interview with the Director of Nursing (DON) on [DATE], at 8:20 a.m., in the 300 and 400 hall medication room, confirmed the insulin had not been dated when opened… | 2014-02-01 |
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CREATE TABLE [cms_TN] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );