CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1451 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 160 | D | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 51 sampled records related to residents' personal funds accounts, it was determined that facility staff failed to convey funds within 30 days of the death of two (2) residents. Residents' #T1 and #T2. The findings include: 1. Facility staff failed to convey funds within 30 days of the death of Resident #T1. A personal funds account review was conducted on [DATE] at approximately 3:00 PM with Employee #29 and the following was identified: The Resident's Fund Management Service Status Change Form revealed that the resident expired on [DATE]. The Resident's Fund Management Service: Closed Account Summary form from: [DATE] to [DATE] revealed that the account was closed on [DATE]. The check payable to the (relative ' s name) in the amount of $37.00 was dated February 21, 2014. A face-to-face interview was conducted on [DATE] at approximately 3:00 PM with Employee #29. A query was made regarding the delay in closing and conveying the resident ' s funds to the relative. Employee #29 stated that the delay was due to the fact that the (deceased ) resident ' s (relative) could not be found. We (facility) had to go through another family member. Facility staff failed to convey funds within 30 days of the resident's death. 2. Facility staff failed to convey funds within 30 days of the death of Resident #T2. A review of the Resident's Fund Management Service Status Change Form revealed that the resident expired on [DATE]. The Resident's Fund Management Service: Closed Account Summary form from: [DATE] to [DATE] revealed that the account was closed on [DATE]. However, the check payable to the (relative ' s name) in the amount of $70.03 was dated February 18, 2014. A face-to-face interview was conducted on [DATE] at approximately 3:00 PM with Employee #29. A query was made regarding the delay in closing and conveying the resident ' s funds to the relative. Employee #29 stated that the delay was due to a delay in processing of the paper work. Facility staff failed to convey the resident's funds within 30 days of the death residents death. | 2017-02-01 |
| 1452 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 164 | D | 0 | 1 | 0SN511 | Based on observations and interview for one (1) of 51 sampled residents, it was determined that facility staff failed to provide privacy during toileting of a resident as evidenced by an observation of one (1) resident who was exposed from his/her head to his/her groin area while using the urinal in his/her room with the door open and in plain view of passersby for Resident #1. The findings include: Facility staff failed to provide privacy to Resident #1 who was observed exposed from (his/her) head to (his/her) groin area while using the urinal in (his/her) room with the door open and in plain view of staff, other residents and visitors who passed by the room. On April 17, 2014 at approximately 10:18 AM, Resident #1 was observed exposed from (his/her) head to (his/her) groin area. He/she had a clear colored urinal in (his/her) left hand at his/her groin area. The door to the room was open. The surveyor was standing in the hallway when the observation was made. Employee #39 was approximately four feet from the resident ' s room door, acknowledged the finding and closed the door to the room. There was no evidence that facility staff provided privacy to Resident #1 when (he/she) was observed using a urinal in (his/her) room with the door open and in plain view of staff, other residents and visitors. The observation was made on April 17, 2014. | 2017-02-01 |
| 1453 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 166 | D | 0 | 1 | 0SN511 | Based on record review and staff interview for one (1) of 51 sampled residents, it was determined that facility staff failed to resolve a grievance for Resident #174 ' s allegation of physical abuse. The findings include: The Resident/Family Communication Tool Concern form initiated on February 24, 2014 at 11:30 PM by the facility staff on behalf of Resident #174 revealed: Resident Name and Room Number: (Resident ' s name and room number); Detailed Information: February 27, 2014- 10:40 PM- (Registered Nurse) was notified by (evening charge nurse named) that the resident reported that (he/she) was smacked on (his/her) face by (his/her) CNA (Certified Nursing Assistant) 15 minutes ago. . It was observed that resident ' s right side of eye sclera was reddish with minimal watery drainage. No swelling noted to external upper/lower eyelids. No visible skin discoloration nor any swelling noted to (his/her) face, mouth and nose. (He/she) denied any pain . (Named physician) was notified of resident ' s right eye redness, (neurological) checks ordered. Medical team to follow up in AM (morning). (Resident ' s responsible party named) was also notified by phone. The back of the Resident/Family Communication Tool Concern form revealed, Describe action taken to address concern: Copy provided to Clinical Manager (unit named) to follow-up. Signed :(evening supervisor's signature ); Concern Resolved- space left blank ; Dated Resolved- Blank; Reviewed by (space for Administrator ' s signature): was left blank; Date; was left blank. According to the Facility ' s Policy and Procedure, Family/Resident Communication Tool revised October 2010 stipulates: (#) 9. The Department Director/Manager or designee receiving the concern will contact the writer of the Family/Resident Communication Tool by telephone, within five (5) business days with a response and/or resolution. 10. It is the responsibility of the Department Director/Manager or designee to document on the Family/Resident Communication Tool the date, time and spoken to in regards to the concern, and (#11) The Family/Resident Communication Tool will contain documentation of the response/resolution including the action steps and/or follow-up taken to address the concern and the staff members involved. At the time of this review, there was no evidence that facility staff ensured that a prompt effort was made to resolve the grievance for Resident #174 for two (2) months. A face-to-face interview was conducted with Employee #2 on April 18, 2014 at approximately 11:21 AM. He/she stated that (he/she) talked to the employee regarding the incident. The employee further stated, that human resources intervened in the matter. However, the communication/concern form lacked evidence that an internal investigation was conducted. When queried if (he/she) and the administrator had signed the form to indicate that the concern was resolved. He/she stated, This is not the original .let me get the original form. A follow-up interview was conducted with Employees #1 and #2 on April 21, 2014 at approximately 11:30 AM. Both employees stated that the concern form did not come down to the administrator, and further stated, It (the concern form) was found in Employee #25 ' s office. Facility staff failed to resolve a grievance for Resident #174 ' s allegation of physical abuse in a timely manner. The record was reviewed on April 21, 2014. | 2017-02-01 |
| 1454 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 176 | D | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interview for two (2) of 51 sampled residents, it was determined that facility staff failed to ensure that the residents medications were properly stored and the residents were monitored for self administration of medications. Residents ' #136 and #300. The findings include: Review of the facility ' s policy Self Administration of Medication, Revised 01/11 stipulates; Policy: Residents who desire to exercise their right to self-administer their medications are assessed by the interdisciplinary care plan team to be appropriate; An initial assessment is conducted followed by a quarterly reassessment, with a change in condition and more frequently as indicated. Procedure: The attending physician must write an order that the medications may be kept in the resident ' s room, the licensed nurses must monitor the use of medications and maintain documentation in the medical record, the licensed nurses must instruct the resident of proper use of medications including what the medication is for, how it is used, (and) how often the medication is used. This information will be documented in the resident ' s medical record. 1. Facility staff failed to ensure medications for Resident #136 could be kept in his/her room and that he/she could self administer his/her own eye drops and shampoo. During a resident interview conducted on April 15, 2014 at approximately 10:15 AM, it was observed that the resident had eye drops and baby shampoo on the over bed table. A query was made to the resident regarding the medication on the table and if (he/she) is allowed to administer (his/her) own eye drops and shampoo. The resident stated yes, this is my medication, I have to give myself eye drops for eye irritation, I give myself my own eye drops, and I use the shampoo too. The Interim Order Form dated and signed March 24, 2014, it directed, .(1) warm compression x (times) 5 minutes; (2) clean eye lash area with 3 (three) drops baby shampoo in 1 oz (ounce) H2O (water), Apply with cotton ball 15 sec (seconds) side-to-side, rinse with water daily. Patient may do by (himself/herself) under supervision. The Physicians ' Order Sheet signed and dated by the physician on April 7, 2014 directed, warm compression x (times) 5 minutes to eyes daily. Clean eye lash area with 3 drops baby shampoo in 1 oz (ounce) of H2O (water). Apply with cotton ball 15 sec (seconds) side-to-side. Rinse with water daily. Patient may do by (himself/herself) under supervision. There was no evidence in the physicians ' orders that the resident could keep the medications in his/her room and that the resident could administer his/her eye drops and shampoo without supervision. A review of the Medication Administration Records (MAR ' s) for April 2014 revealed that the resident received the above order on April 4, 7, 9, 11, 14, 16, 18, and 21. A face-to-face interview was conducted on April 15, 2014 at approximately 11:00 AM with Employees #5 and #30. A query was made regarding the medications observed on the residents over the bedside table, and if the resident is allowed to administer his/her own medications. Employee #30 stated, The resident does not have medications in (his/her) room, the medications are in the medication cart. Employee #30 proceeded to the residents ' room, and acknowledged that the eye drops and baby shampoo were on the resident's table. Employee #5 stated, The resident is very independent and involved in his/her care. The resident will make (his/her) own doctor's appointment and get (his/her) own prescriptions filled without the staff knowing sometimes. There was no evidence that the physician or the interdisciplinary team had determined that the resident had the ability to self-administer medication(s) keep the medications at the bedside. 2. Facility staff failed to ensure that Resident #300 ' s medication was properly stored and that the resident was monitored for self administration of medications. The Interim Order Form dated and signed March 12, 2014 directed, Mosapride 5mg, 1 (one) (tablet) po (by mouth) four (4) times daily as needed [MEDICAL CONDITION]([MEDICAL CONDITION] reflux syndrome) - (patient can take (his/her) own Mosapride). Resident # 300 ' s physician's order [REDACTED]. (Patient can take her own Mosapride); [MEDICATION NAME] Severe (Preservative Free) P/F, (Sterile) 0.3% Gel (Gms)- Instill two (2) drops in each eye every 6 hours as needed for dry eyes *Patient May Administer*. A review of the MAR for April 2014 lacked evidence that the resident had taken or received the Mosapride 5mg by mouth as needed for his/[MEDICAL CONDITION] the [MEDICATION NAME] Severe eye drops in accordance with the physician's order [REDACTED]. A face-to-face interview was conducted on April 22, 2014 at approximately 12:00 Noon with Resident #300 in the presence of Employee #7. The eye drop medication was observed in a small basket which was sitting on top of the resident's over-the-bed table. At this time the resident was queried about the eye drops and [MEDICAL CONDITION]. He/she stated, Yes, I take my own medication for my GERD. I also administer my own eye drops/gel for my dry eyes. I have taken my medication for my reflux about three (3) times since being admitted . I use my eye drop medication several times a day. The resident further stated that he/she keeps his/her reflux medication with his/her personal items. There was no evidence that the attending physician wrote an order for [REDACTED]. A follow-up face-to-face interview was conducted with Employees #7 and #26 on April 22, 2014 at approximately 12:30 PM. The employees stated, (Resident #300) self administers (his/her) eye drops and takes (his/her) medication for GERD. When queried about the communication from the resident regarding the frequency (he/she) takes the medications the employees responded, (He/she/) usually informs the nurses when (he/she) self administers the medication. The observation occurred on April 22, 2014. The clinical record was reviewed on April 22, 2014. | 2017-02-01 |
| 1455 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 221 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview for eight (8) of 51 sampled residents, it was determined that facility staff failed to ensure residents were free from physical restraints as evidenced by: eight (8) residents who were observed seated in mobility aids merry walkers and were unable to self release and exit at will. Residents' #26, 43, 95, 102, 106, 118, 183 and 177. The findings include: According to the Code of Federal Regulations 483.13 (a) Restraints- Definition of Terms stipulates; An enclosed framed wheeled walker, with or without a posterior seat, would not meet the definition of a restraint if the resident could easily open the front gate and exit the device. If the resident cannot open the front gate (due to cognitive or physical limitations that prevent him or her from exiting the device or because the device has been altered to prevent the resident from exiting the device), the enclosed framed wheeled walker would meet the definition of a restraint since the device would restrict the resident ' s freedom of movement. The Facility's Policy and Procedure No.TX- .11 - Restraints Physical: effective 04/11 and revised 10/11 stipulated the following: If the IDT (Interdisciplinary Team) determines a physical restraint is needed for a resident an assessment must be completed prior to placement of the resident, quarterly, and with any significant change. Any resident requiring the use of a restraint, as determined by the IDT, must have a restraint reduction assessment completed quarterly and /or with a significant change . Procedure: Steps for Assessment 1. Consult with the IDT to determine the resident ' s cognitive and physical limitations. 2. Review the resident ' s medical record. 3. Review the definition of restraint: focus on the effect the device will have on the resident, not the type of device. 4. If the device meets the definition of a restraint complete the following as applicable. a. Pre-restraining Assessment (complete as initial assessment only) b. Side Rail Assessment (complete quarterly and/or with significant change) c. Merry walker Ambulation Assessment (complete quarterly and/or with significant change) d. Physical Restraint Elimination (complete quarterly and/or with significant change) 5. If the IDT determines a physical restraint is needed , ensure the following steps: a. Notify the resident and/or responsible party b. Physician must document a medical symptom that supports the use of a restraint c. Obtain a physician order [REDACTED]. d. Initiate a care plan that includes a process of gradual restraint reduction and/or elimination as appropriate. e. Assess that the restraint used is the least restrictive, to meet the resident ' s current needs. 6. As part of the IDT care plan the Physical Restraint Elimination Assessment must be completed quarterly and at the time of significant change. 1.Facility staff failed to ensure that Resident #95 was free from physical restraints. Resident #95 was observed seated in a merry walker in the dining room area on unit 2A, with a self-release front arm cross bar, covered by a lap tray at approximately 11:30 AM on April 17, 2014. The resident did not respond to a query from the surveyor to remove the lap tray and self-release bar to exit the merry walker. A review of the physician's orders [REDACTED]. Patient to have lap-tray on merry walker whenever patient is in merry walker. A review of the Quarterly MDS (Minimum Data Set) of Resident #95 dated January 24, 2014 revealed that Section G (Functional Status) coded as total dependent for bed mobility, and extensive assistance for transfer, walking in room, corridor and locomotion on unit. Balance during transitions, and walking was coded as not steady, only able to stabilize with staff assistance, Section I (Active Diagnoses) lists, Non-Alzheimer ' s and Dementia, and Section P (Restraints) was coded as no restraints being used. A face-to-face interview was conducted with Employee #4 on April 17, 2014 at approximately 11:45AM. He/she was queried regarding Resident # 95 ' s ability to exit the merry walker at will. Employee #4 stated, No, he/she can ' t release the bar or remove the lap tray, however the merry walker is used to provide dignity and to keep him/her from falling. This was implemented by (the) Rehab (Rehabilitation) Department. A face-to-face interview was conducted with Employee #10 on April 17, 2014 at approximately 12:00 PM. When queried regarding Resident #95 ' s use of the merry walker. He/she stated, Resident #95 has been using the merry walker for years, as a safety measure to prevent falls. Upon further query regarding the last time the resident was assessed regarding his/her cognitive ability to remove the bar and lift the lap tray, Employee #10 stated, The Occupational Therapist recommended and implemented the lap tray. Resident #95 can't be taught how to remove (the) bar to self-release the bar or (the) lap tray. When queried if the resident has been assessed or evaluated for least restrictive device the Employee #10 replied, No, the merry walker is not a restraint. Employee #10 stated, merry walkers are recommended for residents with falls as a safety measure to prevent injuries. A face-to-face interview was conducted with Employee #11 on April 17, 2014 at approximately 2:30 PM. When queried regarding Resident # 95 ' s ability to remove the lap tray, and exit the merry walker at will. Employee #11 stated, I observed Resident #95 lying with his/her head on his /her arms across the safety bar. Employee #11 further stated, The lap-tray was recommended and implemented to assist with better positioning and comfort. When queried regarding Resident # 95 ' s ability to be taught to remove the safety bar and lap-tray at will, the employee stated, No . The clinical record lacked evidence that the medical team identified a symptom for the use of the merry walker, and there was no evidence that the interdisciplinary team followed a systematic process for evaluation, and care planning prior to and/or after the use of the merry walker. There was no evidence that the facility staff completed quarterly merry walker ambulation assessments, documented medical symptoms or obtained parameters that supports its use, initiated care plans to include a process of gradual restraint reduction and/or elimination as appropriate, or assessed that the restraint use is the least restrictive, to meet the resident ' s current needs. A face-to-face interview was conducted with Employee #4 on April 17, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. The record was reviewed on April 17, 2014. Facility staff failed to ensure that Resident #95 was free from physical restraints. 2. Facility staff failed to ensure that Resident #26 was free from physical restraints. Resident #26 was observed seated in a merry walker in a dining room on unit 2A with a self-release front arm cross bar at approximately 2:30 PM on April 21, 2014. A face-to-face interview was conducted with Employee #4 immediately after the observation on April 21, 2014. A query was made to determine if the resident could self-release his/her front arm cross bar at will. Employee #4 stated, None of the residents in merry walkers on this unit can self release and exit at will, because of their dementia. The physician's orders [REDACTED]. A review of the Quarterly MDS (Minimum Data Set) of Resident #26 dated March 7, 2014 revealed that Section G (Functional Status) coded as extensive assistance for bed mobility and transfer, and limited assistance for walking in room, corridor, and locomotion on and off unit. Section I (Active Diagnoses) lists Non-Alzheimer ' s and Dementia, Section P (Restraints) was coded as restraints being used daily. There was no evidence that the medical team identified a symptom for the use of the merry walker and there was no evidence that the interdisciplinary team followed a systematic process for evaluation and care planning prior to and/or after the use of the merry walker. There was no evidence that the resident was able to voluntarily release the cross bar latch. There was no evidence that the facility staff completed quarterly merry walker ambulation assessments, documented medical symptoms, obtained parameters that supports its use, initiated care plans to includes a process of gradual restraint reduction and /or elimination as appropriate, or assessed that the restraint use is the least restrictive, to meet the resident ' s current needs. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. The Medical Record was reviewed on April 21, 2014. Facility staff failed to ensure that Resident #26 was free from physical restraints. 3. Facility staff failed to ensure that Resident #43 was free from physical restraints. Resident #43 was observed seated in a merry walker in an open day room area on unit 2A with a self-release front arm cross bar at approximately 2:30 PM on April 21, 2014. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 2:45 PM. A query was made to determine if the resident could self-release his/her front arm cross bar at will. Employee #4 stated, No A review of a physician's orders [REDACTED]. A review of the Quarterly MDS (Minimum Data Set) of Resident #43 dated March 7,2014 revealed that Section G (Functional Status) was coded as supervision needed for bed mobility, transfer, walking in room and corridor and locomotion on unit with limited assistance with locomotion off unit. Section I (Active Diagnoses) lists, Non-Alzheimer ' s and Dementia, and Section P (Restraints) was coded as restraints being used daily. There was no evidence that the medical team identified a symptom for the use of the merry walker and there was no evidence that the interdisciplinary team followed a systematic process for evaluation and care planning prior to and/or after the use of the merry walker. There was no evidence that the facility staff completed quarterly merry walker ambulation assessments, documented medical symptoms or obtained parameters that supports its use, initiated care plans to includes a process of gradual restraint reduction and /or elimination as appropriate, or assessed that the restraint use is the least restrictive, to meet the resident ' s current needs. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. Facility staff failed to ensure that Resident #43 was free from physical restraints. 4. Facility staff failed to ensure that Resident #102 was free from physical restraints. Resident # 102 was observed seated in a merry walker in the day room area on the unit 2A with a self-release front arm cross bar at approximately 2:30 PM on April 21, 2014. A review of the Physician order [REDACTED]. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 2:45 PM. A query was made to determine if the resident could self-release his/her front arm cross bar at will. Employee #4 stated, No . There was no evidence that the medical team identified a symptom for the use of the merry walker and there was no evidence that the interdisciplinary team followed a systematic process for evaluation and care planning prior to and/or after the use of the merry walker. A review of the Quarterly MDS (Minimum Data Set) of Resident #102 dated January 24, 2014 revealed that Section G (Functional Status) was coded as extensive assistance for, bed mobility and for transfer, and limited assistance for walking in room, corridor, locomotion on unit and extensive assistance with locomotion off unit. Section I (Active Diagnoses) lists, Non-Alzheimer ' s and Dementia. Section P (Restraints) was coded as no restraints being used. There was no evidence that the facility staff completed quarterly merry walker ambulation assessments, documented medical symptoms or obtained parameters that supports its use, initiated care plans to includes a process of gradual restraint reduction and /or elimination as appropriate, or assessed that the restraint use is the least restrictive, to meet the resident ' s current needs. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. Facility staff failed to ensure Resident #102 free from physical restraints. The medical record was reviewed on April 22, 2014. 5. Facility staff failed to ensure that Resident #106 was free from physical restraints. Resident # 106 was observed seated in a merry walker in an open day room area on the unit 2A with a self-release front arm cross bar at approximately 2:30 PM on April 21, 2014. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 2:45 PM. A query was made to determine the Resident #106 could self-release his/her front arm cross bar at will. Employee #4 stated, No . A review of the Physician order [REDACTED]. A review of the Quarterly MDS (Minimum Data Set) of Resident #106 dated February 10,2014 revealed that Section G (Functional Status) was coded as extensive assistance for bed mobility and transfer, and limited assistance for walking in room, corridor, and locomotion on unit. Section I (Active Diagnoses) lists, Non-Alzheimer ' s and Dementia, and Section P (Restraints) was coded as restraints being used daily. There was no evidence that the medical team identified a symptom for the use of the merry walker and there was no evidence that the interdisciplinary team followed a systematic process for evaluation and care planning prior to and/or after the use of the merry walker. There was no evidence that the facility staff completed quarterly merry walker ambulation assessments, documented medical symptoms or obtained parameters that supports its use, initiated care plans to includes a process of gradual restraint reduction and /or elimination as appropriate, or assessed that the restraint use is the least restrictive, to meet the resident ' s current needs. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. Facility staff failed to ensure Resident #106 free from physical restraints. The Medical Record was reviewed on April 21, 2014. 6. Facility staff failed to ensure that Resident #118 was free from physical restraints. Resident # 118 was observed seated in a merry walker in an open day room area on the unit 2A with a self-release front arm cross bar at approximately 2:30 PM on April 21, 2014. A face- to- face interview was conducted with Employee #4 on April 21, 2014 at approximately 2:45 PM. A query was made to determine if Resident # 118 could self-release his/her front arm cross bar at will. Employee #4 stated, No A review of a physician's orders [REDACTED].>A review of the Quarterly MDS (Minimum Data Set) of Resident #118 dated March 27, 2014 revealed that Section G (Functional Status) was coded as extensive assistance for bed mobility, transfer, and limited assistance for walking in room, corridor, and locomotion on unit. Section I (Active Diagnoses) lists Non-Alzheimer ' s and Dementia, Section P (Restraints) was coded as restraints being used daily. There was no evidence that the medical team identified a symptom for the use of the merry walker and there was no evidence that the interdisciplinary team followed a systematic process for evaluation and care planning prior to and/or after the use of the merry walker. There was no evidence that the facility staff completed quarterly merry walker ambulation assessments, documented medical symptoms or obtained parameters that supports its use, initiated care plans to includes a process of gradual restraint reduction and /or elimination as appropriate, or assessed that the restraint use is the least restrictive, to meet the resident ' s current needs. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. Facility staff failed to ensure that Resident #118 was free from physical restraints. The Medical Record was reviewed on April 21, 2014. 7. Facility staff failed to ensure that Resident #183 was free from physical restraints. Resident #183 was observed seated in a merry walker in the day room area on the unit 2A with a self-release front arm cross bar at approximately 2:30 PM on April 21, 2014. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 2:45 PM. A query was made to determine if Resident # 183 could self-release his/her front arm cross bar at will Employee #4 stated, No . A review of the Physician order [REDACTED]. A review of the Quarterly MDS (Minimum Data Set) of Resident #183 dated January 18, 2014 revealed, Section G (Functional Status) was coded as extensive assistance for bed mobility, limited assistance for transfer, walking in room, corridor and locomotion on unit. Section I (Active Diagnoses) lists Non-Alzheimer ' s and Dementia, and Section P (Restraints) was coded as restraints being used daily. There was no evidence that the medical team identified a symptom for the use of the merry walker and there was no evidence that the interdisciplinary team followed a systematic process for evaluation and care planning prior to and/or after the use of the merry walker. There was no evidence that the facility staff completed quarterly merry walker ambulation assessments, documented medical symptoms or obtained parameters that supports its use, initiated care plans to includes a process of gradual restraint reduction and /or elimination as appropriate, or assessed that the restraint use is the least restrictive, to meet the resident ' s current needs. A face-to-face interview was conducted with Employee #4 on April 21, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. Facility staff failed to ensure that Resident #183 was free from physical restraints. The Medical Record was reviewed on April 21, 2014. 8. Facility staff failed to ensure that Resident #177 was free from physical restraints. Resident #177 was observed from April 17, 2014 at approximately 10:30 AM and on April 22, 2014 at approximately 9:45 AM on unit 1A in the common area, sitting in merry walker in with a self-release latch front arm cross bar. A face-to-face interview was conducted with Resident #177 on April 22, 2014 at approximately 9:45 AM. Resident #177 was asked if he/she could remove him/herself from the device (merry walker). The Resident replied, I have been trying to get out of this (placing his/her hands on the self-release bar and pulling on it) but I can ' t. A face-to-face interview was conducted with Employee #3 on April 22, 2014 at approximately 10:55 AM. A query was made to determine if the resident could self-release and Employee #3 stated, The resident was not able to self- release from merry walker . A review of Section G, Functional Status of the Quarterly MDS (Minimum Data Set) dated January 24, 2014 revealed Resident #177 was coded as total dependent for bed mobility and required extensive assistance for transfers. Section P (Restraints) was coded as no restraints being used A review of a physician's interim orders and Physician order [REDACTED]. There was no evidence that the resident could remove or release him/her self from the merry walker at will. There was no evidence that medical team identified a symptom for the use of the merry walker; and there was no evidence that the interdisciplinary team followed a systematic process for evaluation and care planning prior to and/or after the use of the merry walker. A face-to-face interview was conducted with Employee #4 on April 22, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. The medical record was reviewed on April 22, 2014. Facility staff failed to ensure Resident #177 free from physical restraints. | 2017-02-01 |
| 1456 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 226 | D | 0 | 1 | 0SN511 | Based on resident interview and record review for two (2) of 51 sampled residents, it was determined that facility staff failed to report allegations of verbal abuse and misappropriation of property for one (1) resident and an allegation of mistreatment for one (1) resident. Residents #6 and 28. The findings include: Facility staff failed to report an allegation of staff to resident verbal abuse and possible misappropriation of property (items not specified). During a resident interview conducted on April 17, 2014 at 2:00 pm with Resident #6, he/she stated I had two (2) legitimate complaints about two (2) CNA ' s (Certified Nurse ' s Assistant). A. The first complaint involved a CNA that had been accused of stealing by other people. I saw (him/her) go into my cabinet when (he/she) thought I was asleep. That employee was suspended and brought back and I agreed to let (him/her) work with me again. The resident did not specify the date of alleged occurrence. A review of the facility ' s Disciplinary Action Form revealed that Employee #23 was suspended on December 4, 2013 and returned to duty, allegations were not confirmed. A face-to-face interview was conducted on April 18, 2014 at 11:00 AM with Employees #1, 2 and 12. A query was made regarding the above incident. Employee #1 stated the incident was investigated and not substantiated. B. Resident #6 alleged that a CNA would yell and be moody and snappy at times. Talking with him/her (the CNA) was not effective. The resident did not specify a date of occurrence. A face-to-face interview was conducted on April 18, 2014 at 11:00 AM with Employees #1, 2 and 12. A query was made regarding if the State Agency was notified regarding Resident #6 ' s allegations. Employee #1 stated that the facility ' s form, Resident/Family Communication Tool was completed, however; he/she had no evidence to support notification to the State Agency. Facility staff failed to report an allegation of verbal abuse and misappropriation of property for Resident #6. 2. Facility staff failed to report an allegation of mistreatment expressed by Resident #28. During a resident interview conducted on April 15, 2014 at 2:30 PM the resident responded no in reply to a query does staff treat you with respect and dignity? He/she stated I cannot remember the exact date but a CNA put me to bed one time and that ' s when (he/she) acted up There was one (gender specified) that was rough. He/she came in here and threw my shoes and clothes everywhere. I don ' t ' know (his/her) name but they call (his/her name mentioned). (he/she) no longer takes care of me. I reported (him/her) to the supervisor. A review of the facility documents lacked evidence of any allegations of abuse from Resident #28. A face-to-face interview was conducted with Employee #30 on April 18, 2014 at 1:00 PM. The employee acknowledged that Resident #28 alleged the throwing of clothes and shoes by a CNA on the unit. I spoke to the CNA and (he/she) said that the resident ' s clothes were placed on the chair and shoes placed beside the wheelchair. He/she denied reporting the incident to the State Agency, I did not write it up because I thought it had been resolved However, Employee 35 was made aware. A face-to-face interview was conducted with Employee #5 on April 18, 2014 at 1:15 PM. Tin response to a query regarding the alleged mistreatment by Resident #28, he/she stated I did not write anything up because I thought it had been resolved. Facility staff failed to report an allegation of mistreatment expressed by for Resident #28. | 2017-02-01 |
| 1457 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 241 | E | 0 | 1 | 0SN511 | Based on observations and staff interviews for three (3) of 51 sampled residents, it was determined that facility staff failed to promote dignity as evidenced by posting of signage of resident ' s personal plan of care for (2) residents and one (1) resident whose name was written on the front of his/her jacket. Residents #34, #62 and #115. The findings include: 1. Facility staff failed to promote dignity for Resident #34 as evidenced by the observation of signage of resident ' s confidential clinical and personal information that could be viewed by the public. During a resident observation conducted on April 15, 2014 at approximately 11:40 AM and April 22, 2014 at approximately 1:00 PM; observed signage posted on wall behind the head of Resident #34 ' s bed. The signage revealed; No B/P (blood pressure) or venipuncture on right arm. Aspiration precautions: Diet: Pure; Position meal tray on right side. A face-to-face interview was conducted on April 22, 2014 at approximately 1:00PM with Employees #5 and #7. In response to a query regarding the signage observed posted behind Resident #34 ' s bed; both replied that the signage is not to be visibly posted. The observation was made on April 22, 2014. Facility staff failed to promote dignity for Resident #34 as evidenced by the observation of signage of resident ' s confidential clinical and personal information that could be viewed by the public. 2. During tour of Resident #62 ' s room on April 14, 2014 and April 22, 2014 between the hours of 9:00 AM and 4:00 PM, observed signage posted on wall behind the resident ' s head of bed. The signage revealed; Resident name, Full Code, Bathing: Total Care; Dressing: Total Care; Toilet Transfers-Dependent; Ambulation- Assistive device/at risk for falls/WC (wheelchair); Diet: Diabetic Regular NCS (No Concentrated Sweets); Oral Care: Partials/Dentures; Toileting: Adult briefs (size) M (medium); Activities: Participate Ad-lib (as often as liked); Vigelon monitor on chair . Second signage revealed; Attention Staff: Swallowing Precautions, No Straws, (Resident named) should be upright at 90 (degrees) when eating in bed. Thank you! (Discipline named). Facility staff failed to promote dignity for Resident #62 as evidenced by the observation of signage of resident ' s confidential clinical and personal information that could be viewed by the public. A face-to-face interview was conducted with Employees #6 on April 22, 2014 at approximately 12N. In response to a query regarding the signage observed posted behind the head of Resident #62 ' s bed, he/she replied that the signage was suppose to be posted inside the resident ' s closet. The signage was immediately removed and posted inside the resident ' s closet door. The observation was made on April 22, 2014. 3. Facility staff failed to promote dignity for Resident #115 whose name was written on the front of his/her jacket. During the breakfast meal, Resident #115 was observed during the breakfast meal on April 15, 2014 at approximately 8:50 AM seated in his/her geri-chair in the dining area on Unit 2 B. He/she was dressed in a blue sweater jacket that had his/her name visibly written in a black colored marker across the left front of the jacket. The observation was made in the presence of Employee #4 who acknowledged the findings, and stated that The family wrote Resident#115 ' s name on (his/her) jacket and we educated them that the resident name goes in the back on the inside of the clothing. | 2017-02-01 |
| 1458 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 253 | E | 0 | 1 | 0SN511 | Based on observations made during an environmental tour of the facility on April 18, 2014 at approximately 11:00 AM, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior as evidenced by seven (7) of seven (7) torn window curtains in two (2) of 27 resident's rooms, loose wallpaper in three (3) of five (5) resident's units, broken window blinds slats in two (2) of 27 resident's rooms and marred walls in four (4) of 27 resident's rooms. The findings include: 1. Five (5) of five (5) sets of window curtains in room #351 were torn in several areas and one (1) of one (1) set of window curtains in room #349 was also torn, two (2) of 27 resident's rooms. 2. The wallpaper was hanging loose, unglued from the wall in three (3) of five (5) resident's units. 3. One (1) of five (5) window blinds had a broken slat in room #254 and two (2) of two (2) window blinds in room #128 had broken slats; two (2) of 27 resident's rooms surveyed. 4. The walls were marred in four (4) of 27 resident's rooms (#254, #154, #135, #129). These observations were made in the presence of Employee #9 who acknowledged the findings. | 2017-02-01 |
| 1459 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 272 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on record review and staff interview for five (5) of 51 sampled residents, it was determined that the facility staff failed to accurately code the Minimum Data set (MDS) for one (1) resident's total care, urinary continent and [DIAGNOSES REDACTED]. edentulous on the significant change MDS, one (1) resident for [DIAGNOSES REDACTED]. Residents #1, #34, #62 ,#116, #252 and #291 The findings include: 1a. Facility staff failed to accurately code Resident #1's Minimum Data Sets (MDS) for total care, urinary continent and [MEDICAL CONDITION]. A review of the clinical record for Resident #1 revealed facility staff failed to accurately code Section G, Functional Status - G0110 Activity of Daily Living Assistance of the quarterly MDS dated [DATE] and annual MDS dated [DATE]. The check box allotted next to Section G0110 - Activity of Daily Living Assistance was coded as 4 indicating that the resident was total dependence (full staff performance every time during entire 7-day period). On April 17, 2014 at approximately 10:18 AM, Resident #1 was observed exposed from his/her head to his/her groin area with a clear colored urinal in his/her left hand. He/she was observed independently using (his/her) urinal. The observation of Resident #1 independently using the urinal on April 17, 2014 at approximately 10:18 AM provided evidence that facility staff miscoded MDS Section G0110 - Activity of Daily Living Assistance. A face-to-face interview was conducted with Employee # 27 on April 17, 2014 at approximately 10:22 AM. He/she reviewed the clinical record and acknowledged the findings. The record was reviewed April 17, 2014. 1b. A review of the clinical record for Resident #1 revealed facility staff failed to accurately code Section G, Functional Status - H0300 Urinary Continence of the quarterly MDS dated [DATE] and annual MDS dated [DATE]. The check box allotted next to Section H0300A - Urinary Continence was coded as 3 indicating that the resident was always incontinent (no episodes of continent voiding). On April 17, 2014 at approximately 10:18 AM, Resident #1 was observed exposed from his/her head to his/her groin area with a clear colored urinal in his/her left hand. He/she was observed to be independently using the urinal. There was no evidence that facility staff accurately coded Resident #1's urinary continence on the quarterly MDS. A face-to-face interview was conducted with Employee # 27 on April 17, 2014 at approximately 10:22 AM. After reviewing the clinical record; he/she acknowledged the findings. The record was reviewed April 17, 2014. 1c. A review of the clinical record for Resident #1 revealed facility staff failed to accurately code Section I, Active [DIAGNOSES REDACTED]. A review of the comprehensive care plan initiated on February 8, 2014 revealed; Problem (Resident's name) has a visual impairment. The care plan of Resident #1 provided evidence that facility staff miscoded MDS Section I8000D - Additional Active [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee # 27 on April 17, 2014 at approximately 10:22 AM. He/she reviewed the clinical record and acknowledged the findings. The record was reviewed April 17, 2014. 2. Facility staff failed to accurately code Section K( Swallowing/Nutritional Status) on the admission Minimum Data Set (MDS) dated [DATE] for Resident #34. An admission history and physical dated March 26, 2014 included Diagnoses: [REDACTED]. He/she has had thrush of (the) mouth for some time. Treated with magic mouth wash and Nystastin. (He/she\) has trouble eating solid food. According to a nutrition care progress note dated March 26, 2014 revealed: Weight is 84 (pounds) . does not want mechanical soft or puree diet has thrush so bad cannot swallow at all. Have list of foods to send . The admission MDS dated [DATE] lacked evidence that facility staff coded (the section was blank) Section K, Swallowing/Nutritional Status (K0100-C) to include complaints of difficulty or pain with swallowing. Facility staff failed to code Resident #34 for a swallowing disorder on the admission MDS. A face-to-face interview was conducted with Employee #14 on April 22, 2014 at approximately 10:30 AM. After review of the MDS, he/she acknowledged the aforementioned findings. The record was reviewed on April 22, 2014. 3. Facility staff failed to accurately code Section L (Oral/Dental/Status) of the significant change MDS for no natural teeth (edentulous) for Resident #62. According to a dental consultation dated June 6, 2013 revealed: Upon clinical exam patient presents totally edentulous. No soft or hard tissue pathology noted. No facial asymmetry. Patient seems to be OK. Patient wearing dentures upper/lower. During an isolated observation of Resident #62 in the presence of Employee #28 on April 21, 2014 at approximately 10:00 AM, the resident mouth was observed with no teeth. The assigned CNA was completing the resident ' s am care. He/she was in the process of cleaning the resident ' s dentures. Observed upper and lower dentures in the denture cup. The significant MDS dated [DATE] and September 12, 2013 lacked evidence that facility staff coded (the section was blank) Section L, Oral/ Dental Status (L0200-B) to include the resident being edentulous on the dentist assessment. Facility staff failed to code Resident #62 for no natural teeth (edentulous) on the significant change MDS. A face-to-face interview was conducted with Employee #27 on April 22, 2014 at approximately 11:00AM. After reviewing the clinical record, he/she acknowledged the aforementioned findings. The record was reviewed on April 22, 2014. 4. Facility staff failed to accurately code Resident #116's admission Minimum Data Sets (MDS) for a [DIAGNOSES REDACTED]. This was a closed record review. A review of the Admissions MDS with an ARD (Assessment Reference Date) of February 11, 2014 revealed facility staff failed to accurately code Section I, Active [DIAGNOSES REDACTED].>A review of the admissions Physician order [REDACTED]. The check box allotted next to Section I0700 - Hypertension was left blank indicating that the resident was not coded for the [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee #27 on April 17, 2014 at approximately 2:30 PM. After review of the admissions MDS He/she acknowledged the findings. The record was reviewed April 17, 2014. 5 . Facility staff failed to accurately code Resident #252's admission Minimum Data Set (MDS) for [DIAGNOSES REDACTED]. This was a closed record review. A review of the Admissions MDS with an ARD (Assessment Reference Date) of February 12, 2014 revealed that facility staff failed to accurately code Section I, Active [DIAGNOSES REDACTED]. The check box allotted next to the Sections were left blank indicating that the resident was not coded for the above diagnoses. A review of the admission ' s Physician order [REDACTED]. A face-to-face interview was conducted with Employee #27 on April 17, 2014 at approximately 2:30 PM. After review of the admissions MDS, he/she acknowledged the findings. The record was reviewed April 17, 2014. 6. Facility staff failed to accurately code Resident #291's admission Minimum Data Set (MDS) for a [DIAGNOSES REDACTED].#291. A review of the admissions MDS with an ARD date of March 6, 2014 revealed that facility staff failed to accurately code Section I, Active [DIAGNOSES REDACTED]. A review of the admissions Physician order [REDACTED]. The check box allotted next to Section I0400 - [MEDICAL CONDITION] was left blank indicating that the resident was not coded for the [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee # 27 on April 17, 2014 at approximately 2:30 PM. After review of the admissions MDS, he/she acknowledged the findings. The record was reviewed April 17, 2014. B. Based on record review and staff interview for two (2) of 51 sampled residents, it was determined facility staff failed to identify the location and date of Care Area Assessment (CAA) information on Minimum Data Sets (MDS) under Section G (G0110) and H (H0300) for one (1) resident, Section V (V0200A) for one (1) resident and Residents #1, and # 62. The findings include: According to Chapter 4 of the MDS 3.0 Users ' Manual, for each triggered care area, indicate the date and location of the CAA documentation .CAA documentation should include information on the complicating factors, risks and any referrals for the resident for this care area . 1.Facility staff failed to indicate in the location and date of CAA documentation column for Resident #1 where information related to the CAA could be found on the Annual MDS dated [DATE]. A review of Resident #1' s annual Minimum Data Set, dated dated dated [DATE] revealed that in the Care Areas Assessment (CAA) Results section revealed the following: Care Plan triggered areas for #3 Visual Function, #5 ADL (Activities of Daily Living) Functional/ Rehabilitation Potential and #6 Urinary Incontinence and Indwelling Catheter slots allotted for location, date of CAA documentation were left blank. The clinical record lacked evidence of documentation regarding complicating factors, risks and any referrals related to the triggered care areas. A face-to-face interview was conducted with Employees #27 on April 22, 2014 at 10:30 AM. He/she acknowledged that the date and locations where information related to the CAA can be found was not documented on the CAA Summary. 2. Facility staff failed to identify the location and date of Care Area Assessment (CAA) information under Section V (V0200A), Care Area Assessment Summary of the significant Minimum Data Set (MDS) for Resident #62. A review of Resident #62 ' s annual Minimum Data Set, dated dated dated [DATE] revealed that Care Areas Assessment and ' addressed ' in Care Plan triggered for #1 [MEDICAL CONDITION], #2 Visual Function, #4 Communication, #6 Urinary Incontinence and Indwelling Catheter, #7 Psychological Well-Being, ##9 Behavioral Symptoms, #11 Falls, #12 Nutritional Status, #13 Feeding Tube, #16 Pressure Ulcer, and #17 [MEDICAL CONDITION] Drug Use. The record revealed that the location and date of CAA information (for care areas #1, 2, 4, 6, 7, 9, 11, #12, #13, 16, and #17) were recorded as CAA Analysis, Disease Process ., and 1:1 interactions . There was no evidence that facility staff documented where in the clinical record information related to the CAA ' s could be found. There were no CAA worksheets available for review. The clinical record lacked evidence of documentation regarding complicating factors, risks and any referrals related to the triggered care areas. A face-to-face interview was conducted with Employees #27 on April 22, 2014 at 10:30 AM. He/she acknowledged that the date and location where information related to the CAA can be found was not documented on the CAA Summary. | 2017-02-01 |
| 1460 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 279 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 51 sampled residents, it was determined that facility staff failed to develop care plans with goals and approaches for the management of a Nephrostomy tube for one (1) resident, one (1) resident receiving hospice services and for the use of compression stockings for one (1) resident with [MEDICAL CONDITION]. Residents # 207, #211 and #252 The findings include 1. Facility staff failed to develop a care plan with goals and approaches to address resident#207 ' s use of a Nephrostomy tube. This was a closed record review. A review of the physician history and physical signed and dated December 14, 2013 revealed, . Nephrostomy tube placement secondary to acute [MEDICAL CONDITION]. A review of physician's order [REDACTED]. Change dressing to Nephrostomy tube every three days and as needed. Flush Nephrostomy tube every 8hrs (hours) with 30ml (milliliters) water. Measure output every shift. A review of the care plan section lacked evidence that a care plan with goals and approaches were developed to address Resident #207 ' s Nephrostomy tube management. A face-to-face interview was conducted on April 15, 2014 at approximately 11:20 AM with Employee #7. He/she acknowledged the findings after reviewing the record. The record was reviewed April 15, 2014. 2. Facility staff failed to develop a jointly coordinated care plan with goals and approaches between the facility and the hospice services for Resident #211. A review of the Physician order [REDACTED]. According to the Interdisciplinary Progress Note dated February 24, 2014, no time indicated, [AGE] year old woman with [MEDICAL CONDITIONS] admitted to (facility name) 2/21/14 (February 21, 2014) DNR/DNI (Do Not Resuscitate/Do Not Intubate) in Hospice. Review of the Progress Notes by Resident progress notes identified that hospice care had been conducted February 22, 2014 through March 12, 2014. Review of the resident ' s care plans lacked evidence of a jointly coordinated care between the hospice services and the facility. A face-to-face interview was conducted with Employee #32, after review of the medical record he/she acknowledged that the resident's record lacked evidence of a jointly coordinated care plan between the hospice service and the facility. Facility staff failed to initiate an integrated care plan with goals and approaches to reflect the resident ' s current status. 3. Facility Staff Failed to develop a care plan with goals and approaches to address resident#252 ' s use of compression stockings for [MEDICAL CONDITION]. This was a closed record review. A review of the physician history and physical signed and dated February 5, 2014 revealed, . (4) [MEDICAL CONDITION] (Congested Heart Failure): compensated, EF (Ejection Fraction) 58; continue [MEDICATION NAME] (antihypertensive); off [MEDICATION NAME] (diuretics) due to dehydration. Start compression stockings. A review of physician's order [REDACTED]. Compression stocking B/L (bilateral) lower legs on 8AM (morning) off 8PM (night). A review of the care plan section lacked evidence that a care plan with goals and approaches were develop to address Resident #252 ' s use of Compression stockings. A face-to-face interview was conducted on April 15, 2014 at approximately 11:20 AM with Employee #7. After the review of the care plan, he/she acknowledged the findings. The record was reviewed April 15, 2014. | 2017-02-01 |
| 1461 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 280 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview for three(3) of 51 sampled residents, it was determined that facility staff failed to review and revise a care plan with goals and approaches to reflect the resident ' s current status for one (1) resident with a change in delivery of ADL (Activities of Daily Living) care; one (1) who refused care, one (1) resident abnormal INR (international Normalized Ratio) levels. Residents #6, #122 and #154 The findings Include: 1. Facility staff failed to review and revise a care plan for Resident #6 who had a change in delivery of ADL care. A resident interview was conducted on April 17, 2014 at approximately 2:00 PM with Resident #6. The resident stated that on all three (3) shifts that his/her care has been expanded to include two (2) CNA ' s (Certified Nursing Assistants), and that he/she could understand a second person during the night shift for turning and repositioning because of the wedge pillow that is put in place, but not on all three (3) shifts. Resident #6 further indicated that there is also a timer placed in his/her room to let the CNA ' s know when 45 minutes are up, that is the time limit to provide care to me. A face-to-face interview was conducted on April 18, 2014 with Employees #1, #2, and #12 at approximately 2:00 PM. A query was made regarding the above statement voiced by the resident. Employee #2 stated there are two (2) persons per shift to perform direct care, if water needed or if trash is to removed, there is only a need for one (1) person. The 45 minute timer is still in use. A review of the resident care plan lacked evidence of revision to include the two (2) CNA ' s that are required for direct care during all three (3) shifts and a time to identify 45 minutes of time allowed to provide care by the CNA. A face-to-face interview was conducted with Employee #6 on April 21, 2014 at approximately 1:00 PM. After review of the care plan he/she acknowledged the findings and stated that the previous unit manager is not here, when I took over, these issues were already addressed. Facility staff failed to review and revise a care plan with goals and approaches to reflect the resident ' s current status. 2. Facility staff failed to review and revise Resident #122 ' s care plan to include refusal of care. During an initial tour conducted on April 14, 2014 at approximately 9:15 AM, observed Resident #122 lying in bed on his/her back. Resident was covered with a white sheet and blanket. Observed resident hair with multiple braids held together with a single rubber band. His/her hair was untidy and matted in the back. A second observation occurred on April 22, 2014 at approximately 3:00 PM. Resident #122 was lying in his/her bed; observed resident ' s hair with white flakes throughout his/her hair. The back of his /her head; the hair was braided and held together with a single rubber band. The hair was matted and untidy. A face-to-face interview was conducted with Employee #36 on April 22, 2014 at approximately 3:05 PM. When queried regarding care of resident ' s hair; he/she replied; He/she refused to get his/her hair cut and combed. He/she gets a shower and his/her hair is washed. However, he/she does not want anyone to comb it. A face-to-face interview was conducted with Employee #35 on April 22, 2014 at approximately 3:20 PM. He/she stated; (Resident named) POA (Power of Attorney) wanted him/her to go down to the barber .but when I ask him if he/she is ready to go down to the barber; he always states, Not today. The comprehensive care plan most recently updated, February 16, 2014 lacked evidence of a revision to include goals and approaches to manage repeated refusal of hair grooming. Facility staff failed to review and revise Resident #122 ' s care plan to include refusal of care. A follow-up face-to-face interview was conducted with Employee #6 on April 22, 2014 at approximately 3:30 PM. He/she acknowledged the aforementioned findings. The observation and clinical record review was conducted on April 22, 2014. 3. Facility staff failed to review and revise Resident #154's care plans with approaches and interventions to reflect the residents abnormal INR levels. A review of the clinical record revealed lab work with PT/INR levels that follows: January 2, 2014 PT/INR was 1.90 low ranges (2.00 - 3.00) February 3, 2014 PT/INR was 1.60 low ranges (2.00 - 3.00) March 13, 2014 PT/INR was 3.69 high ranges (2.00 - 3.00) March 20, 2014 PT/INR was 2.23 WNL (2.00 - 3.00) A review of the physician orders [REDACTED]. January 2, 2014 directed PT/INR in one month, no change to [MEDICATION NAME] dose at this time. February 3, 2014 directed, D/C [MEDICATION NAME] 2mg, [MEDICATION NAME] 2.5mg by mouth daily for A-fib. February 25, 2014 directed check PT/INR Dx A-fib March 13, 2014 directed D/C [MEDICATION NAME] 2.5mg, [MEDICATION NAME] 2mg by mouth daily for A-fib, check PT/INR in one week 3/20/14 A review of the careplan on the active clinical record for Resident #154 revealed that the facility staff failed to update the care plans with approaches and interventions to reflect the abnormal INR levels. The careplan lacked evidence that the facility staff updated the careplan with approaches and interventions to reflect the abnormal INR lab values as it relates to the resident. A face-to-face interview was conducted on April 14, 2014 with Employee #3 at approximately 3:05PM. He /she acknowledge the findings. The record was reviewed April 15, 2014. | 2017-02-01 |
| 1462 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 281 | D | 0 | 1 | 0SN511 | Based on observations and staff interview for two (2) of 51 sampled resident, it was determined that facility staff failed to ensure proper techniques were followed according to accepted standards of clinical practice prior to administration of medications. Residents #78 and #182. The findings include: Facility staff failed to ensure proper techniques were followed according to accepted standards of clinical practice prior to administer medications via the gastrostomy tube for Residents #78 and #182. Employee #34 was observed on April 14, 2014 during two (2) medication pass at approximately 12:30 PM and 1:10 PM. The employee was observed preparing Resident #78 and #182 ' s medications. Prior to administering the medications via gastrostomy tube, he/she informed the residents the indications for each medication. After checking for residual, Employee #34 proceeded to administer each medication separately through a 60 ml (millimeter) syringe attached to the gastrostomy tube and allowed each to infuse by gravity. He/she did not check for correct placement of the gastrostomy tube prior to the administration of the medications. The facility ' s policy entitled; Medication Administration, Policy No: TC- .12, page 5 of 6 stipulates: Prior to infusion of a feeding and/or before administering medications via a feeding tube, the feeding tube must be checked for placement each time. To accomplish this task do the following: Remove the plug from the end of the tube, Attach a 50-60 ml. syringe to the end of the tube, Place a stethoscope over the abdomen approximately 3cm below the sternum. Unclamp tube and inject 10 ml of air into the stomach: listen for a gurgling sound- gurgling equals probable proper placement of tube, As a second check, draw back on the syringe and aspirate stomach contents: . According to The Lippincott Manual of Nursing Practice , Seventh edition, page 664 stipulates; Procedure- Nursing Action-Preparatory Phase- #7. Use the catheter-tipped syringe, inject 20 cc-30cc of air while listening with a stethoscope positioned at the epigastric area. Rationale: Auscultation of a whooshing or bubbling sound assists in confirmation of proper tube placement. Facility staff failed to ensure proper techniques were followed according to accepted standards of clinical practice prior to administering medications via the gastrostomy tube for Residents #78 and #182. A face-to-face interview was conducted with Employee #34 on April 14, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. The observation was conducted on April 14, 2014. | 2017-02-01 |
| 1463 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 309 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview for ten (10) of 51 sampled residents, it was determined that facility staff failed to ensure that each resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by a failure to: administer medications in accordance with physician's orders for three (3) residents; assess oxygen saturation levels for one (1) resident as prescribed; consistently conduct monitoring and assessments for one (1) resident with a respiratory disorder; provide end of life services and implement end of life policies for three (3) residents identified as receiving palliative care; assess oxygen saturation levels as prescribed for one (1) resident; obtain physician's orders for one (1) resident who received hospice services and assess the level of pain for one (1) resident prescribed more than one (1) [MEDICATION NAME] for pain. Residents #78, #95, #98, #106, #153, #182, #211, 213, #291, #305. The findings include: The facility ' s policy entitled; Medication Administration, Policy No: TC- .12, page 5 of 6 stipulates: Prior to infusion of a feeding and/or before administering medications via a feeding tube, the feeding tube must be checked for placement each time. To accomplish this task do the following: Remove the plug from the end of the tube, Attach a 50-60 ml. syringe to the end of the tube, Place a stethoscope over the abdomen approximately 3cm below the sternum. Unclamp tube and inject 10 ml of air into the stomach: listen for a gurgling sound- gurgling equals probable proper placement of tube, As a second check, draw back on the syringe and aspirate stomach contents: . The American Academy of Hospice and Palliative Medicine (AAHPM) www.aahpm.org Clinical Practice Guidelines for Quality Palliative Care Statement: The goal of palliative care is to prevent and relieve suffering, and to support the best possible quality of life for patients and their families, regardless of their stage of disease or the need for other therapies, in accordance with their values and preferences. Palliative care is both a philosophy of care and an organized, highly structured system for delivering care According to the Lippincott Manual of Nursing Practice Seventh Edition Palliative Care P162 Palliative care is the active total care of patients with advanced illness. The focus is no longer on curative treatment, but on quality of life and integrating the physical, psychological, spiritual, and social aspects of care. Principles of Palliative Care P163: 1. Palliative care is an interdisciplinary team approach, including experts from medicine, nursing, social work, the clergy and nutrition. This team is approach is needed to make necessary assessments and to institute appropriate interventions. 2. The essential components of Palliative care are relief of relief of symptom distress, improved quality of life, opening of communication on a regular basis with patients to provide appropriate care on their terms, and psycho social support for patients and families. 3. The goal is to provide comfort and maintain the highest possible quality of life for a long as possible. 4. The traditional focus of palliative care is not on death but on a [MEDICATION NAME] understanding of patient suffering and focuses on providing effective pain and symptom management to seriously ill patients, while improving quality of life. 1. Facility staff failed to administer medications in accordance with physician's orders, via (by) Gastrostomy tube, for Resident #78. Employee #34 was observed on April 14, 2014 during a medication pass at approximately 12:30 PM. The employee was observed preparing Resident #78 ' s medications for administration via Gastrostomy. After checking for residual, Employee #34 proceeded to administer each medication separately through a 60 ml syringe attached to the Gastrostomy tube and allowed each to infuse by gravity. He/she did not check for correct placement of the Gastrostomy tube prior to the administration of the medications. According to the physician ' s order form dated April 4, 2014 directed: Flush [DEVICE] (Gastrostomy Tube) with 300 ml of water every shift. Check residual before feeding ., Check tube for proper placement prior to each feeding, flush or medication administration every shift. Facility staff failed to check for proper placement of Gastrostomy tube prior to administration of medications. A face-to-face interview was conducted with Employee # 34 on April 14, 2014 at approximately 3:00 PM. He/she acknowledged he/she did not listen with his/her stethoscope for proper placement of the Gastrostomy tube prior to administering the medication. The observation was made on April 14, 2014. 2. Facility staff failed to develop and implement measures to provide comfort care services for Resident #95 who was identified as receiving comfort care. A review of the QIS (Quality Indicator Survey) entrance conference worksheet submitted upon request to the survey team, Resident #95 was identified as requiring Comfort Care/End of Life Care. A review of the clinical record revealed that there were no physician orders, treatment or care plan directing staff in caring for and meeting Residents #95 ' s comfort care needs. A fact- to- face interview was conducted with Employee# 2 on April 21, 2014 at approximately 3:00 PM, when queried requesting a copy of the facilities palliative care policy, he/she stated there is no policy related to palliative/comfort care. A face-to-face interview was conducted with the Employee #4 on April 21 at approximately 3:30 PM, when queried regarding how staff knew what comfort care orders and treatment to implement he/she stated the, Physician Orders for Life Sustaining Treatment (POLST) is used as comfort care orders on the unit. Employee #4 stated he/she was not aware of a specific comfort care policy. When queried regarding POLST form last signed and dated April 4, 2008 he/she stated I was not aware of that. A face to face interview was conducted with Employee #20 on April 21, 2014 at approximately 4:00 PM, when queried about a comfort care treatment plan he/she replied The medical team does not write comfort care orders, they discuss care with families and document in the medical record progress notes which the nurses always can use as a guideline Employee #20 further stated I don ' t see a need for writing specific comfort care orders. A face to face interview was conducted with Employee #1 on April 20, 2014 at approximately 5:00 PM when questioned about the facility ' s Palliative/Comfort care program and policies he/she stated there is no program or policies. A face to face interview was conducted with Employee #1 on April 21 at approximately 9:15 AM when queried if there was a policy or guidelines for use of Physician Orders for life sustaining treatment form(POLST) His/her response was no. There was no evidence that the facility was providing palliative care to Resident #95. A face to face interview was conducted with Employee #2 on April 21, 2014 he/she acknowledged the aforementioned findings. The medical record was reviewed on April 21, 2014. 3. Facility staff failed to develop and implement measures to provide comfort care services for Resident #98. A review of the QIS entrance conference worksheet submitted upon request to the survey team, identified Resident #98 as requiring Comfort Care/End of Life Care. A review of the clinical record revealed that there were no orders, treatment or care plan directing staff in caring for and meeting Residents #98's comfort care needs. A fact to face interview was conducted with Employee# 2 on April 21, 2014 at approximately 3:00 PM, when queried requesting a copy of the facilities palliative care policy, he/she stated there is no policy related to palliative/comfort care . A face-to-face interview was conducted with the Employee #4 on April 21 at approximately 3:30 PM, when queried regarding how staff knew what comfort care orders and treatment to implement he/she stated the, Physician Orders for Life Sustaining Treatment (POLST) is used as comfort care orders on the unit. Employee #4 stated he/she was not aware of a specific comfort care policy. When queried regarding POLST form last signed and dated April 4, 2008 he/she stated I was not aware of that. A face to face interview was conducted with Employee #20 on April 21, 2014 at approximately 4:00 PM when queried about a comfort care treatment plan he/she replied The medical team does not write comfort care orders, they discuss care with families and document in the medical record progress notes which the nurses always can use as a guideline Employee #20 further stated I don ' t see a need for writing specific comfort care orders, the residents care is individualized. A face to face interview was conducted with Employee #1 on April 21, 2014 at approximately 5:00 PM when questioned about the facility ' s Palliative/Comfort care program and policies he/she stated there is no program or policies. A face to face interview was conducted with Employee #1 on April 21 at approximately 9:15 AM when queried if there was a policy or guidelines for use of Physician Orders for life sustaining treatment form(POLST) His/her response was no. There was no evidence that facility was providing palliative care to Resident #98. A face to face interview was conducted with Employee #2 on April 21, 2014 he/she acknowledged the aforementioned findings. The medical record was reviewed on April 21, 2014. 4. Facility staff failed to develop and implement measures to provide comfort care services for Resident #106 who was identified as receiving comfort care. A review of the QIS entrance conference worksheet submitted upon request to the survey team, identified Resident #106 as requiring Comfort Care/End of Life Care . A review of the clinical record revealed that there were no orders, treatment or care plan directing staff in caring for and meeting Residents #106's comfort care needs. A fact to face interview was conducted with Employee #2 on April 21, 2014 at approximately 3:00 PM, when queried requesting a copy of the facilities palliative care policy, he/she stated there is no policy related to palliative/comfort care. A face-to-face interview was conducted with the Employee #4 on April 21 at approximately 3:30 PM, when queried regarding how staff knew what comfort care orders and treatment to implement he/she stated the, Physician Orders for Life Sustaining Treatment (POLST) is used as comfort care orders on the unit. Employee #4 stated he/she was not aware of a specific comfort care policy. When queried regarding POLST form last signed and dated March 13, 2009 he/she stated I was not aware of that. A face to face interview was conducted with Employee #20 on April 21, 2014 at approximately 4:00 PM when queried about a comfort care treatment plan he/she replied The medical team does not write comfort care orders, they discuss care with families and document in the medical record progress notes which the nurses always can use as a guideline Employee #20 further stated I don ' t see a need for writing specific comfort care orders , the residents comfort care is individualized . A face to face interview was conducted with Employee #1 on April 20, 2014 at approximately 5:00 PM when questioned about the facility ' s Palliative/Comfort care program and policies he/she stated there is no program or policies. A face to face interview was conducted with Employee #1 on April 21 at approximately 9:15 AM when queried if there was a policy or guidelines for use of Physician Orders for life sustaining treatment form(POLST) His/her response was no. There was no evidence that facility was providing palliative care to Residents #106 A face to face interview was conducted with Employee #2 on April 21, 2014 he/she acknowledged the aforementioned findings. The medical record was reviewed on April 21, 2014. 5. Facility staff failed to complete an admission assessment for Resident #153 in a timely manner. Additionally, facility staff failed to consistently assess and monitor the status of Resident #153 ' s condition. The resident was assessed as having an unwitnessed fall, complaints of shortness of breath and an alteration in skin integrity. A. According to the facility ' s policy Charting-Documentation Policy No: IM- .86, Revised 11/13, stipulates: Nursing- 5. A comprehensive note detailing the patient/resident ' s condition is written on admission is entered into the electronic medical record. A review of the electronic Progress Notes By Resident dated March 4, 2014 at 04:34 PM revealed Resident #153 was readmitted from (hospital named) With (diagnoses) of [MEDICAL CONDITION] Fibrillation, CAD [MEDICAL CONDITIONS] and Dementia . On (oxygen) . on 2 liter via nasal cannula. A further review of the Cardiovascular and Respiratory sections of the nurses ' observation form revealed that the blood pressure and pulse rate was recorded as being completed on April 18, 2014. The comments section of the form revealed the following note, 03/04/2014 PM, (nurse named): Resident readmitted note. The Attestation section of the form was signed by a License Practical Nurse and the date recorded as being completed was April 20, 214 at 4:13 AM. There was no documented evidence that Resident #153 ' s vital signs were assessed and recorded in a timely manner. There was a time lapse of 45 days from when the admission observation form was started on March 4, 2014 to actual completion date of April 20, 2014. A face-to-face interview was conducted with Employee #3 on April 20, 2014 at approximately 11:00 AM regarding the aforementioned findings. He/she acknowledged that the admission assessment was not completed in a timely manner. The clinical record was reviewed on April 20, 2014. B. Facility staff failed to consistently assess and monitor the status of Resident #153 ' s condition. The resident was assessed as having an unwitnessed fall, complaints of shortness of breath and an alteration in skin integrity. Resident #153 was transferred to another assigned room within the same unit on December 2, 2013 at 03:04 PM. According to a quarterly Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of October 15, 2013 revealed in Section I (Active Diagnoses) [DIAGNOSES REDACTED]. Physician ' s Orders: The physician ' s order form dated and signed January 6, 2014; with a start date of January 1, 2014 directed, (Oxygen) at 2 liters via nasal cannula for shortness of breath, Change O2 humidifier bottle and nasal cannula weekly and as needed . Check O2 (saturation) as needed and monitor # (number) of times (resident) is taking off (his/her) nasal cannula. Skin checks by licensed nurse every week. [MEDICATION NAME] monitor. Interim order dated January 30, 2014 at 4:22 AM directed, (Physical Therapy/Occupational Therapy) Screen post fall. Nursing Notes: A review of the clinical record revealed the following nursing notes: December 9, 2013- 10:21 PM- Comments: Resident complains (of shortness of breath) on assessment, HR (Heart rate- 91- ), B/P (Blood Pressure) - O2 sat (saturation) checked 95% with 2L/minute Oxygen via nasal cannula continues. Breathing treatment provided as ordered. December 11, 2013- 10:37 PM- Resident alert and responsive. Medication provided as ordered. No acute distress or (shortness of breath) noted at this time. December 12, 2013- 4:21 AM- Resident transferred from (room assigned) on unit (unit named) to room (room and unit named) at 3PM this afternoon. (He/she) remains alert and on continuous oxygen at 2L/minute. (He/she) remains alert and (quiet). (He/she) refused to go in bed and was still sitting (in) dining area watching television. (He/she) denied pain and discomfort. VS (Vital signs) - B/P- 118/64, Respirations-20, Temperature- 97.3 and O2 (saturation) 96% at 2l/min. December 12, 2013 -4:51 AM- Monthly Summary for November 2013- Resident had fall (times) 1 without injury on November 2, 2013 during the 7AM-3PM shift when staff responded to an alarm and upon entering (room named), observed resident in sitting position leaning against the bed. Neuro check protocol initiated and within resident ' s limits Continues to receive oxygen via nasal cannula for shortness of breath. No increase (shortness of breath) noted. December 30, 2014- 4:52 AM- . Respiratory: Shortness of breath or trouble breathing with exertion, Oxygen delivered via Nasal cannula in l/min=2, (status [REDACTED]. December 31, 2013 12:02 PM- No acute distress noted, no (shortness of breath) noted . continue on oxygen on 2 liter via (nasal cannula) with no discomfort noted. January 30, 2014- 4:52 AM- Audible bed sensor alarm. Entered resident ' s room. Observed resident on floor. Resident returned to bed via (a) hoya lift. (Range of motion) to upper and lower extremities without statement of discomfort, (Medical doctor) and family notified. Neuro checks in progress. February 2, 2014 11:40 AM- .sitting in wheelchair with oxygen, no evidence of any respiratory distress noted at around 8 AM. Assigned CNA (Certified Nursing Assistant) reported that patient has a (bruise) to (his/her) left upper arm measuring 8 (cm) by 9.3 cm . denies pain when touch. (Medical doctor) on call was notified . Vital signs are Temp-97, respirations-20, Pulse-89, Blood Pressure- 123/68, O2 saturation 97%. Continue to monitor patient. February 9, 2014 12:01 PM- While performing ADL (Activities of Daily Living) care, CNA observed resident with skin discoloration, upon assessment, resident was noted with skin discoloration located at left lateral thigh measured 3 cm x1.5cm, non tender upon palpation, surrounding tissue normal . Will continue to monitor. February 27, 2014 5:14 AM- Resident observed with shortness of breath with (oxygen) via (nasal cannula). Pulse oximetry- 61%, heart rate-108, (blood pressure) 96/53, Temperature- 95, Respirations-46 and shallow. (Medical doctor) notified. Order obtained to transfer (to hospital) 911. Family notified of transfer to (hospital named). A review of the record lacked documented evidence of consistent respiratory assessment(s) for the resident between December 9, 2013 and the time that the resident was transferred out via 911 to an acute hospital on February 27, 2014. The progress notes documented by the nurse on December 9, 2013 revealed that Resident # 153 complained of (shortness of breath) on assessment; utilizing O2 at 2l/min via nasal cannula for shortness of breath. There were inconsistencies in assessing the resident ' s respiratory status and a lack of follow up assessment to indicate that interventions were effective and episodes of shortness of breath were resolved. The clinical record lacked documented evidence that Resident #153 was consistently monitored after an unwitnessed fall on January 30, 2014. The clinical record lacked documented evidence that skin assessments were consistently conducted on Resident #153 after an alteration in skin integrity was identified by the Certified Nursing Assistant on February 9, 2014. Facility staff failed to consistently assess and monitor the status of Resident #153 ' s condition. A face-to-face interview was conducted with Employee #3 on April 18, 2014 at approximately 10:00 AM. He/she acknowledged the aforementioned findings. The clinical record was reviewed on April 18, 2014. 6. Facility staff failed to administer medications in accordance with physician's orders, via (by) Gastrostomy tube, for Residents #182. Employee #34 was observed on April 14, 2014 during a medication pass at approximately 12:30 PM. The employee was observed preparing Resident #182 ' s medications for administration via Gastrostomy. After checking for residual, Employee #34 proceeded to administer each medication separately through a 60 ml syringe attached to the Gastrostomy tube and allowed each to infuse by gravity. He/she did not check for correct placement of the Gastrostomy tube prior to the administration of the medications. According to physician order for [REDACTED]. Check tube for proper placement prior to each feeding, flush or medication administration every shift. Facility staff failed to check for proper placement of Resident #182 ' s Gastrostomy tube prior to administration of medications. A face-to-face interview was conducted with Employee #34 on April 14, 2014 at approximately 3:00 PM. He/she acknowledged that he/she did not check for proper placement with her stethoscope prior to administering the medication. The observation was made on April 14, 2014. 7. Facility staff failed to obtain physician's orders for hospice services for Resident #211. A review of the Physician Order Sheet and Plan of Care revealed that the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. According to the Interdisciplinary Progress Note dated February 24, 2014, no time indicated, [AGE] year old with Esophogeal [MEDICAL CONDITION] admitted to (facility name) 2/21/14 (February 21, 2014) DNR/DNI (Do Not Resuscitate/Do Not Intubate) in Hospice. Review of the Progress Notes By Resident revealed that hospice care had been conducted February 22, 2014 through March 12, 2014. Further review of the medical record lacked evidence of physician orders to initiate hospice services for Resident #211. A face-to-face interview was conducted on April 21, 2014 with Employee #1 at approximately 10:00 AM. A query was made regarding the facility ' s process when admitting a resident to hospice service. Employee #1 stated that if the resident is an in patient resident, the medical director would be the admitting physician that is already on staff. If the resident is not a resident of this long term care facility, the hospital will speak with the liaison here at this facility and then admit through the regular process and the admitting nurse would call and confirm the admissions orders. Employee #1 acknowledged that there were no admitting orders for hospice services for the Resident #211. A face-to-face interview was conducted on April 21, 2014 with Employee #20 at approximately 10:00 AM. A query was made regarding the lack of physician ' s orders for admitting the resident to hospice services. After review of the medical record, Employee #20 acknowledged the lack of an order for [REDACTED]. 8. Facility staff failed to ensure Resident #213 was administered a nasal spray in accordance with the physician ' s orders. A medication observation was conducted on April 15, 2014 at approximately 10:00 AM. During the observation Employee #16 administered two (2) sprays of Deep Sea 0.65% Spray in each nostril of the resident. A review of the April 2014 Physician ' s Order Form last signed and dated April 7, 2014 directed, Deep Sea 0.65% Spray - 1 spray each nostril every four hours as needed for dryness. Facility staff failed to ensure that a nasal spray was administered to resident in accordance with the physician ' s orders (one (1) spray per nostril as opposed to 2 sprays). A face-to-face interview was conducted with Employee #16 on April 15, 2014 at approximately 10:15 AM. He/she acknowledged that the resident was administered two (2) sprays in each nostril at the time of the administration. The observation occurred on April 15, 2014. 9. Facility staff failed to assess Resident #291 ' s oxygen saturation level as directed by the physician. A review of the Physician ' s order sheet and plan of care signed and dated on February 27, 2014 directed, Oxygen at 2 liters per minute via nasal cannula continuous, check pulse ox (oxygen saturation) every shift. A review of the Medication and Treatment Administration record revealed that the 11P-7A shift left the slot allotted for check pulse ox every shift scheduled for April 22, 2014 was blank indicating that the treatment was not done. The Medication and Treatment Administration record lacked evidence that resident #291 ' s pulse oximetry was checked on February 22, 2014 11PM - 7AM shift. A face-to-face interview was conducted on April 22, 2014 at approximately 3:05PM with Employee #7. After reviewing the medication and treatment administration record, he /she acknowledge the findings. The record was reviewed April 22, 2014. 10. Facility staff failed to assess Resident #305 ' s pain prior to administration of pain medication. A. According to the facility ' s policy Pain Management , Policy No: PE- .01, revised date 11/13 stipulates, II- Pain Assessment- Administration of Pain medications: [REDACTED]. The quantitative scale is 0-10: 1 being the less severe level of pain and 10 being the most severe level of pain A medication observation was conducted on April 14, 2014 at approximately 10:30 AM. During the observation Employee #16 made an attempt to reposition Resident #305. At this time, the resident grimaced. Employee #15 asked the question, Are you in pain. Resident #305 replied, Yes. Employee #16 stated, I will give you something for pain. The employee returned to the medication cart, obtained two (2) tablets of [MEDICATION NAME] along with the other scheduled medications from the medication cart. He/she returned to the resident ' s room and administered the pain medication. The physician ' s order dated April 12, 2014 and signed by the physician on April 13, 2014, directed [MEDICATION NAME] 325mg 2 (two) (tablets) p.o. (by mouth) q (every) 6 h (hours) prn (as needed) for pain. According to an interim order form dated April 11, 2014 at 4:00 PM directed, MSO4 ([MEDICATION NAME]) (20 mg/ml) oral concentrate. Take 0.25ml (5mg) by mouth or under the tongue every 4 (hours) prn (as needed) (for) moderate to severe pain or shortness of breath. The April 2014 MAR (Medication Administration Record) revealed: [MEDICATION NAME] 20mg/ml 0.25ml (5mg by mouth or under the tongue every 4 (four) hours as needed (for) moderate to severe pain or shortness of breath. A review of the back of the MAR indicated [REDACTED]. There was no evidence that facility staff assessed the resident ' s level of pain prior to the administration of [MEDICATION NAME] to determine the appropriate medication to administer based on the parameters. A face-to-face interview was conducted with Employee #18 on April 14, 2014 at approximately 10:30 AM. He/she acknowledged the aforementioned findings. The observation and clinical record was conducted on April 14, 2014. | 2017-02-01 |
| 1464 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 323 | E | 0 | 1 | 0SN511 | Based on observations made during an environmental tour of the facility on April 18, 2014 at approximately 11:00 AM, it was determined that facility staff failed to maintain the facility free of accident hazards as evidenced by: four (4) of four (4) power strips and two (2) of two (2) extension cords that were observed on the floor in three (3) of 27 resident's rooms, unsercured oxygen tanks in two (2) of five (5) storage rooms and in one (1) of 27 resident's rooms and one (1) of one (1) mirror that was stored on top of a dresser unsecured in one (1) of 27 resident's rooms. The findings include: 1. Three (3) of three (3) power strips were in use and stored on the floor of room # 356A, one (1) of one (1) power strip was in use and stored on the floor of room #323, two (2) extension cords were in use and on the floor of room #323, and a three-outlet, electrical connector was in use in room #305, three (3) of 27 resident's rooms. 2. Oxygen tanks were observed unsecured on numerous occasions including: One (1) of eight (8) E-cylinder type tank in the Oxygen storage room on Unit 3A (#A345A) in one (1) of five (5) Oxygen storage rooms and two (2) of 14 E-cylinder type tanks in the Oxygen storage room on Unit 1, two (2) of five (5) Oxygen storage rooms. One (1) of one (1) E-cylinder type tank in resident room #129, one (1) of 27 resident's rooms. 3. One (1) of one (1) mirror was observed on top of a dresser, loose and unmounted in room #135, one (1) of 27 resident's rooms. These observations were made in the presence of Employee #9 who acknowledged the findings. | 2017-02-01 |
| 1465 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 332 | D | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview for two (2) medication pass observations conducted, it was determined that facility staff failed to instill eye drops according to physician orders [REDACTED]. Residents' #213 and #217. The findings include: 1.Facility staff failed to ensure Resident #213 was administered a nasal spray in accordance to the physician's orders [REDACTED]. A medication observation was conducted on April 15, 2014 at approximately 10:00 AM. During the observation Employee #16 administered two (2) sprays of Deep Sea 0.65% Spray in each nostril of the resident. A review of the April 2014physician's orders [REDACTED]. Facility staff failed to ensure that a nasal spray was administered to resident in accordance with the physician's orders [REDACTED]. A face-to-face interview was conducted with Employee #16 on April 15, 2014 at approximately 10:15 AM. He/she acknowledged that the resident was administered two (2) sprays in each nostril at the time of the administration. The observation occurred on April 15, 2014. 2. Facility staff failed to ensure Resident #217 was administered the correct amount of eye drops in accordance with physician orders. According to the physician's orders [REDACTED]. According to the Medication Administration Record (MAR) for April 2014, it directed Dorzolamide - Timolo 2% (percent)-0.5% original order date March 18, 2014 .Drops; [MEDICATION NAME] PLUS: Instill 1 drop to right eye twice daily, for [MEDICAL CONDITION] . During a medication pass observation with Employee #40 on April 14, 2014, at approximately 10:49 AM the following was observed: After Employee #40 followed necessary measures to ensure sanitization of hands, identification of the resident and ensuring the right medication by reading the label on the medication bottle and the physician's orders [REDACTED]. Employee #40 used his/her left hand to open the lower lid and the right had to hold the eye drops, the resident assisted by opening his/her eye also. Employee #40 instilled one (1) and then immediately another drop equating to two (2) drops of medication given in the right eye. A face-to-face interview was conducted at that time following the administration of the eye drops. A query was made how many eye drops did the physician's order [REDACTED].#40 reviewed the MAR and stated one (1); and how many eye drops did you give? Employee #40 stated two (2) and that the one (1) had fell out However, if that was the case, the employee failed to allow the eye drop to contact the eye for a sufficient period of time before the next eye drop was instilled. Facility staff failed to administer eye drops according to physician orders. | 2017-02-01 |
| 1466 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 371 | D | 0 | 1 | 0SN511 | A. Based on observations made on April 17, 2014 at approximately 9:00 AM, it was determined that the facility failed to store, prepare, distribute and serve food under sanitary conditions as evidenced by expired foods in one (1) of three (3) refrigerators, one (1) of one (1) soiled flat top grill and two (2) of two (2) soiled convection ovens and two (2) of three (3) soiled air curtains fron one (1) of one (1) dishwashing machine. The findings include: 1. A one-third pan of guacamole stored in refrigerator #3 was expired as of April 12, 2014 and a partially filled salad bar container with shredded yellow cheese stored in refrigerator #3 was expired as of April 13, 2014. 2. One (1) of one (1) flat top grill and two (2) of two (2) convection ovens were soiled. 3. Two (2) of three (3) air curtains from the dishwashing machine were soiled. These observations were made in the presence of Employee #8 who acknowledged the findings. B. Based on observation and staff interview, for one (1) of 51 sampled residents, it was determined that facility staff failed to prepare residents food in a sanitary manner as evidenced by the following: The findings include: During a dining observation conducted on April 18, 2014 at approximately 1:00 PM. Employee #33 was observed touching a resident ' s food with his/her bare hands. A face-to-face interview was conducted with Employee #4 on April 22, 2014 at approximately 2:00 PM. After review of the above, he/she acknowledged the findings and stated that we have gloves on the unit that is not acceptable. | 2017-02-01 |
| 1467 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 431 | D | 0 | 1 | 0SN511 | Based on observations made on one(1) of four nursing units it was determined that the facility failed to ensure that one (1) of one (1) of vial of Influenza Virus Vaccine was stored beyond the expiration date. The findings include: At approximately 10:30 AM, on April 15, 2014, in the medication storage refrigerator, one (1) vial of Influenza Virus Vaccine was observed with an open date of 2/2/14. Expiration date on the vial was March, 2014. The observation was made in the presence of Employee # 5. He/she acknowledged the findings. | 2017-02-01 |
| 1468 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 441 | D | 0 | 1 | 0SN511 | Based on observations, staff interview and record review for three (3) of 51 sampled residents, it was determined that the facility failed to follow infection control practices to prevent potential cross contamination and spread of infection as evidenced by: failure to clean the over bed table after removing a urine filled catherization tray for one (1) resident, and failure to wash/sanitize hands prior to administration of medications for two (2) residents. Residents' #1, #78 , #182. The findings include: 1. Facility staff failed to clean Resident #1's over-bed table after removing a urine filled catherization tray. On April 21, 2014 at approximately 12:30 PM Employee #38 was observed performing an in and out catherization. After measuring the urine, he/she picked up the catherization tray from the over bed table and emptied the urine into the commode. Employee #38 proceeded to dispose of the tray in the trash can. After washing his/her hands, he/she readjusted the resident, washed his/her hands and left the resident's room. After the nurse returned to the medication cart, he/she was asked had she finished caring for the resident,. he/she replied, Yes. At that time she was told that she failed to clean the overbed table. He/she acknowledged theaforementioned finding in the presence of Employee #3. The observation was conducted on April 21, 2014. Facility staff failed to clean Resident #1's over bed table after removing a urine filled catherization tray. 2. Facility failed to follow accepted standards of hand hygienepractices during medication administration for Resident #78. During a medication pass observation on April 14, 2014 at approximately 12:30 PM. Prior to administering Resident #78's medication. Employee #34 washed his/her hands and donned gloves. He/she repositioned the resident's wheelchair and locked its brakes. Using the same gloved hands, he/she proceeded to administer the medication through Resident #78's gastrostomy tube. Facility failed to follow infection control practices to prevent potential cross contamination and spread of infection during medication administration. A face-to-face interview was conducted with Employee #34 on April 14, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. The observation occurred on April 14, 2014. 3. Facility failed to follow infection control practices to prevent potential cross contamination and spread of infection during medication administration for Resident #182. During a medication pass observation on April 14, 2014 at approximately 1:00 PM. Prior to administering Resident #182's medication, Employee #34 washed his/her hands and donned the gloves. He/she removed the fall matt from the floor. Using the same gloved hands, proceeded to administer medication through Resident #182's gastrostomy tube. Facility failed to follow infection control practices to prevent potential cross contamination and spread of infection during medication administration. A face-to-face interview was conducted with Employee #34 on April 14, 2014 at approximately 3:00 PM. He/she acknowledged the aforementioned findings. The observation occurred on April 14, 2014. | 2017-02-01 |
| 1469 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 456 | D | 0 | 1 | 0SN511 | Based on observations made on April 17, 2014 at approximately 9:00 AM, it was determined that the facility failed to maintain all essential mechanical, electrical, and patient care equipment in safe operating condition as evidenced by two (2) of five (5) Reach-in refrigerators and one (1) of two (2) freezers that have been out of order for more than a year, five (5) of five (5) type E fire extinguishers and two (2) of two (2) type K fire extinguishers that have not been inspected monthly. The findings include: 1. Two (2) of five (5) Reach-in refrigerators located in the kitchen have been out of order for about a year. 2. One (1) of two (2) freezers was inoperable. 3. Fire extinguishers located in the kitchen are not inspected monthly as required. These observations were made in the presence of Employee #8 who acknowledged the findings. | 2017-02-01 |
| 1470 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 463 | E | 0 | 1 | 0SN511 | Based on observations made during an environmental tour of the facility on April 18, 2014 at approximately 11:00 AM, it was determined that facility staff failed to maintain call bells in good working condition as evidenced by call bells that fail to function as intended in three (3) of 27 resident's rooms, frayed call bell cords in two (2) of 27 resident's rooms and a call bell that was secured with transparent tape in one (1) of 27 resident's rooms. The findings include: 1. Call bells in rooms #249B, #237A and #116 did not consistently initiate an alarm when tested , in three (3) of 27 resident's rooms. 2. Call bell cords were torn and frayed in two (2) of 27 resident's rooms #154 and #114 and the call bell in room #128 was secured with transparent tape in one (1) of 27 resident's rooms (#128). These observations were made in the presence of Employee #9 who acknowledged the findings. | 2017-02-01 |
| 1471 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 492 | E | 0 | 1 | 0SN511 | A. Based on record review and staff interview for four (4) of 7 sampled residents reviewed for transfer/discharge rights; it was determined that facility staff failed to provide transfer/discharge and appeal rights notices in accordance with state law. D.C. Law 6-108. Residents 37, 59, 237 and 299. The findings included: Pursuant to D.C. Code ?44-1001.01.1; Law 6-108 .Whenever a resident is to be discharged , transferred or relocated, a facility representative shall give that resident and his or her representative both oral and written notice of the reasons for, procedures for contesting and proposed effective date of the discharge, transfer or relocation . During a review of clinical records on April 21, 2014 at approximately 5:00 PM, the following residents were transferred out of the facility and there was a lack of documented evidence that transfer/discharge and/or appeal rights notices were provided to the residents and/or their representative. Resident #237- Transferred to hospital on April 2, 2014. Had not returned to facility. Resident #59- Transferred to hospital on March 28, 2014; returned to facility on April 7, 2014 Resident #37- Transferred to hospital on March 4, 2014; returned to facility. Resident #299- Transferred to hospital on April 3, 2014; had not returned. Facility staff failed to provide transfer/discharge notices and appeal rights as required by state law. A face-to-face interview was conducted with Employee#12 on April 21 2014 at approximately 5:00 PM. He/she stated they have been having problems with the submission of the forms. When they are not done electronically, it is done manually. He/she further stated that one of the social worker positions was vacant and the other social workers were covering. The clinical record was reviewed on April 21, 2014. B. Based on record review and staff interview during a review of staffing (direct care per resident day hours), it was determined that facility staff failed to meet minimum nurse staffing requirements in accordance with Title 22 DCMR Section 3211, Nursing Personnel and Required Staffing Levels. The findings include: A review of Nurse Staffing was conducted on April 21, 2014 at approximately 1:30 PM. According the District of Columbia Municipal Regulations for Nursing Facilities: 3211.5 Beginning January 1, 2012, each facility shall provide a minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day, of which at least six tenths (0.6) hours shall be provided by an advanced practice registered nurse or registered nurse, which shall be in addition to any coverage required by subsection 3211.5. Of the five (5) days reviewed, one (1) of the days failed to meet the 0.6 (six tenths) hours of direct nursing care per resident day for Registered Nurse/APRN (Advanced Practice Registered Nurse) as follows: April 20, 2014 - 0.51 hours of direct nursing (RN) care per resident day. Of the five (5) days reviewed, two (2) of the days failed to meet minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day as follows: April 19, 2014 - 3.3 hours of direct nursing care per resident day April 20, 2014 - 3.66 hours of direct nursing care per resident day The review was made in the presence of Employee #37 who acknowledged the findings. | 2017-02-01 |
| 1472 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 514 | D | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 51 sampled residents, it was determined that facility staff failed to initiate transfer orders for one (1) resident transferred to the emergency room , record the correct date on a STAT (administer immediately) potassium chloride order for one (1) resident, document a physician's order [REDACTED]. Residents #23, #207, #211 The findings include: 1. Facility staff failed to initiate 6-108 for Resident #23 ' s transfer to the emergency room (ER). Resident #23 was transferred to acute hospital ER for evaluation. No 6-108 was generated. A face to face interview was conducted with Employee #12 on April 21, 2014 at approximately 5:00 PM. He/she acknowledge the aforementioned findings. 2. Facility staff failed to document the correct date for Resident #207 ' s potassium chloride (KCl) order. This was a closed record review. A review of a physician order [REDACTED]. A review of the Medication Administration Record [REDACTED]. The Potassium chloride was then continued to be administered on December 23, 2013 at 9AM to be given daily per physician order. A review of the Interim order form revealed that the KCL order signed and dated December 24, 2013 was documented on December 20, 2013 at 2:25PM as evidence by the verification date December 20, 2013 at 6:00PM written across the page of the medication order. Facility staff was queried concerning the difference in the documented physician date compared to the date of medication administration. Employee #2 stated that the physician wrote the wrong date when he/she was prescribing Resident #207 ' s order. A face-to-face interview was conducted on April 22, 2014 at approximately 3:05PM with Employee #2. He /she acknowledge the findings. Facility staff failed to document the correct date for Resident #207 ' s potassium chloride (KCL) order. This was a closed record review. The record was reviewed April 22, 2014. 3a. Facility staff failed to write hospice orders for a Resident #211 who received receiving hospice services. A review of the Physician order [REDACTED]. According to the Interdisciplinary Progress Note dated February 24, 2014, (no time indicated), (Resident #211) with [MEDICAL CONDITIONS] admitted to (facility name) 2/21/14 (February 21, 2014) DNR/DNI (Do Not Resuscitate/Do Not Intubate) in Hospice. Review of the Progress Notes By Resident documented that hospice care had been delivered February 21, 2014 through March 12, 2014. The medical record lacked evidence of written physician orders [REDACTED].#211. A face-to-face interview was conducted on April 21, 2014 with Employee #1 at approximately 10:00 AM. A query was made regarding the facility ' s process when admitting a resident to hospice service. Employee #1 stated that if the resident is an in patient resident, the medical director would be the admitting physician that is already on staff. If the resident is not a resident of this long term care facility, the hospital will speak with the liaison (located) here at this facility and then admit through the regular process and the admitting nurse would call and confirm the admissions orders. Employee #1 acknowledged that there were no admitting orders for hospice services for the Resident #211. 3b. Facility staff failed to ensure that the medical record was inclusive of the hospice documents for Resident #211. A review of the Physician order [REDACTED]. According to the Interdisciplinary Progress Note dated February 24, 2014, no time indicated, [AGE] year old woman with [MEDICAL CONDITIONS] admitted to (facility name) 2/21/14 (February 21, 2014) DNR/DNI (Do Not Resuscitate/Do Not Intubate) in Hospice. Review of the Progress Notes By Resident progress notes identified that hospice care had been conducted February 22, 2014 through March 12, 2014. According to the hospice sign in sheets the resident was seen by the RN (Registered Nurse) on February 22, 2014 and February 23, 2014; the Case Manager on February 26, 2014; the Social Worker on March 4, 2014and the RN Case Manager on March 5 and March 10, 2014. The medical record lacked evidenced of the initial nurses assessment, the twenty-four hour nurse follow up, the initial case manager documents and the coordinated care plan between the facility and hospice services. A face-to-face interview was conducted on April 22, 2014 at approximately 10:19 AM with Employee #32. A query was made regarding the process when a resident is admitted to hospice services through their organization. Employee #32 stated Once at the facility I would talk to the nurses and CNA ' s. I would complete an assessment and hand write notes that are placed in the chart (medical record). Each time I come I would sign in on the sign in sheet. There should have been documents from the admitting nurse, the nurse that conducts the 24 hour follow-up visit and the case manager ' s documents. I would then meet every two (2) weeks with the team to review and discuss the patients care and formulate a care plan. I speak to the charge nurse, the nurse ' s aides and document in my notes which are kept in the medical record. There was no evidence of any of the above mentioned documents in the medical record. A face-to-face interview was conducted on April 22, 2014 with Employee #1 at approximately 10:30 AM. A query was made regarding if the system that the hospice services use to electronically document interface with the facility ' s electronic documentation system. Employee #1 indicated that the electronic systems for documentation are separate and do not interface. Facility staff failed to ensure that the medical record was inclusive of the hospice documents. | 2017-02-01 |
| 1473 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-08-14 | 282 | D | 1 | 0 | BIX611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, it was determined that facility staff failed to follow interventions initiated for Resident #1 to prevent lab draws from the left arm and hand. The findings include: Resident #1 was admitted to the facility on [DATE]. According to the Minimum Data Set assessment, with an assessment reference date of June 26, 2014, Resident #1 was assessed with [REDACTED]. Resident #1 was assessed as requiring extensive assistance for transfers, walking, and bathing and totally independent for bed mobility, dressing, eating, toilet use, and personal hygiene in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated July 4, 2014 at 9:40 AM: Around 6:45 AM, CNA assigned to resident reported that he/she was in the middle of changing the resident when he/she heard a knock on the door and saw the Lab tech enter the room without waiting for a response. CNA said he/she asked the lab tech to wait but he/she proceeded to draw the blood. Lab tech drew the blood from the back of the left hand. Charge nurse went into the room and saw lab tech still in the room and noticed a tape at the back of the left hand. He/She was informed that no blood draws from the left arm but he/she said he/she saw the sign after he/she drew the blood. Supervisor and DON made aware. Checked blood draw site for swelling or bleeding, none noted at 7:30 AM. (Family member) will be notified. On December 16, 2013, a blood draw was done from the left hand, despite signage posted in the resident ' s room. As a resolution to the lab draw from the left hand that occurred on December 16, 2013, was to place an arm band with Restricted Extremity printed in black and placed on Resident #1 ' s left wrist. According to the nurses ' notes and staff interviews, the arm band was not on Resident #1 ' s wrist from July 2 through July 4, 2014. Subsequently, a lab draw from the left hand was done on July 2, 2014. According to a nurse ' s note dated. According to a nurse ' s note dated July 5, 2014 at 5:16 AM: status [REDACTED]. Checked area, no swelling or sign of alteration in skin integrity noted, no expression or indication of pain noted when are touched. A face-to-face interview was conducted with Employee #1on August 14, 2014 at 11:45 AM. Employee #1 was asked about the above incident and stated, One of the interventions for the December (16, 2013) lab draw in the left hand was to place an arm band on Resident #1 ' s left arm. Employee #1 acknowledged that Resident #1 ' s arm band was not present. An observation of Resident #1 was conducted on August 14, 2014 at 11:30 AM in the presence of Employee #1. Resident #1 was observed awake, lying in bed on his/her right side, fully dressed. There was no [MEDICAL CONDITION] noted in either of Resident #1 ' s upper extremities. Resident #1 responded to all questions with non-sensical words or no response. A red and white arm band was observed on his/her left wrist. Printed on the arm band in black was Restricted Extremity. A sign posted on white paper was above the bed. Printed in large red letters was No Procedure on Left Arm/Hand. Facility staff failed to follow interventions initiated for Resident #1 to identify that labs should not be drawn from the left arm and hand. The record was reviewed August 14, 2014. | 2017-02-01 |
| 1474 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 157 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interview for one (1) of 37 sampled residents, it was determined that facility staff failed to notify the physician when a second area of skin impairment was first noted on Resident #23's left buttocks. The findings include: Through staff interview it was determined facility staff observed a new wound on Resident # 23 ' s left buttock on the weekend of May 9 to 10, 2015; however, notification to a physician or nurse practitioner was not made. Treatment orders for management of the wound were initiated on May 13, 2015 (approximately 4 days later) after the area was assessed as a stage 3 pressure ulcer during routine wound rounds by the Nurse Practitioner. On May 13, 2015 (Wednesday) incontinence care was observed for Resident #23. It was noted that the resident had two (2) dressings on his/her left buttock and one (1) on the right buttock all initialed by a licensed nurse and dated May 12, 2015. A review of the most recent Skin Condition Report dated May 4 and 7, 2015 revealed that Resident #23 had two (2) wounds: left buttock (abscess) and right buttock (abrasion). There was no documentation of a second skin integrity concern on the left buttock as observed on May 13, 2015. Subsequent to the observation of incontinence care on May 13, 2015 the following progress notes were recorded. An Interdisciplinary Progress Note dated May 13, 2015 at 11:15 AM, by the Nurse Practitioner Student revealed the following, . Pt. (patient) has not been out of bed .Skin breakdown - wound care rounds - new orders. L (left) Buttock abscess 2 x 1 x .01cm healing; R (right) buttock 1.5 x 2.5 x .01 cm unstageable, L buttock Stage III 2 x 1 x .01cm .ordered alternating pressure mattress . A review of the Nurse Practitioner ' s note dated May 13, 2015 (no time indicated) revealed, . Abscess to L butt is healing s/p antbx (antibiotics) - has new pressure ulcers - will order alternating pressure mattress and PT (physical therapy) to evaluate seating for new cushions. Interviews A face-to-face interview was conducted with Employees #22 (Certified Nurse Aide) on May 15, 2015 at approximately 3:40 PM. He/she stated, I observed three (3) areas on the resident this weekend May 9, and 10, 2015. A face-to-face interview was conducted with Employees # 20 and 29 (License Practical Nurses) on May 15, 2015 at approximately 3:43 PM. They stated, We treated the new area on the left buttocks the same as we did the other areas. It looked the same. We treated it with warm compress and dry dressing. A face-to-face interview was conducted on May 15, 2015 at 3:45 PM with Employee #6. He/she reviewed the physician's order [REDACTED]. There was no evidence in the clinical record that facility staff notified the physician, when there was a second area of skin impairment identified on Resident #23's left buttock. The record was reviewed on May 22, 2015. | 2017-02-01 |
| 1475 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 167 | C | 0 | 1 | X0E311 | Based on observation and staff interview for six (6) of six (6) areas in which the facility posts the survey results, it was determined that facility staff failed to ensure that the survey results were located in an accessible location as evidenced by unavailable survey results in the lobby area of the facility and a lack of signage to indicate the availability and location in five (5) of five (5) resident care units. The findings include: A tour of the facility to confirm the availability of the survey results was conducted with Employee # 1 on May 21, 2014 at approximately12:10 PM. Entrance- A sign posted in the lobby area indicated that the survey results were available at the front desk, however Employee #1 could not locate them. Unit 1A, first floor- The survey results were located in a common area at the entrance of Unit 1A and were readily avialble but there was no notice posted to indicate the availability or location. Unit 2A, second floor- The survey results were found at the nursing station on 2A, however there was no notice posted to indicate the availability or location. Unit 2B, second floor- The survey results on 2B were placed in a common area at one (1) of two (2) entrances to the unit, however there was no notice posted to indicate the availability or location. Unit 3A, third floor- The survey results on 3A were placed in a common area at one (1) of two (2) entrances to the unit, however there was no notice posted to indicate the availability or location. Unit 3B, third floor- The survey results on 3B were placed in a common area at one (1) of two (2) entrances to the unit, however there was no notice posted to indicate the availability or location. These findings were confirmed by Employee # 1 who was present at the time of the observations. | 2017-02-01 |
| 1476 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 174 | D | 0 | 1 | X0E311 | Based on observations, resident and staff interviews for two (2) of 37 sampled residents, it was determined that facility staff failed to provide a private area when residents can make and receive telephone calls without being overheard. Residents' # 66 and #164 The findings include: 1. Facility staff failed to provide Resident #66 a private area to make and receive telephone calls without being overheard. A resident interview was conducted on May 12, 2015 at approximately 4:35PM. In response to a query, Do you have privacy when on the telephone? The resident responded, No and added that everyone can hear his/her conversations. The telephone for resident use was located on a wall directly across from the nursing station on Unit 1A. The telephone was also located in an area where calls can be overheard by residents, staff and visitors. A face-to-face interview was conducted on May 18, 2015 with Employee #4 at approximately 3:00PM. He/she acknowledged the aforementioned findings. 2. Facility staff failed to provide Resident #164 a private area to make and receive telephone calls without being overheard. A resident interview was conducted on May 13, 2015 at approximately 4:26PM. In response to a query, Do you have privacy when on the telephone? The resident responded, No and added that everyone can hear his/her conversations. The telephone for resident use was located on a wall directly across from the nursing station on Unit 1A. The telephone was also located in an area where calls can be overheard by residents, staff and visitors. A face-to-face interview was conducted on May 18, 2015 with Employee #4 at approximately 3:00PM. He/she acknowledged the findings. | 2017-02-01 |
| 1477 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 225 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for 16 of 46 Resident/Family Communication forms reviewed, it was determined that facility staff failed to implement policies and procedures to ensure that allegations of mistreatment and/or abuse were reported to the State Agency. The findings include: The Code of Federal Regulations 483.13 (b) defines abuse as: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (42 CFR 488.301) This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. A review of the facility ' s Resident/Family Communication forms revealed 46 forms that were recorded as concerns. 16 of the 46 forms identified as concern revealed allegations of mistreatment and/or abuse by staff that ranged from failure to provide timely incontinent care, rough handling, speaking in a harsh tone to missing property. Exampes of allegations are as follows: 1.Relative reported to facility on December 8, 2014 that their (mother/father) was crying and holding the call bell because no one came to assist their (mom/dad.) It was reported by staff that they were under staffed. Resident #186 2.Resident reported on May 21, 2014 an allegation of verbal abuse with a (male/female) Registered Nurse. Resident #6 3 Relative reported to the facility on [DATE] that a Certified Nursing Assistant came into his/her mom/dad ' s room woke him/her up to put him/her on a bed pan. The resident screamed No, No, No that he/she did not need to go to the bathroom. The resident was left flat on his/her back and had a difficult time breathing and his/her back was in pain. Resident #186 4.Resident reported to the facility on [DATE] that his/her significant other was wearing the same clothes for two (2) days and was soaking wet after having lunch. Resident #139 5.Relative reported to the facility on [DATE] that night aide was verbally abusive and called his/her mom crazy and that (his/her) (mom/dad) was a trouble maker. Resident #14 6.Resident reported on July 19, 2014 that he/she felt intimidated by the staff assigned to (him/her) on the 3-11 shift. TSD#2 The records lacked evidence that the allegations were fully investigated and reported to the State Agency. A face-to-face interview was conducted with Employee #37 on May 21, 2015 at approximately 2:00 PM. Employee #37 was designated to manage allegations of abuse in the facility and stated that he/she was not aware of the 16 allegations of mistreatment illustrated on the Resident/Family Communication forms. Employee #37 stated that the Department of Nursing was responsible for reviewing the forms and would forward to his/her department as necessary. He/she denied having knowledge of the concerns recorded in the 16 forms reviewed, that alleged mistreatment/abuse. A face-to-face interview was conducted with Employee #2 on May 21, 2015 at approximately 3:30 PM. He/she stated that he/she would research whether or not the allegations of mistreatment and/or abuse recorded on the Family/Relative Communication forms were reported to the Department of Health. There was no evidence provided by Employee #2 to reflect that the allegations of abuse were reported. The records were reviewed May 21, 2015. | 2017-02-01 |
| 1478 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 226 | E | 0 | 1 | X0E311 | Based on record review and staff interview of the facility's policy regarding Abuse and Neglect, it was determined that facility staff failed to develop specific procedures to ensure that allegations of mistreatment, neglect and/or abuse are thoroughly investigated, the means by which residents would be protected from further abuse and that the allegations are reported to the State Agency. The findings include: A review of the facility ' s policy on Abuse and Neglect lacked evidence of a systematic process for staff to follow in the event of alleged abuse. For example, under the facility ' s Abuse policy Number TX- .97, section VI Protection; protect residents from harm during an investigation, lacked evidence of specific procedures that staff should follow to protect the resident(s) in the event of an allegation of abuse. A face-to-face interview was conducted with Employee #1 on May 21, 2015 at approximately 3:30 PM who confirmed the abuse policy had been provided to the survey team. Facility staff failed to develop abuse policies with specific procedures for staff to follow in the event of allegations involving mistreatment, neglect and/or abuse. | 2017-02-01 |
| 1479 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 241 | E | 0 | 1 | X0E311 | Based on observations and staff interview for three (3) of 37 sampled residents, it was determined that facility staff failed to ensure a resident's dignity was promoted as evidenced by, failing to enhance dignity during dining for one (1) resident and failing to knock before entering one (1) resident ' s room and maintain an environment free of signage with personal information for (1) one resident ' s #200 # 157 and #162. The findings include: 1. Facility staff failed to provide an environment of dining with dignity for Resident #200. During the lunch observation conducted on May 11, 2015 at approximately 1:30 PM, facility staff was observed using table where Resident# 200 was seated as a central location area for sanitizing their hands and dispensing hand wipes to sanitize other residents hands prior to serving their meals. These activities continued as Resident #200 sat eating his/her meal. During a second breakfast observation on May12, 2015 at approximately 8:50 AM Resident #200 was sitting alone eating his/her meal, as the facility staff use the area as central location for sanitizing their hands and dispensing hand wipes to sanitize other residents hands prior to serving their meals. A face-to-face interview was conducted with Employee #8 on March 12, 2015 at approximately 09:00 AM regarding the aforementioned observation. Immediately, Employee #8 instructed staff to remove items from the residents table acknowledging the findings. The observation was made on May 12, 2015 at approximately 09:00 AM. 2. Facility staff failed to knock and await permission prior to entering Resident #157 ' s room during an isolated observation. On May 13, 2015 at approximately 10:30 AM Employee #35 entered Resident #157 ' s room without knocking. A face-to-face resident interview was in progress and Resident # 157 immediately stated this happens all the time . A face-to-face interview was conducted on May 13, 2014 with Employee # 8 at approximately 12:30 PM. A query was made regarding the facility's practice when needing to enter a resident ' s room. Employee # 8 stated They should have knocked and waited for permission prior to enter. The observation was made on May 13, 2015. 3. Facility staff failed to maintain Resident #162 ' s environment in which there were no signs posted in the resident ' s area in view of other residents and visitors which included personal information. A resident room observation was conducted on May 13, 2015 at approximately 9:40 AM. Two (2) signs were observed on the wall inside the resident room. The sign indicated Do not get up on your own . One of the sign was posted on the wall adjacent to the resident ' s bed and on the wall to the right of the bathroom door. Several observations were made during the survey period. A face-to-face interview was conducted with Employee #6 on May 22, 2015 at approximately 1:00 PM. After the observation Employee #6 acknowledged the observation and removed the signs. The observation was made on May 13, 2015. | 2017-02-01 |
| 1480 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 248 | D | 0 | 1 | X0E311 | Based on observation, record review staff and resident interview for one (1) of 37 sampled residents, it was determined that facility staff failed to provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and psychosocial well-being for Resident #19 who sat idle and not participating in activities. The findings include: A face-to-face interview was conducted with Resident #19 on May 12, 2015 at approximately 10:05 AM. The following questions were asked followed by the resident ' s response: Do the activities meet your interests? He/she replied, Some of them. Are the activities provided as often as you would like, including on weekends and evenings? He/she replied, Yes, but they are the same thing. Does staff provide items so you can do activities on your own, like books or cards? No On May 15, 2015 Resident #19 was observed sitting idle on Unit 2B in his/her wheel chair at the table where he/she eats his/her meal. The television was on however the volume low from on Friday May 15, 2015 from 10:00 AM - 1:00 PM. At no time was the resident offer an activity by the Certified Nurse Aides assigned to provide care on the unit. On Monday, May 18, 2015 at approximately 10:15 AM Employee # 6 was asked who was providing activities to the resident today. He/she stated, there is no activity aide on duty today (Monday, May 18, 2015), (he/she) worked the weekend. On Monday, May 18, 2015 from 10:15 AM to 11:30 AM; and from 2:00 PM to 4:30 PM. The resident was observed sitting idle at no time was the resident offer an activity by the CNAs on the unit. A face-to-face interview was conducted with Employee # 24 on Tuesday May 19, 2015 at approximately 11:15 AM. He/she stated, I was off on Friday (May 15, 2015) and Monday (May 18, 2015) . A face-to-face interview was conducted on May 21, 2015 at 10:26 AM with Employee # 28. At this time he/she was made aware of the concerns related to the lack of activities provided to Resident #19 on Unit 2B. Employee #28 acknowledged the findings. There was no evidence that while the resident sat idle on the unit that facility staff provided resident with activities on May 15 and 18, 2015. | 2017-02-01 |
| 1481 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 253 | E | 0 | 1 | X0E311 | Based on observations made during an environmental tour of the facility on May 15, 2015 at approximately 11:30 AM, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior as evidenced by broken slats from window blinds in three (3) of 45 resident's rooms, marred walls in five (5) of 45 resident's rooms, marred entrance doors in seven (7) of 45 resident's rooms, loose wallpaper in the hallways of unit 2B, paint peeling from the ceiling above the resident ' s bed, clear pieces of tape stuck in several areas in the ceiling of room #251 and a missing floor tile in the bathroom of room #251, one (1) of 45 resident's rooms surveyed. The findings include: 1. There was one (1) broken slat from one (1) of one (1) window blind in room #105, two (2) broken slats from one (1) of two (2) window blinds in room #144 and one (1) broken slat from one (1) of two (2) window blinds in room #249, three (3) of 45 resident's rooms surveyed. 2. Walls in five (5) of 45 resident's rooms were marred including rooms #123, #144, #237, #249 and #256 and entrance doors in seven (7) of 45 resident's rooms were marred including rooms #104, #105, #106, #115, #116, #202B and #207B. 3. The wallpaper hanging in the hallways of unit 2B was loose in several areas. 4. The paint was peeling off an area from the ceiling above the resident's bed in room #251B and there were multiple pieces of clear tape stuck to other areas in the ceiling, one (1) of 45 resident's rooms surveyed. 5. There was a floor tile missing in the bathroom of resident room #251 on May 19, 2015 at approximately 12:05 PM, one (1) of 45 resident's rooms surveyed. These observations were made in the presence of Employee #11 and Employee #12 who acknowledged the findings. B. Based on observation and staff interview for one (1) of 37 residents it was determined that facility staff failed to decrease the spread of disease causing organisms as evidence by oxygen tubing lying uncovered on the floor, oxygen bag with tubing inside lying on the floor. Resident #106 The findings include: A resident room observation was conducted on May 15, 2015 at approximately 10:00 AM. The following was observed: In a chair adjacent to the resident ' s bed, was a BiPAP (bi-level positive airway pressure) machine with a face mask and long hose attached. Portions of the hosing was observed uncovered on the floor in front of the chair; oxygen tubing connected to the portable oxygen tank with portions coming in contact with the floor; extra oxygen tubing covered in a plastic bag observed on the floor. A face-to-face interview was conducted on May 22, 2015 with Employee #6 at approximately 11:30 AM. A second observation was made in the room. The tubing from the BiPAP was observed on the floor; the oxygen tubing connected to the portable oxygen tank was observed on the floor, and the oxygen tubing within a bag was observed on the floor. Employee #6 acknowledged the findings. | 2017-02-01 |
| 1482 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 256 | D | 0 | 1 | X0E311 | Based on observation and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to ensure adequate lighting in the resident ' s room closet. Resident #106 The findings include: A resident room observation was conducted on May 15, 2015 at approximately 10:00 AM. The closet light bulb failed to illuminate when activated. A face-to-face interview was conducted with Employee #6 on May 22, 2015 at approximately 11:30 AM. Employee made an attempt to turn the light on by pulling the light string. The light did not illuminate. Employee #6 acknowledged the findings at the time of the observation. | 2017-02-01 |
| 1483 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 272 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A.Based on record review and staff interview for six (6) of 37 sampled residents, it was determined that facility staff failed to code the residents Quarterly (Minimum Data Set (MDS) for Other Health Conditions, to accurately complete the quarterly MDS to include a history of fall for two (2) residents; for one (1) resident who used a wheel chair for mobility and was admitted with an active [DIAGNOSES REDACTED]. Residents' #23, #125, #139, #161, #216 and #241. The findings include: 1. Facility staff failed to accurately code the quarterly MDS to include a history of fall's for Resident #23. Resident #23 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of an Incident Report dated February 10, 2015 revealed the following, Resident called, upon entering the room immediately after answering call, found resident sitting on the floor and leaning on wheel chair. Assessment conducted (he/she) verbalized sliding off the wheel chair. Denies pain, denies hitting head. ROM (range of motion) within normal limit, no apparent injury noted. Remain alert and oriented at this time. A review of the care plan initiated on February 12, 2015 revealed the following, Problem Statement - Resident was observed sitting on the floor on 2/10/2015. No injuries noted; Interventions and approaches - Resident will be transferred with a mechanical lift at all times by nursing staff, and will be assisted on a bed pan as needed. A review of the quarterly MDS dated [DATE] revealed the following: Under Section J (Health Conditions) the resident was coded for having no falls since admission/entry or reentry or prior assessment. A review of the medical record showed that facility staff did not accurately code the quarterly MDS to include a fall that the resident sustained [REDACTED]. An interview was conducted with Employee #6 on May 15, 2015 at 4:30 PM. He/she acknowledged the findings. 2. Facility staff failed to accurately code Resident #125's admission Minimum Data Set (MDS) for [DIAGNOSES REDACTED]. A review of the Quarterly MDS with an ARD (Assessment Reference Date) of February 16, 2015 revealed that facility staff failed to accurately code Section I, Active [DIAGNOSES REDACTED]. The check boxes allotted next to the Sections were left blank indicating that the resident was not coded for the above diagnoses. A review of the History and Physical record for resident #125 60 day review dated September 24, 2014 revealed a note under HPI (History of Present Illness) that reads .[MEDICAL CONDITION], Fe (iron) deficiency [MEDICAL CONDITION] and HLD (Hyperlipedemia) . A face-to-face interview was conducted on May 18, 2015 at approximately 2:30 PM with Employee #15. He/she acknowledged the findings. The record was reviewed May 18, 2015. 3 (a).Facility staff failed to accurately code Resident #139's Admission MDS dated [DATE] under Section G, Mobility Devices. A review of Resident #139 ' s clinical record revealed that he/she was admitted to facility on November 24, 2014. The admissions observation comments stated gait unsteady . (Gender) is up in wheel chair at this time in dining room for dinner . A review of the resident ' s Admission MDS with an Assessment Reference Date (ARD) of December 5, 2014 revealed that the MDS was coded Z. None of the above were used , in response to the question in Section G 0400 (Mobility Devices) Check all that were normally used; cane/crutch, walker, wheelchair, limb prosthesis, none of the above were used . A face-to-face interview was conducted with Employee # 30 at approximately 11:00 AM on May 22, 2015. After reviewing the MDS, the employee acknowledged the findings. The record was reviewed on May 22, 2015. 3(b). Facility staff failed to accurately code Resident #139's Admission MDS dated [DATE] under Section I, Active Diagnoses. A review of Resident #139 ' s clinical record revealed that he/she was admitted to facility on November 24, 2014. The admission history and physical dated November 25, 2014 revealed, [AGE] year old .with PMH of HTN( Hypertension),DM( Diabetes Mellitus), [MEDICAL CONDITIONS] and dementia, who was admitted to hospital recently with confusion, found to have UTI (Urinary Tract Infection) . A review of the Interim Order form dated November 25, 2014 at 12:30 PM revealed [MEDICATION NAME] [PHONE NUMBER] 1(one) tab(tablet) po (by mouth) BID (two times a day) through November 26, 2014 first dose now for UTI . A review of the nursing admissions observation section, Infections: Did Resident have any infections- Urinary Tract was checked. A review of the resident ' s Admission MDS with an Assessment Reference Date (ARD) of December 5, 2014 revealed that the MDS was not coded under section I (Infections) urinary tract infections [MEDICAL CONDITION] (Last 30 days) to indicate the resident was admitted with a urinary tract infection. A face-to-face interview was conducted with Employee #30 at approximately 11:00 AM on May 22, 2015. After reviewing the MDS, the employee acknowledged that the resident ' s MDS was not coded for resident ' s urinary tract infection. The record was reviewed on May 22, 2015. 4. Facility staff failed to accurately code Resident #161's admission Minimum Data Sets (MDS) for Toileting Program). This was a closed record review. A review of the Quarterly MDS with an ARD (Assessment Reference Date) of February 26, 2015 revealed facility staff failed to accurately code Section H, Bladder and Bowel - H0200 Urinary Toileting Program, A review of the care plan initiated January 12, 2015 revealed under Urinary Incontinence approaches Toilet Program: Toilet resident upon rising, after meals, before bedtime, and ask/offer resident toilet throughout the day The check box allotted next to Section H0200C - Current toileting program or trial was left blank indicating that the resident was not coded for Toileting Program. A face-to-face interview was conducted on May 15, 2015 at approximately 1:30 PM with Employee # 15. He/she acknowledged the findings. The record was reviewed May 15, 2015. 5a.Facility staff failed to code Resident #216 ' s quarterly MDS Section J110 Shortness of Breath. A review of the quarterly MDS with an Assessment Reference Date of February 13, 2015 revealed Section J110. Shortness of Breath (dyspnea) was coded (z) none of the above. A review of the Progress Notes Dated February 13, 2015 10:30 AM revealed Acute Visit - pt (patient) noted to have difficulty breathing shortly after having (hin/her) breakfast. Pt (patient) states (he/she) was sitting upright while eating and recalls what (he/she) had . A face-to-face interview was conducted with Employee #6 who acknowledged the finding. 5b. Facility staff failed to code Resident #216 Significant Change MDS Section J1400 Prognosis. A review of the Significant Change MDS with and Assessment Reference Date of March 14, 2015 revealed J1400 Prognosis (Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 (six) months? (Requires physician documentation) was coded 0 No. A review of the Physicians Order Sheet signed by the physician on May 11, 2015 revealed that the physician direct the following: Order date March 6, 2015, Start date March 6, 2015, Order Details: admit to hospice 1 (one) time per day during day. A review of the Interdisciplinary Progress Notes dated 3/6/15 (March 6, 2015) no time indicated revealed, A/P (Assessment/Plan) (3) End Stage Parkinson - admit to hospice. A review of the Progress Notes By Resident 3/8/15 23:07 revealed Comments: General Terminal Illness comments = alert and verbally responsive .Hospice Nurse visited this evening. A review of the Hospice (facility Sign-In Sheet) revealed a hospice representative visited the resident on March 9, and 12, 2015 as evidenced by a signature on the corresponding lines. A review of the Progress Notes by Resident 3/14/15 22:32 revealed Comments: General Terminal Illness Comments = Resident continue on hospice care no changes in mental status noted . A face-to-face interview was conducted with Employee #6 May 21, 2015 at approximately 11:00 AM . He/she acknowledged the findings. Facility staff failed to code Resident #216 Significant Change MDS Section J1400 Prognosis. 6. Facility staff failed to identify pressure ulcer dimensions on the Admissions MDS: Skin Condition s for Resident #241 with a stage 3 pressure ulcer. The facility staff failed to identify pressure ulcer dimensions on the admissions MDS (Minimum Data Set). A review of the Skin Condition Report with Images revealed that the resident was admitted on [DATE] 12:25 AM with a sacral pressure ulcer wound 6x7x0cm (centimeters.) A review of admissions MDS with an Assessment Reference Date of January 6, 2015 revealed: Section M Skin Conditions; M0610. Dimensions of Unhealed stage 3 or 4 pressure Ulcers or Eschar .if the resident has one or more unhealed stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar, identify the pressure ulcer with the largest surface area (length x width) and record in centimeters: 3.0 cm A. Pressure ulcer length: longest length from head to toe; 1.0 cm B. Pressure ulcer width of the same pressure ulcer, side-to-side perpendicular (90 degree angle) to length; 0.9 cm C. Pressure ulcer depth: Depth of the same pressure ulcer from the visible surface to the deepest area (if depth is unknown, enter a dash in each box.) A face-to-face interview was conducted on May 21, 2015 with Employee #30 at approximately 11:30 AM regarding the location of information pertaining to the dimensions of the sacral ulcer. Employee #30 indicated that the dimensions were consistent with what the nurse measured, however he/she failed to change it in the computer after obtaining the measurements. The facility staff failed to identify pressure ulcer dimensions on the admissions MDS. B.Based on record review and staff interview for four (4) of 37 sampled residents, it was determined that facility staff failed to identify the location and date of the Care Area Assessment (CAA) information on the admission, annual or significant change Minimum Data Sets (MDS) under Section V0200A for four (4) residents. Resident ' s #139, 200, 208, 216 and 236. The findings include: According to Chapter 4 of the MDS 3.0 Users ' Manual, for each triggered care area, indicate the date and location of the CAA documentation .CAA documentation should include information on the complicating factors, risks and any referrals for the resident for this care area . 1. Facility staff failed to identify the location and date of Care Area Assessment (CAA) information under Section V (V0200A), Care Area Assessment Summary of the admission Minimum Data Set (MDS) for Resident #139. A review of Resident #139 ' s admission MDS with an Assessment Reference Date (ARD) of December 05, 2014 revealed that Care Area Triggered and the Care Planning Decision Area selected were, #2 Cognitive Loss/Dementia, #3 Visual Function, #5 ADL (Activities of Daily Living) Functional Status, #6 Urinary Incontinence / Catheter, #11 Falls, #12 Nutrition, #15 Dental Care, and #16 Pressure Ulcers. The record revealed that the location and date of CAA information for care areas (#2, 3, 5, 6, 11, 12, 15, and 16) were recorded as CAA Analysis -(Employee Name)12/06/14. There was no evidence that facility staff documented the date and location where in the clinical record the information related to the triggered areas could be found. A face-to-face interview was conducted with Employee #30 on May 22, 2015 at 10:00 AM. He/she acknowledged the findings. The record was reviewed May 22, 2015. 2. Facility staff failed to identify the location and date of Care Area Assessment (CAA) information under Section V (V0200A), Care Area Assessment Summary of the admission Minimum Data Set (MDS) for Resident #200. A review of Resident #200 ' s admission MDS with an Assessment Reference Date (ARD) of November 25, 2014 revealed that Care Area Triggered and the Care Planning Decision Area selected were #5 ADL (Activities of Daily Living) Functional Status, #6 Urinary Incontinence / Catheter, #11 Falls, #12 Nutrition, #15 Dental Care, and #16 Pressure Ulcer. The record reflects that the location and date of CAA information for care areas (# 5, 6, 11, 12, 15, and 16) were recorded as CAA Analysis - (employee name) 11/26/14. There was no evidence that facility staff documented the date and location where in the clinical record the information related to the triggered areas could be found. A face-to-face interview was conducted with Employee #30 on May 22, 2015 at approximately 10:00 AM. He/she acknowledged the findings. The record was reviewed May 22, 2015. 3.Facility staff failed to identify the location and date of Care Area Assessment (CAA) information under Section V (V0200A), Care Area Assessment Summary of the admission Minimum Data Set (MDS) for Resident #208. A review of Resident #208 ' s admission MDS with an Assessment Reference Date (ARD) of March 04, 2015 revealed that Care Area Triggered (and) the Care Planning Decision Area selected were #2 Cognitive Loss/Dementia, #4 Communication, #7 Psychological, #9 Behavioral , #12 Nutrition, and #19 Pain. The record reflects that the location and date of CAA information for care areas (#2, 4, 7, 9, 12, 12, and 19) were recorded as CAA Analysis . . There was no evidence that facility staff documented the date and location where in the clinical record the information related to the triggered areas could be found. A face-to-face interview was conducted with Employee #30 on May 22, 2015 at approximately 10:00 AM. He/she acknowledged the findings. The record was reviewed May 22, 2015. 4. Facility staff failed to identify the location and date of Care Area Assessment (CAA) information under Section V (V0200A), Care Area Assessment Summary of the admission Minimum Data Set (MDS) for Resident #236. A review of Resident #200 ' s admission MDS with an Assessment Reference Date (ARD) of December 25, 2014 revealed that Care Area Triggered and the Care Planning Decision Area were selected for#2 Cognitive Loss, #5 ADL (Activities of Daily Living) Functional Status, #6 Urinary Incontinence / Catheter,# 7 Psychological Well-being,#9 Behavioral Symptoms, #11 Falls, and #16 Pressure Ulcer. The record reflects that the location and date of CAA information for care areas (# 2, 6, 7, 9, 12, and 16) were recorded as CAA Analysis - (Employee Name) There was no evidence that facility staff documented the date and location where in the clinical record the information related to the triggered areas could be found. A face-to-face interview was conducted with Employee #30 on May 22, 2015 at approximately 10:00 AM. He/she acknowledged the findings. The record was reviewed May 22, 2015. | 2017-02-01 |
| 1484 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 279 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to develop a care plan with goals and approaches for one (1) resident ' s [DIAGNOSES REDACTED].# 4 The findings include: Facility failed to develop a care plan with goals and approaches for the care of a resident diagnosed with [REDACTED].#4 A review of the physician's order [REDACTED]. A review of the plan of care for Resident #4 lacked evidence that a care plan with goals and approaches was developed to address resident #4 ' s [DIAGNOSES REDACTED]. A face-to-face interview with Employee #6 was conducted on May 19, 2015 at approximately 3:00 PM. He/she reviewed the care plans and acknowledged that a care plan for [MEDICAL CONDITION] was not initiated for Resident #4. The record was reviewed on May 19, 2015. | 2017-02-01 |
| 1485 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 280 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 37 sampled residents, it was determined that facility staff failed to review and revise resident care plans to reflect an integrated approach with the participation of hospice, the facility, and the resident or representative to the extent possible for (2) residents; and to address one (1) resident ' s activity needs. Residents ' #109, 120 and 216. The findings include: 1.Facility staff failed to review and revise Resident # 109 ' s care plan for hospice to reflect an integrated approach with the participation of hospice, the facility and the resident or representative to the extent possible. A review of the Physician order [REDACTED].`April 2015 directed: Admit to Hospice for End Stage [MEDICAL CONDITION] (Chronic Obstructive [MEDICAL CONDITION]) start date (November 11, 2014). A review of the residents care plan revealed a care plan for Resident is Hospice Care with goals and approaches initiated February 10, 2015. However, the care plan lacked specific identification of the disciplines responsible for the approaches/interventions with hospice, the facility, resident or the responsible party. Facility staff failed to review and revise the resident ' s care plan for hospice to reflect an integrated approach with the participation of hospice, the facility and the resident or representative to the extent possible. The record was reviewed on May 22, 3015. 2. Facility staff failed to updated the care plan with appropriate goals and approaches to address the resident ' s activity needs for Resident #120. A review of the clinical record revealed that the Activities care plan was last updated on May 3, 2015. Revealed Problems: Patient is in an adjustment period due to recent admission to facility for rehab service. However, Resident #120 was admitted to the facility on [DATE] and has resided in the facility for approximately two years. In addition, the Evaluation of goals and approaches related to the activity problem was s last updated on February 15, 2014. A face-to-face interview was conducted with Employee# 24 on May 19, 2015 at 11:15 AM. He/she stated, I give (him/her) the choice in the morning by letting (him/her) know what the activities are for the day .The last thing (he/she) went to was happy hour . (He/she) goes outside and collects the tennis balls that the schools hit over. (He/she) likes to read and (he/she) stays to (him/herself) a lot of the time. There was no evidence that the care plan was updated to include current goals and approaches to address the resident ' s activities needs. During the aforementioned face-to-face interview with Employee # 24, he/she acknowledged the findings. The record was reviewed on May 19, 2015. 3.Facility staff failed to review and revise Resident #216 ' s care plan for hospice to reflect an integrated approach with the participation of hospice, the facility and the resident or representative to the extent possible. A review of the Physician order [REDACTED]. A review of the residents care plan revealed a care plan for death with dignity, comfort and support care plan with goals and approaches initiated March 6, 2015. However, the care plan lacked specific identification of the disciplines responsible for the approaches/interventions with hospice, the facility, resident or the responsible party. A face-to-face interview was conducted on May 22, 2015 with Employee #6 at approximately 11:30 AM. After review of the care plans he/she acknowledged the findings. Facility staff failed to review and revise Resident # 216's care plan for hospice to reflect an integrated approach with the participation of hospice, the facility and the resident or representative to the extent possible. The record was reviewed on May 21, 2015. | 2017-02-01 |
| 1486 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 282 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to implement toilet training as scheduled for one (1) resident with urinary incontinence. Resident #139 . The findings include: 1. Facility staff failed to follow toileting program for Resident # 139. A review of the resident's clinical record revealed that Resident #139 ' s Admission Observation Form dated November 24, 2014 revealed that the resident was occasionally incontinent of bowel and bladder and was on a urinary toileting program. A review of the Incontinent of urine care plan dated March, 10, 2015 revealed the following: Toileting Program: toilet resident upon rising, after meals, before bedtime, and ask/offer resident toilet throughout the day. A review of the residents Bowel & Bladder Risk assessment dated [DATE] revealed: Bladder Control Status as occasionally incontinent, Score 8 (Moderate Restorative Potential), 04/03/2015 Toileting programs selected (none were indicated) A review of the ADL Recordings by resident dated March 31 through - April 28, 2015 revealed resident was not toileted as care planned after meals upon rising and at bedtime. The scheduled unit meal times were as follows: 7:30 AM Breakfast 12:15 PM Lunch 4:30 PM Dinner A review of the ADL Recordings by Resident (Activities of Daily Living) for dates May 1, 2015 through May 14, 2015 revealed Resident # 139 was toileted at the following times: May 1, 2015 -7:05 PM May 2, 2015 -2:07 AM 10:58 AM/8:01 PM May 3, 2015 2:07 AM/10:52 AM/7:32 AM May 4 2015-2:18 AM/2:16 PM/7:33 PM May 5, 2015 -2:15 PM-8:37PM May 6, 2015-3:05 AM-2:33 PM-8:36 PM-2:33AM- May 7, 2015 2:39 PM/8:39 PM- May 8, 2015 10:48 AM- 8 12PM/*:16 PM/ May 9, 2015 12:15 PM-10:06 PM- May10, 2015 12:59 PM-1:49 PM-8:47 PM May 11, 2015 - 2;42 AM 2:45 PM-7:30 PM May 12, 2015-2:55 AM-2:09 PM-8:04 PM- May 13, 2015-2:19 AM 9:36 PM May 14, 2015- 2:35 AM 1:46 PM There was no evidence the facility staff addressed and modified Resident # 139 ' s toilet training schedule as the residents need changed based on is cognitive status. A face-to-face interview was conducted with Employee #34 at approximately 10:00 AM on May 21, 2015. The employee was queried regarding the residents toileting schedule he/she stated Resident #139 does not follow instructions well and does not always listen when asked to go to toilet. A face-to-face interview was conducted with Employee #5 at approximately 1:00 PM on May 21, 2015. The employee was queried regarding the toileting training program not being followed as scheduled. He/she acknowledged aforementioned findings. The record was reviewed on May 21, 2015. | 2017-02-01 |
| 1487 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 309 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for four (4) of 37 sampled residents, it was determined that facility staff failed to ensure that an initial nursing assessment for hospice was a part of the residents clinical active file for two (2) residents; assess for pain, monitor effectiveness of pain medication, and modify the approaches to pain as necessary for one (1) resident; ensure that the physician's order [REDACTED]. Residents #109, #120 #125 and #216. The findings include: 1.Facility staff failed to ensure that the initial nursing assessment for hospice was a part of Resident #109 active clinical file. A review of the Physician order [REDACTED]. Further review of the clinical record lacked evidence of the Admission-Initial and Comprehensive Assessment. A face-to-face was conducted on May 21, 2015 at approximately 11:00 AM with Employees #6, 17, 18, and 19. After review of the A review of the clinical all acknowledged the finding. 2. Facility staff failed to assess for pain, monitor effectiveness of pain medication, and modify the approaches to pain as necessary for Resident #120. Resident #120 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Resident #120 on May 18, 2015 at 11:50 AM. The resident stated, Right now my pain is a 6/10 (range 0 is the lowest and 10 is the highest). I always have pain. The medication helps but it doesn ' t relieve the pain. The nurses don ' t ask me if I am in pain. This interview was held in the presence of Employee #6. A review of the quarterly MDS dated [DATE] section J0300 (Pain Presence) Have you had pain or hurting at any time in the last 5 days? The section was coded as No . Section I8000 (Additional active diagnoses) is coded for other Chronic pain. A review of the clinical record revealed a care plan updated on May 3, 2015 for Pain Management. The Problem is alteration in comfort related chronic pain (lower extremities). Resident has a history of Cellulites, right foot plantar ulcer, and [MEDICAL CONDITION]. A review of the electronic physician's order [REDACTED]. Order and Start date March 14, 2015, [MEDICATION NAME] 500 mg give 2 tablets by mouth 3 times per day; Order and Start date March 16, 2015, [MEDICATION NAME] 10 mg give 1 tablet by mouth 3 times per day at 06:00, 14:00, 22:00 for pain; Order and Start date March 16, 2015, [MEDICATION NAME] 5 mg give 1 tablet by mouth 1 time per day at 06:00 for diabetic [MEDICAL CONDITION]; Order and Start date March 16, 2015, [MEDICATION NAME] 5 mg give 1 tablet by mouth 1 time per day at 22:00 for pain A review of the March, April and May 2015 Medication Administration Records revealed that the resident received [MEDICATION NAME] 500 mg, [MEDICATION NAME] 10mg and 5 mg as per the physician's order [REDACTED].>Review of the nursing notes from March 16, 2015 to May 21, 2015 revealed pain assessments that contained inconsistent /inaccurate information for example: Pain assessment for March 18, 2015 Cancer pain: Controlled by current interventions. The resident did not have a medical [DIAGNOSES REDACTED].>Pain assessment for March 19, 2015 Cancer pain: Levels unchanged in the last 6 months controlled by current interventions. The resident did not have a medical diagnosis Observation: Chronic pain level=0/10 Pain perceived as an ache, but pain level is recorded as 0/10 Pain related to chronic process osteo[DIAGNOSES REDACTED] Pain assessment for April 7, 2015 History noted as cardiovascular pain, pain from emotional psychological distress Pain is recorded as intermittent pain in the leg Observation reveals that resident verbalizes pain, chronic pain level 0/10 relieved by medication Pain assessment for May 3, 2015 Cancer pain: Levels unchanged in the last 6 months controlled by current interventions. The resident did not have a medical diagnosis Observation: Chronic pain level=0/10 Pain perceived as an ache, but pain level is recorded as 0/10 Pain related to chronic process osteo[DIAGNOSES REDACTED] There is no evidence that facility staff consistently and accurately assessed Resident #120 ' s level of pain. A face-to-face interview was conducted with Employee #6 on May 18, 2015 at approximately 12:30 PM. He/she acknowledged the findings. The record was reviewed on May 20, 2015. 3a Facility staff failed to ensure that the physician's order [REDACTED]. Resident #125 A review of the Physician order [REDACTED]. A review of ETAR (electronic treatment record) Report for the month of January, 2015 lacked evidence that the order Treatment staff for functional/maintenance program and foot brace to be worn on left foot for 1 hour as tolerated each day was carried over and was documented as discontinued. A face-to-face interview was conducted on May 20, 2015 at approximately 10:30AM with employee #4. He/she acknowledged the findings. The record was reviewed on May 20, 2015. 3b. Facility staff failed to ensure physician orders [REDACTED]. Resident #125 A review of the physician order [REDACTED]. Several observations on the following days May 18, 19 and 20, 2015 of resident #125 sitting in her wheel chair with foot on leg rest revealed that he/she was not wearing socks and not Ted stockings in accordance with the physician order. A review of ETAR (electronic treatment record) Report for the month of May, 2015 lacked evidence that the order Knee High Ted Stockings on in AM 1 time per day, was documented as discontinued. A face-to-face interview was conducted on May 20, 2015 at approximately 10:30AM with employee #4. He/she acknowledged the findings. The record was reviewed on May 20, 2015. 4. Facility staff failed to ensure that the initial nursing assessment for hospice was a part of Resident #216 active clinical file. A review of the Physician order [REDACTED]. Further review of the clinical record lacked evidence of the Admission-Initial and Comprehensive Assessment. A face-to-face was conducted on May 21, 2015 at approximately 11:00 AM with Employees #6, 17, 18, and 19. After review of the A review of the clinical all acknowledged the finding. | 2017-02-01 |
| 1488 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 312 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to ensure that Resident #55, who is unable to carry out activities of daily living the necessary services received grooming to his/her face and nails. The findings include: According to the annual Minimum Data Set, dated dated dated [DATE] Resident #55 was coded as totally dependent with one (1) person physical assistance in personal hygiene under Section G110 Activities of Daily Living (ADL) Assistance. The resident ' s [DIAGNOSES REDACTED]. On May 13, 2015 at approximately 3:11 PM Resident #55 was observed in the dayroom/television room seated in a recliner chair. His/her chin had gray hair on both sides and his/her finger nails on the left hand were observed with a dark substance underneath the nail beds. Employee #6 was present at the time of the observation and acknowledged the findings. There was no evidence that facility staff carried out activities of daily living necessary to maintain good grooming for Resident #55. | 2017-02-01 |
| 1489 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 314 | G | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview it was determined facility staff failed to notify a resident ' s physician/nurse practitioner when a new wound was identified at Stage III and failed to obtain orders for the immediate care and treatment of [REDACTED]. Resident #23. The findings include: Through staff interview it was determined facility staff observed a new wound on Resident # 23 ' s left buttock on the weekend of May 9 to 10, 2015; however, notification to a physician or nurse practitioner was not made. Treatment orders for management of the wound were initiated on May 13, 2015 (approximately 4 days later) after the area was assessed as a stage 3 pressure ulcer during routine wound rounds by the Nurse Practitioner. On May 13, 2015 (Wednesday) incontinence care was observed for Resident #23. It was noted that the resident had two (2) dressings on his/her left buttock and one (1) on the right buttock all initialed by a licensed nurse and dated May 12, 2015. A review of the most recent Skin Condition Report dated May 4 and 7, 2015 revealed that Resident #23 had two (2) wounds: left buttock (abscess) and right buttock (abrasion). There was no documentation of a second skin integrity concern on the left buttock as observed on May 13, 2015. Subsequent to the observation of incontinence care on May 13, 2015 the following progress notes were recorded. An Interdisciplinary Progress Note dated May 13, 2015 at 11:15 AM, by the Nurse Practitioner Student revealed the following, . Pt. (patient) has not been out of bed .Skin breakdown - wound care rounds - new orders. L (left) Buttock abscess 2 x 1 x .01cm healing; R (right) buttock 1.5 x 2.5 x .01 cm unstageable, L buttock Stage III 2 x 1 x .01cm .ordered alternating pressure mattress . A review of the Nurse Practitioner ' s note dated May 13, 2015 (no time indicated) revealed, . Abscess to L butt is healing s/p antbx (antibiotics) - has new pressure ulcers - will order alternating pressure mattress and PT (physical therapy) to evaluate seating for new cushions. Skin Condition Reports A review of facility documents revealed licensed nurses conducted and recorded wound/skin assessments weekly on a form entitled Skin Condition Report Without Images. The Skin Condition Report Without Images for Resident #23 was reviewed for the period of May 1 - 13, 2015. The (wound/skin) forms lacked evidence of a wound assessment related to the ' new ' alteration in skin integrity that was initially observed on May 9, 2015. The alteration in skin integrity identified as one (1) of two wounds on the left buttocks was assessed by the Nurse Practitioner during routine scheduled wound rounds on Wednesday, May 13, 2015 wherein the wound was initially assessed at an advanced stage 3 (full thickness tissue los .slough may be present but does not obscure the depth of tissue loss .). Physician Orders On May 13, 2015 (time not recorded) Ulcers to bilateral buttocks . New treatment 1 time per day at 09:00, . clean ulcers with NS (normal saline) pat dry, cover with Sratasorb daily. The prior physician orders for wound care were as follows: May 11, 2015 - Right Buttock clean with NS, pat dry apply [MEDICATION NAME] dressing every Monday and Thursday and PRN. On April 30, 2015 for the left buttock (note only one (1) wound identified on the Skin Condition Report at the time of this order) three times a day during day, evening, night - warm compress from the store room, apply 15 minutes. Staff Interviews A face-to-face interview was conducted with Employee #22 (Certified Nurse Aide) on May 15, 2015 at approximately 3:40 PM. He/she stated, I observed three (3) areas on the resident this weekend (May 9, and 10, 2015). A face-to-face interview was conducted with Employees # 20 and 29 (License Practical Nurses) on May 15, 2015 at approximately 3:43 PM. Both employees stated, Noticed the area a few days ago. Treated the new area on the left buttocks the same as the other areas. It looked the same. Treated it with warm compress and dry dressing. A face-to-face interview was conducted on May 15, 2015 at 3:45 PM with Employee #6. He/she reviewed the physician ' s orders and acknowledged that there was no order to treat three (3) open areas on the resident ' s buttocks. The resident ' s care needs are documented as dependent care and has incontinence on the most recent Minimum Data Set (MDS). A review of the quarterly MDS dated [DATE] revealed the following: Under Section G (Functional Status) the resident required extensive assistance for Bed mobility, Transfers, Toilet Use, and Personal hygiene, two plus persons physical assist. Under section H (Bladder and Bowel) the resident was coded as being frequently incontinent of bladder and bowel; Under section M (Skin Conditions), in response to the question is this resident at risk for developing pressure ulcers the resident was coded as no. Under Skin and Ulcer Treatments the resident is coded for pressure reducing device for bed, turning/repositioning program, applications of ointments/medications other than to feet. Through staff interview it was determined that a second wound on the left buttock (the area superior to the abscess/furuncle on the left buttock) was first observed on May 9, 2015 by facility staff. Four (4) days lapsed without physician and/or nurse practitioner assessment and treatment orders. The record was reviewed on May 22, 2015. | 2017-02-01 |
| 1490 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 323 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made on during the survey, it was determined that facility staff failed to ensure resident ' s environment was free of accident hazards as evidenced by a electric space heater observed in one (1) residents room; an extension cord observed in use to supply power to the fish tank on unit 2B, a wood plank lifted from the floor in the hallway of the nursing unit and a splintered headboard that was attached to the wall in one resident's room. The findings include: 1. On May 18, 2015 at 10:50 AM, a space heater was observed on the floor of the resident ' s room between the bed and the window. The heater was plugged into the wall and actively circulating warm air about the room in one (1) of one (1) space heater observed. Employee #6 was present at the time of the observation and acknowledged the finding. 2. On May 13, 2015 at approximately 2:30 PM a extension cord was observed plugged in to the wall and to the fish tank located on unit 2B. This observation was made in the presence of Employee # 12, who acknowledged the finding. 3. On May 13, 2015 at 11:00 AM a wood plank was observed lifted from the floor in the hallway nearby the storage closet on unit 2B. Employee #6 was present at the time of the observation and acknowledged the findings. 4. On May 13, 2015 a headboard attached to the wall in one (1) residents room was observed to be splintered. A tour of Resident #162's room was conducted on May 13, 2015 at approximately 10:30 AM. It was observed that the wall in the resident ' s room adjacent to the residents bed (towards the foot of the bed) was splintered wood. A face-to-face interview was conducted with Employee #6 on May 22, 2015 at approximately 11:30 AM. After making an observation of the room, he/she acknowledged the findings. B. Based on observation, record review, and staff and resident interview it was determined that facility staff failed to keep resident free from falls as evidenced by failure to transfer resident in accordance with the plan of care using two (2) persons and a mechanical lift. The findings include: Resident #23 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of an Incident Report dated February 10, 2015 revealed the following, Resident called, upon entering the room immediately after answering call, found resident sitting on the floor and leaning on wheel chair. Assessment conducted (he/she) verbalized sliding off the wheel chair. Denies pain, denies hitting head. ROM within normal limit, no apparent injury noted. Remain alert and oriented at this time. Review of the care plan initiated on February 12, 2015 revealed the following, Problem Statement - Resident was observed sitting on the floor on 2/10/2015. No injuries noted; Interventions and approaches - Resident will be transferred with a mechanical lift at all times by nursing staff, and will be assisted on a bed pan as needed. A review of the quarterly MDS dated [DATE] revealed the following: Under Section G (Functional Status) the resident required extensive assistance for Bed mobility, Transfers, Toilet Use, and Personal hygiene, meaning the resident was involved in activity, staff provides weight bearing support, two (2) plus persons physical assist. Under section H (Bladder and Bowel) the resident was coded as being frequently incontinent of bladder and bowel meaning 7 or more episodes of urinary incontinence, but at least on episode of continent voiding. Under section J (Health Conditions) the resident was coded for having no falls since admission/entry or reentry or prior assessment. Review of the nursing note dated April 15, 2015 revealed the following, .Resident was transferred from unit #(unit letter) to (unit number) today during morning shift. Alert and verbally responsive. Denied pain and breathing normal. Resident is dependent with ADLs two (2) person assist and transfer by Hoyer lift . A review of the nursing note dated April 16, 2015 revealed, General Pain Comments -Writer was called into room (room number) at 10 AM. Staff explained that resident told (him/her) (that) (he/ she) can walk to the toilet, staff assisted resident to the toilet .Upon assisting resident to the chair (he/she) slid to the floor in front of the toilet. No injury sustained. Resident was assisted to (his/her chair). Denies pain/discomfort. There is no evidence that facility staff followed the plan of care which stated that the resident was a two person assist with a Hoyer lift, for safe transfer and toileting. A face-to-face interview was conducted on May 15, 2015 at 3:43 PM with Employee #6. He/she also stated, The (certified nurse aide) should have asked for help when transferring the resident from the commode. The record was reviewed on May 15, 2015. Based on an observation made on May 11, 2015 at approximately 3:00 PM and on May 15, 2015 at approximately 11:30 AM, it was determined that the facility failed to ensure that it was free of accident hazards as evidenced by one (1) of one (1) oxygen tank stored unsecured in one (1) of 45 resident ' s rooms (#324B) and a loose, in use extension cord located on the floor of room #211, one (1) of 45 resident rooms surveyed. The findings include: 1. An oxygen tank was observed in room #324B, on the floor and unsecured, one (1) of 45 resident ' s rooms surveyed. 2. An extension cord was observed in use, on the floor of room #211, one (1) of 45 resident ' s rooms surveyed. These observations were made in the presence of Employee #11 and Employee #12 who acknowledged the findings. | 2017-02-01 |
| 1491 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 329 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to clarify the indication of use for the medication [MEDICATION NAME] ([MEDICATION NAME]) with the physician. Resident #133 The findings include: Facility staff failed to clarify the indication of use for the medication [MEDICATION NAME] with physician. Resident #133 During an Unnecessary Medication Review, it was noted on the Interim Order Form signed and dated April 7, 2015 that Resident #133 was placed on MPAP ([MEDICATION NAME] Extra Strength) Tablet 500mg, Give 2 tablets by mouth every eight hours at 06:00, 14:00, 22:00, for [MEDICAL CONDITION] A review of Admission and Annual Physical Examination Form signed and dated August 15, 2014 revealed the following [DIAGNOSES REDACTED]. A review of the Interdisciplinary progress note revealed Resident #133 ' s 60 day review dated April 6, 2015 at 1:40PM reads as follow: HIV,[MEDICAL CONDITIONS], CKD stage 2, HTN, Frequent falls, (R) tib/fib fracture s/p (status [REDACTED].#6 reads Back pain + (positive), pt (patient) c/o (complain of) mild intermittent achy pain, start scheduled Tylenol Q (every) 8 hours. A review of the Minimum Data Set (MDS) dated [DATE] revealed in Section 1 Active [DIAGNOSES REDACTED]. Review of the EMAR (Electronic Medication Administration Record) for the month of April, 2014 revealed electronic order for [MEDICATION NAME] 500mg: Give 2 tablets by mouth every eight hours (from Pharmacy) at 06:00, 14:00, 22:00, for [MEDICAL CONDITION]; from Nurse practitioner, order enter by registered nurse. The medical record lacked evidence of facility staff clarifying the indication for use of the MPAP with the physician's for a [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee #4 on May 20, 2015 at approximately 2:30 PM. After review of the above, Employee #4 acknowledged the findings. The record was reviewed on May 20, 2015. | 2017-02-01 |
| 1492 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 364 | D | 0 | 1 | X0E311 | Based on observation and resident interview for one (1) of 37 sampled residents, it was determined that a resident was served food that was palatable and attractive, as evidenced by failure to ensure that the Resident #19 received a breakfast meal that taste good an looked appetizing. The findings include: A face-to-face interview was conducted with Resident # 19 on May 12, 2015 at approximately 10:17 AM. The resident was asked, Does the food taste good and looks appetizing? He/she replied, No indeed. The resident was observed having his/her breakfast on May 21, 2015 at 9:50 AM. The resident was asked how your breakfast is. He/she replied by shaking his/her head, then touched the banana and said it ' s (the banana) rotten. On the resident ' s plate was, the edge of toast, a half eaten boiled egg, and an off white and deep brown colored banana. This observation was made in the presence of Employee #6 who acknowledged the findings. | 2017-02-01 |
| 1493 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 371 | E | 0 | 1 | X0E311 | Based on observations made on May 11, 2015 at approximately 9:15 AM, it was determined that the facility failed to prepare and store food under sanitary conditions as evidenced by foods such as one (1) of four (4) bags of cheddar cheese, one (1) of one (1) pan of tomato, ham and turkey breast chunks, one (1 ) of one (1) pan of roast beef slices, one (1) of one (1) pan of chopped meat, one (1) of one (1) pan of noodles and carrots slices, one (1) of one (1) pan of shredded lettuce and one (1) of one (1) pan of onions and celery slices that were stored in the walk-in refrigerator undated, a soiled floor in the main kitchen, dry food storage and dishwashing area, two (2) of two (2) convection ovens that were soiled on the inside and outside and one (1) of one (1) plate warmer with clean plates that was left uncovered. The findings include: 1. One (1) of four bags of cheddar cheese, one of (1) pan of tomato, ham and turkey breast chunks, one (1 ) of one (1) pan of roast beef slices, one (1) of one (1) pan of chopped meat, one (1)of one (1) pan of noodles and carrots slices, one (1) of one (1) pan of shredded lettuce and one (1) of one (1) pan of onions and celery slices were stored in the walk-in refrigerator undated. 2. The entire kitchen floor, including the floor in the dry food storage area and in the dishwashing area was marred, scarred and discolored. 3. The inside and the outside of two (2) of two (2) convection ovens were soiled. 4. One (1) of one (1) plate warmer with clean plates was observed uncovered in the main kitchen. These observations were made in the presence of Employee #9 and/or Employee #10 who acknowledged the findings. | 2017-02-01 |
| 1494 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 428 | D | 0 | 1 | X0E311 | Based on record review and staff interview for one (1) of 37 sampled residents, it was determined that the facility failed to maintain a resident ' s highest practicable level of functioning related to medication therapy to the extent possible as evidenced by its failure to provide a licensed pharmacist's review of each resident's regimen of medications at least monthly. Resident #4. The findings include: A review of the clinical record revealed a Medication Regimen Review (MRR) sheet from November 6, 2014 through May 6, 2015. The clinical record lacked a MRR sheet for the months of May 2014 through October 2014. A face to face interview with Employee #6 was conducted on May 20, 2015 at approximately 3:00 PM. When queried regarding the missing MRR sheet he/she responded That he/she did not know where the previous MRR was and said pharmacy takes care of that . The record was reviewed on May 20, 2015. | 2017-02-01 |
| 1495 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 431 | D | 0 | 1 | X0E311 | Based on observation, record review and staff interview, it was determined that facility staff failed to maintain medication storage in accordance with accepted professional principles as evidenced by: one (1) blister packet medication was stored beyond the expiration date for one (1) resident; two (2) unit refrigerator temperature log sheet was not consistently check and record once a day and the Controlled Drug Count Verification (shift count sheet for Narcotics) was reconciled by two nurses ' signatures. The findings include: Facility failed to maintain medication storage in accordance with accepted professional principles as evidenced by: 1. One (1) blister packet medication was stored beyond the expiration date for one resident. (Resident #95) On May 21, 2015 at approximately 11:40AM one (1) blister packet medication was found stored beyond the expiration date. The medication storage observations revealed the following: On Unit 3A Resident# 95 had 28 tablets of Oxycodone 5mg stored for use. The expiration date on the package was March 2015. The observation was made in the presence of Employee #8. He/she acknowledged the findings. 2. Two (2) unit refrigerator temperature log sheet was not consistently check and record once a day. (Unit 3A and 3B) On May 21, 2015 at approximately 11:45AM a review of the Refrigerator Monitoring Log on unit 3A and 3B revealed that the temperature recordings were left blank indicating not completed on the following month and days: Unit 3B: February 15, 16 17, 26, 2015 Unit 3A: April 12, 26, 27, 2015 Unit 3A: May 2, 13, 2015 Unit 3B: May 1, 3, 4, 8, 9, 20, 2015 There was no documented evidence that facility staff consistently monitored the temperature of the Medication refrigerator located in the nurse ' s station medication rooms on units 3A and 3B. 3. Facility staff failed to ensure that the Controlled Drug Count Verification (shift count sheet for Narcotics) was reconciled by two nurses ' signatures. (Unit 2B) A review of the Controlled Drug Count Verification records conducted on May 21, 2015 at approximately 11:55AM revealed the following Narcotics reconciliation concerns: On November 21, 2014 11:00 PM to7:00AM shift the Narcotic reconciliation had one (1) nurse signature in the space allotted for going off duty. The space allotted for signature of nurse coming on duty was left blank indicating the narcotics reconciliation was conducted by one nurse. On November 21, 2014 3:00 PM to 11:00 PM shift the Narcotic reconciliation Narcotics had one (1) nurse signature in the space allotted for coming on duty. The space allotted for signature of nurse going off duty was left blank indicating the narcotics reconciliation was conducted by one nurse. . A face -to -face interview was conducted on May 21, 2015 at approximately 11:56AM with Employee #6. He/she stated that according to facility ' s Controlled Substances Policy Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together and they must document and report any discrepancies. There was no evidence that facility staff ensured the Controlled Drug Count Verification records had two nurse ' s signature for Narcotic reconciliation of controlled medications. Controlled substance reconciliation records were blank or signed by one (1) nurse as either ' off-going and on-coming ' (tour of duty) on the shifts delineated above. A face-to-face interview was conducted on May 21, 2015 at approximately 11:58AM with Employees #8. After reviewing the signature sheet forms, he/she acknowledged the aforementioned findings. The observation was conducted May 21, 2015. | 2017-02-01 |
| 1496 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 441 | D | 0 | 1 | X0E311 | Based on observation and staff interview, it was determined that facility staff failed to help decrease the spread of infection as evidenced by having multiple unlabeled bed pans in one (1) resident ' s bathroom; failed to sanitize hands in between feeding and assisting two (2) residents; and failed to ensure the toilet seat riser was stored properly when not in use. The findings include: 1.Facility staff failed to help decrease the spread of infection by not clearly labeling three (3) bed pans in Resident #162 ' s bathroom that was shared with another resident. An observation of resident #162's bathroom was conducted on May 13, 2015 at approximately 9:45 AM. It was observed that two (2) pink bedpans were observed stored in the resident ' s room. One (1) behind the commode on the floor; one (1) on the grab bar behind the toilet and one (1) white fracture bedpan observed stored on the grab bar to the left of the toilet. A face-to-face interview was conducted on May 22, 2015 at approximately 1:00 PM with Employee #6. At that time a second observation was made of the resident ' s bathroom. After making the observation Employee #6 acknowledged the finding. 2.Facility staff failed to decrease the spread of infection as evidenced by not sanitizing hands in between assisting two (2) residents. Employee #20 was observed on May 21, 2015 at approximately 12:45 PM feeding a male resident. Employee #20 observed that another resident at the table needed assistance, stopped and assisted that resident (touching the hands of the resident) and returned back to feeding the first male resident without sanitizing his/her hands. A face-to-face interview was conducted with Employee #6 on May 22, 2015 at approximately 11:40 AM. After review of the above scenario, he/she acknowledged the findings. 3. Facility staff failed to ensure the toilet seat riser was stored properly when not in use. On May 19, 2015 at 12:05 PM a tour of Resident #23 ' s bathroom was conducted. At this time a white toilet seat riser was observed on the floor in the bathroom. Employee #6 was present at the time of the observation and acknowledged the finding. | 2017-02-01 |
| 1497 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 456 | E | 0 | 1 | X0E311 | Based on observations and interview on May 11, 2015 at approximately 9:10 AM, it was determined that the facility failed to maintain essential equipment in safe, operating condition as evidenced by: one (1) of one (1) toaster oven that lacked a temperature adjustment knob, one (1) of two (2) hand washing sinks housing with a loose cover, one (1) of one (1) ice machine with a cracked plastic lid, one (1) of two (2) non-functioning garbage disposals and one (1) of one (1) reach-in box that has been out of order for more than a year. The findings include: 1. One (1) of one (1) toaster oven in the main kitchen was without a temperature adjustment knob. 2. The cover to the housing of one (1) of two (2) hand washing sinks hung loosely from the sink and needed to be repaired. 3. The plastic cover on the inside of the lid of one (1) of one (1) ice machine was cracked. 4. One (1) of two (2) garbage disposals was not functioning. 5. One (1) of one (1) reach-in box has been broken for over a year. During an environmental tour of the main kitchen on May 11, 2015 at approximately 9:30 AM, Employee #9 was asked about the reach-in box that was no longer operational and he/she responded that it had been out of service for over a year. These observations were made in the presence of Employee #9 who acknowledged the findings. | 2017-02-01 |
| 1498 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 463 | E | 0 | 1 | X0E311 | Based on an observations made on May 15, 2015 at approximately 11:30 AM, it was determined that the facility failed to maintain the call bell communication system in good working condition as evidenced by: call bell pull cords that were too short in three (3) of 45 resident's bathrooms, a non-functioning call bell in one (1) of 45 resident's rooms and a missing call bell in one (1) of 45 resident's rooms. The findings include: 1. Call bell pull cords located in the bathroom of resident rooms #135, #146, and #227 were too short and could not function as intended in three (3) of 45 resident's rooms surveyed. 2. The call bell in resident rooms #78, #150 did not emit an alarm when tested , two (2) of 45 resident's rooms surveyed. 3. The call bell in resident room #214A was missing, one (1) of 45 resident's rooms surveyed. These observations were made in the presence of Employee #11 and/or Employee #12 who acknowledged the findings. | 2017-02-01 |
| 1499 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 492 | E | 0 | 1 | X0E311 | Based on record review and staff interview of the facility's policy regarding Abuse and Neglect, it was determined that facility staff failed to implement policies and procedures to ensure that allegations of mistreatment and/or abuse were acted on, investigated, resolved and reported to the State Agency. The findings include: 22b DCMR 3232.4, Incident Reporting- Stipulates, Each incident shall be documented in the resident's record and reported to the licensing agency within forty-eight (48) hours of occurrence, except that incidents and accidents that result in harm to a resident shall be reported to the licensing agency within eight (8) hours of occurrence. A review of the facility ' s Policy No: TX - .97 P&P (Policy and Procedure) Name: Abuse and Neglect identified the Resident Abuse and Neglect policy and procedures 7 (seven) step approach, however, the policy lacked procedures that allegations of mistreatment and/or abuse were acted on, investigated, resolved and reported to the State Agency. A review of page 2 of 4 of the Abuse and Neglect Policy, Procedure: lacked evidence of procedures to on how to protect the resident. A face-to-face interview was conducted with Employee #1 on May 21, 2015 at approximately 3:30 PM. A query was made regarding the policy on Abuse and Neglect the complete policy. Employee #1 responded yes , this is all we have. Facility staff failed to implement policies and procedures to ensure that allegations of mistreatment and/or abuse were acted on, investigated, resolved and reported to the State Agency. | 2017-02-01 |
| 1500 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 514 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 37 sampled residents, it was determined that facility staff failed to consistently document characteristics and status of abrasions, open areas, and pressure ulcers for two (2) residents with multiple areas of skin impairment; and accurately document (1) one resident's race. Residents' #23, 139 and 241. The findings include: 1. Facility staff failed to consistently document the status of wounds/skin impairment for Resident #23. A review of the facility ' s documents revealed licensed nurses recorded wound/skin assessments weekly on a form entitled Skin Condition Report Without Images. The Skin Condition Reports Without Images for Resident #23 were reviewed and revealed that licensed staff recorded conflicting documentation related to wound assessments as follows: May 13, 2015 at 2:58 PM, Skin and Wound Update to Site - 340. Present on the Left Lower Buttocks is a Abrasion. The following findings were documented, Staging, Stage 3, Length in cm=2, Width in cm =1, Depth in cm=0.1, no odor is apparent, no drainage is apparent, Recent changes were made to the treatment orders for this site. This wound was not present on admission, Wound base is visible. Other color in wound base = 100%. General comments: New treatment order . May 13, 2015 at 3:09 PM New (2nd recording) for Site 340. Present on the Left Lower Buttocks is a Pressure Ulcer. The following findings were documented, Unable to accurately stage - Slough and/or Eschar covered, Length in cm = 2, Width in cm = 1, Depth in cm = 0.1, no odor is apparent, no drainage is apparent, Wound base is visible, Slough tissue type = 100%, General Comments: New orders given . Facility staff failed to consistently document characteristics and status of skin impairment for Resident #23. 2. Facility staff failed to consistently document characteristics and status of abrasions, pressure ulcers and open areas for Resident #241 with multiple areas of skin impairment. According to the Skin Care Management policy No. .01 The nursing staff performs skin assessments on admission and documents the integrity on the skin. If there is disruption in skin integrity on admission then the area is measured and documented on the Decubitus Report sheet every week until healed. A review of the clinical record revealed that the resident was admitted to the facility on [DATE] and discharged to another level of care on January 31, 2015. A review of the residents Skin Condition Report With Images sheet for date range from December 30, 2014 to January 31, 2015 revealed that the resident was assessed as having the following wounds: Left scapula (open); lower mid spine ([MEDICATION NAME]) abrasion; lower spine (lumbar) abrasion; left upper buttock 3 x 4 x 0 centimeters; sacrum 6x7x0 cm; right lower buttocks 3.5x10x0 cm. Left Scapula - On January 14, 2015 there was no documentation recorded regarding the condition of the wound and the status of the area upon discharge; Lower mid spine- On January 7 and 14, 2015 there was no documentation recorded regarding the condition of the wound and the status of the area upon discharge; The lower spine (lumbar)- On January 7 and 14, 2015 there was no documentation recorded regarding the condition of the wound and the status of the area upon discharge; Left upper buttock- On January 31, 2015 there was no documentation recorded regarding the condition of the wound and the status of the area upon discharge; Sacrum - On January 31, 2015 there was no documentation recorded regarding the condition of the wound and the status of the area upon discharge; Right lower buttock- On January 31, 2015 there was no documentation recorded regarding the condition of the wound and the status of the area upon discharge; A face-to-face interview was conducted on May 22, 2015 at approximately 1:00 PM with Employee #8. After review of the above he/she acknowledged the findings. The record was reviewed on May 22, 2015. 3. Facility staff failed to accurately document the Resident # 139 ' s race. A review of the clinical record revealed Resident #139 was described on his/her Admissions information Face Sheet in the ethnic background section as African American .The Nursing Admission observation comments section written on November 24, 2014 at 17:24 documented Resident is [AGE] year old male Caucasian new admitted . A review of the admission and annual physical examination form, history section documented [AGE] year old Caucasian with PMH (past medical history) . The Minimum Data Set (MDS) dated [DATE] section A. Identification information Section A 1000 Race /Ethnicity was coded as (c) African American. A face-to- face interview was conducted with Resident# 139 ' s power of attorney on May 15, 2015 at approximately 11:00 AM. When queried he/ she stated that Resident is African American and that they have known each other over [AGE] years, Facility staff failed to accurately document Residents # 139 ' s Race and Ethnicity. A face-to-face interview was conducted with Employee #5 on May 15, 2013 at approximately 11:15 AM he/ she acknowledged the aforementioned findings. The clinical record was reviewed on May 15, 2015. | 2017-02-01 |
| 1501 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-08-20 | 329 | D | 1 | 0 | OLV611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that facility staff failed to monitor INR levels. Subsequently, INR level was found to be 8 (normal range between 2-3). The findings include: Resident #1 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment with an assessment reference date of July 1, 2015, Resident #1 scored 3/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User ' s Manual , page C-14, a score of 0-7 suggests that the resident is severely cognitively impaired. Resident #1 was assessed as requiring supervision for eating, extensive assistance for bed mobility and totally dependent for transfers, dressing, personal hygiene, toileting and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. Resident #1 was admitted to the hospital on July 11, 2015. According to the hospital discharge summary dated July 23, 2015, the resident had an INR of 8 (desired range 2-3) on admission to the hospital (July 11, 2015). A review of the nursing home record revealed that Resident #1 had been receiving [MEDICATION NAME] since admission on January 5, 2015. INR levels had been drawn frequently and the [MEDICATION NAME] dosage was adjusted as indicated by the blood test results. On June 17, 2015, the INR was 1.70 and the [MEDICATION NAME] was increased to 3 mg daily. A repeat INR level was scheduled for June 24, 2015. However, the test drawn was a PTT not an INR. A notation on the laboratory result indicated PT/INR ordered will add on. There was no evidence in the record that that an INR level was drawn after June 24, 2015. A review of the June and July 2015 Medication Administration Records, revealed that the resident received [MEDICATION NAME] 3 mg daily from June 17, 2015 through July 11, 2015. According to the nurse practitioner ' s order dated April 30, 2015: [MEDICATION NAME] 100 mg PO BID x 7 days for abscess. A nurse ' s note dated April 30, 2015 at 11:34 PM, Alert and verbally responsive. Denies pain. Tolerated all due medications Started on ABT [MEDICATION NAME] 100 mg BID for abscess. No adverse reaction noted. Pharmacy called to notify that [MEDICATION NAME] increases the effect of [MEDICATION NAME] and thus will recommend PT/INR labs to be done twice a week. Nursing supervisor notified for resident to be put on acute list. In stable condition at this time. Temp 98.2 There was no follow-up note by the nurse practitioner or the physician regarding the warning from the pharmacy. However, INR levels were drawn on May 4, May 7, May 11 and May 14, 2015. According to a physician's order [REDACTED]. (treatment for [REDACTED]. According to www.nih.gov : [MEDICATION NAME] can enhance the anticoagulant effect of [MEDICATION NAME]. This is likely due to competitive interaction for [MEDICATION NAME] binding and possibly inhibition of the cytochrome P-450 system. An increase in plasma levels of free [MEDICATION NAME] may result in severe bleeding. It is important to recognize this potential interaction and obtain a complete medication profile prior to initiating [MEDICATION NAME]. There were no INR levels drawn after the [MEDICATION NAME] was prescribed. A face-to-face interview was conducted with Employee #1 on August 19, 2015 at 12:20 PM. Dr. McDonald was asked about the above concern and stated, [MEDICATION NAME] potentiates [MEDICATION NAME] and labs should have been drawn. I don ' t see any labs drawn for the PT/INR after this medication was started. We missed this. The record was reviewed August 19, 2015. | 2017-02-01 |
| 1502 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-08-20 | 428 | D | 1 | 0 | OLV611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that the pharmacist failed to identify that an INR level was not drawn on June 24, 2015 and after Doxycycline therapy was initiated. The findings include: Resident #1 was admitted to the hospital on July 11, 2015. According to the hospital discharge summary dated July 23, 2015, the resident had an INR of 8 (desired range 2-3) on admission to the hospital (July 11, 2015). A review of the nursing home record revealed that Resident #1 had been receiving Coumadin since admission on January 5, 2015. INR levels had been drawn frequently and the Coumadin dosage was adjusted as indicated by the blood test results. On June 17, 2015, the INR was 1.70 and the Coumadin was increased to 3 mg daily. A repeat INR level was scheduled for June 24, 2015. However, the test drawn was a PTT not an INR. A notation on the laboratory result sheet indicated PT/INR ordered will add on. There was no evidence in the record that that an INR level was drawn after June 24, 2015. The pharmacist reviewed the resident ' s medication regimen review as follows: January 26, 2015 February 18, 2015 March 31, 2015 April 23, 2015 May 6, 2015 June 6, 2015 July (unable to read), 2015 There were no recommendations made by the pharmacist regarding the resident ' s medications for any of the above cited dates. According to the Chronological Record of Medication Regimen Review, the pharmacist reviewed the resident ' s medications on July (unable to read date), 2015. The pharmacist wrote 6/17 - 1.70 INR (unable to read). The pharmacist circled NR (no recommendations). The pharmacist failed to identify that an INR was not drawn on June 24, 2015. According to the nurse practitioner ' s order dated April 30, 2015: Doxycycline 100 mg PO BID x 7 days for abscess. A nurse ' s note dated April 30, 2015 at 11:34 PM, Alert and verbally responsive. Denies pain. Tolerated all due medications Started on ABT Doxycycline 100 mg BID for abscess. No adverse reaction noted. Pharmacy called to notify that Doxycycline increases the effect of Coumadin and thus will recommend PT/INR labs to be done twice a week. Nursing supervisor notified for resident to be put on acute list. In stable condition at this time. Temp 98.2 There was no follow-up note by the nurse practitioner or the physician regarding the warning from the pharmacy. However, PT/INR levels were drawn on May 4, May 7, May 11 and May 14, 2015. According to a physician's order [REDACTED]. (treatment for [REDACTED]. The pharmacist failed to identify that a follow-up INR level was not obtained after June 24, 2015 and additional INR levels were drawn after Doxycycline was prescribed on June 21, 2015. A face-to-face interview was conducted with Employee #2 on August 19, 2015 at 2:00 PM. He/she acknowledged the above concerns. The record was reviewed August 19, 2015. | 2017-02-01 |
| 1503 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 246 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made on February 22, 2016 between 11:30 am and 3:00 pm, it was determined the facility failed to accommodate one resident ' s needs as evidenced by a call bell cord in one (1) of 38 resident rooms that was too short to be easily accessible. The findings include: The call bell cord in the bathroom of room [ROOM NUMBER] was too short to be easily accessible for the Resident in one (1) of 38 resident rooms surveyed. These observations were made in the presence of Employees' #22 and #23 who acknowledged the findings. | 2017-02-01 |
| 1504 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 253 | E | 0 | 1 | 2L6211 | Based on observations made on February 22, 2016 between 11:30 AM and 3:00 PM, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior as evidenced by loose wallpaper on two (2) of five (5) resident care units, soiled bathroom vents in three (3) of 38 resident rooms, a loose cove base in one (1) of 38 resident rooms and marred walls in three (3) of 38 resident rooms. The findings include: 1. The wall paper was loose, unglued from the walls in unit 2b across from rooms #203 and #204, between rooms #207 and #208, on unit 2a between rooms #237 and #238 and next to room #247. 2. Bathroom vents were soiled on the inside and outside in three (3) of 38 resident rooms. (#123, #207 and #212). 3. The cove base close to the bathroom was hanging loose and needed to be secured in one (1) of 38 resident rooms (#208). 4.Walls were marred in three (3) of 38 resident rooms (#207, #212, #255). These observations were made in the presence of Employee #22 and Employee #23 who acknowledged the findings. | 2017-02-01 |
| 1505 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 272 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview for one (1) of 17 sampled residents, it was determined that facility staff failed to accurately code Section J, ' Special Treatments and Programs ' of the Significant Change Minimum Data Set (MDS) for Resident #24. The findings include: A review of Resident #24 ' s clinical record revealed his/her [DIAGNOSES REDACTED]. A ' Hospice Recertification ' form signed by the physician on November 4, 2015 included a statement that read, Based on the patient ' s [DIAGNOSES REDACTED]. A review of the Significant Change MDS completed November 17, 2015, with an assessment reference date (ARD) of November 10 - 17, 2015 revealed that Section J, J1400, Prognosis was coded no, indicative that the medical record does not contain physician documentation that the resident is terminally ill. On February 25, 2016 at approximately 2:50 PM a face-to-face interview was conducted with Employee #9, the MDS Coordinator, regarding the coding of section J1400, Prognosis the significant change MDS dated [DATE]. Upon secondary review, Employee #9 acknowledged the aforementioned findings. | 2017-02-01 |
| 1506 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 279 | E | 0 | 1 | 2L6211 | Based on record review and staff interview for nine (9) of 17 Stage 2 sampled residents and three (3) supplemental residents, it was determined that facility staff failed to develop comprehensive care plans with measurable goals, timetables and specific interventions to manage the discharge needs of residents. Residents' #20, 24, 37, 56, 62, 69, 84, 88, and 112. The findings include: The provider ' s ' Notice of Closure ' A review of the facility ' s documents revealed the facility provided a Notice of Closure letter signed by the Chief Executive Officer and dated November 3, 2015 (initial notification was September 15, 2015) addressed to all residents (and/or responsible parties) residing in the facility that read: This letter serves each of you as your official notice of closure and the need to transfer or discharge to another location. Final closure will be December 15, 2016 .We will assure the continuity of services by providing the receiving facility with assessment and care plan, and for discharge, by arranging for those services required by the post discharge plan . Pursuant to The District of Columbia ' s Transfer/Discharge statute - D.C. Law 6-108, the Nursing Home and Community Residence Facilities Protections Act, DC Code 44-1003.01 .Residents residing at the facility will undergo involuntary discharge as follows: Chapter 10. Nursing Homes and Community Residence Facilities Protections. Subchapter III. Discharge, Transfer, and relocation of residents. 44-1003.01. Grounds for involuntary discharge, transfer, or relocation by facility. (a) Unless a resident and his or her representative consent otherwise, a facility may discharge the resident, transfer the resident to another facility, or relocate the resident from one part or room of the facility to another only: .(5) If the facility is closing or officially reducing its licensed capacity . 1. Facility staff failed to develop a discharge plan of care for Resident #20. A review of Resident #20's clinical record revealed a social service progress note dated September 18, 2015 at 3:21 PM that read , Spoke with (family member) about the closing of (facility). S/he is interested in working with (family member) to find a place for (him/her) to live SE (southeast), NE (northeast) are a possibility. Also (local facility) is an option. Will continue to work with them to explore a safe discharge plan. A social service progress note dated November 9, 2015 at 4:37 PM read, The formal letter to resident notifying (gender) of closure of (name of facility) in December 2016, has been placed in the chart. This letter has also been mailed to the resident's responsible representative. The interdisciplinary team last updated Resident #20 ' s comprehensive care plan on January 22, 2016. However, there was no evidence of a care plan that reflected problem identification, goals and approaches to address the resident ' s impending involuntary discharge. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged there was no discharge plan. The record was reviewed February 26, 2016. 2. Facility staff failed to develop a discharge plan of care for Resident #24. A review of social work progress notes revealed the following: January 7, 2016 at 2:38 PM Have been speaking with (family members named). They have begun to look into facilities. The requested a referral to go to (facility named). Called that facility and had Medical records send them a packet. The family is to visit other facilities .but does not want referrals sent to them as yet . January 14, 2016 at 4:09 PM (family members named) are now actively working on placement. They visited (facility named) and felt that this was an acceptable place to transfer the resident .spoke with admission coordinator and they don ' t have any LTC (long term care) beds. As asked, will check back . The interdisciplinary team last updated Resident #24 ' s comprehensive care plan on November 17, 2015. However, there was no evidence of a care plan that reflected problem identification, goals and approaches to address the resident ' s impending involuntary discharge. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged there was no discharge plan. The record was reviewed February 26, 2016. 3. Facility staff failed to develop a discharge plan of care for Resident #37. A review of Resident #37 's clinical record revealed the following Social Service progress note dated and timed 12:42 PM February 24, 2016; On January 1/14/2016, (attendees named including responsible party(s)) met for the individualized discharge planning meeting. The resident had been denied by (Facility name) for admittance, so family had many questions about the reason. Per (responsible party) it was because of aggressive behavior so (attendee named) reviewed the resident ' s chart and spoke with the psychiatrist about behaviors. SW (social worker) explained the process of finding, applying, and being transferred to another facility. It was decided, after reviewing the facility ' s lists, that resident ' s (responsible party) was going to explore some out of state facilities. The interdisciplinary team last updated Resident #37 ' s comprehensive care plan on February 20, 2016. However, there was no evidence of a care plan that reflected problem identification, goals and approaches to address the resident ' s impending involuntary discharge. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged there was no discharge plan. The record was reviewed February 26, 2016. 4. Facility staff failed to develop a discharge plan of care for Resident #56. A review of Resident #56 ' s clinical record revealed the following Social Services progress notes: October 26, 2015 11:26 AM: Care conference / discharge planning on10/14/15: The interdisciplinary team met with the resident and (his/her) RP (Responsible Party). Care plans and medications were reviewed RP is pleased with (his/her) family members care .RP has visited nursing homes but has not made a decision where to apply. December 17, 2015 15:32(3:32PM) Length of Stay discharge planning comment= Residents RP, has had many conversations with the social worker regarding (his/her) family member. RP feels that as long as (resident) is receiving good care, (he/she) will remain at (Name of facility). SW (Social Worker) gave RP the list of DC (District of Columbia) nursing homes, which (she/he) used when (he/she) visited them . RP told SW that (he/she) was not impressed with any of the homes. RP stated that (he/she) was instead working on getting extension until 6/2017 (June 2017). December 30, 2015 16:21 (4:21PM) Length of Stay discharge planning comments= On 12/30/15(at) 3:00 PM, the SW (social worker), SW Director, RP (responsible party) and (family member) met for a discharge assessment meeting. RP was given the Maryland and DC lists of nursing homes and a source book . The interdisciplinary team last updated Resident #56 ' s comprehensive care plan on January 31, 2016. However, there was no evidence of a care plan that reflected problem identification, goals and approaches to address the resident ' s impending involuntary discharge. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged there was no discharge plan. The record was reviewed February 26, 2016. 5. Facility staff failed to develop a discharge plan of care for Resident #62. A review of Resident #62 ' s clinical record revealed the following Social Services progress notes: November 9, 2015 16:54 (4:54PM) General Social Services Comments = The formal letter to the resident notifying (him/her) of the closure of (Facility Name) in December 2016, has been placed in the chart. The letter has also been mailed to the resident's responsible representative. December 18, 2015 14:38 (2:38PM) General Social Services Comments = Speak regularly to (family member). (His/her) first choice had been for (facility name) for transfer .Discussed with the (family member). Explained that other options needed to be explored .Will continue to follow and assist with planning . February 26, 2016 at 14:35 (2:35 PM) Formal discharge planning meeting was held on 2/4/16 .(attendees listed, including family member) .(family member) made it clear that (he/she felt that the only comparable transfer location for (Resident) would be (facility named) .SW (social worker) offered to continue to have follow up informal and formal meetings (family member) said (he/she) would like to continue to meet The interdisciplinary team last updated Resident #62 ' s comprehensive care plan on December 15, 2015. However, there was no evidence of a care plan that reflected problem identification, goals and approaches to address the resident ' s impending involuntary discharge. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged there was no discharge plan. The record was reviewed February 26, 2016. 6. Facility staff failed to develop a discharge plan of care for Resident #69. A review of social worker progress notes dated February 3, 2016 revealed a care conference was conducted on February 3, 2016 to address the resident's continuing care needs and discharge planning. The resident and family member was in attendance. The interdisciplinary team last updated Resident #69 ' s comprehensive care plan on November 29, 2015. However, there was no evidence of a care plan that reflected problem identification, goals and approaches to address the resident ' s impending involuntary discharge. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged there was no discharge plan. The record was reviewed February 26, 2016. 7. Facility staff failed to develop a discharge plan of care for Resident #84. A review of Resident #84 ' s clinical record revealed the following Social Services progress notes: November 12, 2015 at 17:31 (5:31PM); The RP (responsible party) has submitted (his/her) preferences. Medical records has sent records to (facility names) .Will continue to follow for discharge plans. November 13, 2015 at 17:31 (5:31PM); The formal letter to the resident notifying (gender) of closure of (name of facility) in December 2016, was given and read to the resident. A copy has been placed in the chart. This letter has also been mailed to the resident ' s responsible representative. December 1, 2015 at 13:33 (1:33PM); RP has released medical records to (names of facilities) No bed matches yet .SW to continue to follow for discharge planning . The interdisciplinary team last updated Resident #84 ' s comprehensive care plan on February 1, 2016. However, there was no evidence of a care plan that reflected problem identification, goals and approaches to address the resident ' s impending involuntary discharge. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged there was no discharge plan. The record was reviewed February 26, 2016. 8. Facility staff failed to develop a discharge plan of care for Resident #88. A review of Resident #88 ' s clinical record revealed the following Social Services progress notes: November 9, 2015 at 16:50 (5:50PM); The formal letter to resident notifying (gender) of closure of (name of facility) in December 2016, has been placed in the chart. This letter has also been mailed to the resident's responsible representative. November 20, 2015 at 16:07 (4:07PM); Left message for RP (responsible party) on this date, to discuss discharge planning. Await call back. January 18, 2016 at 15:37 (3:37 PM); Placed follow up call to (RP name) .Awaiting call back to discuss transition planning. The interdisciplinary team last updated Resident #88 ' s comprehensive care plan on December 5, 2015. However, there was no evidence of a care plan that reflected problem identification, goals and approaches to address the resident ' s impending involuntary discharge. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged there was no discharge plan. The record was reviewed February 26, 2016. 9. Facility staff failed to develop a discharge plan of care for Resident #112. A review of Resident #112 ' s clinical record revealed the following Social Services progress note dated and timed November 11, 2015 at 12:49; On November 6, 2015, the social worker hand delivered and read to the resident the official letter of closure of (name of facility). The interdisciplinary team last updated Resident #112 ' s comprehensive care plan on November 17, 2015. However, there was no evidence of a care plan that reflected problem identification, goals and approaches to address the resident ' s impending involuntary discharge. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged there was no discharge plan. The record was reviewed February 26, 2016. | 2017-02-01 |
| 1507 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 284 | E | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for seven (7) of seven (7) discharged sampled residents, it was determined that facility staff failed to develop a post-discharge plan of care to ensure the individual ' s needs will be met after discharge from the facility into the community. Residents ' #12, #40, #96, #100, #101, #107, and #118 The findings include: A letter sent to the residents from the Chief Executive Officer and Administrator of the facility dated November 3, 2015, regarding the facility ' s closure stipulated; This letter is to establish the next steps as required by the District of Columbia Model Resident Transfer and Discharge Plan for Nursing homes When you and your representative are ready to move, we will provide you with the following information: A written statement of the medical assessment and evaluation, and post-discharge plan of care . A review of the District of Columbia official Code 2001 Edition, Division VIII. General Laws Title 44. Charitable and Curative Institutions. Subtitle I. Health Related institutions. Chapter 10. Nursing Homes and Community Residence Facilities Protections. Subchapter III. Discharge, Transfer and Relocation of Residents. 44-1003.04 Discussion and Counseling Before a resident is voluntarily or involuntarily discharged , transferred to another facility or reacted within a facility, a facility representative shall discuss the reasons for the move with the resident and his or her representative and shall answer any questions they must have about the move or the written notice they received pursuant to 44-1003.02 (a). The contents of the discussion shall be summarized in writing, include the names of the individuals involved in the discussion and be made a part of the resident ' s clinical record. In addition, the facility representative shall strongly recommend and offer to provide counseling services to the resident and his or her representative before the move. If the resident has requested a hearing pursuant to 44-1003.03 (a), facility staff shall attempt to prepare the resident for the possibility of having to move on 3-day (for an intra-facility relocation) or 5-day (for a discharge or transfer to another facility) notice should the hearing decision not be in his or her favor. 1. Facility staff failed to develop a post discharge plan of care for Resident #12. A review of Resident #12 ' s closed record revealed that the resident was admitted to the facility on [DATE] and was discharged to another facility on December 22, 2015. There was no evidence that facility staff developed a post discharge plan to assess Resident #12 ' s continued care needs and developed a plan of care designed to ensure the individual ' s needs would be met after discharge from the facility. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 1:00 PM regarding the aforementioned findings. He/she acknowledged there was no post discharge plan. The record was reviewed February 26, 2016. 2. Facility staff failed to develop a post discharge plan of care for Resident #40. A review of Resident #40 ' s closed record revealed that the resident was admitted to the facility on [DATE] and was discharged to another facility on November 23, 2015. There was no evidence that facility staff developed a post discharge plan to assess Resident #40 ' s continued care needs and developed a plan of care designed to ensure the individual ' s needs would be met after discharge from the facility. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 1:00 PM regarding the aforementioned findings. He/she acknowledged there was no post discharge plan. The record was reviewed February 26, 2016. 3. Facility staff failed to develop a post discharge plan of care for Resident #96. A review of Resident #96 ' s closed record revealed that the resident was admitted to the facility on [DATE] and was discharged to another facility on February 5, 2016. There was no evidence that facility staff developed a post discharge plan to assess Resident #96 ' s continued care needs and developed a plan of care designed to ensure the individual ' s needs would be met after discharge from the facility. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 1:00 PM regarding the aforementioned findings. He/she acknowledged there was no post discharge plan. The record was reviewed February 26, 2016. 4. Facility staff failed to develop a post discharge plan of care for Resident #100. A review of Resident #100 ' s closed record revealed that the resident was admitted to the facility on [DATE] and was discharged to another facility on December 11, 2015. There was no evidence that facility staff developed a post discharge plan to assess Resident #100 ' s continued care needs and developed a plan of care designed to ensure the individual ' s needs would be met after discharge from the facility. 5. Facility staff failed to develop a post discharge plan of care for Resident #101. A review of Resident #101' s closed record revealed that the resident was admitted to the facility on [DATE] and was discharged to another facility on February 26, 2016. There was no evidence that facility staff developed a post discharge plan to assess Resident #101 ' s continued care needs and developed a plan of care designed to ensure the individual ' s needs would be met after discharge from the facility. 6. Facility staff failed to develop a post discharge plan for Resident #107. A review of Resident #107 ' s closed record revealed that the resident was admitted to the facility on [DATE] and was discharged to another facility on October 12, 2015. The resident ' s discharge date was prior to the facility ' s closure letter sent to the residents. However, there was no evidence that facility staff developed a post discharge plan to assess Resident #96 ' s continued care needs and developed a plan designed to ensure the individual ' s needs would be met after discharge from the facility. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 1:00 PM. He/she acknowledged that there was no post discharge plan. The record was reviewed February 26, 2016. 7. Facility staff failed to develop a post discharge plan for Resident #118. A review of Resident #118' s closed record revealed that the resident was admitted to the facility on [DATE] and was discharged to another facility on December 6, 2015. The resident ' s discharge date was prior to the facility ' s closure letter sent to the residents. However, there was no evidence that facility staff developed a post discharge plan to assess Resident #118's continued care needs and developed a plan designed to ensure the individual ' s needs would be met after discharge from the facility. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 1:00 PM. He/she acknowledged that there was no post discharge plan. The record was reviewed February 26, 2016. | 2017-02-01 |
| 1508 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 309 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 17 stage 2 sampled residents, it was determined that facility staff failed to provide the necessary care and services to ensure residents attain or maintain the highest practicable state of well-being as evidenced by failure to perform pain assessments and re-assessments prior to and after the administration of as needed (prn) pain medication and failed to clarify physician ' s orders for the prescribed indication for use of [MEDICATION NAME] ([MEDICATION NAME] medication) for one (1) resident; and failed to administer a pneumococcal vaccine and follow through with timeliness on a physician ' s order for a speech evaluation for one (1) resident. Resident ' s #24, and #92. The findings include: 1. Facility staff failed to perform pain assessments prior to and following the administration of as needed (prn) pain medication ([MEDICATION NAME] - an Opioid [MEDICATION NAME] medication.) and failed to clarify physician ' s orders for the prescribed 'indication for use' of [MEDICATION NAME]. A Facility staff failed to conduct pain assessments prior to and following the administration of prn [MEDICATION NAME]. A review of the facility policy titled, Pain Management Revised July, 2015 states under the section titled ' Purpose, ' To relieve or decrease the level of the resident ' s/patient ' s pain. 1). Pain assessment .3) pain evaluation . In section ' II ' titled ' Pain Assessment - Administration of Pain Medications. ' a. Prior to administration of PRN (as needed) medications for pain, the licensed nurse must assess the resident ' s/patient level of pain using a quantitative scale .A Progress Note with the quantitative pain measurement documented in the note, must be entered in the EMR (electronic medical record) under the category of Pain management. One hour (or earlier if the resident/patient voices concern) following the administration of the PRN pain medication the licensed nurse must re-assess the resident ' s/patient ' s level of pain using the quantitative scale . A review of the clinical record revealed that Resident #24 ' s [DIAGNOSES REDACTED]. A Physician's progress note dated January 27, 2016 revealed, .Pain 2/2 (secondary to) Cancer: well controlled w/ (with) [MEDICATION NAME] (narcotic pain medication) and PRN (as needed) [MEDICATION NAME] (narcotic pain medication). The Physician's Order Sheet dated February 1, 2016 directed the administration of [MEDICATION NAME] solution, give 60mg (milligrams) under the tongue as needed, every hour for dyspnea (shortness of breath). On February 24, 2016 at approximately 2:10PM, a face-to-face interview was conducted with Employee #11, the nurse for Resident #24. When asked why Resident #24 was receiving [MEDICATION NAME], Employee #11 stated, The resident receives [MEDICATION NAME] for pain. [MEDICATION NAME] was typically given prior to wound care. The employee was asked how pain was assessed for Resident #24. Employee #11 stated, When the resident is in pain, I see it on (his/her) face. When asked where the effectiveness of the medication is documented, Employee #11 stated, We do not always document the effectiveness. A review of the Electronic Medication Administration Record [REDACTED] [MEDICATION NAME] was administered on February 14, 2016 at 11:00AM for pain. The result was documented as Effective. [MEDICATION NAME] was administered on February 23, 2016 at 11:42 AM for pain. The result is documented as effective. [MEDICATION NAME] was administered on February 24, 2016 at 10:42 AM, however the reason documented was Given as ordered. The result was documented as effective no pain A review of the nursing notes and the pain management notes lacked documented evidence that pain assessments were performed prior to, and after the administration of PRN (as needed) pain medication. On February 25, 2016 at approximately 4:45 PM, a face-to-face interview was conducted with Employee #4. He/she acknowledged the aforementioned findings. The record was reviewed on February 24, 2016. B. Facility staff failed to clarify the prescribed ' indication for use ' of [MEDICATION NAME] an Opioid [MEDICATION NAME] medication. A review a physician ' s progress note signed and dated November 24, 2015, in the section titled HPI (history and physical information) revealed, .prn (as needed) [MEDICATION NAME] sulfate for dyspnea, for pain uses (approximately) 4 (times) a month usually (with) dressing (changes) . A Physicians progress note dated January 27, 2016 revealed, .Pain 2/2 (secondary to) Cancer: well controlled w/ (with) [MEDICATION NAME] and PRN (as needed) [MEDICATION NAME] (narcotic pain medication). The Physician Order Sheet dated February 1, 2016 directed that the resident was prescribed [MEDICATION NAME] solution, give 60mg (milligrams) under the tongue as needed, every hour for dyspnea. The order was initially ordered July 8, 2015. On February 24, 2016 at approximately 2:10PM, a face-to-face interview was conducted with Employee #11, the nurse for Resident #24. When asked why Resident #24 was receiving [MEDICATION NAME], Employee #11 stated that the resident received [MEDICATION NAME] for pain. The physician ' s order lacked evidence that the [MEDICATION NAME] was to be administered as needed for pain. Facility staff failed to clarify the prescribed indication for use for ' as needed ' [MEDICATION NAME]. On February 25, 2016 at approximately 4:45 PM, a face-to-face interview was conducted with Employee #4. He/she acknowledged the aforementioned findings. The record was reviewed on February 24, 2016. 2. Facility staff failed to administer Resident #92's pneumococcal vaccine in accordance with physician's orders and failed to follow through with timeliness on a physician 's order for a speech evaluation. A. Facility staff failed to administer Resident #92's pneumococcal vaccine in accordance with physician's orders. A Physician ' s Order Sheet dated February 5, 2016 directed, [MEDICATION NAME] 23 (Pneumococcal 23-Valps Vaccine), Injectable, 25mcg (micrograms) /05ml (milliliters): Inject 0.5 ml Intramuscular as needed for immunization. A review of the Medication Administration Record [REDACTED]. It was further determined through review of the electronic clinical record and the immunization history form that Resident #92 was not administered the pneumococcal vaccine. There was no evidence that facility staff offered and/or administered the [MEDICATION NAME] to Resident #92 in accordance with physician's orders. A face-to-face interview was conducted with Employee #4 and Employee #8 on February 24, 2016 at approximately 11:00 AM. Both acknowledged the aforementioned finding. The clinical record was reviewed on February 24, 2016. B. Facility staff failed to follow through with timeliness on a physician's order for a speech evaluation for Resident #92. An Interim Order Form dated January 8, 2016 at 11:30AM directed, Speech screen for upgrade in diet consistency, especially the meat items per resident ' s request. A review of the speech section of the clinical record revealed the most recent speech screen/evaluation was October 1, 2015. The clinical record lacked evidence of a speech evaluation subsequent to October 1, 2015. A face-to-face interview was conducted with Employee#4 on February 25, 2016 at 3:00 PM. He/she acknowledged that the speech therapist had not seen the resident. A follow-up interview was conducted with Employee #19 on February 24, 2016 at approximately 3:30 PM regarding the aforementioned order. He/she acknowledged the finding and further stated, I never received the consult for an evaluation. However, I will follow-up. Facility staff failed to follow through with timeliness on a speech evaluation, until brought to their attention during the survey process. A period of 30 days lapsed before the evaluation occurred. There was no evidence that the resident exhibited any nutritional status deficits secondary to the delay. The clinical record was reviewed on February 24, 2016. | 2017-02-01 |
| 1509 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 323 | G | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observations, record review and staff interview for one (1) of 17 sampled residents, it was determined that facility staff failed to ensure that the resident environment remained as free from accident hazards as is possible and that adequate supervision was provided in order to enhance safety and reduce the risk of an accident as evidenced by one (1) resident who sustained a fall with injury. Resident #54 The findings include: On February 26, 2016 at approximately 9:00 AM, Employee #2 informed the survey team that Resident #54 sustained a fall with injury this morning and was sent to a local hospital for emergency treatment via ambulance. A review of the facility ' s incident report titled, Incident Details, documented by nursing staff, dated February 26, 2016 at 4:48 AM read as follows: Around 2:48 AM there was a sound from resident ' s room, writer and the assigned CNA (certified nursing assistant) rushed to the room where resident was found on the floor in sitting position leaned on (his/her) right side noted with blood all over (his/her) face. Resident alert and oriented x3 (person, place, time), resident stated to writer (he/she) fell from chair and hit (his/her) head on the floor. Supervisor made aware and came to the unit. Resident noted with laceration on (his/her) forehead .and laceration on left eyebrow pressure dressing applied to the sites. Resident denied back and neck pain at this time, pupils react to light equal. Active and passive ROM (range of motion) with normal limit to all extremities. Dr (named) notified and new order received to transfer resident to hospital ER (emergency room ' for further evaluation and treatment. 911 (emergency medical services) called and resident was transferred to hospital (named) ER at around 3:25 AM . {SIC} On February 26, 2016 at approximately 9:30 AM, an observation was conducted of Resident #54 ' s room. The room was observed cluttered. Multiple items were noted scattered along the floor surface and the bed was covered with personal belongings. For example the observations included but was not limited to the following: A dining tray was noted lying upside down on the floor proximal to the room entrance, blocks of wood, long rolls of paper, plastic containers, cans, a towel and a blow dryer were observed on the floor surface posing a potential trip hazard and an unsafe environment. The room had three (3) free-standing garment racks, three (3) stationary chairs, one (1) wheelchair and a rolling cart similar to a shopping cart filled with items. Resting atop the rolling cart was a carpenter-style hand saw approximately 15 - 18 inches in length readily accessible to anyone entering the room. The private bathroom was filled with clutter including large plastic bags and plastic containers. The toilet and sink were not accessible because the entryway and space was blocked with items. On February 26, 2016 at approximately 10:15 AM, during the observation of Resident #54 ' s room, the resident appeared in the doorway lying on a stretcher accompanied with private ambulance transporters. A gauze bandage was observed on his/her forehead and alongside the left eyebrow. He/she stated what ' s going on .why are you in my room, get out of my room. When greeted, Resident #54 responded in the affirmative to his/her name and stated fine in response to the query, How are you? The resident was advised regarding the survey process and the purpose for observing his/her room. The resident further verbalized take me to my room, my room is fine. A review of the quarterly Minimum Data Set (MDS) dated [DATE] (assessment reference date (ARD) 11/19 - 26/2015) under Section I, Active [DIAGNOSES REDACTED]. Section G, Functional Status was coded as the resident utilized a wheelchair for mobility, required limited assistance for transfer between bed and chair, supervision for locomotion and limited assistance for toilet use; G0400, Functional Limitation in Range of Motion was coded as B1, indicative of impairment on one side of the lower extremity. Section C, Cognitive Patterns revealed the resident was moderately cognitively impaired with a score of 9 in the Brief Interview for Mental Status. Section E, Behavior was coded as Delusions, verbal behavioral symptoms directed toward others occurred 4 to 6 days out of seven days and rejection of care occurred daily. A review of the most recent psychiatric consultation dated December 22, 2015 revealed Resident #54 ' s mental health [DIAGNOSES REDACTED]. The psychiatric follow up note dated December 22, 2015 included: (Resident named) has a long history of depression and obsessive compulsive disorder. There has been a history of agitation with both verbal and physical aggressiveness, particularly when (Resident) is confronted about (his/her) hoarding or any of (his/her) habits. Staff has spent a great deal of time developing a treatment plan for (Resident) trying to accommodate (his/her) whishes while also making sure that (his/her) room was safe .of note is that while (his/her) room is quite cluttered with unnecessary paraphernalia, the room in passable and safe for easy entry and exit (a difference from the past) . A review of the comprehensive care plan for Resident #54 revealed the interdisciplinary team (IDT) updated the plan on November 17, 2015 and updated the problem area related to Falls on February 26, 2016. The following problem areas (including but not limited to) were identified by the IDT: Problem: Falls - potential for falls related to history of falls. Goals: resident will have no injury related to falls in the next 90 days. Approaches: give resident verbal reminders to ask or call for assistance when (he/she) needs it .have staff clear bed each evening of all belongings, if (he/she) will permit it to allow resident choice of sleeping in bed or chair. This may prevent (him/her) from falling from chair when (he/she) is sleeping Under the evaluation section dated 9/14/15 had a fall from wheelchair; abrasion noted on LUA (left upper arm). Bacitracin ordered till healed. Probably fell asleep in chair, where (he/she) sleeps most of the time. Clutters bed so that (he/she) can ' t go to bed and sleep. This is (his/her) normal routine sitting up in chair and sleeping. Refuses to go to his bed even when offered to remove clutter from bed . Problem: Behavior problem - Resident displays inappropriate behavior when (he/she) is asked to make (his/her) room more tidy, to remove excess items from room and when (he/she) is denied access to things (he/she) wants to do; resident exhibits inappropriate behavior toward staff as evidenced by verbal and physical abuse when asked to tidy up room or does not get (his/her) way; pillaging and hoarding. Goals: resident will decrease episode of inappropriate behavior .will not display verbal and/or physical abuse towards staff .pillaging and hoarding will not negatively impact self or others through next review. Approaches: allow resident to be aware of the harmful items that will be removed .check for harmful items weekly and remove from room, report the resident informed refusal of having the harmful items removed to the family members. Evaluation: continues to have verbally abusive outbursts .refuses psyche meds (psychotherapeutic medications) as well as other meds at times, still gets upset and agitated at times especially when it comes to referencing room cleaning .Still gets very angry and agitated at times when staff tell (him/her) (he/she) can ' t do certain things . Problem: Noncompliance to calling for assistance with transfers and ADLs (activities of daily living). Goal: resident will adhere to calling for assistance when needed with transfers and ADLs. Approaches: praise resident for demonstrating desired behavior, discuss with resident implications of not complying with therapeutic regime Evaluation: remains non-adherent to calling for assistance with transfers and ADLs. Attempts to do things for (him/herself) but not able to, so when staff see (him/her) struggling, they assist . Problem: Mood State, resident continues to hoard and store too much in room, causing safety issues. Goal: room will be tidy and less congested. Approaches: monitor room for tidiness .solicit friends or family to help (him/her) pare down (his/her) belongings. Evaluation: limits have been placed on (him/her) to remove the trash and clean up the room. (He/she) straightens it up a little and before many hours have passes the room looks horrible . A review of the behavior monitoring records for the period of January 1, 2016 to February 26, 2016 revealed that nursing staff documented three times daily regarding the occasions that Resident #54 exhibited combativeness and/or medication non-compliance. The records revealed no problem behaviors noted for the review period with the exception of January 16, 2016 at 6:43 AM when the resident exhibited an episode of screaming when he/she wanted a drink from the refrigerator. A review of nursing notes for February 25 and 26, 2016 (the day prior to and of the fall incident) read as follows: February 25, 2015 at 7:53 AM resident remain alert and verbally responsive, no complain of pain or any discomfort, status [REDACTED].no adverse reaction noted. Will continue with plan of care. February 25, 2016 at 18:07 (6:07 PM) S/P ABT for ([DIAGNOSES REDACTED]. Resident refused both breast to be assessed, MA (physician) aware. Denied any pain/discomfort. No concern verbalized. {SIC}. February 25, 2016 at 19:29 (7:29 PM) Patient had quiet evening. ADLs (activities of daily living) provided. Patient tolerated due medication and feeding well. No acute distress noted. Post ABT therapy. February 26, 2016 at 00:38 (12:38 AM) Resident remain alert and stable, status [REDACTED]. February 26, 2016 at 03:37 (3:37 AM) Transfer to emergency department 2/26/16 03:35 (3:25 AM). Fall related minor injury . A review of the facility ' s document detailing Resident Rights included in the admission packet, included but was not limited to the following: Your rights as a resident .you have the right to exercise you rights as a resident of this facility and as a citizen or resident of the United States .you have the right to retain and use personal possessions including some furnishings, and appropriate clothing as space permits, unless to do so would infringe upon the rights or health and safety of other residents. A face-to-face interview was conducted with Employee # 25 on February 26, 2016 at approximately 10:45 AM. He/she stated that Resident #54 had a long history of hoarding behaviors and that it was challenging to get him/her to be compliant. He/she was seen by the psychiatrist recently. The family, facility administration and the Long Term Care (LTC) Ombudsman have participated in meetings involving concerns with this resident and related behaviors. A face-to-face interview was conducted with Employee #26 on February 26, 2016 at approximately 11:00 AM. He/she stated that Resident #54 most often sleeps in the chair. That is his/her preference. He/she does not like people to change his/her room and prefers his/her bed cluttered. He/she verbalized that Resident #54 had a long history of challenging behaviors and that the facility administration was directly involved with managing his needs. A face-to-face interview was conducted with Employee #1 on February 26, 2016 at approximately 1:00 PM. He/she was aware of the hoarding behaviors of Resident #54 and that the facility was trying to balance the rights of the resident and safety of the resident and others. He/she stated that dangerous items such as an electric drill and lumbar have been removed from the resident ' s possession. He/she was unaware that Resident #54 had a hand saw in his/her room. Resident #54 had a documented history of behavioral challenges and hoarding practices that the interdisciplinary team identified and recommended approaches for managing. The IDT identified an approach to have staff clear bed each evening of all belongings, if (he/she) will permit it to allow resident choice of sleeping in bed or chair. This may prevent (him/her) from falling from chair when (he/she) is sleeping There was no evidence that staff implemented measures to clear the resident ' s bed so that he/she may sleep in it on February 26, 2016. The resident reportedly fell from sleeping in a chair and sustained lacerations to the head and face. There was no evidence in the behavior monitoring records and/or nursing notes that Resident #54 exhibited noncompliance and/or refusals on or about February 26, 2016, the day of the fall with injury. There was no evidence that the resident ' s bed was cleared so that he/she could sleep in it. Additionally, observations of the resident ' s room during the period that he/she was out of the facility obtaining medical treatment at a local emergency department on February 26, 2016, revealed that the resident ' s bed surface was filled with clutter, the room floor had items scattered across the surface posing a trip hazard and a hand saw was readily accessible to whomever entered which posed a potential accident hazard. Facility staff failed to ensure that Resident #54 ' s room was free from accident hazards and that the resident, who was assessed as moderately cognitively impaired, was adequately supervised as to prevent accidents. The record was reviewed February 26, 2016. B. Based on observations made on February 22, 2016 between 11:30 AM and 3:00 PM, it was determined that the facility failed to provide an environment that is free from accident hazards as evidenced by surge protectors that were not mounted in two (2) of 38 resident rooms, a loose carpet on one (1) of three (3) pods on the third floor and a cluttered resident room was observed with a hand saw. The findings include: 1. The surge protector was not properly mounted and was observed on the floor in two (2) of 38 resident rooms. (#208 and #323). 2. The carpet in the hallway of unit 3A (blue pod) was loose and presented a tripping hazard. 3. Resident room #323 was cluttered with numerous items such as nails, screws, pieces of wood and metal that were scattered throughout and presented an accident hazard to the resident, staff and visitors, one (1) of 38 rooms surveyed. 4. The call bell in one (1) of 38 resident rooms surveyed was torn (#104) exposing the electrical wiring. These observations were made in the presence of Employee #22 and Employee #23 who acknowledged the findings. An isolated observation conducted on February 26, 2016 at approximatley 10:00 AM revealed that a carpenter-style hand saw approximately 15 - 18 inches in length was observed in one (1) resident room, resting atop a push cart readily accessible to anyone entering the room which posed a potential accident hazard. The findings were acknowledged by Employee #26 at approximately 10:05 AM on February 26, 2016. | 2017-02-01 |
| 1510 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 329 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 17 stage 2 sampled residents, it was determined that facility staff failed to ensure that one (1) resident was free of unnecessary medications as evidenced by a failure to consistently monitor psychopharmacological medications for Resident #24. The findings include: A review of the clinical record revealed that Resident #24 ' s [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#24 ' s medication regimen included the following: 1. [MEDICATION NAME] (anxiolytic) 0.25mls (milliliters) sublingual (under the tongue) every 12 hours for anxiety/[MEDICAL CONDITION]. 2. [MEDICATION NAME] (antidepressant) 20mg (milligram), 1 tablet by mouth, 1 time a day for depression A review of the Electronic Medication Administration Record [REDACTED]. [MEDICATION NAME] was given every day at 9:00AM between February 1, 2016 and February 24, 2016. A review of the clinical record lacked documented evidence of behavior monitoring in the section of the Electronic Medical Record (EMR) dedicated to documenting behaviors, or in the nursing progress notes. On February 24, 2016 at approximately 2:10PM, a face-to-face interview was conducted with Employee #11. When asked what behaviors were exhibited by Resident #24, he/she stated that the resident is agitated at times, (uses profanity) and calls the staff names. When asked where that information is documented Employee #11 stated that they don ' t always document those behaviors. On February 24, 2016 at approximately 2:25 PM a face-to-face interview was conducted with Employee #4 regarding the aforementioned findings. He/she acknowledged the findings. There was no evidence that facility staff monitored Resident #24 ' s target symptoms; therapeutic effectiveness and/or potential adverse consequences of the resident ' s anxiolytic and antidepressant medications. The record was reviewed on February 24, 2016. | 2017-02-01 |
| 1511 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 334 | E | 0 | 1 | 2L6211 | Based on record review and staff interview for 15 of 17 Stage 2 sampled residents and 35 supplemental residents, it was determined that facility staff failed to ensure that the immunization program included a method to track the status of pneumococcal immunization for eligible residents and determine those residents who might benefit from pneumococcal revaccination. Residents' #7, 20, 24, 26, 39, 54, 69, 72, 74, 75, 84, 86, 92, 101 and 112. Supplemental residents' # 1, 5, 16, 18, 23, 27, 28, 30, 31, 42, 43, 44, 45, 48, 49, 50, 51, 52, 55, 56, 58, 59, 62, 63, 64, 68, 71, 81, 87, 91, 97, 106, 113, 115 and 117. The findings include: A review of the facility ' s Immunization Protocol (Effective date July 2002 and last reviewed July 2012) revealed: Policy: The(NAME)Home will provide education to residents and family regarding the importance of the pneumococcal .vaccines as well as administration and documentation of vaccines. Procedure: 4) .If the consent box is not checked then the admitting nurse of Clinical Manager contacts the responsible party to determine why the resident is not to receive the immunizations. The Clinical Manager or admitting nurse will discuss the importance of the vaccination program to the health of the resident, of other residents, and the staff in the building. If the answer is still no, the admitting nurse or Clinical Manager contacts the medical staff so that the further discussions with the resident/responsible party take place. 5) When the resident receives the vaccinations this information is entered into the resident immunization record. 6) Resident immunization status will be reviewed every 60 days. Their status will be placed on the physicians round sheet .8) Weekly monitoring of the immunization status as updated on the HCFA 672 Form . A review of the facility ' s immunization program lacked evidence that resident ' s pneumococcal vaccination status was monitored on an ongoing basis. Additionally, there was no evidence that a monitoring mechanism was in place to determine whether or not residents were eligible for and should be offered an opportunity for revaccination. A face-to-face interview was conducted with Employee #3 on February 26, 2016 at approximately 9:20 AM. In response to a query regarding the vaccination status of residents in the facility, he/she requested additional time to obtain the information. At approximately 1:30 PM, Employee #3 produced a line listing of some residents that had received the pneumococcal from data that was available via the facility ' s electronic medical record system. However; s/he stated that he/she would need to manually review archived records to obtain data on all eligible residents. Employee #3 acknowledged that there was no mechanism currently in place to monitor and/or track pneumococcal immunization status of residents. The immunization records for the 15 Stage 2 sampled residents and 35 supplemental residents reviewed; indicated that they were eligible for the pneumonia vaccination and/or revaccination, however; there was no evidence that the facility developed a mechanism for consistently tracking his/her pneumonia vaccination status. The records were reviewed February 26, 2016. | 2017-02-01 |
| 1512 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 371 | E | 0 | 1 | 2L6211 | Based on observations that were made during a tour of the dietary services on February 22, 2016 at approximately 9:45 AM, it was determined that the facility failed to store, prepare and serve food under sanitary conditions as evidenced by nine (9) of nine (9) plates of chicken salad, one (1) of one (1) tray of macaroni salad, a quarter pan of cooked broccoli and one whole pan of cooked chicken breast that were not dated , eight (8) of eight (8) steam wells and two (2) of two (2) grease fryers that were soiled, a leaking inlet valve to one (1) of one (1) juice machine, a leaking control valve to one (1) of one (1) tilt skillet, a missing handle to one (1) of one (1) tilt skillet and a broken plastic cover to one (1) of one (1) sugar storage bin. The findings include: 1. Nine (9) of nine (9) plates of chicken salad with tomatoes and crackers, stored in refrigerator box #7 were not dated. 2. One (1) of one (1) tray of macaroni salad, a quarter pan of cooked broccoli and one whole pan of cooked chicken breast stored in the walk-in refrigerator were not dated. 3. Eight (8) of eight (8) steam wells from two (2) of two (2) steam tables were soiled with food residue. 4. Two (2) of two (2) grease fryers were soiled with leftover fried food residue. 5. The water inlet valve to one (1) of one (1) juice machine was leaking. 6. The on/off control valve to one (1) of one (1) tilt skillet was leaking. 7. The handle from the lid cover to one (1) of one (1) tilt skillet was missing. 8. One (1) of two (2) plastic covers to one (1) of one (1) sugar storage bin was broken and a piece of that cover was missing. 9. Two (2) of two (2) scoop storage containers were soiled at the bottom with excess sugar and flour. 10. Two (2) of two (2) convection ovens were soiled with burnt food deposits. These observations were made in the presence of Employee #20 and Employee #21 who acknowledged the findings. | 2017-02-01 |
| 1513 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 386 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview for one (1) of 17 stage 2 sampled residents, it was determined the physician failed to review the total program of care for Resident #69 as evidenced by a failure to act on a consulting specialists ' recommendation to initiate rehabilitation services. The findings include: Random observations of Resident #69 during the survey period, February 22 through 26, 2016 revealed the resident stayed mostly in his/her room in the bed. The resident was interviewed during the Stage I phase of the survey process and verbalized he/she was able to make his/her needs known. During the interview, he/she stated that staff would assist him/her to get out of bed when he/she wanted; however had no desire to get out of bed at the time of the interview on February 23, 2016 at approximately 1:00 PM. According to the physician ' s progress note dated November 24, 2105, Resident #69 ' s [DIAGNOSES REDACTED]. A psychiatric follow up note dated February 9, 2016 included the following: (Resident named) .has noted recently that (he/she) has spent more time in (his/her) room than usual. While (he/she) will say that (he/she) goes out once a day the staff reports that (he/she) is resistant to get dressed and go outside of (his/her) room despite many invitations and encouragements. (Resident) denies being depressed .(he/she) is pleasant most of the time but that (he/she) does not like to change (his/her) routine recommendations .if available, would restart the physical therapy with (Resident) as (he/she) will otherwise develop muscle weakness . A review of physician progress notes [REDACTED].#69. There was no documentation by the physician/medical to indicate that he/she was aware of the recommendation or that he/she disagreed with the recommendation. A face-to-face interview was conducted with Employee #19 on February 25, 2016 at approximately 3:00 PM. In response to a query regarding rehabilitative services for Resident #69, he/she stated that physical, occupational and speech therapy services are available but that he/she had not received a request or referral for rehab services for the resident. A face-to-face interview was conducted with Employee #4 on February 25, 2016 at approximately 12:30 PM. The employee stated that he/she was unaware of a request for rehab services for Resident #69 but advised that he/she would inquire with the physician regarding rehab. The record was reviewed February 25, 2016. | 2017-02-01 |
| 1514 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 431 | D | 0 | 1 | 2L6211 | Based on observation and staff interview it was determined that the facility failed to ensure that medications were not stored beyond the manufacturer's expiration date in one (1) of three (3) Medication Rooms observed. The findings include: On February 25, 2016 at approximately 11:00 AM, during an inspection of Unit 1A (the locked medication refrigerator), three (3) of three (3) boxes of Pneumovac- Pneumococcal Vaccine Polyvalent- 10 single- dose- 0.5ml (millimeters) vials were observed with an expiration date of January 13, 2016 on each of the vials. The observation was made in the presence of Employee #18 on February 24, 2016 at approximately 4:10 PM. He/she acknowledged the findings and removed the vials from the refrigerator. | 2017-02-01 |
| 1515 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 441 | D | 0 | 1 | 2L6211 | Based on observation and staff interview for one (1) of 17 sampled residents it was determined that facility staff failed to manage wound treatment supplies in a manner equipment as to reduce and/or prevent the potential for cross contamination during a wound treatment; and facility staff failed to ensure that the Infection Control Program included a consistent and systematic collection, analysis, interpretation and dissemination of data to identify infections and infection risks in the facility. Resident #24 The findings include: 1. Facility staff failed to manage wound treatment supplies in a manner as to reduce and /or prevent the potential for cross contamination during wound care for Resident #24. On February 26, 2016 at approximately 10:15AM, a wound care observation was conducted. During this time Employee #12 removed clean uncovered/unwrapped cotton tipped applicators from a package and placed them uncovered into a cardboard box containing Non-Woven Sponges. The clean tips of the applicators were touching the inside surface of the box. When Employee #12 started to perform the dressing change to the resident ' s right hip, he/she removed the cotton tip applicators from the box and placed them on an open, clean gauze pad wrapper. The employee then applied Skin integrity Hydrogel dressing (a gel that is used to maintain a moist wound environment) to the wound on the resident's right hip. He/she then used the cotton tip applicator to spread the gel around the wound. On February 26, 2016 at approximately 11:00AM a face-to-face interview was conducted with Employee #12 regarding clean technique and the potential for cross contamination. He/she acknowledged the findings and stated that the cotton tipped applicators should have been placed on the clean gauze when removed from the package. Facility staff failed to manage wound treatment supplies in a manner as to reduce and/or prevent the potential for cross contamination during wound care. 2. Facility staff failed to ensure the implementation of an infection control program that included a consistent and systematic collection, analysis, interpretation and dissemination of data to identify infections and infection risks in the facility. A review of the November 2015 surveillance forms lacked evidence of consistent tracking and trending such as: The Most recent Admit or Readmitted was not recorded for nine (9) of nine (9) residents listed; The Infection Site was not recorded for one (1) of nine (9) residents listed; The onset date of the infection was not recorded for nine (9) of nine (9) residents listed; The infection was in-house acquired was not recorded for two (2) of nine (9) residents listed Present on Admission was not recorded for two (2) of nine (9) residents listed Antibiotic the strength of the antibiotic and duration of use was not record for two (2) of nine (9) residents listed. The date the antibiotic was initiated and completed was not recorded for four (4) of nine (9) residents listed A review of the December 2015 surveillance forms lacked evidence of consistent tracking and treading such as: The Most recent Admit or Readmitted was not recorded for nine (9) of 10 residents listed; The onset date of the infection was not recorded for five (5) of 10 residents listed; The infection was in-house acquired was not recorded for two (2) of 10 residents listed Present on Admission was not recorded for four (4) of 10 residents listed Antibiotic the strength of the antibiotic and duration of use was not recorded for one (1) of 10 residents listed. The date the antibiotic was initiated and completed was not recorded for nine (9) of 10 residents listed A review of the January 2015 surveillance forms lacked evidence of consistent tracking and treading such as: The Most recent Admit or Readmitted was not recorded for five (5) of 10 residents listed; The Infection Site was not recorded for one (1) of 10 residents listed; The onset date of the infection was not recorded for six (6) of 10 residents listed; The infection was in-house acquired was not recorded for three (3) of 10 residents listed The infection site was not recorded for four (4) of 10 residents listed Present on Admission was not record for two (2) of 10 residents listed Antibiotic the strength of the antibiotic and duration of use was not recorded for two (2) of 10 residents listed. The date the antibiotic was initiated and completed was not recorded for seven (7) of 10 residents listed There was no evidence that the facility ' s Infection Control Program included a consistent and systematic collection, analysis, interpretation and dissemination of data to identify infections and infection risks in the facility. In addition, at the time of this review the facility had no residents on transmission based precautions and no evidence of outbreaks of communicable disease. A face-to-face interview was conducted with Employee # 3 on February 23, 2016 at 3:16 PM. He/she acknowledged the findings and stated, I have implemented a new surveillance sheet. | 2017-02-01 |
| 1516 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 463 | D | 0 | 1 | 2L6211 | Based on observations made on February 22, 2016 between 11:30 AM and 3:00 PM, it was determined that the facility failed to maintain resident call systems as evidenced by inoperative call bells in two (2) of 13 resident rooms. The findings include: Call bells did not function as intended in two (2) of 38 resident rooms (#115 and #127). These observations were made in the presence of Employee #22 and Employee #23 who acknowledged the findings. | 2017-02-01 |
| 1517 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 514 | E | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for three (3) of 17 sampled residents and three (3) supplemental residents, it was determined that facility staff failed to ensure that a hospice discharge note was readily available in the active clinical record for Resident #24 and that the clinical record included documented evidence of discharge planning activities for two (2) residents. Additionally, facility staff failed to ensure that eight (8) of eight (8) glucometers (a medical device for measuring blood glucose) were set with the current date(s) and time. Resident's #20, 24 and 88. The findings include: 1. Facility staff failed to document evidence of measures related to facilitating Resident #20 ' s involuntary discharge from the facility. A review of the facility ' s documents revealed the facility provided a Notice of Closure letter signed by the Chief Executive Officer and dated November 3, 2015 (original notification was dated September 15, 2015) addressed to all residents (and/or responsible parties) residing in the facility that read: This letter serves each of you as your official notice of closure and the need to transfer or discharge to another location. Final closure will be December 15, 2016 .We will assure the continuity of services by providing the receiving facility with assessment and care plan, and for discharge, by arranging for those services required by the post discharge plan . A social service progress note dated September 18, 2015 at 3:21 PM read, Spoke with (family member) about the closing of (Facility named). S/he is interested in working with (family member) to find a place for (him/her) to live SE (southeast), NE (northeast) are a possibility. Also (local facility) is an option. Will continue to work with them to explore a safe discharge plan. A social service progress note dated November 9, 2015 at 4:37 PM read, The formal letter to resident notifying (gender) of closure of (name of facility) in December 2016, has been placed in the chart. This letter has also been mailed to the resident's responsible representative. The clinical record lacked documented evidence of measures implemented by the social work staff subsequent to September 2015, as it relates to facilitating Resident #20 ' s involuntary discharge from the facility. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM who acknowledged the findings. The record was reviewed February 26, 2016. 2. Facility staff failed to ensure that a hospice discharge note was readily available in Resident #24 ' s active clinical record. A review of a physician order [REDACTED]. A review of a Community Hospices note dated November 3, 2015 read: .Swer (social worker) discussed with pt (patient) discharge from hospice . A review of the clinical record lacked documented evidence of a hospice discharge note. On February 25, 2016 at approximately 9:45 AM a face-to-face interview was conducted with Employee #14 regarding the process of discharging a resident from hospice. He/she stated that the hospice staff will review the care plan to see if it has been adjusted, and a discharge note is placed in the chart. When asked where the discharge summary from hospice is found in the chart, Employee #14 stated that (vendor named ) is the electronic medical record ssytem that is used by hospice and that the information is typically placed in the hospice section of the active clinical record. Employee #14 acknowledged that the hospice discharge summary was not in Resident #24 ' s clinical record. The record was reviewed February 24, 2016. 3. Facility staff failed to document evidence of measures related to facilitating Resident #88 ' s involuntary discharge from the facility. A review of the facility ' s documents revealed the facility provided a Notice of Closure letter signed by the Chief Executive Officer and dated November 3, 2015 (initial notification was September 15, 2015) addressed to all residents (and/or responsible parties) residing in the facility that read: This letter serves each of you as your official notice of closure and the need to transfer or discharge to another location. Final closure will be December 15, 2016 .We will assure the continuity of services by providing the receiving facility with assessment and care plan, and for discharge, by arranging for those services required by the post discharge plan . A review of Resident #88 ' s clinical record revealed the following Social Services progress notes: November 9, 2015 at 16:50 (5:50PM); The formal letter to resident notifying (gender) of closure of (name of facility) in December 2016, has been placed in the chart. This letter has also been mailed to the resident's responsible representative. November 20, 2015 at 16:07 (4:07PM); Left message for RP (responsible party) on this date, to discuss discharge planning. Await call back. January 18, 2016 at 15:37 (3:37 PM); Placed follow up call to (RP name) .Awaiting call back to discuss transition planning. A review of the facility ' s social work discharge planning tracking document(s) revealed that Resident #88 ' s primary representative (family) was contacted via teleconference on February 9, 2016. A discussion was held regarding discharge options. There was no evidence of documentation related to the February 9, 2016 teleconference regarding discharge options. A review of social service progress notes lacked documented evidence of measures implemented to facilitate Resident #20 ' s involuntary discharge from the facility. A face-to-face interview was conducted with Employee #10 on February 26, 2016 at approximately 3:30 PM regarding the aforementioned findings. He/she acknowledged the social service notes were not current The record was reviewed February 26, 2016. 4. Facility staff failed to ensure that eight (8) of eight (8) glucometers were set with the current date(s) and time. An observation of eight (8) of eight (8) glucometers (on Unit 1A, 2A, 2B, 3A) revealed that the current date and time was not set on the devices/machines; and the dates and times of the blood glucose results registered in the device did not reconcile with the dates and times recorded in the electronic medical record for the respective resident(s). A face-to-face interview was conducted on February 22, 2016 at approximately11:25AM with Employees #4, #5, #6 and #7. They verified that the glucometers were not calibrated yearly for accuracy, they are used until they are unable to be turned on then they would be discarded and be replaced with new ones. There was no evidence that the glucometers machines were being checked by the facility to make sure the correct dates and times were set. A face-to-face interview was conducted with the Employee #24 on February 22, 2016 at approximately 12:05PM. He/she acknowledged findings. This record was reviewed February 22, 2016. | 2017-02-01 |
| 1518 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-09-26 | 371 | D | 1 | 0 | S7P711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews and record review for Resident #1, it was determined that facility staff failed to prepare food in a safe manner as evidenced by several pieces of a foreign object found in pureed meat on September 21, 2016. The findings include: Resident #1 was born on August 13, 1933 and was admitted to the facility on [DATE]. According to the Minimum Data Set assessment with an assessment reference date of August 2, 2016, Resident #1 was assessed as having severely impaired cognitive skills for daily decision making in Section C (Cognitive Patterns). Resident #1 was assessed as requiring extensive assistance for bed mobility, transfers, dressing, eating, toileting, and personal hygiene and totally dependent for bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. On September 21, 2016 during the evening meal, it was noted that several small pieces of a hard, plastic, grey foreign substance were observed in the pureed meat. Employee #1 was notified and called Employee #2 to the unit. Both employees observed the hard, grey plastic foreign objects in the pureed meat. Face-to-face interviews were conducted with Employees #1 and #2 on September 26, 2016 between 5:00 PM and 5:30 PM who acknowledged the presence of several small grey plastic foreign objects in the pureed meat on September 21, 2016. Employee #1 instructed facility staff to check the other residents ' with pureed food for the small plastic grey foreign objects. There were eight (8) total residents who received pureed food. Two (2) additional trays were found with small plastic grey foreign objects. According to Employee #1, neither resident had been fed prior to the discovery of the hard, grey plastic foreign objects found in the food. The food was discarded and fresh food was prepared for the three (3) residents identified by facility staff with small plastic grey foreign objects in their food. The blender that was used to prepare the pureed food on September 21, 2016, was inspected on September 26, 2016 at 6:00 PM. The cover that was used to prepare the pureed food on September 21, 2016 was inspected and it was noted that one edge of the wiper was jagged and unsmooth. The wiper was the same color as the foreign objects found in the pureed food. This piece was immediately replaced on September 22, 2016 and staff was in-serviced on the use of the machine at that time. A face-to-face interview was conducted with Employee #2 on September 27, 2016 at 2:30 PM, who plated the food on September 21, 2016 at the evening meal, was asked about the above incident and stated that he/she did not see anything in the food. Face-to-face interviews were conducted on September 26, 2016 between 4:00 PM and 6:00 PM, with Residents #2, 3, and 4, who have been resident ' s on an average of [AGE] years, acknowledged that they had never seen any foreign object in their food. According to the manufacturer ' s recommendations, there was no suggested preventive maintenance for the wiper. A face-to-face interview was conducted with Employee #4 on September 26, 2016 at 1:45 PM who acknowledged the above findings. The record was reviewed September 21, 2016. | 2017-02-01 |
| 1519 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-10-20 | 203 | D | 1 | 0 | L5DV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that facility staff failed to issue a transfer/discharge notice for two (2) hospitalization s. The findings include: Resident #1 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment with an assessment reference date of June 11, 2016, the resident was assessed with [REDACTED]. Resident #1 was assessed as being totally dependent for all Activities of Living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. A review of the resident ' s record revealed that the resident had been hospitalized on [DATE], September 4, 2016, and September 9, 2016. According to the MDS (Minimum Data Set) 3.0 User ' s Manual , page 2-9, Discharge refers to the date a resident leaves the facility .There are two types of discharges - return anticipated and return not anticipated. A Discharge assessment is required with both types of discharges .Any of the following situations warrant a discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds .resident is admitted to a hospital (regardless of whether the nursing home discharges or formally closes the record.) . A transfer/discharge notice was issued on September 6, 2016 by facility staff for the hospitalization of September 4, 2016. There were no discharge notices issued for the hospitalization s of August 6, 2016 and September 7, 2016 to the QIES to Success data base. According to the QIES to Success website: : Welcome to QIES to Success, the custom web-based system developed to assist in managing and monitoring information and applications within the Quality Improvement Evaluation System. To find information in a quick and efficient manner, visit the QIES to Success pages anytime you need to find information on CASPER, MDS, OASIS, RAVEN, HAVEN, and ASPEN, to name a few. A face-to-face interview was conducted with Employee #1 on October 14, 2016 at 2:00 PM. He/she stated, I send all the notices to the Department of Health and the Ombudsman. I don ' t know the notices were not sent for the resident ' s hospitalization s. The record was reviewed October 14, 2016. | 2017-02-01 |
| 1520 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-10-20 | 286 | D | 1 | 0 | L5DV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, facility staff failed to compete and transmit discharge assessments to the MDS data base for Resident #1 and Resident #2. The findings include: According to the MDS (Minimum Data Set) 3.0 User ' s Manual , page 2-9, Discharge refers to the date a resident leaves the facility .There are two types of discharges - return anticipated and return not anticipated. A Discharge assessment is required with both types of discharges .Any of the following situations warrant a discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds .resident is admitted to a hospital (regardless of whether the nursing home discharges or formally closes the record.) . According to the QIES to Success website: : Welcome to QIES to Success, the custom web-based system developed to assist in managing and monitoring information and applications within the Quality Improvement Evaluation System. To find information in a quick and efficient manner, visit the QIES to Success pages anytime you need to find information on CASPER, MDS, OASIS, RAVEN, HAVEN, and ASPEN, to name a few. A review of Resident #1 ' s record revealed that the resident had been hospitalized on [DATE], September 4, 2016, and September 9, 2016. A review of the QIES to Success website, MDS 3.0 viewer, revealed that a discharge assessment was not completed for Resident #1for any of the above cited hospitalization dates. A review of Resident #2 ' s clinical record revealed that the resident was transferred to another nursing facility on August 15, 2016. A review of the QIES to Success website, MDS 3.0 viewer, revealed that a discharge assessment was not completed for Resident #2 for the above cited transfer date. A telephone interview was conducted with Employee #2 on October 18, 2016 at 12:25 PM. He/she acknowledged that the discharge notice was not transmitted to the MDS data base. The records were reviewed October 14, 2016. | 2017-02-01 |
| 1521 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-10-20 | 287 | D | 1 | 0 | L5DV11 | Based on record review and staff interview for four (4) residents, it was determined that facility staff failed to submit the discharge assessments to the QIES to Success data base in a timely fashion. Residents #3, 4, 5, and 6. The findings include: According to the MDS 3.0 User ' s Manual , page 5-3, Submission Time Frame for MDS Records , directed .Transmission requirements apply to all MDS 3.0 records used to meet both Federal and state requirements .Discharge (assessments) - Final Completion or event date Z0500B (Date RN signed assessment as complete) +14 (days). 1. A review of Resident #3 ' s record revealed a Z0500B date of July 19, 2016. The submission date was August 9, 2016, 22 days later. 2. A review of Resident #4 ' s record revealed a Z0500B date of August 16, 2016. The submission date was September 23, 2016, 39 days later. 3. A review of Resident #5 ' s record revealed a Z0500B date of August 18, 2016. The submission date was September 23, 2016, 37 days later. 4. A review of Resident #6 ' s record revealed a Z0500B date of July 25, 2016. The submission date was September 23, 2016, 61 days later. A telephone interview was conducted with Employee #2 on October 18, 2016 at12:25 PM. He/she acknowledged that the discharge notice was not transmitted to the MDS data base. The records were reviewed October 14, 2016. | 2017-02-01 |
| 1715 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-06-03 | 323 | G | 1 | 0 | HX0R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that inadequate supervision was given to the resident who was improperly transferred and subsequently was found to have a fractured right distal third of the tibia and fibula. The findings include: Resident #1 was born on March 15, 1935 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #1 was assessed as having short and long-term memory problems with severely impaired cognitive skills for daily decision-making in Section C (Cognitive Patterns). Resident #1 was assessed as being totally dependent for all Activities of Daily Living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated April 20, 2013 at 1:06 AM: At 10 PM CNA assigned to the patient called me to come to the patient ' s room to show me the right foot and ankle. He stated that as he/she was doing his/her ADLs he/she noticed a change in (Resident #1 ' s) facial look as he/she was turning him/her. (The CNA) noticed his/her right foot and ankle to be slightly bent. The patient was assessed by (writer) and Nursing Supervisor. The right foot and ankle did slightly bend inside. NP notified and responded with new orders. The right foot is not discolored or swollen upon assessment. Daughter is aware. This is for 4/19/13 at 10 PM. A telephone interview was conducted with Employee #1 on May 2, 2013 at 11:25 AM. Employee #1 was asked about the above concerns and stated, (Resident #1) was sitting in a geri-chair and he/she was making a face like he/she was going to cough. He/she makes that face all the time. That was something normal for him/her. I put him/her back to bed with the Hoyer lift about seven o ' clock (7:00 PM). I had to do it by myself because I couldn ' t find any help. The transfer was okay. Nothing happened during the transfer. I positioned him/her on his/her right side. I put pillows under both legs and between his/her knees and behind his/her back. When I came back about two hours later he/she was grimacing when I touched him/her. I had to find out what happened so I looked at him/her and saw that his/her right foot was bent. I called the charge nurse right away and then I found out that he/she had a broken leg. I know that the Hoyer transfer is supposed to be with two people but I couldn ' t find another person to help me. According to the reports of the x-ray dated April 20, 2013 at 2:56 PM: Spiral fractures distal thirds of tibia and fibula. According to the facility ' s Mechanical Lift , policy no: TX- .05, page one (1) of one (1), effective November 2005: Purpose: To provide a safe transfer of residents/patients by the healthcare provider while operating the equipment in a safe and proper manner at all times . Procedure: 1. The Mechanical lift should be used by at least two (2) care providers at all times with patients/residents who cannot use any other means of transfer . A face-to-face interview was conducted with Employee #2 on April 23, 2013 at 3:30 PM. He/she stated, I don ' t know why (Employee #1) transferred the resident with a Hoyer lift without assistance. That is not our policy. Facility staff failed to properly transfer Resident #1 from the geri-chair to the bed using the Hoyer lift. Resident #1 subsequently sustained a spiral fracture of the distal third of the right tibia and fibula. The record was reviewed April 13, 2013. | 2016-06-01 |
| 1742 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 241 | D | 0 | 1 | RSE411 | Based on an isolated observation for one (1) of 41 sampled residents, it was determined that facility staff failed to promote dignity for one (1) resident as evidenced by the observation of a paper towel applied proximal to the resident ' s ear as a skin protectant. Resident #43 The findings include: Facility staff failed to promote dignity for Resident #43. The resident was observed on February 20, 2013 at approximately 11:30 AM seated in a wheelchair in the common area of the nursing unit with portable oxygen infusing via nasal cannula. The nasal cannula was applied as prescribed, to the resident ' s nares and secured behind his/her ears. A paper towel was observed resting loosely and unevenly along the tubing of the nasal cannula proximal to the resident ' s right ear. At the time of the observation, Employee #5 was queried as to the purpose of the paper towel observed proximal to the resident ' s ear. He/she stated that the resident had a tendency to have skin break down behind the ears secondary to the oxygen tubing and that the paper towel served to protect the resident ' s skin. He/she added, 4 x 4 gauze pads are supposed to be used (instead of the paper towel). A face-to-face interview was conducted with Employee #17, the licensed staff assigned to Resident #43, on February 20, 2013 at approximately 2:30 PM. In response to a query regarding the paper towel observed proximal to Resident #43 ' s ear, he/she replied that the paper towel served to protect the skin behind the resident ' s ear from breaking down. However, he/she stated that gauze sponges are usually used to protect the skin behind the resident ' s ear from the oxygen tubing rubbing against it. Facility staff failed to promote dignity for Resident #43 as evidenced by the observation of a paper towel applied proximal to the resident ' s ear as a skin protectant. | 2016-04-01 |
| 1743 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 246 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews for two (2) of two (2) resident rooms observed, it was determined that the facility failed to ensure that residents' received services with reasonable accommodations of individual needs as evidenced by two (2) of two (2) call bells were not accessible for communication from the residents' rooms and/or bathrooms. The findings include: 1. Facility staff failed to ensure that the call bell system in resident room was accessible for communication from the resident. The call bell was not accessible for communication for one (1) of one (1) resident's room [ROOM NUMBER] on February 13, 2013 at approximately 4:37 PM. Resident #20 was observed sitting in his/her chair. The call light was wrapped around the bedrail. The resident was sitting on the opposite side and was not in reach of the call light. Subsequently, the call bell was unwrapped from the bedrail and placed within the resident 's reach. These observations were made in the presence of Employee #6 who acknowledged the findings 2. A resident room observation was conducted on February 14, 2013 at approximately 11:09 AM on 3A in room [ROOM NUMBER]. The following was observed: The resident ' s pull cord in the bathroom was wrapped around the grab bar, tied in a knot, about 12 inches from the floor. The observations were made in the presence of Employees #16 and #32. | 2016-04-01 |
| 1744 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 253 | E | 0 | 1 | RSE411 | A.Based on observations made during an environmental tour of the facility on February 13, 2013 at approximately 2:00 PM and on February 14, 2013 at approximately 10:00 AM, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior as evidenced by two (2) of four (4) broken window blinds in two (2) of seven (7) resident rooms; a damaged door frame in one (1) of seven (7) residents' rooms, a stained commode in the bathroom of one (1) of seven (7) residents rooms, marred and scarred closet doors in two (2) of seven (7) residents rooms, a pillar and an adjacent wall damaged with numerous holes five (5) in one (1) of seven (7) residents rooms, and peeling wallpaper on both sides of the hallway between rooms #226 and #238. The findings include: 1. Window blinds were broken in rooms #216 and #230, in two (2) of seven (7) residents' rooms. 2. The door frame to the entrance door of room #216 was damaged with a hole on the left side of the frame in one (1) of seven (7) resident's rooms. 3. The bathroom commode was stained in room #257, one (1) of seven (7) resident's rooms. 4. Closet doors in two (2) of seven (7) residents' rooms were marred and scarred (rooms #222 and #223). 5. A pillar in room #237 and the adjacent wall were damaged with holes in one (1) of seven (7) resident's rooms. 6. The wallpaper on both sides of the hallway between rooms # 226 and #238 was peeling off the walls in one (1) of three (3) hallways observed and needed to be repaired. These observations were made in the presence of Employee #6 at approximately 2:00 PM on February 13, 2013 and at approximately 10:00 AM on February 14, 2013. He/she acknowledged the findings. B. Based on observations of 39 randomly selected rooms during an environmental tour of the facility on February 20, 2013 at 10:30 AM, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior as evidenced by defects along wall surfaces in 19 rooms; leaking faucets in two (2) rooms; damaged blinds and/or window screens in six (6) rooms; soiled floor surfaces in four (4) rooms; exhaust vents accumulated with dust in four (4) rooms, one (1) call light was secured with electric tape and one (1) drawer pull was partially detached. The findings include: 1. Nineteen (19) of 39 rooms were observed with surface defects along wall surfaces as follows: Marred areas: Rooms #357, 351, 315, 211, 204, 215, 116 Spackling paste without finishing paint: Rooms: #357, 351, 346, 332, 216, 211, 203 Holes in the wall surfaces: Rooms: #350, 259 Nails and/or hinges protruding from wall surfaces: Rooms: #316, 314, 259 2. Two (2) of 39 bathroom faucets were leaking and would not turn off with spigot: Rooms #154, 155 3. Five (5) of 39 rooms were observed with damaged window blinds and/or screens: Blinds - Rooms #155, 304 Screens - Rooms #249, 229, 250, 227 4. Floor surfaces were soiled with dust, marred and/or observed with a dull finish in four (4) of 39 rooms: Rooms: #315, 313, 356, 358 5. Exhaust vents accumulated with dust in four (4) of 39 rooms: Rooms #325, 345, 345, 358 6. One (1) call light was secured with electric tape in an isolated observation in Room #204. 7. One (1) night stand drawer pull was partially detached in an isolated observation in Room #333. The observations were made in the presence of Employees #1 and 14 during an environmental tour of the facility on February 20, 2013. | 2016-04-01 |
| 1745 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 279 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, record review and staff interviews for three (3) of 41 sampled residents, it was determined that facility staff facility staff failed to obtain specialized rehabilitative services for a resident who had a positive - PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Level II Screen. Resident #2. an integrated care plan for hospice services for one (1) resident; and to address a swallowing impairment or potential for aspiration for one (1) resident. Residents #2, #9, and #164. The findings include: 1. Facility staff failed to obtain specialized rehabilitative services for a resident who had a positive - PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Level II Screen. Resident #2. A review of the medical record for Resident #2 identified that the resident was admitted to the facility in March 25, 1968. Review of the PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Screen dated January 20, 2008, identified the resident as positive for Mental [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set with an ARD (Assessment Reference Date) of November 15, 2012 identified in Section I the following Diagnoses: [REDACTED]., Slow transit constipation, other drug allergy, Unspecified Infantile [MEDICAL CONDITION], Mild Intellectual Disabilities (Mental [MEDICAL CONDITION]). Review of the Care Plan Face Sheet identified that the IDT (Interdisciplinary Team Meeting) was conducted on November 15, 2012. Further review of the care plans lacked evidence of a care plan with goals and approach to address Resident #2's positive screen for Mental [MEDICAL CONDITION]. A face-to-face interview was conducted with Employee #4 on February 14, 2013 at approximately 5:10 PM. After a review of the care plans, he/she acknowledged the findings. Facility staff failed to develop a care plan with measurable goals and approaches for Resident #2 who had a positive PASRR. This is a repeat deficiency from the QIS recertification survey of March 6, 2012. 2. Facility staff failed to initiate an integrated care plan for hospice services for Resident #9. A review of the resident ' s clinical record revealed that the resident was hospitalized in an acute care facility on December 25, 2012 and returned to the facility on [DATE]. Review of an Interim Order Form revealed two (2) orders. The first order was written by the nurse practitioner and documented the following, Patient for hospice services as of 1/28/13. That order was also dated and signed January 28, 2013. The second was a telephone order which directed, Pt. (patient) admitted to Community Hospices under (MD' s name) was dated January 29, 2013. Further review of the record revealed that the resident was visited by the Hospice nurse on January 29, 2013. According to the admission Minimum Data Set (MDS) with an Assessment Reference Date of February 8, 2013 the resident was coded for Hospice care in Section O. However, review of the care plans failed to reveal a care plan with goals and approaches to address the delivery of Hospice Care to the resident. A face-to-face interview was conducted with Employee #4 on February 20, 2013 at 4:00PM. During the interview the employee acknowledged that no integrated care plan was developed and/or initiated for the resident ' s Hospice care. The clinical record was reviewed on February 20, 2013. 3. Facility staff failed to develop a care plan for safe swallowing/aspiration for Resident #164 who was identified as requiring mechanical soft meal and nectar thicken liquids. On February 13, 2013 at 9:50 AM a medication administration observation was conduct. Employee # 19 was observed administering oral medications to Resident #164. While at the bedside of the resident, Employee #19 administered medications which included Calcium [MEDICATION NAME] one (1) tablet, [MEDICATION NAME] 100mg two (2) tablets, and [MEDICATION NAME] one (1) tablet. The Employee gave Resident #164 approximately 50 ml of cranberry juice in a cup with a straw for the resident to swallow his/her medication. The resident drank the cranberry juice by sipping it from the straw. Observed on Resident #164 ' s over-the-bed table was one (1) packet of Instant Food Thickener and one (1) container of Thick and Easy pre-thickened beverage. At no time did Employee #19 mix the thickener with the cranberry juice that was given to Resident #164 to drink while taking his/her medications. According to the History and Physical dated May 4, 2012 Resident #164 had a [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. A review of the Functional Maintenance Program-recommendations dated October 22, 2012 revealed, Referral to restorative nursing for .cue as needed for adherence to safe swallow strategies/aspiration precautions and required diet/liquid consistencies . A review of the Nutritional Assessments dated November 12, 2012 and February 13, 2013 revealed, Current diet order- Mech (mechanical soft, nectar thick, NCS (no concentrated sweets) A review of the Care Plans printed by the facility and those located on the active clinical record revealed that there was no care plan with goals and approaches to address the resident ' s swallowing impairment or potential for aspiration. A face-to-face interview was conducted with Employees #3 and #29 on February 19, 2013 at approximately 10:30 AM. They acknowledged that there was no care plan developed to address the resident ' s swallowing impairment or potential for aspiration. The record was reviewed on February 19, 2013. | 2016-04-01 |
| 1746 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 309 | E | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for seven (7) of 41 sampled residents, it was determined that facility staff failed to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by a failure to: consistently assess and monitor the status of altered skin integrity for two (2) residents; follow through on a physician's order [REDACTED]. [REDACTED]. Residents ' #82, 107, 205, 252, 273, 286 and 292. The findings include: 1. A review of the clinical record for Resident #82 revealed facility staff failed to consistently assess and monitor the status of an alteration in skin integrity and failed to follow through on a physician's order [REDACTED]. A. An electronic entry entitled Incident details dated January 2, 2013 at 10:33 PM read: Resident reported with new open area of inner buttock measure 2.5 cm (centimeter) x 2 cm and cluster of small skin open areas at the same site. (physician named) notified, order given to clean open area with soap and water, pat dry, apply [MEDICATION NAME] each shift after each incontinent care. A nurse ' s entry dated January 3, 2013 at 12:25 AM read, (family member named) called and was informed of skin impairment to sacral area. A review of the corrected quarterly Minimum Data Set (MDS) signed January 8, 2013; assessment reference date January 3, 2013 was coded in Section M, Skin conditions that the resident had one (1) Stage 1 pressure ulcer. The clinical record lacked evidence of monitoring and ongoing assessments of the status of the alteration in skin integrity of the sacral area and/or inner buttocks for Resident #82. There was no evidence of documentation regarding the status of the resident ' s altered skin subsequent to the initial assessment on January 2, 2013. An observation of the resident ' s sacral region on February 19, 2013 lacked evidence of a break in skin integrity. The findings were acknowledged by Employees #4 and #8 during face-to-face interviews conducted on February 20, 2013 at 10AM and 1:00 PM respectively. B. Facility staff failed to follow through on a physician's order [REDACTED]. An interim physician's order [REDACTED]. The clinical record lacked evidence that the resident was evaluated by the wound care team as prescribed. A face-to-face interview was conducted with Employee #4 on February 20, 2013 at 10:00 AM who acknowledged that the record lacked evidence of an assessment by the wound care team. The record was reviewed February 20, 2013. 2. Facility staff failed to identify and implement measures to manage the postural/positioning concerns for Resident #107. Resident #107 was observed on February 20, 2013 at approximately 11:00 AM seated at a table in the common area (day/dining room) in his/her wheelchair. The resident was observed excessively leaning to one side without support to maintain an upright position. There was no evidence of needed torso support. Employee #6 who was present during the time of the observation, was queried regarding the lack postural and/or positioning supports for Resident #107. He/she responded that the resident often falls asleep while seated in his/her wheelchair and tends to lean. He/she asked a staff person to obtain a pillow to assist with positioning. Additional observations of positioning/postural concerns were observed during the survey period as follows: Observed Resident #107 in the activity area on February 14, 2013 at 10:00 AM and 3:00 PM sitting in a wheelchair. The resident was leaning to his/her right without support to maintain an upright position. Observed February 15, 2013 in the activity area at approximately 9:54 AM, Resident #107 was sitting in a wheelchair at a table; the resident was leaning to one side without support to maintain an upright position. A face-to-face interview was conducted with Employee #37 on February 21, 2013 at 11:00 AM. He/she stated that the resident has a [DIAGNOSES REDACTED]. The rehabilitation division had not received a communication from nursing regarding positioning concerns for this resident. He/she stated an evaluation will be conducted. An annual physical therapy (PT) screen dated January 26, 2013 read: patient was seen today for annual screen. There has been no change of condition or any recent change in safety status. Wheelchair in good condition. PT evaluation not indicated. Facility staff failed to identify and implement measures to address the postural/positioning concerns for Resident #107. 3. A review of the clinical record for Resident #205 revealed facility staff failed to consistently assess and monitor the status of an alteration in skin integrity. A nurse ' s entry dated December 31, 2012 read: New (1st recording) for Site - 352. Present on the Coccyx is a skin tear/laceration. The following findings were documented, general comments: This abnormality was recorded using an assessment other than skin & wound during a body check. The clinical record lacked evidence of status of the skin alteration of the coccyx initially identified on December 31, 2012. An observation of the resident ' s skin on February 19, 2013 at approximately 11:30 AM lacked evidence of an alteration of the skin of the coccyx. A face-to-face interview was conducted with Employee #4 on February 19, 2013 at approximately 9:30 AM; he/she acknowledged that the record lacked evidence of the status of the resident ' s alteration in skin integrity identified December 31, 2012. However, he/she stated that the resident ' s skin was intact at present. 4A. Facility staff failed to identify the type of device that was inserted for Resident #252 ' s Intravenous access site. The Central Venous Catheter-Physician order [REDACTED]. There was no evidence that facility staff identified the Device type information (listed above) on the Central Venous Catheter-Physician order [REDACTED].# 252. A face-to-face interview was conducted with Employee #7 on February 21, 2013 at approximately 11:08 AM. He/she acknowledged that the device information was not listed on the Central Venous -Physician order [REDACTED]. The record was reviewed on February 21, 2013. 4B. Facility staff failed to consistently conduct a comprehensive pain assessment for Resident #252 who was in pain and received pain medication. The physician's order [REDACTED]. [MEDICATION NAME] IR 5mg- Take (two) 2 tablets by mouth every (four) 4 hours as needed for severe pain. The November 2012 Medication Administration Record [REDACTED]. The November 2012 Medication Administration Record [REDACTED]. There was no evidence that facility staff consistently conducted an assessment that included a description of the location of the pain; the intensity of the pain (e.g. numeric scale) before to determined whether to administer one or two tablets of [MEDICATION NAME]; and there was no evidence that an assessment was completed after the administration of [MEDICATION NAME] IR 5 mg for mild or severe pain. A face-to-face interview was conducted with Employee #7 on February 21, 2013 at approximately 11:08 AM. He/she acknowledged that the pain assessment was not consistently completed to include the location and the intensity of the pain before the pain medication was administered and after pain medication was administered to determine the effectiveness. The record was reviewed on February 21, 2013. 5. Facility staff failed to consistently conduct a complete pain assessment for Resident #273 who was in pain and received pain medication. The physician's order [REDACTED]. The February 2013 Medication Administration Record [REDACTED]. There was no evidence that facility staff consistently conducted an assessment that included a description of the location of the pain, the intensity of the pain (e.g. numeric scale) before and after the administration of [MEDICATION NAME] IR 5 mg. A face-to-face interview was conducted with Employee #7 on February 20, 2013 at approximately 10:50 AM. He/she acknowledged the aforementioned findings. The record was reviewed on February 20, 2013. 6. Facility staff failed to measure the arm circumference and the external catheter length for Resident #286 ' s Intravenous access site. The Central Venous Catheter -Physician order [REDACTED]. Treatment orders: PICC catheters: Measure upper arm circumference (3 in (inches) or 10 cm (centimeters) above insertion site) on admission, with dressing change and PRN (as needed) . A review of the January 2013 Central line Catheter Treatment Record and Medication Administration Record [REDACTED]. The Central Venous Catheter-Physician order [REDACTED]. Treatment orders: PICC catheters: Measure upper arm circumference (3 in (inches) or 10 cm (centimeters) above insertion site) on admission, with dressing change and PRN (as needed) . Measure external catheter length on admission, with each dressing change and prn . A review of the February 2013 Central line Catheter Treatment Record and Medication Administration Record [REDACTED]. There was no evidence that Resident #286 ' s arm circumference was measured in accordance with the physician's order [REDACTED]. A face-to-face interview was conducted with Employee #7 on February 19, 2013 at approximately 11:45 AM. He/she acknowledged that the arm circumference and the length of the external catheter were not measured. The record was reviewed on February 19, 2013. 7. Facility staff failed to ensure that Resident #292 received Incentive Spirometer treatments as prescribed. Resident #292 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission orders [REDACTED]. A review of the February 2013 Treatment Administration Record revealed that the order, Use the Incentive Spirometer every 1-3 hours while awake until normal activity is resumed. was transcribed for frequency as FYI (for your information). There was no evidence in the clinical record that facility staff carried out the order for the resident to use the Incentive Spirometer every one (1) to three (3) hours. A face-to-face interview was conducted on February 20, 2013 at 10:25 AM with Employee #22. He/she stated, We test the resident ' s oxygen levels each day during therapy. On evaluation (he/she) did the incentive spirometer. We discussed it daily. I instructed (him/her) to do it every commercial break. I made sure (he/she) knew how to do it and understood the instructions. A face-to-face interview was conducted on February 20, 2013 at 11:10 AM with Employee #21. He/she stated, You could hear the [MEDICATION NAME] when (he/she) was using it. I was in the room with (him/her) when (he/she) used it. I didn ' t look at the numbers on it (the spriometer). I didn ' t document (him/her) using it (the incentive spirometer). A face-to-face interview was conducted on February 20, 2013 at 11:00 AM with Employee #7. He/she acknowledged that the there was no evidence that the order for the use of [REDACTED]. The record was reviewed on February 20, 2013. | 2016-04-01 |
| 1747 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 323 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews for one (1) of 41 sampled residents, it was determined that facility staff failed to ensure that Resident #164 received adequate services /supervision as to promote safe swallowing during a medication administration observation. The findings include: On February 13, 2013 at 9:50 AM a medication administration observation was conduct. Employee # 19 was observed administering oral medications to Resident #164. While at the bedside of the resident, Employee #19 administered medications which included Calcium Carbonate one (1) tablet, Neurontin 100mg two (2) tablets, and Xifaxan one (1) tablet. The Employee gave Resident #164 approximately 50 ml of cranberry juice in a cup with a straw for the resident to swallow his/her medication. The resident drank the cranberry juice by sipping it from the straw. Observed on Resident #164 ' s over-the-bed table was one (1) packet of Instant Food Thickener and one (1) container of Thick and Easy pre-thickened beverage. At no time did Employee # 19 mix the thickener with the cranberry juice that was given to Resident #164 to drink while taking his/her medications. According to the History and Physical dated May 4, 2012 Resident #164 had a [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. A review of the Functional Maintenance Program-recommendations dated October 22, 2012 revealed, Referral to restorative nursing for .cue as needed for adherence to safe swallow strategies/aspiration precautions and required diet/liquid consistencies . A review of the Nutritional Assessments dated November 12, 2012 and February 13, 2013 revealed, Current diet order- Mech (mechanical soft, nectar thick, NCS (no concentrated sweets) A review of the Care Plans printed by the facility and those located on the active clinical record revealed that there was no care plan with goals and approaches to address the resident ' s swallowing impairment or potential for aspiration. A face-to-face interview was conducted on February 20, 2013 at 10:02 AM with Employee #19. He/she stated, I did not give the resident thickener in (his/her) juice. His/her care plan was not updated. The kitchen brings the thickener to him/her. I wanted the doctor to clarify the problem but he/she wasn ' t here that day. The next day I was off (not scheduled to work), I did not give report on it (the use of thickener for Resident #164). I have not spoken to the doctor. I speak with (him/her) today. Facility staff failed to ensure that adequate service/supervision was provided to promote safe swallowing during a medication administration observation. | 2016-04-01 |
| 1748 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 329 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 41 sampled residents, it was determined that facility staff failed to ensure that residents were free from unnecessary drugs as evidenced by: failure to clarify two (2) physician 's orders for pain medication, and failed to determine under which condition/s each medication was to be administered for one (1) resident; and facility staff administered an antihypertensive medication outside of the prescribed parameters for one (1) resident. Residents #4 and 286. The findings include: 1. Facility staff failed to determine under which condition/s each pain medication was to be administered to Resident #4. A review of a physician's order [REDACTED]. The first order was [MEDICATION NAME] 325mg 2 tabs (tablets) (650mg) by mouth every four hours as needed for pain . The second order was [MEDICATION NAME]-APAP (n=Acetyl Para Amino [MEDICATION NAME]) 5mg/325mg 2 tabs by mouth every 6 hours as needed for pain . A review of the Medication Administration Record [REDACTED]. The [MEDICATION NAME] was administered 10 times between February 1 and February 18, 2013; once on February 1, 4, 5, 6, 10, 12, 14 and 18 and twice on February 15, 2013. A review of the back of the February 2013 MAR indicated [REDACTED]. The nurses documented the sites of the pain in nine (9) of the 10 instances of administration. The level of the pain and the effectiveness were documented in three (3) of the 10 instances when the medication was administered. A review of the Pain Management Policy, Item number Six (6) under Pain Assessment indicated that Pain assessment includes quantitative and qualitative rating and description using pain scale with 0 - 5 (zero to five) rating. A face-to-face interview was conducted with Employee #6 at approximately 3:15PM on February 20, 2013. The employee was queried regarding the two orders of pain medications prescribed for the resident and the fact that only one medication had been administered. The employee stated that the resident does not want the Tylenol. The employee added, We should have notified the physician and asked him/her to discontinue it. With regard to rating and documenting the level of pain, the employee stated, I will review the Pain Management /Pain Assessment Policy with the Charge Nurses. The record was reviewed on February 20, 2013. Facility staff failed to determine under which condition/s each pain medication was to be administered and to document the level of the pain prior to administering pain medication and the level of effectiveness after the resident was medicated. 2. Facility staff adminitstered antihypertensive medication outside of the prescirbed parameters for Resident #286. The admission orders [REDACTED]. The Interim Order dated January 29, 2013 directed, Hold [MEDICATION NAME] for SBP (systolic blood pressure) 110 or less. A review of the Medication Administration Record [REDACTED] The resident ' s blood pressure reading on February 12 was 110/66 and on February 17 the reading was 110/58. On both days the [MEDICATION NAME] was administered when it should have been held in accordance with the prescribed parameters set by the physician. There was no evidence that facility staff administered [MEDICATION NAME] 40mg in accordance with the prescribed parameters for Resident #286. A face-to-face interview was conducted on February 19, 2013 at 11:45 AM with Employee #7. He/she acknowledged that the blood pressure medication was not administrated within the order parameters. The record was reviewed on February 19, 2013. | 2016-04-01 |
| 1749 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 371 | E | 0 | 1 | RSE411 | Based on observations made during a tour of Dietary Services on February 19, 2013 at approximately 10:15 AM, it was determined that the facility failed to store, prepare and serve food under sanitary conditions as evidenced by: Four (4) of four (4) hotel pans and 14 of 21 sheet pans that were stored wet and ready for reuse, one (1) of one (1 ) cutting board was observed with an indentation, and two (2) of two (2) convention ovens were observed soiled. The findings include: The following was observed during a tour of the main kitchen: 1. Four (4) of four (4) 4 inch hotel pans were stored wet and ready for reuse 2. 14 of 21 sheet pans were stored wet and ready for reuse 3. A white cutting board was observed with an indentation in one (1) of one (1 ) observed 4. Two (2) of two (2) convention ovens were observed with soiled interiors These observations were made in the presence of Employee # 20. | 2016-04-01 |
| 1750 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 406 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 41 sampled residents, it was determined that facility staff failed to obtain specialized rehabilitative services for a resident who had a positive - PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Screen. Resident #2. The findings include: Facility staff failed to obtain specialized rehabilitative services for a resident who had a positive - PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Screen. Resident #2. Review of the PASRR Screen dated January 20, 2008, identified the resident as positive for Mental [MEDICAL CONDITION] and has been referred to the District of Columbia Department of Mental Health for a Level II evaluation. A review of the clinical record revealed a letter dated and written by Employee #10 on May 24, 2012. The letter revealed that Employee #10 had made contact with a representative from the Developmental Disabilities Administration. and (he/she) faxed the information that is required to obtain a Level II screening. Further review of the medical record identified a letter from the Developmental Disabilities Administration Services (no date indicated), addressed to Employee #10 which revealed the following: RE (reference): PASRR Level II Screen for (Resident #2): In response to your request, the following information is necessary for approval: ? A completed PASRR form (attached); ? A current signed physical assessment including (or with appended statement of) justification for necessity of nursing home placement; ? All current physician orders [REDACTED].>? Any other current assessments (e.g., OT (Occupational Therapy), PT (Physical Therapy, psychiatric, nursing etc) which support the necessity of nursing home placement; ? A psychiatric assessment of the patient response to medication if patient seeking level II is currently prescribed any of the following drug groups: hypnotics, antipsychotics, mood stabilizers, antidepressants, anti-anxiety/sedative agents, anti-Parkinson agents; ? A current assessment by facility social worker of consumer 's status; and ? (A current psychological evaluation including the individual 's cognitive, adaptive and emotional functioning.) ? Copy of the completed D.C. Medicaid Level of Care form A face-to-face interview was conducted on February 14, 2013 with Employee #10 at approximately 4:30 PM regarding if the Level II screen had been completed on Resident #2. He/she indicated that the required information was sent to the Department of Mental Health, but that the screen had not been performed. He/she also acknowledged that there was a period of time which passed and that nothing had been acted upon in getting the information completed, and that he/she will provide a letter of what was done thus far. Employee #10 provided a letter dated February 20, 2013 which indicated the following: Per the survey team, this (Employee #10) has been endeavoring to complete a Level II assessment. As of this entry (Employee #10) has attempted to complete the application by forwarding documentation supporting the validity of this resident ' s medical and cognitive functioning to that agency to satisfy the PASRR requirements. The initial communication was on February 13, 2013. (Employee #10) did not hear back from the agency until 2/15/13. During this conversation (he/she) questioned the need for this after the resident has been at TWH (The Washington Home) for [AGE] years; (he/she) also stated that (he/she) would be arranging a face to face interview with this resident and would be contacting the resident ' s family. (Employee #10) could not follow up on 2/18/13 due to the holiday, but left a message on 2/19/13 explaining the need to complete this application and hopefully obtain resolution and thus far has not heard back. Today (February 20, 2013) (Employee #10) sent an e-mail . Employee #10 will continue to pursue completion of the PASRR Level II as soon as possible. Facility staff failed to obtain specialized rehabilitative services for Resident #2 who had a positive PASRR screen. This is a repeat deficiency from the QIS recertification survey of March 6, 2012. | 2016-04-01 |
| 1751 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 431 | D | 0 | 1 | RSE411 | A. Based on an observations during medication storage review, it was determined that facility staff failed to ensure that intravenous (IV) fluids were not stored beyond the expiration date. The findings include: 1. One (1) of six (6) 5% Dextrose and 0.9% Sodium Chloride Injection USP 1000ml were stored and ready for use, beyond their expiration date of January, 2013. 2. One (1) of two (2) 10% Dextrose Injections 1000 ml had an expiration date of November, 2012 and was stored for use. These observations were made in the presence of Employee #7 at 4:15PM on February 15, 2013 on Unit 3B. B. Based on a medication storage observation of three (3) of five (5) units observed, it was determined that facility staff failed to accurately record the controlled drug sheets verifying the reconciliation of controlled substances; failed to label four (4) of four (4) vials of insulin in two (2) of three (3) medication storage refrigerators; failed to maintain the medication storage refrigerator temperatures between 36 degrees and 46 degrees Fahrenheit and failed to maintain records to identify usage and disposition of a controlled medication. The findings include: 1. Facility staff failed to sign their signatures in the correct columns for Balanced checked by nurse coming on duty and Balance checked by nurse going off duty on the Controlled Drug Count Verification/Shift Count for Narcotics sheet. A medication storage observation was conducted on Unit 2B on February 13, 2013 at approximately 11:25 AM in the presence of Employee #25. A review of the Controlled Drug Count Verification/Shift count sheet for Narcotics sheet, it was observed for February 13, 2013 7:00 AM to 3:00 PM shift that the column titled drug count correct was written yes , Employee #28 ' s name was signed in the coming on duty column and Employee #25 ' s name was signed in the going off duty column. The line just below Employee #28 ' s signature was also Employee #25 ' s signature. Noticing that Employee #25 was delivering morning medications, a query was made regarding who did he/she reconcile the narcotic count with, because there is a blank space in the off going signature space. Employee #25 indicated that he/she reconciled the narcotic count with the Employee #28, the off going nurse, but that the off going nurse signed in the wrong column, and that he/she requested that Employee #28 to resign, but Employee #28 left the unit. Employee #25 indicated that the narcotic count was correct. Facility staff failed to sign their signatures in the correct columns for Balanced checked by nurse coming on duty and Balance checked by nurse going off duty on the Controlled Drug Count Verification/Shift Count for Narcotics sheet. 2. Facility staff failed to label four (4) of four (4) vials of insulin in two (2) of three (3) medication storage refrigerators. Units 2B and 3B A. A medication storage refrigerator observation was conducted on February 13, 2013 at 11: 30 AM on Unit 2B in the presence of Employee #25. It was observed that one (1) vial of Novolog 100 units of insulin was opened with no label to identify the date that the medication was opened. B. A medication storage refrigerator observation was conducted on February 13, 2013 at 11: 40 AM on Unit 3B in the presence of Employee #26. It was observed that one (1) vial of Novolin R insulin 100 units and one (1) vial of Novolog 100 units and one (1) vial of Lantus 100 units were opened with no label to identify the date that the medication was opened. Facility staff failed to label four (4) of four (4) vials of insulin in two (2) of three (3) medication storage refrigerators. 3. Facility staff failed to ensure that medications were stored under proper temperature controls in an isolated observation. During an observation of the medication storage refrigerator on Unit 2B revealed a temperature of 33 degrees Fahrenheit (F) on February 13, 2013 at approximately 11:45 AM. The observation was made in the presence of Employee #25 and the temperature was obtained via the facility ' s refrigerator thermometer. The medications that were stored in the refrigerator included various brands of Insulin solution. According to the facility ' s pharmaceutical provider, Omnicare Inc., Recommended Minimum Medication Storage Parameters (based on manufacturer package inserts) refrigerated insulin vials were to be stored at temperatures between 36?F to 46?F. The refrigerator temperatures were below the recommend parameters for the medications stored. The findings were confirmed with Employee #25 at the time of observation. 4. Facility staff failed to maintain records to identify usage and disposition of a controlled medication. A medication storage observation was conducted on Unit 3B on February 13, 2013 at approximately 11:50 AM in the presence of Employee #26, the following was observed: Upon reconciliation of a Schedule II (two) Narcotic, (Hydromorphone (Dilaudid) HCL (Hydrochloride)) 2mg Tablet (Analgesic). The actual number of tablets on hand was one (1) tablet. Recorded on the Controlled Medication Utilization Record under Amount Remaining was three (3) dated February 12, 2013. A face-to-face interview was conducted on February 13, 2013 at approximately 12:00 PM with Employee #26. He/she indicated that two (2) tablets were given at 9:30 AM this morning (February 13, 2013), but that he/she failed to sign out the medication on the Controlled Medication Utilization Record. The observation was made on February 13, 2013. | 2016-04-01 |
| 1752 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 456 | D | 0 | 1 | RSE411 | Based on observations made during a tour of Dietary Services on February 19, 2013 at approximately 10:15 AM, and during a tour of the facility, it was determined that the facility failed to ensure that essential equipment was maintained in safe operating condition as evidenced by one (1) of two (2) ovens were observed with a missing bottom panel exposed wires and two (2) of two (2) personal refrigerators that were not deemed to be in safe operating condition prior to use. The findings include: 1. During a tour of Dietary Services on February 19, 2013 at approximately 10:15 AM, it was determined that the facility failed to ensure that essential kitchen equipment was maintained in safe operating condition as evidenced one (1) of two (2) ovens were observed with a missing bottom panel exposed wires. This observation was made in the presence of Employee #20 who acknowledged the finding. 2. Two (2) of two (2) personal refrigerators were observed in use in resident rooms (#229 and 137) in the absence of a mechanical clearance (deeming the refrigerators safe for use) determined by the facility. The observation was made in the presence of Employees #1 and 14 during an environmental tour of the facility on February 20, 2013. | 2016-04-01 |
| 1753 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 463 | E | 0 | 1 | RSE411 | Based on observations and staff interview for five (5) of five (5) resident rooms observed, it was determined that facility staff failed to ensure that the call system in five (5) residents' rooms were functioning to allow communication from the residents to the nurses' station. The findings include: 1. Facility staff failed to ensure that the call bell system in the residents' rooms and/or bathrooms were functioning properly. The call bell in Room #230 did not initiate an audible alarm when tested in one (1) of one (1) resident's room observed on February 14, 2013 at approximately 12:25 PM. Employee #6 stated, the staff probably pulled the call bed cord to reach where the resident was sitting, and this loosened the cord from the wall outlet. Subsequently, the call bell was removed and re- inserted into the wall outlet, which initiated an alarm to the nursing station. 2. Facility staff failed to ensure that the call bell system in the residents' rooms and/or bathrooms were functioning properly in three (3) of five (5) rooms observed. 2A. A resident room observation was conducted on February 13, 2013 at approximately 3:19 PM on Unit 3A in Room 305. The following was observed: When the residents ' call bell was activated (pressed) in the room, the call bell would not sound at the nurses ' station, nor would the light (outside of the room over the door) light up. When an attempt was made to answer the resident from the nurses ' station, the audible voice was not heard in the room. Employee #31 made an attempt to readjust the call bell, but was still unsuccessful in getting the call bell to function properly. This observation was made in the presence on Employee #30 and Employee #31. 2B. A resident room observation was conducted on February13, 2013 at approximately 4:26 PM on Unit 3A in Room #323. The following was observed: When the resident ' s call bell was activated (pressed) in the room, the bell would sound at the nurses ' station. When an attempt was made to answer the resident from the nurses ' station, the audible voice was not heard in the room. When the bathroom call bell was pulled, the red light (over the door outside of the room) would not light up to signal for assistance needed in the bathroom. These observations were made in the presence of Employee #32. 2C. A resident room observation was conducted on February14, 2013 at approximately 10:40 AM on Unit 3A in Room 334. The following was observed: The residents' call bell did not activate in the room when pressed. Employee #30 made an attempt to answer the call bell from the nurses ' station, the voice was not audible in room. Employee #16 was also present at the time of the observation. Employee #30 indicated to Employee #16 that the only way he/she knew the call bell was pressed , is that he/she looked at the system at the front desk and noticed the light blinking, it did not sound at the nurses ' station either. When the bathroom light was activated, the red light outside of room (over the door) did not light up, although audible in the bathroom when answered. The observation was made in the presence of Employee #16 and #30. 2D. A resident room observation was conducted on February14, 2013 at approximately 11:09 AM on 3A in Room 307. The following was observed: The residents ' call bell did not activate in the room when pressed, when Employee #32 made an attempt to answer the call bell from the front desk, the voice was not audible in room. The resident light did not light up (outside of the room over the door) 2E. A resident room observation was conducted on February14, 2013 at approximately 12:02 PM on Unit 3A in Room #332. The following was observed: When the residents' call bell (cord) was pulled in the bathroom, the light would activate, when Employee #30 answered the call bell from the nurses station, the response was not audible in room 332, the audibility was heard in the room next door to room 332 (334). The observations were made in the presence of Employees #16 and #30. | 2016-04-01 |
| 1754 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 469 | D | 0 | 1 | RSE411 | Based on observation and staff interview it was determined that facility staff failed to maintain an effective pest control program to ensure that the facility is free of pests. The findings include: Flying pests were observed as follows: 1. On unit 1-A at the nursing station in the presence of Employee #4 on February 14, 15 and 19, 2013. 2. In room #102 while observing incontinence care, in the presence of Employee #15 on February 19, 2013. | 2016-04-01 |
| 1755 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 514 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 41 sampled residents, it was determined that facility staff failed to ensure that one (1) resident's weight was accurately documented in the clinical record. Resident #98. The findings include: According to the clinical record, Resident #98 was admitted to the facility on [DATE] for Physical Therapy, Occupational Therapy and Speech Therapy. A review of the Master problem list revealed resident ' s [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of October 25, 2012 revealed Resident #98 was coded under Section K0200 as weighing 160 pounds on admission. The physician's orders [REDACTED]. The unit's Up To Scale Weight Record revealed the following weights: October 18, 2012- 217.7 pounds October 19, 2012 - 157.8 pounds October 24, 2012- 158 pounds October 31, 2012- 159.6 pounds A review of a printout from Optimus (electronic medical record) titled Resident ' s Weight On or after 10/18/12 revealed the following weights: October 18, 2012- 217.7 lbs (pounds) October 24, 2012 - 158 lbs November 7, 2012 - 159 lbs November 14, 2012 - 157.2 lbs An Initial Nutrition Risk Assessment dated October 22, 2012 (no time indicated) revealed: . Interventions - Monitor weight weekly x 4; on mechanical soft d/t (due to) swallowing deficient, po (by mouth intake) good- 75-100 percent of meals, 217.7 (pounds). Over wt (weight) but weight loss not an issue at this point due to age, (no) recent labs, no [MEDICAL CONDITION], no skin openings. Continue to F/U (follow-up), diet meets needs. Facility staff failed to document or address the weight variance of 59.7 pounds; which is indicative of a significant weight change from October 18, 2012 to October 19, 2012. A face-to-face interview was conducted with Employee #7 on February 20, 2013 at approximately 3:30 PM. After reviewing the clinical record; he/stated: The admission weight is not correct, the weight on the second day is correct. Another face-to-face interview was conducted with Employee #23 on February 21, 2013 at approximately 10:30 AM. Employee #23 acknowledged that he/she failed to look at the 2nd (second) day weight recorded on the weight sheet prior to his/her nutrition assessment written on October 22, 2013. The clinical record was reviewed on February 21, 2013. | 2016-04-01 |
| 1973 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 166 | D | 0 | 1 | KI3J11 | Based on observations, record review, staff and family interview for one (1) of 50 sampled residents, it was determined that facility staff failed to ensure that a prompt effort was made to resolve a grievance concerning Resident #74's missing eyeglasses. The findings include: During an initial tour conducted on February 21, 2012 at approximately 9:42 AM; Resident #74 was observed sitting in a chair with a breakfast tray in front of him/her. His/her hands were positioned in front of the food on his/her plate; however, he/she was not eating. The resident was queried about why he/she was not eating. He/she responded, I can ' t see. Employee #10 proceeded to ask; where are your glasses? He/she stated, I don ' t know. Another observation was made on February 24, 2012 at approximately 4:30 PM; the resident was lying flat in bed and was not wearing his/her eyeglasses. An interview was conducted with Employee #74 ' s responsible party (RP) on February 22, 2012 at approximately 12:45 PM. He/she stated, This is the second pair of eyeglasses I have brought for (Resident #74). I have not seen his/her eyeglasses since Friday (February 17, 2012). I reported this to (Employee #10). According to the Resident's Property List dated Novevmber 1, 2011, articles retained by resident included glasses and case. A review of the facility's policy titled: Family/Resident Communication Tool indicated that the family/resident will be contacted within five (5) business days with a response and/or resolution. A review of the facility's Communication Forms lacked evidence that a grievance/concern form was initiated as a result of the resident ' s responsible party's verbalized concern to facility management staff. A face-to-face interview was conducted with Employee #10 on February 24, 2012 at approximately 1:15 PM he/she confirmed the RP's reporting of the resident ' s missing eyeglasses. He/she stated, I will follow-up with the RP. The clinical record was reviewed on February 24, 2012. | 2015-09-01 |
| 1974 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 224 | D | 0 | 1 | KI3J11 | Based on observations and staff interview, during the environmental tour of the facility on February 29, 2012, it was determined facility staff failed to safeguard one (1) of one (1)resident ' s personal property after death. Resident #F1. The findings include: The policy entitled, Gifts, Gratuities, & Payment Policy No. Re- .97 Policy: Employees and volunteers are prohibited from receiving any gift, gratuity or payment for services rendered, making any promises on behalf of the facility or engaging in any activity, practice, or act which conflicts with the interests of the facility or its residents. Procedure: 1. At no time will an employee or volunteer accept money, gifts valued over $10.00, jewelry etc, from a resident/patient and/or family. Human Resources should be consulted to determine value. If the resident/patient or family is insistent, the employee/volunteer will suggest that they make a donation to The Washington Home or Hospice of Washington. If the party is still insistent, the matter should be presented to the Director of Social Work who will then contact the patient, resident or family member to reaffirm the Home ' s policy . During an environmental tour of Unit 2B on February 29, 2012 at approximately 9:45 AM in the presence of Employee #31 a television and its accompanying equipment (cable box, remotes and cords) were atop shelving in the resident multipurpose area. The television, approximately 19 inches desktop style, was stored in a clear plastic bag proximal to Employee #29 ' s personal belongings (purse/tote bag) and the equipment was observed wrapped in newspaper behind the employee ' s personal belongings. In response to a query regarding the storage of the items atop the shelving, Employee #31 asked Employee #7 to whom do the items belong too. S/he stated that the items belonged to Employee #29. A face-to-face interview was conducted with Employee #15 on February 29, 2012 at 2:00 PM. S/he stated that the television belonged to Resident # F1 who died on yesterday. His/her relative wanted me to have the television and (I) declined to accept it. The relative asked me to put the television away for another relative so that s/he would not have access to the resident ' s other personal property. Employee #29 stated that the TV was placed on the shelf at approximately 7:30 AM on February 29, 2012 and s/he was assisted by Employee #28. Employee #29 confirmed that the TV was stored on the shelf in the multipurpose room proximal to his/her purse. Employee #29 stated that the customary process that is used to safeguard resident ' s property at the time of death is to lock the resident ' room door and allow the family and/or responsible party to remove the items. Usually the Social Worker coordinates that process. I used poor judgment. A face-to-face interview was conducted with Employee #28 on February 29, 2012 at 3:00 PM. S/he acknowledged that s/he assisted Employee #29 to remove the TV and accompanying equipment from Resident #F1 ' s room on the morning of February 29, 2012. (He/she) told me that the TV was given to him/her and I just helped him/her to carry it out of the room and placed the item(s) on the shelf (in the resident multipurpose area). In response to a query regarding the customary method that staff follow to safeguard resident ' s personal property in the event of death, Employees #15 and #29 stated that the clinical staff lock the resident ' s room and allow the responsible party and/or next of kin to obtain the property. Facility staff improperly apportioned the personal property of Resident # F1 at the time of death. The resident ' s property was removed from the resident ' s room and comingled with Employee #29 ' s personal belongings. There was no evidence that Employee # 15 complied with the facility ' s policy on receiving gift(s) from a resident/patient/family. | 2015-09-01 |
| 1975 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 241 | E | 0 | 1 | KI3J11 | Based on resident observations and staff interviews for four (4) of 50 sampled residents, it was determined that facility staff failed to maintain dignity as evidenced by staff standing while assisting resident with meal for one (1) resident; allowing one (1) resident to sit idle as others dinned; one (1) resident asked by staff if he/she wanted an alcoholic beverage and one (1) resident pulled backwards following dinning. Residents #144, #155, #170 and #195. The findings include: 1. Facility staff failed to promote dignity post dining by pulling Resident #144 backwards from the dining area to social area. On February 20, 2012 at approximately 12:40 PM, Employee #22 was observed pulling Resident #144 backwards from the dining area to the social area. A face-to-face interview was conducted with Employee #4 on February 20, 2012 at approximately 12:41 PM. He/she brought the concern to the attention of Employee #22 and corrected the deficient behavior. The observation was made on February 20, 2012. 2. Facility staff failed to ensure Resident #155 ' s dignity was maintained in two (2) of two (2) dining observations as evidenced by Employee #19 standing while assisting with lunch meal. During dining observations conducted on February 21, 2012 at approximately 12:40 PM and March 1, 2012 at approximately 12:45 PM in Resident #155 ' s room on Unit #3A, Employee # 19 was observed assisting Resident #155 with meal consumption. Employee #19 stood proximal to the resident ' s bed and offered spoonfuls of food for the resident to consume. A face-to-face interview was conducted with Employee #10; who observed Employee #19 standing while assisting resident with meal, on March 1, 2012 at approximately 12:45 PM. He/she acknowledged at the time of observation that the employee should have sat down while assisting the resident with lunch meal. 3. Facility staff failed to maintain the resident ' s dignity by asking the resident did he/she wanted an alcoholic beverage. On February 21, 2012 at 12:32 PM during a lunch meal dining observation, Resident #170 stated, This is water I want juice. Employee #38 who was assisting residents with their meal replied, (Resident #170) do you want Gin? The resident did not respond and Employee #38 stated again, (Resident #170) do you want Gin? On February 21, 2012 at approximately 12:45 PM Employee #7 was made aware. Employee #7 then ask Employee #39 (who was providing the resident with the juice at the time of this incident) did this happen. Employee #39 replied, Yes. There was no evidence that facility staff spoke to the resident with respect and dignity. 4. Facility staff failed to promote dignity during dining by allowing Resident #195 to sit idle on two (2) different occasions as others dined. During a dining observation that was conducted on February 20, 2012 at approximately 12:30 PM the following was observed of Resident #195. The lunch trays arrived to Unit 1A at approximately 12:37 PM, seven (7) residents were seated for dinning, two (2) residents were served trays and ate independently. At approximately 12:55 PM Resident #195 had not been served, at approximately 1:02 PM, Resident #195 resident had not been served. The resident was served at approximately 1:07 PM. A CNA (Certified Nursing Assistant) assisted the resident to open his/her tray. Employee #4 uttered (he/she) can feed herself. The resident sat for approximately 30 minutes until he/she began to eat his/her meal at approximately 1:09 PM. A second dining observation was conducted on March 1, 2012 at approximately 12:45 PM six (6) residents were seated for dining. All residents were again served and Resident #195 sat for approximately 22 minutes until served. A face-to-face interview was conducted with Employee #4 on March 1, 2012 at approximately 2:00 PM, after review of the events he/she acknowledged the findings. A query was made what was the unit process for distributing trays. Employee #4 indicated that there is no formal process, but those seated in the common dining area are served first, then the residents in the rooms and then the CNA's assist with feeding in the rooms and in the common dining area as needed. Facility staff failed to promote dignity during dining by allowing Resident #195 to sit idle on two (2) different occasions as others dined. The observation was made on February 20, 2012 and March 1, 2012. | 2015-09-01 |
| 1976 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 253 | E | 0 | 1 | KI3J11 | Based on observations during the environmental tours on February 21, 2012 at various times, February 24, 2012 between 9:30 AM and 1:30 PM, and February 29, 2012 from 9:15 AM to12:30 PM, it was determined the facility failed to maintain a sanitary and orderly and comfortable environment as evidence by soiled: carpet in two (2) of 15 hallways observed, carpet in one (1) of one (1) sitting area on Unit 3A; merry walkers in six (6) of six (6) observed; baseboard surfaces in three (3) of 12 observations; Interior and exterior louver surfaces of exhaust vents were soiled in three (3) of 10 observed; surfaces in electrical closets on five (5) of five (5) units; ceiling tile surfaces were soiled in one (1) of two (2) observed. Marred/scarred: surfaces in the pantry in one (1) of five (5) observed; counter top edges at the nursing stations in five (5) of five (5) nursing units observed and entrance doors, door jamb and closet door surfaces were marred and scarred on the frontal surfaces in eight (8) of 20 observed. Damaged: tile in one (1) of three (3) shower rooms observed on Unit 3A; wallpaper was peeled/separated in four (4) of 15 hallways observed; a hole in the wall in the sitting area on one (1) of one (1) observed, a splintered countertop on Unit 1 in one (1) of one (1) countertop observed; a torn white sofa and soiled covering on sofa in one (1) of one (1) white sofa observed; window screens were observed to be damaged and separated from frames in one (1) of four (4) observed and the baseboard was missing in one (1) of one (1) observed. Clutter was observed in two (2) of 30 resident rooms; book shelves were observed with items improperly stored on them in two (2) of two (2) observed and nails were observed sticking out of the wall and the baseboard was detached from the wall in one (1) of 30 resident rooms observed. The findings include: Soiled: 1. Soiled carpet was observed on hallway #1 on Unit 2B, and on hallway #3B in two (2) of 15 hallways observed; Soiled carpet was observed on Unit 3A in the sitting area (near the elevators) in one (1) of one (1) observed. 2. Six (6) of six (6) merry walkers were observed soiled on Unit 2A. 3. Baseboard surfaces in the hallways were soiled on Units: 1A, 2A, 2B and 3B in four (4) of 12 observations; 4. The interior and exterior louver surfaces of exhaust vents were soiled with accumulated dust in soiled linen closets on Units 1A, 1B, and 3B in three (3) of 10 observed. 5. Electrical Closets on five (5) of five (5) units were observed to have soiled floors, walls and door jams. 6. Ceiling tile surfaces were soiled with accumulated dust over washers in the main laundry room in one (1) of two (2) observed. Marred/scarred: 1. In two (2) of five (5) pantries the following was observed: 2A walls in and around the pantry area are marred, counter edges are marred; swing door to the pantry was damaged. 2. Marred/scarred counter top edges at the nursing stations on Units 1, 2A, 2B, 3A and 3B in five (5) of five (5). 3. Marred /scarred wall (by the window) in room #354A. 4. Entrance doors, door jamb and closet door surfaces were marred and scarred on the frontal surfaces in rooms #218 and #253; closet door surfaces in room #253, the Medical Supply room on 2A, #314 and #355, closet door room #368 and the cafeteria entrance door in eight (8) of 20 doors observations. Damaged: 1. The shower room near room #313 on Unit 3A was observed with damaged tile in one (1) of three (3) shower rooms observed. 2. Wall paper was peeled/separated in the following areas: Unit 1 Hallway #1, Unit 2B Hallway # 1. On Unit 2A the wall paper near the activity office was damaged; and on Unit 2A the blue hallway the wall paper was damaged near the end of the hallway in four (4) of 15 hallways observed. 3. The sitting area on Unit 1 was observed to have a hole in the wall/damaged in one (1) of one (1) wall observed. 4. The counter top in the dining area on Unit 1 was observed to be splintered in one (1) of one (1) counter tops observed in the dining area on Unit 1. 5. A torn white sofa with a soiled covering was observed on Unit 2A in one (1) of one (1) white sofa observed. 6. Window screens were observed to be damaged and separated from frames in the hallway near room #329 in one (1) of four (4) window screens observed. 7. Unit 2A near room #227 the baseboard was missing in one (1) of one (1) observed. Other concerns: 1. Resident room ' s #108A and #323A were observed to have cluttered items at beside and on floor in two (2) of 30 resident rooms observed. 2. Bookshelf: water bottles and newspaper items were store on top of the bookshelf in one (1) of one (1) observed on Unit 2A and a pink color hand bag (an employee ' s personal belongings) stored in a clear plastic bag, a 19 /21 television was stored in a clear plastic bag and cable/adaptive wires were stored under news paper (items that belonged to a resident that expired) were observed on the bookshelf in one (1) of one (1) bookshelf observed on Unit 2B. 3. On February 22, 2012 at 11:15 am in room #215B nails were observed sticking out of the wall proximal to bed in one (1) of four (4) walls observed in the resident ' s room; and the baseboard strip wad observed detached from the wall. This was observed in the presence of Employee # 7 who acknowledged the findings at the time of the observation. These observations were made in the presence of Employee #30 or Employee # 31 and they acknowledged the findings at the time of the observations. | 2015-09-01 |
| 1977 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 272 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review resident and staff interview for one (1) of 50 sampled residents, it was determined that facility staff failed to accurately code the annual and quarterly Minimum Data Set (MDS) for [MEDICAL CONDITION] and [MEDICAL CONDITION] for Resident #175. The findings include: A during a face-to-face interview with Resident #175 he/she stated, Staff sometimes place my tray down (on the over-the-bed table) and doesn ' t open the items. I can ' t see to open my tray because I am blind in my left eye. A review of the follow up Ophthalmology Consult dated June 29, 2011 revealed, Findings: [MEDICAL CONDITION] OS (left eye), Blind OS .Recommendations: See pt (patient) in 6 months. Stop drops. A review of the annual Minimum Data Set (MDS) completed on August 30, 2011 Resident #175 was coded in Section B1000 (Vision) as his/her vision being moderately impaired. Under Section B1200 (Corrective Lens) the resident was coded as not using corrective lenses. In Section I (Active Diagnoses) the resident was not coded as having visual impairment. The quarterly MDS completed on November 15, 2011 Resident #175 was coded in Section B1000 (Vision) as his/her vision being highly impaired. Under Section B1200 (Corrective Lens) the resident was coded as not using corrective lenses. In Section I (Active Diagnoses) the resident was not coded as having visual impairment. There was no evidence that facility staff accurately coded Resident #175 for the [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee #10 on February 28, 2012 at 3:40 PM. He/she acknowledged that the MDS was not coded to reflect the Residents [DIAGNOSES REDACTED]. The record was reviewed on February 28, 2012. | 2015-09-01 |
| 1978 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 279 | E | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews for six (6) of 50 sampled residents, it was determined that facility staff failed to initiate care plans with goals and objectives to address: one (1) resident with a positive Level Two Screen; approaches required to ensure safe oral intake of pleasure meals for one (1) resident with dysphagia; for refusal of medications and activities for one (1) resident; for one (1) resident with contractures; one (1) resident with urinary incontinence; and for one (1) resident with allergies [REDACTED].#107, #175, #178, #287 and #337. The findings include: 1. Facility staff failed to develop a care plan with measureable goals and objectives for Resident #2 who has a positive screen for Mental [MEDICAL CONDITION]. A review of the medical record for Resident #2 identifies that the resident was admitted to the facility in March 25, 1968. Review of the PASSAR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Screen dated January 20, 2008, identified the resident as positive for Mental [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set with an ARD (Assessment Reference Date) of November 16, 2011 identifies: Section I : [DIAGNOSES REDACTED]. Review of the Social Service's Notes reviewed that the resident's care conference was conducted on December 1, 2011. Relative attended via telephone. Review of the care plans last updated December 1, 2011 lacked evidence of a care plan with appropriate goals and approach to address and resident with a positive screen for Mental [MEDICAL CONDITION]. A face-to-face interview was conducted with the Employee #4 on February 24, 2012 at 5:10 PM. After a review of the care plans, he/she acknowledged the findings. The record was reviewed on February 24, 2012. 2. A review of the clinical record for Resident #107 lacked evidence of problem identification, goals and approaches required to ensure safe oral intake of pleasure meals for the resident whose [DIAGNOSES REDACTED]. According to physician ' s progress notes dated January 20, 2012, Resident #107 ' s [DIAGNOSES REDACTED]. physician's order [REDACTED]. A review of the speech therapy progress notes dated February 22, 2012 read: the patient is safely tolerating pleasure feeds of nectar-thick liquids and puree consistency solids. SLP (speech/language pathologist) wrote an order and arranged for patient to receive pleasure feedings with the patient to improve quality of life. Patient consumes less than 25% at each pleasure feed meal .provided ongoing diet texture evaluation and established effective swallowing compensatory strategies for the patient. Educated the family on safe swallowing compensatory strategies .(training) ongoing with family/POA (power of attorney) who is the one requesting pleasure feeds and will be the one to give pleasure feeds . The record lacked documented evidence of the development interventions and approaches in the comprehensive care plan to address the swallowing requirements for Resident #107. There was no evidence that training was provided to the caregiver staff as it relates to safe swallow strategies. A face-to-face interview was conducted on March 5, 2012 at approximately 3:30 PM with Employee #40 regarding the lack of a care plan and training of staff regarding the resident ' s oral intake requirements. S/he reviewed the record and acknowledged the findings. The record was reviewed March 1, 2012. 3. Facility staff failed to initiate a care plan for Resident #175 ' s refusal of medication and activities. The resident was observed in room in bed watching television per his/her choice on February 21, 22, 28, and 29, 2012. The psychiatric follow-up note dated February 9, 2012 revealed, Resident #175 has been refusing to go along with the recommended IV (Intravenous) antibiotic treatment for [REDACTED]. He/she has also been losing weight slowly and reluctant to eat regularly. Recommendations: 1. A slight increase in his/her [MEDICATION NAME] (150 mg to 250 mg) may be marginal benefit, although the majority of his/her denial and resistance to therapy appears related to his/her sense of loneliness and loss of control. 2. Given the difficulty with weight control, would recommend that we loosen the dietary restrictions as much as possible to allow him/her to eat what he/she might enjoy more. Ideas discussed included meals brought on visits by (name) team as well as take out lunches ordered through his/her petty cash account by TWH staff . 3. Most importantly, organized and regular visits with volunteers and friends would give him/her more personal contact and help with his/her loneliness. According to the activity notes: dated November 15, 2011 and February 14, 2012 the resident is encouraged to come out of his/her room to activities. One-to-one visits are provided. A telephone interview was conducted with Employee #32 on February 28, 2012 at 1:20 pm. He/she stated, Yes, every day I offer him /her opportunity to participate in activities. He/she refuses to come out of his/her room. Yes, I go in his/her room and speak with him/her. I stress that our volunteers come and talk to him/her as well. A face-to-face interview was conducted with Employee # 26 on February 28, 2012 at 1:15 pm. He/she stated, We put him/her in the chair. He/she comes out of the room on his/her own. He/she is in an electric chair. We offer him/her to come out but he/she doesn ' t. A face-to-face interview was conducted with Employee # 10 on February 28, 2012 at 3:40 PM. He/she stated that the resident has refused his/her medication therapy several times. There was no evidence that the care plan was initiated with goals and approaches to address the residents refusal of medication therapy, reluctance to eat and to come out of his/her room to participate in activities. A face-to-face interview was conducted with Employee # 10 on February 28, 2012 at 3:40 PM. He/she acknowledged that there was not care plan initiated to address the resident ' s refusal of medication therapy, reluctance to eat and to come out of his/her room. The record was reviewed on February 28, 2012. 4. Facility staff failed to initiate a care plan with goals and objectives to address the resident's contracture of his/her right hand/arm. Resident # 178. A review of the admission data base revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident ' s last annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of October 19, 2011 revealed that the resident ' s active [DIAGNOSES REDACTED]. Upon observation the resident was observed seated in a wheel chair with his/her right arm resting on the arm of the wheel chair and fingers clasped to the palm. Review of the care plans in the resident ' s active clinical record failed to reveal a care plan to address the resident's contracture. Employee #22 confirmed that the resident had a contracture of the right arm during a face-to-face interview at 10:56 AM on February 23, 2012. After a review of the care plans in the resident ' s clinical record there was no evidence that a care plan was initiated with goals and approaches to address the resident ' s contracture. A face-to-face interview was conducted with Employee # 4 at approximately 10:33 AM on February 29, 2012. During the interview the employee was queried whether the resident had a care plan that addressed his contractured arm and leg. The employee looked at the record and responded, No. I don ' t see one. The record was reviewed on February 29, 2012. The facility staff failed to initiate a care plan with goals and objectives to address the resident's contracture of his/her right hand/arm. 5. Facility staff failed to initiate a care plan with goals and objectives to address Resident # 287 ' s incontinence. A face-to-face interview was conducted with Resident # 287 on March 1, 2012 at approximately 12:00 PM. He/she informed this investigator that he/she has problems with dribbling and wears pull-ups. A review of the admission data base revealed that the resident was admitted to the facility on [DATE]. A review of the admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of October 14, 2011 revealed that the resident was coded with a one (1) which indicated that the resident was occasionally incontinence under Section H 300 (Urinary Continence). The coding was the same for the 30 day (11/3/11) and the 60 day (12/6/11) assessments. However, the quarterly assessment dated [DATE] revealed that the resident was coded with a three (3) indicating that the resident was always incontinent. The record lacked evidence that a care plan was initiated with goals and approaches to address the resident' s incontinence A face-to-face interview was also conducted with Employee # 10 at approximately 12:15 PM on March 1, 2012. During the interview the employee acknowledged that the resident was incontinent and that the record lacked evidence of a care plan to address the resident ' s incontinence. The record was reviewed on March 1, 2012. 6. Facility staff failed to initiate a care plan with goals and approaches to address Resident #337's allergies [REDACTED]. A review of January 11, 2012 physician's order [REDACTED]. According to the Nursing Admission Assessment form dated January 11. 2012 revealed: Food/Drug allergies [REDACTED]. The resident ' s care plan initiated January 12, 2012, lacked evidence that a care plan with goals and approaches was developed to address the resident ' s allergies [REDACTED].>A face-to-face interview was conducted on February 27, 2012 at approximately 3:00 PM with Employee #6. He/she acknowledged that there was no care plan for allergies [REDACTED]. The record was reviewed February 27, 2012. | 2015-09-01 |
| 1979 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 280 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 50 sampled residents, it was determined that facility staff failed to amend the nutrition care plan for one (1) resident to address the resident ' s current nutritional status and to update one (1) resident ' s care plan to include a [DIAGNOSES REDACTED].# 107 and #175. The findings include: 1. A review of the comprehensive care plan for Resident #107 updated December 6, 2011 revealed facility staff failed to update the nutrition care plan to include the resident ' s current nutritional status. A review of the physician ' s progress notes dated January 20, 2012 revealed the resident ' s [DIAGNOSES REDACTED]. physician's order [REDACTED]. The care plan included the following: problem: alteration in nutrition - needs tube feeding to meet daily needs. The care plan lacked evidence of an update to include the pleasure feeding implemented as of January 25, 2012. The record was reviewed March 1, 2012. 2. Facility staff failed to update the vision care plan to include Resident #175 [DIAGNOSES REDACTED]. A during a face-to-face interview with Resident #175 he/she stated, Staff sometimes place my tray down (on the over-the-bed table) and doesn ' t open the items. I can ' t see to open my tray because I am blind in my left eye. A review of the follow up Ophthalmology Consult dated June 29, 2011 revealed, Findings [MEDICAL CONDITION] OS (left eye), Blind OS .Recommendations: See pt (patient) in 6 months. Stop drops. A review of the annual Minimum Data Set (MDS) completed on August 30, 2011 Resident #175 was coded in Section B1000 Vision as his/her vision being moderately impaired. The quarterly MDS completed on November 15, 2011 Resident #175 was coded in Section B1000 (Vision) as his/her vision being highly impaired. The Visual Function care plan last reviewed November 22, 2011 list, Problem: Visual deficits related to [MEDICAL CONDITION]. There was no evidence that the care plan for vision was updated to include the Resident #175 ' s [DIAGNOSES REDACTED]. At the time of this review there was no evidence in the active clinical record that Resident #175 seen in by the ophthalmologist since June 29, 2011 as recommended. Additionally, there was no documented follow up with the Ophthalmologist after the noted change in vision from the August 30, 2011 to November 15, 2011 MDS. A face-to-face interview was conducted with Employee #10 on February 18, 2012 at 3:40 PM. He/she acknowledged that the care plan was not updated to include the resident ' s [DIAGNOSES REDACTED]. | 2015-09-01 |
| 1980 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 309 | G | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview for one (1) of 50 sampled residents, it was determined that facility staff failed to follow physician's order [REDACTED]. Resident #353. The findings include: Facility staff failed to follow physician's order [REDACTED].#353 who was subsequently hospitalized approximately one week post admission, with an acute exacerbation of [MEDICAL CONDITION]. A review of the clinical record for Resident #353 revealed the [AGE] year old was admitted on [DATE] for physical rehabilitation with [DIAGNOSES REDACTED]. The resident was admitted with an indwelling urinary catheter to manage a history of [MEDICAL CONDITION] and a peripherally inserted central catheter (PICC) of the right upper arm. The resident ' s medication regimen included intravenous antibiotic therapy administered every six (6) hours for urosepsis. Interdisciplinary notes documented by the medical team included, but was not limited to the following: February 10, 2012 (no time indicated)- admission physical examination; Extremities: 3+ [MEDICAL CONDITION]; lungs clear with bilateral congestion and good air flow. February 14, 2012 at 10:00 AM; Patient ' s (responsible party named) concerned that patient is more lethargic and short of breath than usual .Assessment - hypoxic, recent urosepsis, dementia .Plan - [MEDICATION NAME] (diuretic) 40 mg po (by mouth) for one dose, oxygen at 2 liters via nasal cannula with pulse oximetry (P02) assessments every shift, maintain P02 at 94%. February 15, 2012 (no time indicated)-chief complaint: nurse reports patient with [MEDICAL CONDITION] generalized . examination - bilateral lower extremity taut [MEDICAL CONDITION] 2+, right upper extremity [MEDICAL CONDITION] 1+, mild dyspnea (shortness of breath) and tachypnea (rapid breathing); Treatment plan - start low dose [MEDICATION NAME] 10 mg po daily .CXR (chest x-ray), respiratory consult for [MEDICAL CONDITION] toileting, bilateral lower extremity compression stockings . February 17, 2012 at 9:00 AM caregiver feels breathing is about the same, (he/she) has occasional congested cough .Chest x-ray 2/16/12 - bilateral pleural effusion, likely increased; Assessment - Dyspnea, likely increasing pleural effusion, Na (sodium) overload from urosepsis?.on [MEDICATION NAME] 10 mg daily and KCL 10 mg daily, will increase [MEDICATION NAME] to 20 mg bid and K- Dur to 20 mg bid . February 17, 2012 at 5:00 PM, (responsible party named) complaining that patient is swollen .nursing states there is no change in behavior since admission .P02 97% room air, chest clear ; extremity +3 [MEDICAL CONDITION] legs; Assessment/Plan - volume overload, [MEDICATION NAME] increased to 20mg bid, renal function normal, started on [MEDICAL CONDITION] toilet with nebulizer. A review of physician's order [REDACTED]. February 14, 2012 at 9:30 AM: [MEDICATION NAME] 40 mg po x 1 dose now for [MEDICAL CONDITIONS] February 14, 2012 at 4:30 PM: Oxygen at 2 liters/minute via nasal cannula with pulse oximetry (P02) assessments every shift, maintain P02 at 94%. February 15, 2012 at 3:40 PM: [MEDICATION NAME] 10 mg po daily for dyspnea and [MEDICAL CONDITION], hold if systolic blood pressure is less than 110; chest x-ray to evaluate dyspnea; respiratory consult for [MEDICAL CONDITION] toileting. February 17, 2012 at 9:20 AM: increase [MEDICATION NAME] to 20 mg po (by mouth) bid (twice daily) for [MEDICAL CONDITIONS], hold for systolic BP less than 100; K-Dur 20 mg po bid for [MEDICAL CONDITION]. February 17, 2012 at 10:30 AM: Duo Neb (aerosolized nebulization treatment) every 4 hours for [MEDICAL CONDITION] toileting; Incentive spirometer for deep breathing/cough. A review of the Medication Administration Record [REDACTED] February 14, 2012: (transcribed order) [MEDICATION NAME] 40 mg po x 1 dose now for [MEDICAL CONDITION] 10:00 AM. The MAR indicated [REDACTED]. The space allotted for documenting the administration of [MEDICATION NAME] was blank. February 15, 2012: (transcribed order) [MEDICATION NAME] 10mg by mouth daily for dyspnea and [MEDICAL CONDITION], hold for SBP (systolic blood pressure) less than 110, 9AM The MAR indicated [REDACTED]. There was no documented evidence that the [MEDICATION NAME] was held and/or omitted due to the resident ' s inability to meet the parameters of administration (e.g. low blood pressure). February 17, 2012: (transcribed order) increase [MEDICATION NAME] to 20 mg po bid for [MEDICAL CONDITION] - hold for SBP less than 100, 9AM, 5PM The MAR indicated [REDACTED]. February 17, 2012: (transcribed order) [MEDICATION NAME] every 4 hours for [MEDICAL CONDITION] toileting, [MEDICAL CONDITION], bilateral pleural effusion; 1AM, 5AM, 9AM, 1PM, 5PM, 9PM The MAR indicated [REDACTED]. Review of Respiratory Therapy Notes: A review of Respiratory Therapy (RT) notes revealed the initial respiratory therapy consult was performed February 17, 2012 at 10:38 AM, two (2) days after the physician ' s request for services. The Consultation request form for respiratory services dated February 15, 2012 was blank. The RT Recommendations and Order Request form dated February 17, 2012 at 10:38 AM read: patient cannot tolerate any [MEDICAL CONDITION] toileting at this time. Incentive spirometer recommendation for 10 days as tolerated . Review of nurse ' s progress notes as it relates to the resident ' s respiratory status and fluid retention included but was not limited to: February 14, 2012 6:00 AM, .lung sounds clear but slightly diminished on the left upper lobe. February 14, 2012 11:00 PM, O2 at 2 liters running, no SOB (shortness of breath) however, nasal congestion present. February 15, 2012 6:00 AM, .no respiratory distress noted. February 15, 2012 4:00 PM, (Medical staff named) made aware about [MEDICAL CONDITION] on lower extremities and shortness of breath, new orders given. February 16, 2012 7:00 AM, .bilateral lower extremity [MEDICAL CONDITION], non-pitting, [MEDICATION NAME] therapy ongoing . February 16, 2012 8:00 PM, .Pulse oximetry 93% respiratory therapy aware of request for [MEDICAL CONDITION] toileting .on [MEDICATION NAME] and potassium . February 17, 2012 6:45 AM, .no respiratory distress, bilateral lower extremity [MEDICAL CONDITION] noted . February 17, 2012 6:30 PM, patient seen by medical team and respiratory for (upward arrow - increased) [MEDICAL CONDITIONS] and bilateral pleural effusion, new orders received . February 18, 2012 1:50 AM, resident noted with dyspnea, [MEDICAL CONDITION] SOB, shallow respiration, duo neb treatment administered, pulse oximetry still between 88-89%. MD on call notified with new order to send resident to ER (emergency room ) for further evaluation . February 18, 2012 5:30 AM, spoke with nurse at (hospital named) who stated that patient was admitted for exacerbation of [MEDICAL CONDITION]. Summary: According to medical team progress notes, the resident ' s respiratory difficulty and fluid retention progressed and interventions were prescribed. However, licensed nursing staff failed to act on the prescribed interventions and/or act on them with timeliness as follows: The clinical record revealed licensed nursing staff failed to administer diuretic therapy ([MEDICATION NAME] 40mg) ordered by the physician on February 14, 2012 for the management of [MEDICAL CONDITION]. Licensed nursing staff failed to act with timeliness in the implementation of pharmacologic interventions prescribed; several hours (specified above) lapsed prior to administering prescribed diuretic medication and aerosolized nebulization therapy. There was no documented evidence that the prescribed diuretic medication ([MEDICATION NAME]) was held and/or omitted due to the resident ' s inability to meet parameters of administration (e.g. low blood pressure). There was no evidence that staff consulted with the medical team to explore alternative measures when and/or if it was determined that prescribed interventions could not be implemented with timeliness (e.g. medication pending delivery etc.). Nursing assessments of the resident ' s respiratory status were inconsistent. Entries such as (Medical staff named) made aware about shortness of breath (February 15, 2012 at 4:00 PM); there was no evidence of a correlating note related to an assessed state of shortness of breath. On February 17, 2012, during the evening (3 - 11:30 PM) shift, the MAR/TAR revealed the resident ' s P02 level was 98%, however a nurse ' s entry at 1:50 AM on February 18, 2012 read: .pulse oximetry still between 88-89%. There was no evidence of a correlating note and/or assessment that identified a prior P02 level that ranged between 88-89% as implied by still. The medical team prescribed, on more than one occasion, the intervention of [MEDICAL CONDITION] toileting as a component in the management of the resident ' s respiratory status. It was initially prescribed on February 15, 2012 and again on February 17, 2012. However, the respiratory therapy staff failed to implement the treatment. Respiratory therapy staff failed to act with timeliness on a physician ' s request for consultation; a period of 2 days lapsed before the consult was performed. The respiratory therapy consultation lacked documented evidence of a complete assessment of the resident ' s respiratory status. A chest x-ray done February 16, 2012 revealed the resident had [MEDICAL CONDITION] congestion and bilateral pleural effusions; there was no evidence of an assessment of the resident ' s respiratory status consistent with the radiologic result. The physician ' s request for [MEDICAL CONDITION] toileting was not followed through. The order for [MEDICAL CONDITION] toileting was not discontinued even though the therapist recommended patient cannot tolerate any [MEDICAL CONDITION] toileting at this time. Physician ' s notes (February 17, 2012 at 5:00 PM) and orders (February 17, 2012 10:30 AM) referred to [MEDICAL CONDITION] toileting as a component of the resident ' s plan of care. A face-to-face interview was conducted with Employee #36 on March 2, 2012 at approximately 4:00 PM. She/he stated that the resident was not appropriate for [MEDICAL CONDITION] toileting and that the recommendation was verbally communicated to the medical staff prior to February 17, 2012. However, s/he acknowledged that there was no documented evidence of a recommendation against [MEDICAL CONDITION] toileting prior to March 17th and the record revealed the medical team continued to include [MEDICAL CONDITION] toileting in the resident's plan of care. The employee stated that respiratory therapy services were available 7 days per week and requests for respiratory services were usually acted on the same day if it ' s during the hours that a therapist is on duty. In response to a query regarding the delay in initiating the nebulization treatment, Employee #36 stated that the medication had to be ordered and nursing staff administer the treatments in the absence of respiratory staff. In response to a query as to whether or not the medical team was not consulted for an alternative treatment in the interim, s/he stated no, because there is no alternative to Duo-neb (atrovent and albuteral). In response to a query regarding the lack of a full respiratory assessment, Employee #36 stated that the therapist documented (his/her) findings as s/he assessed. Facility staff failed to follow physician's order [REDACTED].#353 ' s respiratory difficulty and fluid retention. The resident was subsequently hospitalized with an acute exacerbation of [MEDICAL CONDITION]. The record was reviewed March 2, 2012. | 2015-09-01 |
| 1981 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 312 | D | 0 | 1 | KI3J11 | Based on observation and interviews for one (1) of 50 sampled residents, it was determined that facility staff failed to ensure incontinence care was provided consistent with one (1) resident ' s needs. Resident #107. The findings include: On February 28, 2012 at approximately 3:40 PM a face-to-face interview was conducted with the responsible party for Resident #107. The responsible party conveyed that s/he had informed the staff that the resident was in need of incontinence care but hours passed and incontinent care had not been provided to the resident. In response to concerns regarding the provision of care verbalized by Resident #107 ' s responsible party (RP), an observation was conducted. On February 28, 2012 at approximately 3:50 PM, moments after the RP verbalized the concerns to the survey team, facility staff were observed transporting the resident from a common area on the unit to his/her room via wheelchair. Staff transferred the resident via mechanical lift and proceeded to provide incontinent care. The staff removed the resident ' s incontinent brief and it was observed to be soggy and thoroughly saturated with urine. An interview was conducted with the staff who performed the incontinence care at the time of the observation. In response to a query regarding the last time the resident received incontinence care, they responded that they were unaware because they recently arrived to duty for the evening shift. Facility staff failed to provide incontinence care consistent with the resident ' s needs as evidenced by the removal of a soggy and thoroughly saturated incontinent brief. The observation was made on February 28, 2012. | 2015-09-01 |
| 1982 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 314 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 50 sampled residents, it was determined that facility staff failed to ensure that one (1) resident received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident #45 The findings include: 1. Facility staff failed to ensure that Resident #45 received necessary treatment and services, promoted healing, prevented infection and prevented new sores from developing. The quarterly Minimum Data Set (MDS) completed November 15, 2011; under Section I (Active Diagnoses) included the following Diagnoses: [REDACTED]. The Braden Scale (for predicting pressure sore risk) completed November 8, 2011equaled a score of 18 (low risk). The Laboratory Report dated January 11, 2012 revealed that the resident ' s Red Blood Count was 3.31-low (range, 4.30-5.70); Hemoglobin was 10.6-low (range, 11.6-15.6); Hematocrit was 30.4-low (range, 34.0-46.0) physician's order [REDACTED].>The physician's order [REDACTED]. The physician's order [REDACTED]. The physician's order [REDACTED]. The physician's order [REDACTED]. The physician's order [REDACTED]. The physician's order [REDACTED]. Cleanse left buttock pressure ulcer with normal saline, pat dry, apply Santyl to wound base, cover with dry dressing twice daily for 30 days and reassess. The physician's order [REDACTED]. Cleanse pressure ulcer to coccyx with normal saline, pat dry, apply Santyl and [MEDICATION NAME] powder to wound, twice daily until healed. The physician's order [REDACTED]. Medication Administration Record On November 2, 2011 the Medication Administration Record [REDACTED]. Nurse ' s initials were placed in the designated box on November 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 indicating adherence to the aforementioned entry. On November 17, 2011 the MAR indicated [REDACTED]. Nurse ' s initials were placed in the designated box on November 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30 indicating adherence to the aforementioned entry. The November 2011 MAR indicated [REDACTED]. Additionally there was no physician's order [REDACTED].# 45 and there were no nurse ' s initials in the designated box for November 16, 2011 indicating the resident did not received treatment on November 16, 2011. On December 3, 2011 the MAR indicated [REDACTED]. Nurse ' s initials were placed in the designated box on December 3, 4, 5, 6, 7 and 8 indicating adherence to the aforementioned entry. On December 8, 2011 the MAR indicated [REDACTED]. Nurse ' s initials were placed in the designated box on December 8, 9, 10, 11, 12,13,14,15,16,17, 18,19, 20, 21,22, 23, 24, 25, 26, 27, 28, 29, 30 and 31 indicating adherence to the aforementioned entry. After reviewing the December 2011 physician's order [REDACTED].#45 ' s open area on the sacral area and there was no order on the MAR indicated [REDACTED]. Additionally, the wound changed from a sacral skin tear on December 3, 2011 to a sacral and right buttock stage II pressure ulcer on December 8, 2011. On January 18, 2012 the MAR indicated [REDACTED]. Cleanse left buttock pressure ulcer with normal saline, pat dry, apply Santyl to wound base, cover with dry dressing twice daily for 30 days and reassess. According to the nurse ' s initials that were placed in the designated box, the treatment as directed began on January 20, 2012 two days after the order originated. The Nutrition Care Progress Notes dated November 15, 2011- Quarterly Note: Wt (weight) 130.6 stable this past Q (quarter) .PO (by mouth) good 75-100%, labs ok, skin intact, no [MEDICAL CONDITION] . December 13, 2011 Skin Note: Open area Stage II sacral per nursing will add foods, increase protein on tray . There was no evidence that the dietitian included Resident # 45 ' s skin tear which was first observed on November 2, 2011 in the November 15, 2011 quarterly note. The dietitian documented that Resident #45 ' s skin was intact. Nursing Notes revealed: November 2, 2011 at 11:35 AM, Resident noted with skin tear on the coccyx. NP (nurse practitioner) notified, new order given . There was no evidence that measurements to the skin tear on the coccyx was noted/documented. The Monthly Note by CRNP dated November 23, 2012 revealed, .11/2/11 resident noted with skin tear on sacrum, treated with [MEDICATION NAME] x 14 days, 11/17/11 reordered [MEDICATION NAME] x14 more days. Resident appears stable . The Weekly Skin Sheet Rounds revealed: November 17, 2011, Date of Onset-left blank; Risk - left blank; Braden Scale-left blank; Pressure Ulcer-IH (In House); Site-Sacrum; Stage-2; Length-0.3 cm; Width-0.2 cm; Depth-none; Drainage-scanty; Current order-[MEDICATION NAME]; .Dietary supplements-N/A; Support Surfaces-air low mattress; .Last [MEDICATION NAME]-N/A; Last pre-[MEDICATION NAME]-N/A; Weekly Documentation-yes . December 15, 2011, Date of Onset-left blank; Risk - left blank; Braden Scale-left blank; Pressure Ulcer-IH Pressure Ulcer; Site-Lt (left) Buttocks; Stage-2; Length-2.0cm; Width-1.0cm; Depth-none; Drainage-none; Current Order-Collagen Dressing; .Dietary supplements-N/A; Support Surfaces-air low mattress; .Last [MEDICATION NAME]-N/A; Last pre-[MEDICATION NAME]-N/A; Weekly Documentation-yes . February 2, 2012, Date of Onset-left blank; Risk - left blank; Braden Scale-left blank; Pressure Ulcer-IH/Stasis, Ulcer; Site-Lower Lt (left) Buttocks; Stage-2; Length-2.0cm; Width-1.5cm; Depth-0.2cm; Drainage-scanty; Current Order-[MEDICATION NAME] and Santyl, cover with Allevyn; .Dietary supplements-N/A; Support Surfaces-air low mattress; .Last [MEDICATION NAME]-N/A; Last pre-[MEDICATION NAME]-N/A; Weekly Documentation-yes . The Skin Condition Report revealed: December 4, 2011, Skin and wound update to site 651 .Sacrum is a skin tear/laceration. The following findings were documented, Skin is not blanchable, no odor is apparent, drainage consistency is thin, moderate drainage is present, color is yellow .This wound was not present on admission, pressure reducing or relieving device(s) are in place . December 8, 2011, Skin and wound update .Present on the Sacrum is a skin tear/laceration. The following findings were documented, skin site is healed. December 8, 2011, (New 2nd recording) for site-651 .Present on the sacrum is a pressure ulcer .Stage 2 length in cm=6, width in cm=3, skin is not blanchable, drainage consistency is thick, moderate drainage is present, color is yellow . This wound was not present on admission .Wound base is visible, pink wound =50%, red wound base=50%, granulation tissue=85%, eschar tissue type=15%. January 5, 2012, New (1st recording) for site-348. Present on the right lower buttocks is a Pressure Ulcer. The following findings were documented, Staging, Stage 2, length in cm=2, width in cm=0.8, skin is not blanchable, no odor is apparent, drainage consistency is thick, moderate drainage is present, color is yellow . This wound was not present on admission . Wound base is visible, pink wound =50%, red wound base=50%. January 5, 2012, Skin and wound update to site-651. Present on the Sacrum is a Pressure Ulcer. The following findings were documented, Staging, Stage 2, length in cm=4, width in cm=4.7, skin is not blanchable, no odor is apparent, drainage consistency is thick, moderate drainage is present, color is yellow . This wound was not present on admission . Wound base is visible, pink wound =50%, red wound base=50%. The Skin Impairment care plan was dated November 2, 2011 revealed, Skin Impairment- Stage II pressure ulcer to sacrum. The care plan update of December 8, 2011 documented that the resident had a Stage II pressure to right buttock. The care plan updated January 18, 2012 documented that both sites continue as Stage II Ulcers, slight decrease in sized noted. Cont (continue) POC (plan of care). After reviewing the Nursing Notes, the Weekly Skin Sheets Round, and the Skin Condition Report there was no evidence that facility staff consistently assessed and measured the open area to the sacrum/coccyx and the lower left buttocks at least weekly as evidenced by: The Nursing Notes revealed that the coccyx was first observed on November 2, 2011 and identified as a skin tear, no assessment/measurements documented. According to the Weekly Skin Sheet Rounds on November 17, 2011(15 days later) the coccyx is now identified as a stage 2 pressure ulcer to the sacrum measuring 0.3cm x 0.2 cm (no depth documented). However the November 17 physician's order [REDACTED]. On November 23, 2011 the Nurse Practitioner documented that the resident had a skin tear, however no assessment/measurements were documented. According to the December 4, 2011 Skin Condition Report (11 days later) the coccyx/sacrum area is documented as a sacrum skin tear/laceration and no measurements are documented. On December 8, 2011 the Skin Condition Report revealed that the sacrum was documented as healed. However, there is a new Stage 2 pressure area on the sacrum measuring, length in cm=6, width in cm=3 (no depth documented). The skin was not blanchable, drainage consistency was thick, moderate drainage was present, color is yellow . This wound was not present on admission .Wound base is visible, pink wound =50%, red wound base=50%, granulation tissue=85%, eschar tissue type=15%. While the facility staff identified the new area to the sacrum , the facility also describes the area as having eschar. According to the Long-Term Care Facility Resident Assessment Instrument User ' s Manual August 2010, page M-46, Necrotic tissue (Eschar)-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin and is considered unstagable. The next entry that referenced the sacrum was on January 5, 2012 (28 days later) the area was now documented as a Stage 2, measuring length in cm=4, width in cm=4.7 (no depth documented) and there is a new Stage 2 pressure area on the right lower buttock measuring length in cm=2, width in cm=0.8 (no depth documented). The Lower Left Buttocks was first identified on December 15, 2011 as in house Stage 2 pressure ulcer measuring, Length-2.0cm; Width-1.0cm; Depth-none; Drainage-none and the treatment is Collagen Dressing. The next entry regarding this area was February 2, 2012 (49 days later) the lower Lt (left) Buttocks was documented as a Stage-2 measuring Length-2.0cm; Width-1.5cm; Depth-0.2cm; Drainage-scanty and the treatment is [MEDICATION NAME] and Santyl, cover with Allevyn. There was no evidence that the Skin Impairment care plan was updated to reflect all of the resident ' s pressure ulcers. There was no evidence in the clinical record that a physician's order [REDACTED]. and left buttocks on January 18 and 19, 2012. A face-to-face interview was conducted with Employees #10 and #33 on February 28, 2011 at 4:00 PM. Employee #33 stated, We were suppose to measure (the sacrum area) on the 8th of December (2011) when the wound got bigger. After Employees #10 and #33 reviewed the record, they acknowledged that the record lacked consistent assessments/measurements and treatment to the open areas and the care plan was not updated to reflect the resident ' s entire pressure ulcer status. The record was reviewed on February 28, 2012. | 2015-09-01 |
| 1983 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 315 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview for one (1) of 50 sampled residents, it was determined that facility staff failed to provide services to improve/prevent a decline in bladder function for Resident #287. The findings include: A face-to-face interview was conducted with Resident #287 at 12 noon on March 1, 2012. Resident informed this investigator that he/she has problems with what he/she described as dribbling and wears what he/she called pull-ups. In response to a query whether he/she participates in any form of bladder training, he/she responded no. A review of the clinical record revealed that the resident was admitted to the facility on [DATE]. A review of the admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of October 14, 2011 revealed that the resident was coded with a one (1) which indicated that the resident was occasionally incontinent under Section H 0300 (Urinary Continence). However, the quarterly assessment dated [DATE] revealed that the resident was coded with a three (3) indicating that the resident was always incontinent in H0300. Resident #287 had not been evaluated for and/or involved in a bladder training program as evidenced by the coding of the admission and quarterly MDS ' dated October 14, 2011 and December 20, 2011 respectively. A no response was coded in Section H-0200, (Urinary Continence), indicative that a toileting plan had not been attempted. There was no evidence that facility staff provided appropriate treatment and services to improve and/or prevent a decline in bladder function for Resident #287. A face-to-face interview was conducted with Employee #10 on March 1, 2012 at approximately 12:15 PM. In response to a query whether the resident receives bladder training, he/she stated no. The record was reviewed on March 1, 2012. | 2015-09-01 |
| 1984 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 323 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on record review and staff interview for three (3) of 50 sampled residents, it was determined that facility staff failed to ensure application and functionality of a posey senor alarm for one (1) resident; failed to properly supervise one (1) resident during transfer from the wheel chair to the bed resulting in an injury, and failed to properly assess the use of a posey sensor monitor for one (1) resident. Residents #107, #137, and #237. The findings include: 1. Facility staff failed to ensure the application and functionality of a posey sensor pad alarm (bed alarm) to Resident #107 ' s bed. physician's order [REDACTED]. An observation of Resident #107 on February 28, 2012 at 4:00 PM revealed the resident was lying in bed after being assisted to bed by facility staff. A cord was observed dangling from the bed onto the floor. Electrical appearing wires of various colors were protruding from the distal end of the cord. The staff assisting the resident stated that the cord was a part of the resident ' s bed alarm, in response to my query regarding the purpose and origin of the wires. They concluded that the cord was not functioning as intended and that an adaptor piece was detached. A review of the treatment administration record (TAR) for February 2012 revealed that staff initialed in the box for the day shift on February 28, 2012 indicating that the bed alarm was in place. A face -to-face interview was conducted with Employee #10 on February 28, 2012 at 4:45 PM. S/he acknowledged the findings. 2. Facility staff failed to properly assess the posey sensor monitor for Resident #137 who was discovered on the fall mat inside of his/her room. A review of the unusual incident report dated February 22, 2012 revealed that Resident #137 sustained a fall without injury on February 22, 2012 at 7:45 AM. The report read: Resident was observed lying on (his/her) floor mat bedside bed. Through face-to-face interview with Employee #20 on February 22, 2012, it was determined that the resident was identified on the floor at his/her bedside by environmental staff who alerted licensed nursing staff. A viglon monitor (sensor pad) was in place on the bed, however failed to activate. The resident sustained [REDACTED]. A physician's orders [REDACTED]. A face-to-face interview was conducted with Employee #21 on February 28, 2012 at approximately 12:30 PM, he/she indicated that random checks were made to test the batteries and the pads of the sensor pads. A face-to-face interview was conducted with Employee #21 on February 28, 2012 at approximately 12:30 PM, a query was made if there was a policy for the use of the bed sensor pads (Vigilon monitors) and the posey sensors. Confirmation was made by Employee #2 that the facility does not have a written policy, however they are checked weekly by the Charge Nurse and documented in the TAR (Treatment Assessment Record) as being checked. Review of the TAR reflects the sensor pad to bed for safety was checked for the 3-11 shift with no indication that there was a problem with the sensor. The facility staff failed to properly assess the functionality of the sensor pad for Resident #137. The record was reviewed on February 22, 2012. 3. Facility staff failed to properly supervise a resident to prevent an injury/accident during transfer from the wheel chair to the residents bed. Resident #237 Resident had an admissions date of February 20, 2009. Last physical exam was performed on February 23, 2012 The resident's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date of February 9, 2012 Section G Physical Function indicated that the resident is a two (2) person transfer, totally dependent with ADL's. Section I Active [DIAGNOSES REDACTED]. A review of the facility's incident report dated February 23, 2012 revealed .CNA (Certified Nursing Assistant)observed and reported during transfer from wheelchair to bed, resident's foot got caught on her wheelchair and went forward and bumped her left l(side) of the face on the right bedside rail.8:20 PM.3cmx4.5cm with slightly bluish skin discoloration at the center aspect 1.3cm x 2.5cm noted on (his/her) left above eyebrow has (slight) swelling area of 1.8cmx1.3cm with slightly reddish skin discoloration at the center aspect 1.9cm x2cm and also noted slightly greenish skin discoloration to his/her inner lower eyelid of 3cmx0.9cm skin remains intact, no skin breakdown, no facial grimaces noted and no signs of discomfort to touch, neuro check initiated. Review of the Nurses Notes revealed on February 23, 2012 11:00 PM indicated CNA (was) taking care of the resident called (writer) to come to the room immediately. CNA informed (writer) that while (he/she) was putting the patient in bed (he/she) hit the side of (his/her) face on the left cheek area- The patient did this. The patient was in the bed when I arrived I (was) assigned to (his/her) and noticed (his/her) face on the left cheek was beginning to swell.No pain noted, the (resident ) is usually alert and oriented times 2-3 and is dysphagic most of the time. Left swollen cheek bone with skin discoloration at the center 1.3x2.5 cm, skin intact, swollen left area above left eyebrow 1.8x1.3cm with reddish color at the center 1.9 on length 2 cm width skin is intact. Left below eyelid bruise is 3 cm x 0.9 cm skin intact.Cold compresses to left cheek, neuro-checks done per protocol. A face-to-face interview was conducted with Employee # 7 at approximately 10:15 AM on March 2, 2012. A query was made of the incident, and what interventions if any were implemented? {if opthalmology or orbital x-rays} were performed, he/she indicated that the physician performed the exam, no further studeies were indicated. A face-to-face interview was conducted with Employee #17 on March 1, 2012 at approximately 11:20 AM. He/she demonstrated how the resident was transferred. The resident was assisted to a standing position, held under left arm, and back of pants. As Employee #17 assisted the resident to his/her feet to pivot the resident, the resident fell forward, and sustained an injury to the left side of the face. Employee #17 saw that the residents right leg was caught behind the leg rest on the right side of the wheelchair which caused the resident to fall forward. Employee #17 acknowledged that the resident was more drowsy than normal. Another face-to-face interview was conducted with Employee #7 on March 2, 2012 at 11:45 AM, a query made if the staff member was sent for reeducation/ training of assisting a resident during transfer. Employee #7 indicated that Employee #17 was not sent for re-education, and the resident was not sent to PT (Physical Therapy) because the resident is not cognitively able to follow instruction. A face-to-face interview was conducted with Employee #9 on March 2, 2012 at 1:30 PM, he/she identified that Employee #17 attended an in-service on February 24, 2012 Transfers, Lifting, Mechanical Lift, falls Management, Body Mechanics. Facility staff failed to properly supervise a resident to prevent an injury/accident. The record was reviewed on February 23, 2012 B. Based on observation and staff interview, it was determined that facility staff failed to ensure that the environment was free of accident hazards as evidenced by: skids lifting inside the shower in one (1) of three (3) observed; carpet was observed buckled in one (1) of three (3) hallways observed, the carpet was torn in one (1) of three (3) hallways observed, and the threshold/metal carpet strip was observed unsecured in one (1) of one (1) observed. The findings include: During a tour of the enviroment on February 29, 2012 from 9:15 AM to12:30PM the following was observed: 1. The shower room near room #313 was observed with skids lifting inside the shower in one (1) of three (3) shower rooms observed on Unit 3A. 2. Carpet was observed buckled on Unit 3A Hallway #1 in one (1) of three (3) hallways observed. 3. The carpet was torn on Hallway #2 on Unit 3B in one (1) of three (3) hallways observed. 4. The threshold/metal carpet strip at the entrance to the hallway was observe unsecured (hallway 104-116) in one (1) of three (3) hallways observed. These observations were made in the presence of Employee #31 and he/she acknowledged the findings at the time of the observation. | 2015-09-01 |
| 1985 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 328 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 50 sampled residents, it was determined that facility staff failed to comprehensively assess and act on physician's order [REDACTED].#353. The findings include: The respiratory therapist failed to comprehensively assess the respiratory status of Resident #353 who exhibited respiratory difficulty and fluid retention, was subsequently diagnosed with [REDACTED]. A review of the clinical record for Resident #353 revealed the [AGE] year old was admitted on [DATE] for physical rehabilitation with [DIAGNOSES REDACTED]. The physician ordered a chest x-ray on February 15, 2012. The study was performed and results provided on February 16, 2012. The findings of the Chest x-ray cardiomegaly (enlarged heart) with [MEDICAL CONDITION] vascular congestion and bilateral pleural effusions. The physician wrote an order for [REDACTED]. A physician's order [REDACTED]. Approximately 10 hours lapsed before the initial neb treatment was administered at 9:00 PM on February 17, 2012. EMS (emergency medical services) was activated and the resident was transported to the hospital approximately 5 hours later at 1:50 AM on February 18, 2012. The request for the respiratory consult was acted on after 2 days, on February 17, 2012 at 10:38 AM. The consultation form remained blank and the therapist completed a Respiratory Therapy Recommendations and Order Request form that read: patient cannot tolerate any [MEDICAL CONDITION] toileting at this time. Incentive spirometer recommendation for 10 days as tolerated by patient. Duo-Neb treatment every 4 hours ordered as well .to start treatment as soon as medication is available. A Respiratory Treatment Note, February 17, 2012 10:55 AM read: IS (incentive spirometer) therapy for [MEDICAL CONDITION] toileting; lung sounds pre-treatment decreased and post-treatment slight improvement. SPO2 88-95%. Patient instructed and encouraged with use of IS at this time. Patient was unable to follow instructions well, but with the assistance from patient ' s (next of kin) patient attempted a maximum effort of 500ml x2. The response to the physician ' s request for a respiratory consult lacked evidence that the respiratory therapist performed a complete assessment of the resident ' s respiratory status. There was no evidence of a respiratory assessment inclusive of inspection, palpation, percussion and auscultation. There was no evidence of an assessment of breath sounds, lung regions, work of breathing or skin color that would correlate with the findings of the chest x-ray report (pleural effusion & [MEDICAL CONDITION] congestion). The physician ' s request for [MEDICAL CONDITION] toileting was not followed through. The order for [MEDICAL CONDITION] toileting was not discontinued even though the therapist recommended patient cannot tolerate any [MEDICAL CONDITION] toileting at this time. Physician ' s notes (February 17, 2012 at 5:00 PM) and orders (February 17, 2012 10:30 AM) referred to [MEDICAL CONDITION] toileting as a component of the resident ' s plan of care. Respiratory Therapy staff failed to act with timeliness on a physician ' s request for consultation; a period of 2 days lapsed before the consult was performed. A face-to-face interview was conducted with Employee #36 on March 2, 2012 at approximately 4:00 PM. She/he stated that the resident was not appropriate for [MEDICAL CONDITION] toileting and that the recommendation was verbally communicated to the medical staff prior to February 17, 2012. However, s/he acknowledged that there was no documented evidence of a recommendation against [MEDICAL CONDITION] toileting prior to March 17th and the record revealed the medical team continued to include [MEDICAL CONDITION] toileting in the resident's plan of care. The employee stated that respiratory therapy services were available 7 days per week and requests for respiratory services are usually acted on the same day if it ' s during the hours that a therapist is on duty. In response to a query regarding the delay in initiating the nebulization treatment, Employee #36 stated that the medication had to be ordered and nursing staff administer the treatments in the absence of respiratory staff. In response to a query as to whether or not the medical team was not consulted for an alternative treatment in the interim, s/he stated no, because there is no alternative to Duo-neb (atrovent and albuteral). In response to a query regarding the lack of a full respiratory assessment, s/he stated that the therapist documented (his/her) findings as s/he assessed. The record was reviewed March 2, 2012. | 2015-09-01 |
| 1986 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 371 | D | 0 | 1 | KI3J11 | Based on a tour of the kitchen on February 24, 2012 at approximately 5:00 PM, it was determined that staff failed to store, prepare and/or distribute foods under sanitary conditions as evidenced by five (5) of 18 damaged pellet plates and one (1) of three (3) hand washing sinks was non-operational. The findings include: 1. Five (5) of 18 burgundy pellet plates were damaged. 2. One (1) of three (3) hand washing sinks was non-operational. These findings were made in the presence of Employee #34 at the time of the observation. | 2015-09-01 |
| 1987 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 386 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 50 sampled residents, it was determined that the physician failed to review the total program of care for one (1) resident as evidenced by the lack of a plan of care and/or directives to address the need for transmission based precautions for a [DIAGNOSES REDACTED]. Diff). Resident #310. The findings include: A review of Resident #310 ' s admission orders [REDACTED].Diff ([MEDICAL CONDITION]); Diabetes Mellitus, Hypertension and Decreased Mobility. A Physician ' s Order Sheet and Plan of Care dated January 24, 2012 directed: [MEDICATION NAME] 125 mg by mouth every (six) hours for (two weeks) until February 6, 2012 (for) [DIAGNOSES REDACTED]. A Nurse ' s note dated January 25, 2012 at 12 PM revealed, Contact isolation for [DIAGNOSES REDACTED] maintained. A review of the MAR (Medication Administration Record) revealed the resident was administered [MEDICATION NAME] 125 mg by mouth at 6 AM, 12 Noon, 6 PM, and 12 AM from January 25, 2012 thru February 6, 2012. A review of the physician's orders and assessments lacked documented evidence that the physician addressed the resident ' s contact isolation needs in his/her total plan of care. A face-to-face interview was conducted with Employee #6 on March 1, 2012 at approximately 11:51 PM, he/she stated that the resident had been on contact isolation for [DIAGNOSES REDACTED] since admission. He/she acknowledged that the physician did not include an order for [REDACTED]. | 2015-09-01 |