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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 192 | RIVER CITY NURSING AND REHABILITATION | 285058 | 7410 MERCY ROAD | OMAHA | NE | 68124 | 2019-09-12 | 812 | L | 0 | 1 | 7GF911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC ,[DATE].11E Based on observations, interviews, review of facility documents, and review of facility policies and procedures, the facility failed to ensure the staff used non-expired test strips to test the sanitizer level of the dishwashing machine, and failed to ensure the water temperature of the dishwashing machine was maintained within an acceptable range for the effective sanitization of kitchen and food-service dishware and utensils. This deficient practice created a likelihood for the occurrence of serious injury, harm, impairment, or death from foodborne illness and placed the 90 residents capable of oral intake in immediate jeopardy. The facility had a census of 93 residents on the first day of the survey. Findings include: During the initial tour of the kitchen, accompanied by the facility's Dietary Manager (DM), on [DATE] beginning at 8:38 AM, observation revealed, and the DM confirmed, that the facility used a low-temp dishwashing machine to clean and sanitize the facility's kitchen ware and food-service ware. At 8:40 AM, observation revealed Dietary Aide (DA)17 checked the water temperature of the dishwashing machine by visualizing the water temperature gauge on the front of the machine below a built-in water reservoir. DA17 reported the water temperature registered 115 degrees Fahrenheit (F). During the observation, the DM confirmed that the water temperature was below the acceptable range of 120 degrees F at the time the temperature was tested . DA17 then tested the level of sanitizer in the water by dipping a test strip into the sanitizing solution collected in the built-in water reservoir on the front of the machine. DA17 reported the sanitizer level as 100 parts per million. At that time, observation of the container of test strips just used by DA17 to test the sanitizer level, revealed the test strips had an expiration date of [DATE]. During an interview at that same time, both DA17 and the DM stated the test strips in the container had been supplied by the vendor that installed the new dishwasher on [DATE], and had been used exclusively since that date to test the sanitizer level of the dishwasher solution. A review of the Dish Machine Log - Low Temp forms posted next to the dishwasher revealed the forms were in a monthly format, and each day of the month was divided into three spaces labeled breakfast, lunch, and dinner. Each of the three daily timeslots had a place to log both the temperature of the water and the sanitizer level. Further review of the (MONTH) 2019 log entries from [DATE] through [DATE] revealed the following information: On [DATE] and [DATE]: No entries were logged for either the water temperatures or the sanitizer levels for any of the three meals on those two dates. On [DATE] and [DATE]: No entries were logged for either the water temperatures or the sanitizer levels for the breakfast and lunch meals on those dates. Supper water temperatures were logged as 100 degrees F, with sanitizer levels within normal limits. On [DATE]: Breakfast and lunch water temperatures were both logged as 100 degrees F, with no water temperature or sanitizer level entries logged for the supper meal. On ,[DATE] /19: Breakfast, lunch, and supper water temperatures were all logged as 100 degrees F, with sanitizer levels within normal limits. On [DATE]: No entries were logged for the breakfast and lunch water temperatures or sanitizer levels. The supper water temperature was logged as 100 degrees F, and the sanitizer level was within normal limits. On [DATE]: No entries were logged for the breakfast and lunch water temperatures or sanitizer levels. The supper water temperature was logged as 115 degrees F, with the sanitizer level within normal limits. On [DATE]: The breakfast water temperature of 115 degrees F, and the sanitizer level of 100 parts per million were logged post-breakfast at 8:50 AM that day. During an interview at the time of the observation, the DM stated he was responsible for ensuring the water temperature was tested prior to cleaning dishes and he failed to monitor the temperature logs for the dishwashing machine during the current month. During an interview with the Grounds Director (GD), the DM, and the Director of Procurement (DOP) on [DATE] at 9:30 AM, the GD stated the water in the building would only be heated to a maximum temperature of 119 degrees F and the dishwashing machine did not have a booster' to increase the temperature to acceptable minimum required temperature for cleaning or rinsing dishes. In addition, the GD stated there had been no work orders submitted for repairs to the dishwashing machine. During an interview on [DATE] at 9:40 AM, the Administrator stated she had not been notified of any problems with the new dishwashing machine and there had been no work order submitted regarding problem with the safe operation of the machine. Review of a facility electronic mail (email) message titled, Dishwasher Replacement, dated [DATE], from the DM to the Administrator, the DOP, and the owners of the facility revealed the DM recommended a High Heat Washer be purchased to replace the facility's dishwasher. The reasons noted by the DM for this recommendation were noted as follows: 1) You wouldn't need a booster due to the machine heating the water which would solve our problem right now, 2) The facility would save money because, you wouldn't need to buy chemicals, and 3) it improves dry times on items washed. A follow-up interview was conducted with the DM on [DATE] at 11:00 AM. The DM confirmed he sent a message to the Administrator, the DOP, and the owners of the facility because there had been problems with inconsistent water temperatures with the facility dishwashing machine and plans were made to replace the machine. A review of a facility's Kitchen Audit, dated [DATE], and conducted by the Registered Dietician (RD) revealed the water temperature noted on the facility's dishwashing machine at the time of the audit was measured as 110 degrees. The audit guidelines noted a low temperature machine's water temperature should be equal to or greater than 120 degrees and should follow the manufacturer's guidelines. The RD's note on the audit reads, temp 110 - replacing dishwasher, An interview with the DOP was conducted on [DATE] at 12:30 PM. The DOP stated he was responsible for the purchase of the new dishwashing machine for the facility. The DOP confirmed he was aware of the recommendations made by the DM to purchase a high temperature dishwashing machine were made on [DATE]. In addition, the DOP confirmed he was aware the facility needed to purchase a new dishwashing machine due to problems with inconsistent water temperatures on the machine. The DOP stated he received a recommendation from a vendor to purchase a low temperature washer and the new dishwashing machine was installed on [DATE]. The DOP did not provide an explanation for why the recommendation to purchase a high temperature dishwashing machine from the DM was not considered and the DOP did not provide an explanation for why a booster was not purchased to increase the temperature of the new machine. An interview was conducted with the Administrator and Regional Administrator on [DATE] at 2:25 PM. The Administrator stated the DOP was responsible for the purchase of a new dishwashing machine for the facility kitchen. The Administrator confirmed she understood the facility needed to purchase a new dishwasher due to inconsistent water temperatures. In addition, the Administrator confirmed she was aware a low temperature dishwashing machine would need a booster to increase water temperatures because the hot water temperatures set in the building would only reach 119 degrees. The Administrator stated she had not been made aware of any problems with the new dishwashing machine and there had been no work orders submitted at the facility related to problems with the operation of the new dishwashing machine since the installation date of [DATE]. The Administrator stated the DOP was responsible for communicating with vendors related to the purchase and would have expected a booster to be purchased at the time the new machine was purchased but could not provide an explanation for the facility's failure to purchase a booster to increase the water temperature for safe operation of the new machine. Observation on [DATE] at 2:35 PM, revealed the manufacturer's guideline and the National Sanitary Foundation requirements were posted on the Data Plate on the front of the dishwasher and read, Wash Temp. - Minimum 120 degrees Fahrenheit, recommended 140 degrees Fahrenheit, Rinse Temp.- Minimum 120 degrees Fahrenheit, recommended 140 degrees Fahrenheit. A review of facility policy titled, Dish Machine Usage, dated ,[DATE], stated the purpose of the policy was, to ensure proper techniques when washing tableware (i.e., dishes, silverware, glasses and cups). The procedure outlined in the policy stated, Wash and rinse tanks should be filled with clear water. Check the temperature of the wash and rinse cycles, verifying that both meet the temperature posted on the dish machine. | 2020-09-01 |
| 1363 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2019-02-19 | 600 | L | 1 | 0 | 2BLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview; the facility staff failed to protect residents during an investigation of a sexual assault allegation. The facility failure had the potential to affect all residents residing in the facility. The facility staff identified a census of 105. Findings are: Record review of the facility Policy and Procedure for Protection of Residents: Reducing the Threat of Abuse & Neglect revised on 2-2018 revealed the following information: -Introduction: -To minimize the threat of abuse and/or neglect , nursing homes must incorporate clear cut policy and practices that demonstrate a hardline,zero tolerance approach to resident abuse. -Position Statement and Guidelines: - Residents must not be subjected to abuse by anyone. -It is the policy and practice of this facility that all residents will be protected from all types of abuse,neglect, misappropriation of resident property and exploitation. -Investigation and Protection: -It is the policy of this facility that reports of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. -Procedure: -1. Following identification of alleged abuse, the resident(s)receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent recurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation. -3. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator. Record review of a Resident Transfer Record dated 2-03-2019 revealed Resident 100 was transferred to the hospital related to increased anxiety and difficulty breathing. Record review of a the facility preliminary investigation note dated 2-04-(2019) revealed the facility Director of Nursing (DON) and the facility Administrator were notified on 2-04-2019 at 12:30 PM of an allegation of sexual assault of 1 of the facility Residents (Resident 100) by the facility Advanced Registered Nurse Practitioner (ARNP) who was following up with Resident 100 in the hospital. Further review of the preliminary investigation note dated 2-04-2019 revealed the police were notified and at apprx (approximately) 1:55 PM returned a call to the facility and obtained the information of the allegation of Resident 100 being sexually assaulted. According to the preliminary investigation note dated 2-04-2019 a police officer followed up with a phone call to the facility on [DATE] at 4:27 PM reporting Resident 100 had injuries to the vaginal region and believed something happened at the facility. On 2-06-2019 at 3:18 PM an interview was conducted with the facility Administrator. During the interview when asked how the facility residents were being protected after the allegation of sexual assault for Resident 100, the facility Administrator reported being instructed not to discuss the issue with anyone and had not implemented interventions to protect the facility residents. The facility Administrator further reported the facility staff had not been educated on the allegation of a facility resident being sexually assaulted. On 2-06-2019 at 4:38 PM an interview was conducted with Detective [MI] During the interview,discussion protecting the facility residents and integrity of the investigation was completed. During the interview, Detective L reported the facility staff should be protecting the facility residents. On 2-06-2019 at 1:20 PM an interview was conducted with Registered Nurse (RN) [NAME] During the interview RN A reported not being aware of an allegation abuse or neglect currently in the facility. On 2-06-2019 at 1:25 PM an interview was conducted with Nursing Assistant (NA) B. During the interview NA B reported not aware of an allegation of abuse currently being investigated in the facility. On 2-06-2019 at 1:30 PM an interview was conducted with Housekeeping (HK) C. During the interview HK C reported not being aware of an allegation of abuse currently being investigated in the building. On 2-06-2019 at 1:35 PM an interview was conducted with LPN D. During the interview LPN D reported not being aware of an allegation of abuse currently being investigated in the building. On 2-06-2019 at 1:45 PM an interview was conducted with NA E. During the interview NA [NAME] reported not being aware of an allegation of abuse currently being investigated in the facility. B. Abatement Statement: Based on the information provided on 2-06-2019 to correct the immediacy of the situation, the facility staff provided the following information to protect residents: 1. No males associates may work unsupervised without female associate in resident care area assisting residents. All staff were to review the requirement prior to starting their next shift. 2. All staff must review and sign off as understanding prior to their next shift of the facility Reducing the Threat of Abuse &Neglect Policy and review of this abatement plan with focus to understand sexual abuse, identifying and reporting injuries of unknown origin. 3. The facility charge nurse must document the review of the policy and is accountable to ensure no males associates may work unsupervised without a female associate in resident care areas (non-public). 4. The facility Executive Director shall ensure a log is maintained of the staff member assigned and reviewing . The log will be verified with those staff members clocked into the facility. 5. All staff are to report immediately to the facility Executive Director any concerns following review of this policy and memo and follow the facility Protection of Residents: reducing the threat of Abuse&Neglect Policy. The immediacy had been removed, however, the deficient practice was not totally corrected. Therefore, the severity was lowered to an F level. | 2020-09-01 |
| 1370 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2019-02-19 | 835 | L | 1 | 0 | 2BLY11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record review and interviews; the facility staff failed to utilize facility resources to ensure provision of care and services were provided to the facility residents. This had the potential to effect all residents who reside in the facility. The facility staff identified a census of 105. Findings are: Review of the facility during a survey revealed the following deficiencies: [NAME] F580. The facility staff failed to notify the practitioner of a new wound for a sampled resident. B. F600. The facility staff failed to protect the facility residents during an allegation and investigation of a sexual assault for a sampled resident. C. F684. The facility staff failed to obtain an treatment order for a new wound for a sampled resident. D. F686. The facility staff failed to evaluate a decline in pressure ulcer healing for a sampled resident. E. F690. The facility staff failed to evaluate a toileting program for a sampled resident. F. F692. The facility staff failed to obtain weights as order by the practitioner. [NAME] 726. The facility staff failed to ensure facility nursing staff had competency reviews completed. H. F730. The facility staff failed to ensure all nursing assistants had 12 hours of education per year. I. The facility failed to have and effective Quality Assurance committee. | 2020-09-01 |
| 1371 | LIFE CARE CENTER OF ELKHORN | 285134 | 20275 HOPPER STREET | ELKHORN | NE | 68022 | 2019-02-19 | 867 | L | 1 | 0 | 2BLY11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assurance (QA) program failed to identify ongoing issues relevant to F580, F600, F684, F686, F690, F692, F726 and F730 and implement plans of action to identify and correct the deficient practice. The facility staff identified a census of 105. Findings are: Record review of the facility policy and procedure for Quality Improvement revised on 6-26-2009 revealed the following information: -Policy: This facility actively participates in a formal, written quality assessment, assurance and improvement process. The comprehensive process involves all facility departments. The process included monitoring, evaluation, and follow up action. -Committee Recommendation: -Recommendation may include, but are not limited to, the following: - Communication methods to disseminate information to resident, staff, family members, community organizations, and/or regulatory agencies. On 2-12-2019 at 7:45 AM an interview was conducted with Licensed Practical Nurse (LPN) [NAME] During the interview when asked what the facility QA committee was working on, LPN G stated I'm not sure. On 2-12-2019 at 7:45 AM an interview was conducted with LPN H. During the interview when asked what the QA committee was working on, LPN H reported could not remember. On 2-12-2019 at 7:50 AM an interview was conducted with Nursing Assistant (NA) B. During the interview, NA B reported not sure what the QA committee was working on. On 2-12-2019 at 9:27 AM a interview was conducted with NA I. During the interview, NA I reported not being aware of what the QA committee was working on. On 2-12-2019 at 9:32 AM an interview was conducted with LPN [NAME] During the interview, LPN J reported not knowing what the QA committee was working on. On 2-12-2019 at 10:30 AM an interview was conducted with Registered Nurse (RN) K. During the interview RN K reported not being aware of what the QA committee was working on. | 2020-09-01 |
| 5836 | ROSE BLUMKIN JEWISH HOME | 285059 | 323 SOUTH 132ND STREET | OMAHA | NE | 68154 | 2016-08-24 | 371 | L | 1 | 0 | Inf | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to maintain food temperatures in a range to prevent food borne illness. The facility staff identified 86 of 87 resident who ate out of the facility kitchen. The facility staff identified a census of 87. Findings are: Observation on 8-12-2016 at 11:30 AM revealed a weekly Deli style lunch was being offered to the facility residents and outside community. An interview was conducted on 8-12-2016 at 11:40 AM with the Director of Food Service (DFS). During the interview the DFS confirmed food for the weekly Deli was prepared in the facility kitchen. When asked if the facility residents could have their lunch from the Deli, the DFS stated yes. On 8-12-2016 at 11:55 AM an interview was conducted with the Assistant Director of Food Service (ADFS). During the interview when asked if a resident could have their meal served from the Deli, the ADFS stated yes. The ADFS reported if residents wanted to eat from the Deli, the staff would take the food order sheet to the residents' nurse to see if what was ordered was with in the diet for the resident. Observation on 8-12-2016 at 12:05 PM revealed the Deli style lunch was being served to those community members and residents who had placed lunch orders. Further observation of the meal service revealed there was a pan of raw Tuna steak. There was brownish liquid partially covering the Tuna Steak and upon request, Cook G using the facility thermometer, obtained the temperature of the Tuna steak. Cook G reported the Tuna Steak was 50 degrees. Continued observation of the Deli service revealed Egg Salad and Tuna Salad were available for community members and residents to order. The Egg salad and the Tuna salad were observed to be sitting on top of a pan of ice. When requested, Cook B using the facility thermometer, obtained the the temperature of the Egg Salad with a resulting temperature of 48 degrees. Cook B then obtained the temperature of the Tuna Salad with the resulting temperature of 48 degrees. The DFS who was assisting with the Deli service was informed of the resulting temperatures of the Tuna and Egg Salad. The DFS stated that's not cold enough and instructed Cook B to retake the temperature of the Egg and Tuna Salad. Cook B using the facility thermometer, obtained the temperature of the Egg Salad with a result of 50 degrees and the Tuna Salad was 52 degrees. Cook B reported the results to the DFS at 12:13 PM on 8-12-2016. The Tuna Salad, Egg Salad and Tuna Steaks were not removed and discarded. Observation on 8-12-2016 at 1:40 PM revealed the deli service was completed. Cook B obtained the temperature of the remaining Egg Salad with a result of 56 degrees and the remaining Tuna Salad temperature was 58 degrees. An interview with the DFS was conducted on 8-12-2016 at 1:40 PM. During the interview the DFS confirmed the Tuna Salad, Egg Salad and Tuna Steaks were too warm and further confirmed the foods were served to residents and guests. An interview on 8-12-2016 at 1:45 PM was conducted with the Catering Coordinator (CC). During the interview the CC reported the food temperature had not been taken for the Deli foods. On 8-12-2016 at 3:35 PM the facility staff identified and provided order sheets of 6 residents who ate from the Deli on 8-12-2016. B. Record review of the facility Production Area Cook sheet revealed start and end temperatures of the specific food items for the facility residents meals revealed the following: -5-19-2016; Pasta Salad Creamy D, starting temperature was 60 degrees, no ending temperature was recorded. -5-19-2016; Coleslaw Creamy D, starting temperature was 60 degrees, no ending temperature was recorded. -5-21-2016; Macaroni Salad, starting temperature was 60 degrees, no ending temperature was recorded. -5-21-2016; Pureed Macaroni Salad, starting temperature was 60 degrees, no ending temperature was recorded. -5-24-2016; Turkey Sandwich, starting temperature was 60 degrees, no ending temperature was recorded. -5-24-2016; Ground Turkey Sandwich, starting temperature was 60 degrees, no ending temperature was recorded. -6-02-2016; Coleslaw Creamy, starting temperature was 59 degrees and the ending temperature was 67 degrees. -6-04-2016; Borscht (soup), starting temperature was 63 degrees and ending temperature was 69 degrees. -6-04-2016; Coleslaw Creamy and Cucumber Onion in Sour Cream, starting temperature was 53 degrees for both and ending temperature for both was 61 degrees. -8-05-2016; Prime Rib, starting temperature was 132 degrees and ending temperature was 146 degrees. -8-09-2016; Ground Chicken Salad, starting temperature 61 degrees and ending temperature was 70 degrees. -8-09-2016; Pureed Chicken Salad, starting temperature was 58 degrees and ending temperature was 69 degrees. -8-11-2016; Coleslaw Creamy, starting temperature was 56 degrees and the ending temperature was 63 degrees. An interview on 8-12-2016 at 4:55 PM was conducted with the FSD. During the interview,review of the recorded food temperatures was completed. The FSD confirmed the cold food temperatures were too warm. The FSD further confirmed the Turkey sandwich was a cold sandwich and should have been below 41 degrees. Record review of the facility recipes printed on 8-24-2016 for Egg Salad, Turkey Salad, Chicken Salad, Creamy Pasta Salad,Tuna Salad and Coleslaw Creamy revealed these foods were to be maintained at a temperature of 40 degrees or lower. On 8-24-2016 at 9:13 AM a follow up interview was conducted with the ADFS. The ADFS reported during the interview that food temperatures were taken to keep foods out of the danger zone. The ADFS confirmed the recorded food temperatures were not being monitored prior to 8-12-2016. According to the USDA Food Safety and Inspection Service (FSIS) found at www.fsis.usda.gov, the danger zone of food was between 40 degrees and 140 degrees as the bacteria grows rapidly in this range. Additional information from the FSIS revealed that to prevent illness,hot foods should be kept at or above 140 degrees and cold food at or below 40 degrees. C. Record review of a Resident Illness sheet revealed between 5-25-2016 and 6-7-2016, 23 residents were identified as having diarrhea or vomiting. D. Record review of a Staff Illness sheet revealed between 5-24-2016 and 6-04-2016, 14 staff members were identified with diarrhea or vomiting. According to information at www.foodsafety.gov, symptoms of food poisoning include upset stomach, abdominal cramps, nausea, vomiting, diarrhea, fever and dehydration. On 8-12-2016 at 5:15 PM the facility Administrator provided a signed Plan of Correction to abate the immediacy of the situation and protect residents from food borne illness. This abatement statement revealed the following information: -1. The egg and tuna salad identified during the deli service was disposed. -2. Temperature of all foods will be checked and recorded before leaving the kitchen. If any food item is outside of the accepted temperature range, that food will be discarded. The cook checking the food temperatures will immediately notify the Food Service Director or designee. -3. Temperatures of all remaining food from a meal will be checked and recorded at the end of the meal services. Food that is outside of the accepted temperature range will be discarded. The cook will immediately notify the Food service Director or designee. -4. The Food Service Director or designee will in-service all dietary personnel that are currently working (8-12-2016) regarding food temperature safety and safe food handling. All other employees will be in-serviced prior to their next scheduled work day. An employee will not be allowed to work until they have received the training. The training will include when to take temperatures, acceptable temperature range for cold and hot food, documenting temperatures, what to do in the event the temperatures are out of range and safe food handling. The food Service Director or designee will in-service all new dietary staff regarding taking food temperatures and safe food handling. -5. The Food service Director or designee will review all temperature recording on a daily basis to ensure that staff are recording and reporting temperatures correctly. -6. The Food Service Director or designee will audit food handling and temperature monitoring at a minimum of weekly at varying times to ensure that staff are handling food correctly. If a discrepancy is noted, the auditor will intervene immediately. -7. The Food Service Director or designee will report to the QAPI (Quality Assurance Performance Improvement) Committee monthly regarding any temperature out of range and any mishandling of food and the corrective action taken. | 2019-08-01 |
| 8311 | HENDERSON CARE CENTER | 2.8e+174 | 1621 FRONT STREET | HENDERSON | NE | 68371 | 2014-02-27 | 323 | L | 0 | 1 | WOMQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 AND 12-006.09D7a Based on observation, interview, and record review; the facility failed to ensure one resident (Resident 18) was not left unattended while bathing in a whirlpool tub with water and failed to maintain the whirlpool tub bath belt free from rips, frayed areas, and peeling plastic pieces with rough edges affecting 37 out of 38 residents. The facility census was 38. Findings are: A. During the initial tour of the facility on 2/25/14 at 8:35 am, the facility bath house door was unlocked. There was no staff member in attendance and Resident 18 was in the whirlpool tub with water, Resident 18 was leaning forward. There was a bath belt around the resident's waist and between the resident's legs. The bath belt was loosely applied and had frayed edges. Approximately one minute later a staff member entered the bath house carrying clothing. B. Interview with BA (Bath Aide) A 2/25/14 at 8:37 am revealed that the staff member never left residents alone in the whirlpool. The BA A stated that the resident lived nearby and just went down the hall to get the resident's clothing. Interview with the DON on 2/25/14 at 9:35 am and revealed that Bath Aide A was the only staff member that bathed residents. There was only one resident that preferred showers. Interview with BA A on 2/27/14 at 9:45 am revealed that with Resident 18 (gender) always used the T- strap bath belt (belt through the legs). BA A stated the staff did not bring the resident's clothing with the resident. The BA stated unsure why left the bath house to get the clothing. BA A stated that the bath belts were the original bath belts that came with the whirlpool tub two years ago. If the BA had any trouble with the tub the BA would report it to the Maintenance department. Interview with Resident 18 on 2/26/14 at 9:05 am revealed that the resident stated that (gender) was left alone in the whirlpool tub once in a while when the resident forgot her clothing. The resident stated that the resident's room was close by and BA A would leave and get the clothing if forgotten. C. Review of Resident 18's Annual MDS (Minimum Data Set: a federally mandated comprehensive data collection tool used for care planning) dated 10/13/13 revealed that the resident's BIMS (Brief Interview for Mental Status) was a 10 (8-12 moderate cognitive impairment). The resident did not have any behaviors. The resident required extensive assistance with activities of daily living which included: transfers, bed mobility, walking in room, locomotion, dressing toilet use, personal hygiene, and bathing. The resident required hands on assistance with correction of all balance. The resident had limited range of motion in the upper and lower extremities on one side. The resident received restorative nursing program for active range of motion. Review of Resident 18's Quarterly MDS dated [DATE] revealed that the residents BIMS was a 10. The resident had a total mood score of 10. The resident did not have any behaviors. The resident required extensive assistance with activities of daily living which included: transfers, bed mobility, locomotion, dressing toilet use, personal hygiene, and bathing. The resident was non-ambulatory. The resident's balance activity required assistance from staff. The resident had limited range of motion in the upper and lower extremities on one side. The resident receive restorative nursing program for active range of motion. The resident had not fallen in the past three months. Review of Resident 18's Care Plan dated 2/4/10 and revised on 1/14/14 revealed that the resident had a self-care deficit related to hyponatremia (low levels of sodium in the bloodstream) and a mild stroke. The resident experienced weakness, fatigue, left sided weakness and an unsteady gait and balance. The resident's goal was to receive the necessary assistance needed to complete ADL (Activities of Daily Living) tasks to allow participation. The resident's interventions included: one to two physical assistance with ADLS; provide two staff assists with transfers using a gait belt; twice weekly whirlpool baths. Review of Resident 18's Fall Risk Assessment and Intervention dated 1/15/14 revealed that the resident had a score of 14. A score of 7+ was a higher risk. D. Observation of Resident 18's transfer from bed to chair on 2/27/14 at 10:35 am revealed NA (Nurses Aides) B and C assisted the resident from a lying position to a seated position on the edge of the bed. The resident required assistance to maintain seated balance. A gait belt was applied around the resident's waist. The resident was assisted to a standing position with extensive assistance of the two NAs and a pivot transfer was done. The resident was unable to move the resident's left foot. E. Interview on 2/25/14 at 8:55 am with the DON (Director of Nursing) revealed that the resident had a CVA - Cerbral Vascular accident (stroke) and was flaccid (weakness) on the resident's left side. The resident required 2 staff assistance with activities of daily living. The resident had poor balance from the resident's CVA. Interview with DON and ADM (Administrator) on 2/25/14 at 11:15 am revealed it had been reported to SS (Social Services) that BA A had left a resident unattended in the whirlpool tub. The staff member had received re-education on the bathing policy and procedure to never leave a resident unattended in the whirlpool. Observation of Resident 11 on 2/27/14 at 9:25 am Bath Aide A attached a ripped, frayed, peeling rough waist bath belt around the resident and lifted the resident approximately four feet up with the lift and lowered the resident into the Superior Aqua Aire Whirlpool Tub. The Bath Aide did not put the strap on between the resident's legs. The Bath Aide did not leave the resident alone during the observation. F. Interview with the DON and ADM on 2/27/14 at 10 am revealed that they acknowledged the peeling plastic, ripped edges, and frayed edges of the bath belt. The DON stated that a bath belt was ordered on [DATE] when it was reported it was frayed. The DON stated that the bath belt had not been on any checklist to monitor when worn for replacement. G. Review of the Facility Bathing Policy dated as revised on 5/2012 revealed that the bath aide was always to ensure the residents were attended to while in the bath. Review of the Penner Superior Aqua Aire whirlpool tub manual stated Daily Safety Checklist Penner Transfer Perform the following safety checks for the Penner Transfer: 1. Seat Belt- Check this is to insure the parts are secure and not missing. WARNING If during the safety checks you find parts are missing are excessively worn, do not function properly, do not operate the equipment until the maintenance department has taken the appropriate corrective action. H. The immediate jeopardy was abated to an E 2/27/14 when the facility provided information that the bath aide had been re-educated to not leave residents unattended in the whirlpool tub. The other nursing staff attended an in-service on 2/26/14 and were educated to not leave residents in the whirlpool unattended. The DON had an additional belt that was on the top of the chair switched to the waist. The DON had ordered a new whirlpool bath belt on 2/25/14 that had not arrived yet on 2/27/14. | 2017-09-01 |
| 12166 | SUTTON COMMUNITY HOME, INC. | 285277 | 1106 NORTH SAUNDERS | SUTTON | NE | 68979 | 2011-06-09 | 323 | L | 1 | 1 | 3HMU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b Based on observation, record review and interview; the facility failed to protect one (Resident 7) from injury of burn from a heat blanket. This had the potential to affect all 30 residents due to all residents have the order for heat packs as desired for generalized discomfort. The facility census was 30 with a sample size of 27 residents. Findings are: Observation of Resident 7 at 3:05 PM on 5/31/11 revealed this resident in the dining room in motorized wheelchair waiting for nails to be polished. This resident had glasses on and was dressed in a blouse and shorts. Had ankle socks on with legs supported by bilateral wheelchair leg supports. Left lower leg wrapped with with clean, dry dressing. Interview of the Resident 7 at 4:30 PM on 5/31/11 revealed that this resident stated, "No" when asked if had pain at this time. Resident was up in motorized wheelchair in dining room watching birds in aviary. Resident pointed to left lower leg dressing and stated, "It feels better now." Resident had slow, garbled speech and was asked to repeat "It feels better now" for proper understanding. Record Review on 5/31/11 of the Physician order [REDACTED]. --original order date of 9/28/10 was for the Heat Packs BID (two times a day) and PRN (when required). May use heat packs one hour after Ketoprofen (Topical medication used for pain on left knee, lower back, left shoulder, and right forearm); --[DIAGNOSES REDACTED]. --another order with original order date of 3/2/11 was for the Heat Pack to the left hand PRN for 30 minutes for comfort and keep a minimum of 30 minutes between the applications; --Heat Pack treatment for [REDACTED]. --No order for lavender spa heat blanket. Record Review on 5/31/11 of Resident 7's MDS (Minimum Data Set federally mandated comprehensive assessment tool used for care planning, version 3.0) dated 4/11/11 revealed: --type of assessment was Annual Assessment; --sometimes makes self understood with the ability limited to making concrete requests; --understands others with clear comprehension; --summary score for repetition of three words, temporal orientation, and recall was 13 total out of 15 questions; --bed mobility was rated at the need for total dependence with assistance of two staff members for the moving to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture; --transfers was rated at the need for total dependence with assistance of two staff members for the Resident 7 to be moved between surfaces including to and from: bed, chair, and wheelchair; --mobility device that was used was the wheelchair; --[DIAGNOSES REDACTED]. --pain management in the last five days stated that Resident 7 had been on a scheduled pain medication regimen, received PRN medication, and had received non-medication intervention for the pain; --pain assessment interview was done with the Resident 7 and Resident 7 had frequent pain or hurting at anytime in the last 5 days and the pain did not affect this resident on the ability to sleep at night and did not cause this resident to limit day-to-day activities because of the pain; --pain intensity was rated by this resident at a numeric scale of 5 with moderate intensity. Record Review on 5/31/11 of the Resident 7's Plan of Care updated on 4/28/11 revealed: A) --a goal of Resident 7 will have no complaints of pain by the next review with the following approaches: 1. Offer massage to me when I am uncomfortable. Typically I like the same person to give my massage when I want it. I become "uncomfortable" when unfamiliar staff give my massage. 2. When I have pain, I am able to point to the appropriate Wong-Baker face (a picture graphic face for rating pain scale); --no further approaches or revision were stated in Resident 7's Plan of Care for use of pain approaches involving medication, non-medication or treatments. B) --a goal of Resident 7 to be able to maintain the ability to independently reposition self while in the bed during the night by next review with the following approaches: 1. When assisted to bed at night, position me on my stomach at the foot of the bed. 2. Attach my call light to my bedding with the attached clip. 3. Ensure that my back side rail is padded and in up position. 4. Use a contour mattress on my bed as a boundary marker. 5. Use the Hoyer lift with two assist for transfers. 6. One person total assist with personal hygiene. 7. One to two person total assist with dressing. 8. I am independent with locomotion throughout the facility in my motorized wheelchair with set up help only. 9. Ensure my safety belt is fastened on my motorized wheelchair, commode, and the foot pedal per my request and my Guardian's order. 10. Place a small pillow under my left armpit and slightly behind per my request and Guardian's request. 11. Place a gel cushion under my contracted toes and feet when in the bed. 12. Encourage me to report any mouth sores or mouth pain and report this to the charge nurse; Record Review on 5/31/11 of Resident 7's Treatment Sheets revealed: A) Heat packs BID and PRN for back pain with Reheater pack to back before arising and at HS (Given after 7 PM) and also PRN. May use heat packs one hour after Ketoprofen for [DIAGNOSES REDACTED]. --hours stated on the treatment sheet for May 2011 were PM (afternoon after 4 PM), NOC (night), and PRN; --no PM heat pack treatments were initialed by nursing staff for the months of May 2011 or March 2011; --one time on April 20th 2011, the PM heat pack treatment was recorded as given for this April 2011; --NOC for the heat pack treatment sheet for March 2011 were initialed as given, except on March 18th, March 20th, and March 24th; --NOC for the heat pack treatment sheet for April 2011 were initialed as given; --NOC for the heat pack treatment sheet for May 2011 were initialed as given, except on May 25th, May 26th, May 29th, and May 30th; B) Heat pack to the left hand PRN for 30 minutes for comfort and keep a inhuming of 30 minutes between applications for treatment of [REDACTED]. --the recorded PRN treatment was recorded as start date of 3/2/2011 with no record of receiving any in the month of March 2011 --received one time for this PRN treatment on April 18th, 2011; --no PRN treatment received for May 2011. Observation (Copies obtained) of Heat Packs (TheraBeads) on 5/31/11 that were used on Resident 7 revealed: --Heat Packs were titled TheraBeads which were in a standard pack of 12"x12"; --Instruction on the TheraBead heat pack stated "When using a Therabead Heating Unit Press code 1," and "When using a conventional microwave unit heat to approximately 2 minutes, refolding and rotating in the oven after half the indicated time increment in 30 second intervals until the skin temperature monitor indicates Therapeutic Range." --the skin temperature monitor is on the heat packs and indicated "Correlated Skin Temperature Therapy Range." On the one end of the temperature monitor is the word of "re-heat" with the Celsius of 40 degrees to 45 degrees and on the right of this is the word "Do not apply." --the heat packs are put into a terry cloth cover before being put on the resident. --4 out of 6 of these heat packs had multiple dark brown areas on each side of them and 3 out of 6 of these had skin temperature monitors that were cracked and peeling; --4 out of the 6 of these heat packs had edges that were frayed. Observation of the Heat Blanket (TheraBeads) on 5/31/11 that was used on Resident 7 revealed: --Heat Blanket was titled TheraBeads and was a Lavender Spa blanket with size of 18"x44" --this heat blanket did not have a skin temperature monitor on it for indicating heating range; --heat blanket had a terry cloth cover to put it before contact with the resident; --microwave instructions on this Heat Blanket stated, "Warning!" Microwaves vary in power. Start at 30 seconds full power. Add time in 10 second increments until desired temperature is reached. "Do Not Overheat To Avoid Risk Of Fire." --WARNING: FOLLOW INSTRUCTIONS TO AVOID INJURY: Cleanse treatment area from body lotions, oils or gels prior to the application of the pad. Contact with lotions, oils or gels can alter the effectiveness of the TheraBeads. Interview with Director of Nursing, Administrator, and Assistant Director of Nursing at 5:25 PM on 5/31/11 revealed: A) The incident was discovered in the morning of 5/28/11 by the NA (Nurse Aide) 1 when Resident 7 was up on the commode and pointed to a red area on left lower leg. NA 1 alerted LPN (Licensed Practical Nurse) 3 and this nurse assessed the wound which at that time was a blister on the left lower leg and notified the Administrator and physician on call. New order from the physician was obtained for the burn and covered. A message was left for the guardian of Resident 7 initially via voice mail but not recorded by the Administrator. The order for the heat pack was to be done BID (twice daily) and PRN (when necessary). The heat packs were stored in the treatment room and warmed up in the microwave and covered with the terry clothes. The heat blanket (Lavender Spa blanket) was stored in Resident 7's room and heated up in the microwave in the treatment room then it was brought back into Resident 7's room with a terry cloth cover on it. There were no orders from the physician on using the heat blanket (Lavender Spa Blanket) and no temperature to heat this too. There was a therapy range for heat indicator on the heat packs, but no heat indicator on the heat blanket. The heat blanket was brought in because of its larger size of 18x44" to cover resident 7's shoulders to lower back when in bed. The treatment times were in the PM (evening) and NOC (early morning around 5 or 6 AM). B) Interview with the Administrator revealed that this person had brought in the Sonoma Lavender Spa Blanket. No order was obtained for use of this blanket. There was no policy and procedure on the use of the heat blanket. C) Interview with the DON and ADON revealed that there was no policy or procedure on the heat blanket and the only guideline on the heat packs was posted in the treatment room on the bulletin board and stated: "Heat Pack Guidelines." 1) Check list of residents for skin sensitivity. 2) Heat ALL heat packs for 1 minute on high. DO NOT EXCEED 1 MINUTE. 3) Check heat pack for hot spots. Twist and roll to distribute heat evenly. Test temperature on bare skin of the employee's arm. 4) Wrap in Terry cloth cover. 5) Chart date, time, heat pack number and initials on clipboard sheet by microwave. 6) Apply heat pack to resident for 15-20 minutes at a time. Keep a minimum of two hours between applications to the resident. Chart time, initial and put results on Treatment Medex for each resident and application. 8) Information: a) Heat packs can only be used four (4) times in any 24 hour period. Please check the heat pack number to see what times it was last used, must keep six (6) hours of rest time between the use of the heat pack. --there were no other policies or procedures on the heat blanket or heat packs as of the date 5/27/11. Interview with Staff Development LPN on 5/31/11 revealed: --no inservices were done on policy and procedure for the use of the heat blanket or the heat packs; --following the burn to Resident 7 a "Heat or Cold Pack Therapy Policy Statement," was done with a note for staff to read and initial the policy with no one-on-one inservices for the staff to check competency; --as of the date of 5/31/11 only four staff had signed the policy statement indicating they read and understood the policy. Observation of Resident 7's left lower leg burn treatment at 8:10 AM on 6/1/11 revealed: --LPN 1 in room with Resident 7 up in motorized wheelchair for dressing change to left lower leg; --non-adherent gauze dressing removed with wound cleaned with sterile water and approximately 3 x 2 cm circular wound with no drainage but this wound did have redness around total circumference; --treatment of [REDACTED]. --Resident 7 complained of discomfort with cleaning of wound; --Resident 7 was watching television in room during treatment. Interview with LPN 1 at 9:00 AM on 6/1/11 revealed that there was no redness yesterday, but the blister on the left lower leg was raised up with fluid in it. Resident 7 was seen by the physician on 5/31/11. Observation of Resident 7 at 8:32 AM on 6/1/11 ; revealed this resident up in motorized wheelchair with a tray on it with food and drink on table eating and drinking without difficulty. Had glasses on and was dressed in a blouse and shorts. Wearing ankle socks. Had intact, clean dressing on left lower leg. Pillow behind left lower shoulder for positioning. Interview with the Administrator at 11:10 AM on 6/2/11 revealed: --the incident with Resident 7 getting a burn on 5/28/11 resulted in an investigation when called by the charge nurse LPN 3 at 7:39 AM; --incident report was filled out and the Administrator came into the facility to look at the burn and investigate what had happened; --the family (guardian) was called and a message was left due to no answer; --the heat blanket had caused the burn and not the heat packs. Interview with the ADON at 11:30 AM on 6/2/11 revealed that Resident 7 had not had the Care Plan updated under the pain management approaches since the date of 5/4/2010 and it is the responsibility of all professional nursing staff to updated the resident care plans. The resident care plans are kept at the nurses station. This violation was abated at the time of survey and the scope & severity was lowered to a 'F'. The facility put the following action into place: -All thermal packs were disposed of. -All heat therapy was suspended. -All current RNs and LPNs were trained by the Nurse Consultant. -All residents' physicians were notified of new procedures and the need for specific instructions and the use of warm compresses for each resident. | 2014-10-01 |
| 1287 | ARBOR CARE CENTERS-NELIGH LLC | 285124 | PO BOX 66, 1100 NORTH T STREET | NELIGH | NE | 68756 | 2019-03-11 | 880 | K | 0 | 1 | UV2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17(17B) (17D) Based on observation, interview, and record review; the facility failed to 1) prevent potential cross-contamination of blood borne pathogens related to the use of a glucometer for Residents 3 and 7, 2) wash hands and change gloves at appropriate intervals during the provision of catheter cares for Resident 14 and incontinence cares for Resident 33, and 3) store respiratory equipment in a sanitary manner for Residents 14, 25, 32, and 21. The sample size was 7 and the facility census was 36. Findings are: [NAME] Review of the undated Blood Glucose Monitoring Competency provided by the facility revealed the following procedure: - Wash hands and apply gloves, - set up a clean field for the glucometer supplies, - turn on the glucometer, - disinfect the resident's finger with an alcohol swab, - insert the test strip into the meter, - puncture the skin with a lancet, - wipe the first drop of blood with a cotton ball, - apply pressure to the finger to collect the blood sample with the glucometer, - clean the resident's finger with a cotton ball and apply pressure until the bleeding stops, - remove the test strip and dispose of it and the lancet into a biohazard container, - remove gloves and wash hands, and - disinfect the glucometer according to manufacturer's instructions. Review of the undated Assure Platinum Blood Glucose Monitoring System User Instruction Manual provided by the facility revealed the following: - Option 1 was to clean and disinfect the glucometer at one time using an EPA-registered disinfectant detergent or germicidal wipe. - To use a wipe, remove it from the container and follow the product label instructions to disinfect the glucometer. - Option 2 was to clean the glucometer first with soapy water or [MEDICATION NAME] alcohol and then disinfect it with a diluted bleach solution or a bleach wipe with a 1:10 concentration. B. Review of Resident 3's current Care Plan with a review date of 12/14/18 revealed the resident had liver disease related to a [DIAGNOSES REDACTED]. It is spread by contaminated blood and may have no visible symptoms). Interventions included: - Dietary consult for recommendations and teaching, - give medications for nausea and vomiting, - provide medications as ordered, - notify the physician of any abnormal vital signs, - monitor for jaundice, - monitor for signs of internal bleeding, - monitor for signs of infection, - weigh weekly, - monitor for signs of complications, and - obtain lab as ordered. A blood glucose monitoring observation was completed on 3/7/19 at 11:30 AM. Licensed Practical Nurse (LPN) -E gathered supplies, washed hands, and applied gloves. LPN-E then entered Resident 3's room and placed the supplies on a paper towel on the resident's bed. LPN-E cleaned the resident's finger with an alcohol prep pad and then pricked the resident's finger with the lancet. LPN-E put pressure on Resident 3's finger to express enough blood for testing and placed the blood on the glucometer test strip. The resident's blood sugar was noted to be 230, the test strip was removed and discarded. The blood on the resident's finger was cleaned off and LPN-E (prior to changing gloves) carried the glucometer and the lancet out of the room. The glucometer was set on a paper towel on the medication cart and the lancet was disposed of in the sharps container. LPN-E's gloves were then removed and hands washed. LPN-E took an alcohol prep pad and wiped the outside of the glucometer (the alcohol dried immediately on contact) and with bare hands placed the glucometer inside the medication cart ready to be used by this or another resident. During an interview with LPN-E on 3/7/19 at 11:35 AM, LPN-E confirmed the glucometer was cleaned using an alcohol wipe. LPN-E stated Clorox wipes were normally used but they didn't have any available at that time. During an interview with the Director of Nursing (DON) on 3/7/19 at 1:45 PM, the DON revealed each unit had 1 glucometer to share among the residents on that unit. Review of a list provided by the facility Accuchecks by Hall (undated) revealed the BC hallways had 2 residents (Residents 3 and 7) that shared a glucometer. Review of Resident 3's Medication Administration Record [REDACTED]. Review of Resident 7's MAR indicated [REDACTED]. During an interview with LPN-G on 3/7/19 at 1:57 PM, LPN-G stated the glucometers should be cleaned with Clorox wipes. Interviews with LPN-H on 3/7/19 from 2:03 PM to 2:10 PM revealed the wipes that were normally used for the glucometers hadn't been available for about a week. LPN-H stated that until the normal glucometer wipes are available they were to use the Clorox wipes. LPN-H then showed the Clorox wipes being used and they were the Clorox Disinfecting Wipes. LPN-H was unaware of the amount of contact time that the glucometer should remain wet to ensure it was disinfected. During an interview with the DON on 3/7/19 at 2:08 PM, the DON confirmed Resident 3 had [MEDICAL CONDITION] and was unaware of any treatment the resident had received for this (which indicated the resident was still contagious). The DON confirmed the facility ran out of the proper glucometer cleaning wipes and the staff were told to use Clorox wipes in the meantime. Further interview confirmed alcohol wipes should not be used to disinfect the glucometer. The immediate jeopardy was abated to an [NAME] level on 3/7/19 at 4:30 PM when: 1) The facility found the proper cleaning wipes (Sani-Cloth Germicidal Disposable Wipes) in the supply room and placed them in the medication carts. 2) All available nurses and medication aides were trained on the proper cleaning of glucometers. For those staff that hadn't been trained yet there was a plan in place to ensure they were trained prior to working again. 3) A bulk order for Sani-Cloth Germicidal Disposable Wipes cleaning wipes was placed to ensure the facility didn't run out again. 4) A plan to get each resident their own glucometer was developed. 5) A plan was developed for audits to ensure continued compliance. C. Review of the facility policy titled Hand-Washing/Hand Hygiene with revision date 8/14, revealed the facility considered hand-washing/hand hygiene the primary method of preventing the spread of infections included [REDACTED]. -before and after direct contact with residents; -when hands are visibly soiled or dirty (with soap and water); -before and after assisting a resident with personal cares; -before and after assisting a resident with toileting; -before handling soiled equipment; and -before putting on clean gloves and after removing soiled gloves. D. During observation of nursing care on 3/5/19 at 1:31 PM, Nursing Assistant (NA)-C and NA-B provided incontinence cares for Resident 33. NA-C provided perineal hygiene, but without removing soiled gloves, placed a clean urinary incontinence brief on the resident, adjusted the resident's clothing, assisted the resident to position on the resident's right side, placed a pillow between the resident's legs and another pillow beneath the resident's head, removed the resident's shoes, covered the resident with a blanket, gave the resident a call light cord and used the bed controls to lower the resident's bed. NA-C finally removed soiled gloves and washed hands in the resident's bathroom. E. During observation of catheter cares for Resident 14 on 3/6/19 at 8:01 AM, NA-L and LPN-G washed hands and donned clean gloves. LPN-G completed urinary catheter cares and then removed soiled gloves. Without washing or sanitizing hands, LPN-G proceeded to reposition Resident 14 in bed, adjusted the resident's clothing and covered the resident with a blanket. LPN-G then returned to the resident's bathroom to wash hands F. Observations of Resident 14's room throughout the survey revealed the following: -3/5/19 from 8:36 AM to 12:36 PM, an oxygen concentrator was positioned next to the resident's bed. Oxygen tubing connected to the concentrator was positioned directly on the floor and draped on the side of the concentrator with the end of the tubing and a nasal cannula coiled on top of the concentrator. The oxygen tubing and nasal cannula were uncovered. In addition, a gallon jug of distilled water was stored directly on the floor next to the concentrator. -3/6/19 at 8:20 AM, the oxygen concentrator remained next to the resident's bed. The oxygen tubing was lying directly on the floor between the concentrator and the resident's bed. The end of the oxygen tubing and the oxygen cannula were draped across the resident's bed linens and pillow. [NAME] Observations of Resident 21's room throughout the survey revealed the following: -3/4/19 at 11:25 AM, a nebulizer machine (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) was positioned on top of the bedside dresser. The mask for the nebulizer was connected to the machine and there were droplets of moisture visible on the inside surface. The mask was uncovered and had been wedged in an upright position in the top drawer of the dresser. -3/5/19 at 2:12 PM, the nebulizer machine remained on top of the bedside dresser. The mask remained uncovered and was hanging down the side of the dresser. -3/6/19 at 8:36 AM, the nebulizer machine continued to be stored on the top of the bedside dresser. The nebulizer mask was uncovered and was also stored directly on top of the dresser as well. The mask had been placed in a face down position so the surface of the mask which would come in contact with the resident's face was lying directly on the surface of the dresser. During interview on 3/11/19 at 9:20 AM, the DON verified the facility policy was to rinse the nebulizer mask after each treatment, allow it to dry, then store it in a plastic bag and the oxygen tubing and nasal cannula should always be stored in a plastic bag. In addition, the DON confirmed staff members were expected to remove soiled gloves and wash/sanitize hands following provision of resident cares. H. During observations on 3/5/19 from 7:44 AM until 1:45 PM, the following were observed: -there was a shelf located immediately to the right of the handwashing sink shared by Residents 32 and 25 that had a nebulizer mask and medication receptacle stored uncovered on a washcloth laid on top of the shelf; and -there was a nebulizer mask and medication receptacle stored uncovered on a washcloth laid on the ledge between the window glass pane and the blinds that were drawn closed in Resident 25's room. This practice caused potential contamination of the residents' nebulizer equipment from water spatter and/or other debris. | 2020-09-01 |
| 1434 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2018-03-19 | 689 | K | 0 | 1 | 93SH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.18E Based on observation, interview and record review, the facility failed to evaluate the safety and provide supervision for smoking for Residents 49 and 85 and failed to ensure that a stationary fireplace did not reach a temperature that had the potential to cause [MEDICAL CONDITION] 12 residents that were identified as self-mobile with poor safety awareness (Residents 64, 25, 43, 81, 67, 13, 65, 21, 34, 32, 23 and 62). The facility Census was 92. Findings are: [NAME] Review of the facility policy dated as effective (MONTH) 2011 revealed the facility is a nonsmoking facility for residents. Residents may not smoke on the campus. The facility will provide residents with smoking cessation assistance such as Nicotine patches to assist in their smoking cessation efforts. Interview on 3/13/2018 at 10:00 AM with the administrator revealed the facility was a non-smoking facility and residents awee required to leave the property to smoke and were not monitored by staff. Review of Resident 85's medical record revealed Resident 85 was admitted to the facility on [DATE] . Review of Resident 85's medical record revealed Resident 85 had a [DIAGNOSES REDACTED]. Review of the Social Services admission assessment dated [DATE] revealed Resident 85 wanted to smoke. Resident 85 had a BIMS (Brief Interview for Mental Status-a tool used to measure cognitive function) score of 15/15 which indicates the resident is cognitively aware. Observation on 03/20/18 at 06:30 AM revealed Resident 85 sitting in a wheelchair just outside of the facility front door. Resident 85 was wearing a coat with a loose hood and cloth gloves smoking a cigarette. Resident 85 had an oxygen tank on the back of the wheelchair. Interview on 03/20/18 at 6:35 AM with Registered Nurse (RN) - J revealed Resident 85 was allowed to go outside to smoke but was not to be smoking on the facility grounds. RN-J stated Resident 85 would be educated but continued down the hall and did not address Resident 85's smoking. Review of Resident 85's care plan dated 2/27/2018 revealed a care plan for smoking. The problem statement was I frequently go outside to smoke. The goal was to not have injuries related to smoking and an intervention was to notify the doctor if Resident 85 sustained an injury while smoking. There was no mention of a smoking safety assessment. Review of Resident 85's medical record revealed no smoking assessment was completed to determine if Resident 85 was safe to smoke independently without supervision. Review of progress notes dated 3/6/2018 revealed Resident 85 did smoke and did not desire to stop smoking or use any type of smoking cessation assistance. Interview on 03/20/18 at 7:50AM with LPN-E (Licensed Practical Nurse) revealed Resident 85 went out to smoke was not supervised. Resident 85 smoked outside and LPN-E had educated Resident 85 not to smoke with oxygen. Interview on 3/20/2018 at 6:45 AM with LPN-E revealed the staff do not keep residents' smoking supplies and was not aware where they were kept. Observation on 3/20/2018 at 6:50 AM revealed Resident 85 in a wheelchair with oxygen on it returning inside the building from smoking outside. No staff had checked on Resident 85 while Resident 85 was outside smoking. Observation on 03/20/18 at 7:57 AM revealed Resident 85 was outside the front door smoking unsupervised. The resident was in a wheelchair with oxygen on it. No staff attempted to intervene. Interview on 3/20/2018 at 9:30 AM with the Administrator revealed the facility does not admit active smokers and the facility is not responsibility for those residents that want to continue to smoke off campus so smoking safety assessments are not completed. B. Record review of Resident 49's MDS (Minimum Data Set) dated 1-12-2018 revealed the facility staff assessed the following about the resident: -BIMS was a 15. -Required limited assistance with transfers with the assistance of 1 person physically assisting. -Required limited assistance off the unit with the assistance of 1 person physically assisting. On 3-20-2018 an interview was conducted with Registered Nurse (RN) I. During the interview RN I identified Resident 49 as a resident who smoked cigarettes at the facility. RN I reported the facility was a smoke free facility and if residents want to smoke, they had to go off facility grounds. When asked if Resident 49 was supervised or if there was a process to evaluate residents for safety, RN I stated no. On 3-20-2018 at 7:40 AM an interview was conducted with Licensed Practical Nurse (LPN) H. During the interview LPN H reported the facility was smoke free and those residents who want to smoke must go off of the facility grounds. When asked if residents were supervised when off the facility grounds, LPN H responded that residents were not supervised. On 3-20-2018 at 7:43 AM an interview was conducted with LPN [NAME] During the interview LPN G identified Resident 49 as a resident who smoked cigarettes at the facility. LPN G further reported Resident 49 does own thing. LPN G reported there was no process to evaluate resident's safety for smoking and that staff did not supervise residents while smoking. On 3-20-2018 at 8:45 AM an interview was conducted with Resident 49. During the interview Resident 49 reported that (gender) smoked and goes out front to do it. Resident 49 reported staff do not supervise while Resident 49 was smoking. On 3-20-2018 at 10:05 AM an interview was conducted with the facility Administrator. During the interview; the Administrator reported the facility was a non-smoking facility and reported when residents who smoked were admitted to the facility, they were considered exsmokers. The Administrator reported evaluations were not completed for smoking safety for residents. As outlined by the Administrator of the facility on 3/21/2018 at 2:30 PM the facility initiated the following plan to address the immediacy of the situation. The facility educated all staff regarding the smoking policy prior to them working their next shift. All residents that leave the facility grounds to smoke will be assessed for safety with smoking and the ability to leave the facility grounds. All smoking material will be kept by the facility. All residents will be advised of the non-smoking policy prior to and at admission. The facility will offer smokers that wish to be admitted to the facility a smoking cessation program. Audits will be conducted on new admissions daily for 30 days and weekly for 90 days to assure the residents were educated on the facility non-smoking policy upon admission and sign a written agreement regarding the non-smoking policy. All current residents that want to smoke have been assessed for safe smoking and ability to safely leave the campus. With the above interventions initiated, the scope and severity of the deficiency was lowered to an E. C. Record review of an article http://www.forensic pathologyonline.com/E-Book/injuries/thermal injuries written by Dr. Dinesh Rao revealed that a burn is an injury which is caused by application of heat to the external or internal surfaces of the body, which causes destruction of tissues. The minimum temperature for producing a burn is about 44 degrees Celsius (C) (111 degrees Fahrenheit (F) for an exposure of 5 to 6 hours or about 65 degrees C ( 149 degrees F) for 2 seconds are sufficient to produce burns. A highly heated solid body, when applied to the body for a very short time, may produce only a blister and reddening corresponding in size and shape to the material used. It will cause destruction, or even charring of the parts, when kept in contact for some time. The epidermis (skin) may be found blackened, dry and wrinkled. Record review of Dr. Moritz and Dr Henriques Harvard medical School Temperature /Time Burn Chart revealed the following temperature versus time to produce 1st ( first [MEDICAL CONDITION] only the outer layer of skin, skin may be red and painful), second (The outer and the layer underneath has been damaged, skin will be bright red, swollen and may look wet and shiny and may be blistered) and third [MEDICAL CONDITION](all layers of the skin have been damaged as well as muscles, tendons, ligaments and possibly organs, there is serious damage to nerves): 131 degrees F: 17 seconds for a first degree burn, 30 seconds for a second-3rd degree burn 140 degrees F: 3 seconds for a first degree burn, 5 seconds for a 2nd-3rd degree burn 151 degrees F: instant for a first degree burn, 2 seconds for a 2nd to 3rd degree burn Observation on 03/14/18 at 07:28 AM revealed a stationary electric fireplace present in the main lobby area of the facility. The fireplace was on, blew out warm air and had no protective barrier in front of the fireplace. The temperature of the exterior surface of the fireplace was taken and read 163.8. Observation on 03/14/18 at 09:27 AM with the Director of Nursing (DON) confirmed that the fireplace was on, blew out warm air and had no protective barrier in front of the fireplace. The temperature of the exterior surface of the fireplace was taken and read 156.2. Interview on 03/14/18 at 09:28 AM with the DON confirmed the temperature of the fireplace read 156.2. The DON confirmed that the exterior of the fireplace was hot to the touch and did have the potential to cause a burn if a resident were to touch it or sit closely to it for an extended period of time. Record review of a document received on 03/14/18 at 09:19 AM revealed a list of self-mobile residents with poor safety awareness and wandering behavior. Interview on 3/14/18 at 9:20 AM with the DON confirmed and identified a total of 12 residents (Residents 64, 25, 43, 81, 67, 13, 65, 21, 34, 32, 23 and 62) that had poor safety awareness, exhibited wandering behavior and were self-mobile. The DON confirmed that those residents would be able to access the fireplace in the lobby and could potentially be burned if they were to touch the exterior of the fireplace. | 2020-09-01 |
| 1442 | LIFE CARE CENTER OF OMAHA | 285137 | 6032 VILLE DE SANTE DRIVE | OMAHA | NE | 68104 | 2018-03-19 | 835 | K | 0 | 1 | 93SH11 | Licensure Reference Number: 175 NAC 12-006.02 Based on observations, record review, and interviews; the facility administration failed to ensure effective management of facility resources to maintain the highest practical wellbeing of residents and the facility environment as evidenced by 1) failure to implement an effective plan of action to maintain correction for previously cited areas of deficient practice, 2) failure to ensure the facility identified and developed plans of action to identify multiple issues of deficient practice Facility Census was 92. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the standard annual survey were completed. Please refer to the Tag citations for specific detailed findings. - F550 (formerly F151) Resident Rights. Previously cited 1/2018. - F580 (formerly F157) Notification of change of condition. Previously cited 3/2017 - F609 (formerly F225) Complete and submit investigations in 5 working days. - F657 (formerly F280) Review and Revise the comprehensive care plan. Previously cited 10/2015 - F676 (formerly F312) Provide ADL assistance. - F689 (formerly F323) Accident Prevention Previously Cited 10/2015, 3/2017, 8/2017, 12/2017. - F692 (formerly F325) Nutrition-Weight loss prevention - F697 (formerly F309) Pain Management Previously Cited 1/2017 - F730 (formerly F497) Nursing Assistants 12 hours annual continuing education. - F755 (formerly F425) Medication Storage and labeling. - F758 (formerly F428) Behavior management for residents on antipsychotic medications. - F812 (formerly F317) Safe food handling and storage. Previously Cited 8/2017 - F835 (formerly F490) Administration. - F867 (formerly F520) Quality Assurance Plan - F880 (formerly F441) Infection Control - F881 (no former F tag) Antibiotic Stewardship Program Interview on 3/21/2018 at 3:40 PM with the administrator confirmed they had multiple deficient practice. | 2020-09-01 |
| 2888 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2019-04-22 | 578 | K | 0 | 1 | BJ6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews; the facility staff failed to ensure the desired code status was documented consistently and correctly throughout the record for 7 (Resident 53, 31, 21, 51, 1, 34, and 309) residents of 30 sampled residents. The findings are: Review of the Policy and Procedure for Code Status Listing dated ,[DATE] revealed a complete list of residents with code status will be kept in a covered paper binder at each nurse's station. [NAME]Record review of Resident 53's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 53's desire to be a DNR (Do Not Resuscitate). Record review of Resident 53's electronic medical record revealed no information regarding Resident 53's code status. Interview conducted with LPN A on [DATE] at 02:15 PM confirmed the code status was not on the electronic medical record. B.Record review of Resident 31's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 31's desire to be a Full Code/CPR. Record review of Resident 31's electronic medical record revealed no information regarding Resident 31's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. C.Record review of Resident 21's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 21's desire to be a Full Code/CPR. Record review of Resident 21's electronic medical record revealed no information regarding Resident 21's code status. Interview conducted with LPN A on [DATE] at 02:17 PM confirmed the code status was not on the electronic medical record. D.Record review of Resident 51's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 51's desire to be a DNR. Record review of Resident 51's electronic medical record revealed a Full Code CPR status. Interview conducted on [DATE] at 02:35 PM with RN B confirmed that the Advance Directive documenting Resident 51's code status did not match Resident 51's electronic medical record. E.Record review of Resident 1's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 1's desire to be a DNR. Record review of Resident 1's electronic medical record revealed no information regarding Resident 1's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. F.Record Review of Resident 34's medical record revealed and Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 34's desire to be a Full Code/CPR. Record review of Resident 34's electronic medical record revealed no information regarding Resident 34's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. Interview conducted on [DATE] at 02:10 pm with LPN A and CMA C (Certified Medication Aide) revealed the way the staff knows the code status of residents was there are blue stars on the doors that mean the resident is to have CPR and red stars are DNR. LPN A revealed the code status for each resident is in the electronic record. Observation conducted with CMA C of residents' doors revealed there were red stars on residents name plates and no blue stars were present. Interview conducted on [DATE] at 02:35 PM with Clinical Resource Nurse confirmed that facility staff were correcting DNR status of residents in the electronic record as the staff made the list of Code Status requested by surveyors. Review of Code status list provided by the facility staff revealed Resident 51 was listed as full code status. Interview conducted with DON (Director of Nursing) on [DATE] at 02:20 PM revealed that an in-service was conducted with the staff on [DATE] on Code status which instructed the staff that blue stars on the residents doors meant do CPR and the stars were on order and had not been placed on the residents doors. Abatement Statement: Based on the information provided on [DATE] to correct the immediacy of the situation, the facility staff provided the following information to protect residents: 1. A full audit of residents' signed code status reviewed and cross checked with the electronic record Point Click Care to ensure correctness. 2. Binders with each residents' signed Advanced Directives on each unit reviewed for correctness. 3. Blue stars to residents' doors implemented. 4. Managers will review all new admits and orders every day and discharges will be reviewed. 5. Full audit once a week x 4 weeks then bring to Quality Assurance for review and revision as warranted. 6. All staff re-educated on code status and Point Click Care Status. 7. Agency staff orientation checklist updated to reflect identifying code status. 8. All staff notified that they cannot work until education is complete. The Policy and Procedure for Code Status Listing updated [DATE] revealed the following: -Upon admission, residents identified as electing Full Code Status will have a blue star placed by the name card outside their room. -A complete list of residents with code status will be kept in a covered binder at each nurse's station. -Medical Records or designee will be responsible to keep code status list current and updated whenever a change occurs. The immediacy had been removed, however, the deficient practice was not totally corrected. Therefore, the severity was lowered to an F level. G: On [DATE], Record review of Resident 309 the Electronic Health Record (EHR) revealed that the Advance Directive was signed and indicated DNR. On [DATE] ,Record review of the Care Plan and the Medication Administration Record( MAR) did not reveal the code status of Resident 309. On [DATE] 1:25 PM an interview with CNA, U, was conducted , during the interview when asked how to tell the code status of the residents, CNA,U reported if there is a Red heart on the residents door it means , do not resuscitate (DNR). On [DATE] 1:35 PM an interview with CNA, V was conducted, during the interview when asked how to tell the code status of the residents CNA, V reported it was in point click care ( Electronic Health Record). On [DATE] 1:40 PM an interview with CNA, C was conducted , during the interview when asked how to tell the code status of the residents, CNA, C stated I do not know. On [DATE] 1:45 PM an interview CNA,N was conducted,during the interview when asked how to tell the code status of the residents , CNA,N reported , if there is a blue star on the door the resident is a Code ( Do Resuscitate) On [DATE] 1 :50 PM an interview with RN M was conducted, during the interview when asked how to tell the code status,he reported it is on the Demo graphic Sheet and report sheet On [DATE] at 1:55 PM observation of the Med. Center floor there were no blue stars on residents rooms. , | 2020-09-01 |
| 2906 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2019-04-22 | 835 | K | 0 | 1 | BJ6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review and interviews the facility staff failed to utilize facility resources to ensure provision of care and services were provided to the facility residents. This had the potential to effect all residents who reside in the facility. The facility staff identified a census of 60. The findings are: Review of the current survey revealed the following deficiencies: [NAME] F578. The facility staff failed to ensure the desired code status was documented consistently and correctly throughout the medical record. B. F582. The facility staff failed to inform one resident of Medicare Coverage change by not issuing the required forms. C. F584. The facility staff failed to ensure sufficient linen and adult briefs were available for use. D. F602. The facility staff failed to complete inventory sheets for residents. E. F609. The facility staff failed to report allegations of abuse within 2 hours and failed to report a significant injury within 2 hours to the state agency. F. F656. The facility staff failed to individualize the care plan for smoking. [NAME] F677. The facility staff failed to provide oral care to a dependent resident. H. F679. The facility failed to implement specific activities. I. F689. The facility staff failed to ensure a resident was supervised during smoking, failed to ensure the laundry room, maintenance room and employee restroom was secured, and failed to maintain bathing temperatures to prevent potential scalds. [NAME] F690. The facility staff failed to implement a toileting program. K. F732. The facilty failed to ensure posted nurse staffing was completely documented. L. F741. The facility failed to ensure sufficient staffing for restorative program, failed to ensure a full time wound nurse, and failed to ensure minimum staffing was completed on the facility assessment. M. F658. The facility failed to ensure insulin and [MEDICATION NAME] were administered as ordered. N. F759. The facility failed to ensure a medication error rate of less than 5%, observations of 25 medications revealed 3 errors resulting in a medication error rate of 12% O. F760. The facility staff failed to administer medication as ordered by the physician. P. F761. The facility failed to ensure medication carts were secured. Q. F812. The facility failed to date food items stored in the refrigerator. R. F835. The facility failed to utilize facility resources to ensure provision of care and services were provided to facility residents. S. F865. The facility failed to have an effective quality assurance program. T. F880. The facility failed to identify organisms that cause illness in the infection control program. U. F921. The facility failed to ensure cleanliness of stairwell, laundry room and handrails. V. F923. The facility failed to ensure that ventilation system was functioning. | 2020-09-01 |
| 2907 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2019-04-22 | 865 | K | 0 | 1 | BJ6K11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility Quality Assurance Improvement Program (QAIP) failed to identify ongoing issues relevant to F578, F582, F584, F602, F609, F656, F658, F732, F741, F761, F880 and F923 and implement effective plans of action to identify and correct the deficient practice. The QAIP failed to ensure repeated deficiencies at F677, F679, F689, F690, F759, F760, F812 and F835 were corrected and the correction maintained. The facility staff identified a census of 60. Findings are: Record review of the facility QAPI Program sheet dated 1-17-2019 revealed the following information: -#3. The outcome of the QAIP is the quality of care and quality of life of the residents. -#4. QAIP includes all employees, all departments and all services provided. -#5. QAIP focuses on systems and process's. The emphasis is on identifying system gaps. -#6. Decisions are based on data, which includes the input and experience of caregivers, residents, healthcare providers and families. -Program Purpose: -The major purpose of the QAPI committee is to improve the residents' total environment and all aspects of their lives-physical, social, physiological, spiritual and intellectual; and to improve the effectiveness, efficiency and quality of healthcare services delivered to the residents. On 4-11-2019 at 7:35 AM an interview was conducted with Licensed Practical Nurse (LPN) I. When asked if LPN J was aware of what the QAPI committee was working on, LPN I reported not aware of what the issues were. On 4-11-2019 at 7:40 AM an interview was conducted with nursing Assistant (NA) C. During the interview, NA C reported now being aware of what the QAIP committee was working on. On 4-11-2019 at 7:42 AM an interview was conducted with NA [NAME] During the interview NA J reported not being aware of what the QAIP committee was working on. On 4-11-2019 at 7:50 AM an interview was conducted with NA K. During the interview NA K was not able to identify any issue the QAIP committee was working on. On 4-11-2019 at 8:00 AM an interview was conducted with LPN [MI] During the interview, LPN L was able to identify the facility had a QAIP proram, however, LPN L was not able to identify any issues the QAIP was working on prior to the start of the annual survey. | 2020-09-01 |
| 2992 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2020-02-25 | 678 | K | 0 | 1 | 3ZNV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 1[AGE] NAC ,[DATE].09 Based on record review and interviews; the facility staff failed to ensure desired code status was identified consistently and correctly for 4 (Resident 3, 32, 30 and 38) of 53 sampled residents. The facility staff identified a census of 53. Findings are: A. Record review of undated Code Status Policy (CSP) sheet revealed the following information: -Full Code: -We will initiate basic life support (oxygen therapy, establishing an airway, providing manual respirations and chest compression). In the event of [MEDICAL CONDITION] or [MEDICAL CONDITION] 911 will be notified immediately for transport to the nearest hospital. -No Code: If the death of a resident is inevitable we do not call 911 for transport to the nearest hospital. We do perform all acts that will give comfort such as oxygen if needed, pain management control, suctioning etc. We keep the physician and family updated on any condition change. The resident will remain in the facility with their normal care givers. In the event either family, resident pr physician change their minds about the code status, CPR will be preformed and then be transported to the nearest hospital. B. Record review of Resident 3's Code Status Policy (CSP) sheet with a dated of [DATE] revealed Resident 3's Representative had marked the section on the CSP to indicate Resident 3 was a full Code. Record review of a second CSP dated [DATE] for Resident 3 revealed Resident 3's Representative indicated Resident 3 was a Full Code. Further review of Resident 3's second CPS revealed Resident 3's practitioner signed the CSP that identified Resident 3 as a Full Code on [DATE]. Record review of Resident 3's Admission Record sheet printed on [DATE] in the section identified as Advanced Directive revealed A DNR (Do Not Resuscitate , or commonly known as a no code). On [DATE] at 2:20 PM an interview was conducted with Licensed Practical Nurse (LPN) A. During the interview LPN A reported if a resident codes or goes to the hospital, there is a binder with a code sheet and face sheet (also known as a Admission record sheet). On [DATE] at 2:23 PM an interview was conducted with LPN C. During the interview LPN C reported there is a binder with a code sheet and face sheet and we can use both. On [DATE] at 4:25 PM an interview was conducted with LPN B. During the interview LPN B reported if some one goes to the hospital or codes we use the code sheet and also can use what is in the computer. On [DATE] at 4:39 PM an interview was conducted with Resource Nurse (RN) A. During the interview, review of Resident 3's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 3 CSP and Admission record sheet printed on [DATE] did not match and should have. C. Record review of Resident 32's CSP revealed on [DATE] Resident 32's Representative signed that Resident 32 was a No Code. Further review of Resident 32's CSP signed by Resident 32's Representative on [DATE] revealed Resident 32's practitioner signed the CSP on [DATE]. Record review of Resident 32's Admission Record sheet printed on [DATE] revealed in the section identified as Advance Directive identified Resident 32 as a Full Code. On [DATE] at 4:39 PM an interview was conducted with RN A. During the interview, review of Resident 32's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 32's CSP and Admission record sheet printed on [DATE] did not match and should have. D. [DATE] 09:46 AM Record Review of Resident 38's Admission Record sheet printed [DATE] , in the section identified as Advance Directive revealed a DNR ( Do Not Resuscitate) or commonly known as a no code. Record review of Resident 38's CSP( Code Status Policy) dated [DATE] revealed Resident 38's representative indicated Resident 38 was a Full Code. Further review of Resident 38's CSP sheet revealed Resident 38's Practitioner signed the CSP sheet that identified Resident 38 as a Full Code on [DATE]. [DATE] 4:30 PM an interview with LPN C revealed to check the code status of facility residents, (gender) would look at electronic records, or would look in the Code Status Book. If the resident was going to the hospital (gender) would send a copy of the Admission record from either the electronic records or from the Code Status Book. E. Record review of Resident 30's admission record reveals the advanced directive is listed as Do Not Resuscitate. Record review of the code status policy which is kept in the Code Status/Face Sheet book revealed the code status for Resident 30 was listed as Full Code. Record review of the physician orders [REDACTED]. An interview with Registered Nurse (RN)- J on [DATE] at 2:30 PM stated that when determining code status for a resident it depends on where they are when a code is called. An interview with LPN-B on [DATE] at 2:30 PM revealed that if they are way down the hall then I would look at the Electronic medical record on the computer which may, or may not be, correct. F. Based on the information provided on [DATE] to remove the immediacy of the situation, the facility staff provided the following information. Immediate action; 1. For the 5 residents identified, the code status has been verified and updated in the electronic health record (Advanced Directive, Physicians orders, Face sheet) and in the Code Status Binder. 3. The Director of Nursing, or the designee will stay in facility and ensure records are correct, with a 100% audit of all residents code status. 4. All nursing staff will be educated on identifying code status preference and where that information is located before leaving this shift. All scheduled staff will be educated before being able to work until all of nursing staff has been educated. 5. Executive Director (ED) or designee will stay to ensure that the aforementioned bullets are completed. Monitoring: 1. Clinical Resources will audit above commitments daily until above audits and education are completed. 2. Director of Nursing or designee will audit all new admissions to verify clear identification of code status with 24 hours of admission. 3. Above audits will be documented and brought to Quality Assurance Performance Improvement (QAPI) for further review and discussion,for 3 months or until substantial compliance is determined. | 2020-09-01 |
| 2997 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2020-02-25 | 835 | K | 0 | 1 | 3ZNV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference No. 1[AGE] NAC ,[DATE].02 Based on Record Review and Interview the Administration failed to utilize resources to ensure facility staff had the correct information regarding CPR status for 4 of 53 Residents, resident 3,30,32,38. The facility staff identified a census of 53. Findings are : D. [DATE] 09:46 AM Record Review of Resident 38 Admission record sheet printed [DATE] , in the section identified as Advance Directive revealed a DNR ( Do Not Resuscitate) or commonly known as a no code. Record review of resident 38 CSP( Code Status Policy) dated [DATE] revealed Resident 38 representative indicated Resident 38 was a Full Code. Further review of Resident 38 CSP sheet revealed Resident 38 Practioner signed the CSP sheet that identified Resident 38 as a Full Code on [DATE]. [DATE] 4:30PM Interview with LPN C ,revealed that to check the code status of facility residents, she would look at electronic records, or she would look in the Code Status Book. If the resident was going to the hospital she would send a copy of the Admission record from either the electronic records or from the Code Status Book. DB [DATE] 1:00PM Record review of all Residents Advance Directives , electronic records, and Facesheets confirmed that 4 of 53 Residents, resident 3,30,32,38, had a discrepancy regarding thier CPR status. A. Record review of undated Code Status Policy (CSP) sheet revealed the following information: -Full Code: -We will initiate basic life support (oxygen therapy, establishing an airway, providing manual respirations and chest compression). In the event of [MEDICAL CONDITION] or [MEDICAL CONDITION] 911 will be notified immediately for transport to the nearest hospital. -No Code: If the death of a resident is inevitable we do not call 911 for transport to the nearest hospital. We do perform all acts that will give comfort such as oxygen if needed, pain management control, suctioning etc. We keep the physician and family updated on any condition change. The resident will remain in the facility with their normal care givers. In the event either family, resident pr physician change their minds about the code status, CPR will be preformed and then be transported to the nearest hospital. B. Record review of Resident 3's Code Status Policy (CSP) sheet with a dated of [DATE] revealed Resident 3's Representative had marked the section on the CSP to indicate Resident 3 was a full Code. Record review of a second CSP dated [DATE] for Resident 3 revealed Resident 3's Representative indicted Resident 3 was a Full Code. Further review of Resident 3's second CPS revealed Resident 3's practitioner signed the CSP that identified Resident 3 as a Full Code on [DATE]. Record review of Resident 3's Admission Record sheet printed on [DATE] in the section identified as Advanced Directive revealed A DNR (Do Not Resuscitate , or commonly known as a no code). On [DATE] at 2:20 PM an interview was conducted with Licensed Practical Nurse (LPN) A. During the interview LPN A reported if a resident codes or goes to the hospital, there is a binder with a code sheet and face sheet (also known as a Admission record sheet). On [DATE] at 2:23 PM an interview was conducted with LPN C. During the interview LPN C reported there is a binder with a code sheet and face sheet and we can use both. On [DATE] at 4:25 PM an interview was conducted with LPN B. During the interview LPN B reported if some one goes to the hospital or codes we use the code sheet and also can use what is in the computer. On [DATE] at 4:39 PM an interview was conducted with Resource Nurse (RN) A. During the interview, review of Resident 3's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 3 CSP and Admission record sheet printed on [DATE] did not match and should have. C. Record review of Resident 32's CSP revealed on [DATE] Resident 32's Representative signed that Resident 32 was a No Code. Further review of Resident 32's CSP signed by Resident 32's Representative on [DATE] revealed Resident 32's practitioner signed the CSP on [DATE]. Record review of Resident 32's Admission Record sheet printed on [DATE] revealed in the section identified as Advance Directive identified Resident 32 as a Full Code. On [DATE] at 4:39 PM an interview was conducted with Resource Nurse (RN) A. During the interview, review of Resident 32's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 3 CSP and Admission record sheet printed on [DATE] did not match and should have. Record review of Resident 30's admission record reveals her advanced directive is listed as Do Not Resuscitate. Record review of the code status policy which is kept in the Code Status/Face Sheet book reveals that the code status for Resident 30 is listed as Full Code. Record review of the physician orders [REDACTED]. An interview with RN- J and LPN-B on [DATE] at 2:30 PM revealed that it depends on where they are when a code is called. If they are way down the hall then they would look at the Electronic medical record on the computer which may, or may not be, correct. F. Based on the information provided on [DATE] to remove the immediacy of the situation, the facility staff provided the following information. Immediate action; 1. For the 5 residents identified, the code status has been verified and updated in the electronic health record ( Advanced Directive, 2.Physcians orders, Face sheet) and in the Code Status Binder. 3. The director of nursing, or the designee will stay in facility and ensure records are correct, with a 100% audit of all residents code status. 4. All nursing staff will be educated on identifying code status preference and where that information is located before leaving this shift. All scheduled staff will be educated before being able to work, until all of nursing staff has been educated. 5. ED or designee will stay to ensure that the aforementioned bullets are completed. Monitoring: 1. Clinical Resources will audit above commitments daily until above audits and education are completed. 2. director of Nursing or designee will audit all new admissions to verify clear identification of code status with 24 hours of admission. 3. Above audits will be documented and brought to QAPI for further review and discussion, X3 months or until substantial compliance is determined.Licensure Refernce Number 1[AGE] NAC ,[DATE].02 [DATE] 11:13 AM Interview with Clinical Resource Nurse (CRN) , D and Administrator in Training E, confirmed, the CRN D and the current Administrator had knowledge of the Sister Facility being sited for not having consistent and clear information for facility residents on CPR status. CRN, D confirmed that an Audit was done at this facility to identify CPR status. CRN D confirmed certain staff members were identified to follow thru with this task and they did not. CRN D confirmed that binders were put in place to include Advance directives, and Face sheets for each resident. CRN D confirmed that new system was not audited to make sure the system was working. Cross Reference F Tag 678. | 2020-09-01 |
| 5462 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 323 | K | 1 | 1 | HUVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7 Based on observation, record review, and interview; the facility failed to ensure 2 residents (Residents 30 and 42) of 2 sampled were supervised during a whirlpool bath and failed to protect 1 resident (Resident 84) from an accident while being transported in the facility van which had the potential to affect 42 residents. The facility also failed to ensure chemicals were secured to protect residents on the SCU (Special Care Unit) from potential ingestion, skin irritation or eye irritation which had the potential to affect 11 of the 18 residents on the SCU. The facility census was 59. Findings are: [NAME] Observation on 3/22/2017 at 11:58 AM revealed Resident 42 was in the bathhouse in the whirlpool tub filled with water unattended. Interview on 3/22/2017 at 11:58 AM with ED (Executive Director) revealed the resident was in the whirlpool tub alone without supervision. Interview on 3/22/2017 at 12:37 PM with NA (Nursing Assistant) K revealed Resident 42 was left alone in the whirlpool bath as NA K went out for break. NA K went on to say the other NA's had instructed NA K it was ok for Resident 42 to be left unattended while in the whirlpool tub. Interview on 3/22/2017 at 12:10 PM with Nurse BB revealed Nurse BB was not sure if the resident had been assessed to be in the whirlpool alone. Nurse BB revealed Resident 42 did not get left in the bathroom alone due to being a fall risk. Interview with Nurse CC revealed NA K did not notify Nurse CC of Resident 42 being left in the bath house alone before taking a break. Nurse CC further stated Resident 42 was not safe to be left alone in the whirlpool. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/6/17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 8 out of 15 which indicated Resident 42 had moderate cognition problems. Resident 42 required limited to extensive assist with mobility tasks and bathing. Review of Resident 42's Care Area Assessments (CAA's - A more in-depth assessment to aid in the development of a resident-specific care plan based on identified problems, needs, and strengths) for Activities of Daily Living (ADLs) dated 1/12/17 revealed, Resident needs assistance with all ADLs recently had a fall that resulted in a fracture. Review of Resident 42's CAAs for Falls dated 1/12/17 revealed, Resident had a recent fall that resulted in a fracture to right second metatarsal (toe ) is at an increased risk for further falls r/t (related to) factors that include but are not limited to weakness and needs assistance with all ADLs Review of Resident 42's Care Plan dated 12/23/15 revealed Resident 42 had impaired cognitive function related to Alzheimer's disease and hallucinations/delusions. Further review of Resident 42's Care Plan revised 1/6/17 revealed Resident 42 required assistance of 1 staff with bathing. Resident 42's Care Plan did not state that Resident 42 was safe to be in the whirlpool unattended. Resident 42's Care Plan revised 6/12/14 further stated Resident 42 was at risk for falls related to impulsivity and needed reminders to wait for assistance from staff. Interview with NA M on 3/22/17 at 1:28 PM revealed NA M had left Resident 42 in the whirlpool alone because NA M was told by administrative staff that it was care planned for Resident 42 to be able to sit in the whirlpool alone. Further interview with NA M revealed it was common practice to leave Resident 30 unattended in the whirlpool and that staff usually left and took their 30 minute break or went to do their charting for the day. Interview with Medication Aide (MA) X on 3/22/17 at 1:43 PM revealed MA X had left Resident 30 unattended in the whirlpool when providing baths. Review of Resident 30's MDS dated [DATE] revealed Resident 30 had a BIMS of 9 out of 15 indicating moderate cognitive impairment and had a [DIAGNOSES REDACTED]. Review of Resident 30's Care Plan dated 10/26/15 revealed Resident 30 preferred a whirlpool and requested time to soak, but bath aide must remain in bath house with resident. Review of Resident 30's Progress Notes dated 3/18/17 revealed Resident 30 was found on the floor after feeling light headed while getting ready for bed. Further review of Resident 30's Progress Notes revealed episodes of confusion documented on 3/18/17 and 2/15/17. Review of the facility's procedure for bathing revised 3/17 revealed, 5. Do not leave resident unattended. Resident may be unattended during bath per his/her request and if assessed by the interdisciplinary team to be safe/independent. Interview with the ED on 3/22/17 at 2:30 PM confirmed that neither Resident 42 nor 30 had been assessed to be safe to be left unattended in the whirlpool tub. The Immediate Jeopardy was abated to an [NAME] level on 3/22/17 at 3:30 PM when the ED stated all staff who had the potential to assist residents with bathing had been educated to not leave any residents alone while in the whirlpool tub. B) Review of the undated census sheet for Resident 84 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS score of 15 which indicated Resident 84 had no cognition problems. Resident 84 was independent with setup help only with bed mobility. The resident did not walk and required extensive assistance of one staff person for transfers, dressing, toileting, and personal hygiene. Review of the Progress Notes dated 5-6-16 revealed Resident 84 was picked up by the facility van from the Dialysis Unit to be transported back to the facility. The employee who drove the van failed to secure the front wheels of the wheelchair prior to leaving and, when the van crossed over an intersection, the resident's wheelchair tipped over backwards with the resident in it. The resident hit the back of the resident's head on the back wall of the bus. The resident was assessed for injury by the staff person then called 911 to assist with lifting the resident and to transfer to the hospital for an evaluation. A CXR (chest x-ray) and CT scan of the head were completed, both were negative. The resident returned to the facility. Review of the physician progress notes [REDACTED]. Review of the facility investigation report revealed the interventions initiated were: 1) Signs were made and posted into each of the facility vehicles (van and bus) with instructions to follow prior to the staff being able to drive the vehicle. The instructions revealed: -strap down and tighten all four latches to the wheelchair -put the seatbelt around the resident -attempt to move the wheelchair and ensure that it is secure 2) The van driver involved was educated. Observation on 3-21-17 at 10:22 AM of Staff J revealed a resident in a wheelchair was loaded into the van and a 4 point wheelchair harness and seatbelt was applied. The driver made sure the wheelchair was secure. Observation inside the van revealed the absence of a sign posted with instructions on wheelchair/seatbelt application. Observation on 3-21-17 at 12:10 PM accompanied by Staff J of the facility bus revealed the absence of a sign posted with instructions to the driver on the wheelchair/seatbelt application. Interview on 3-21-17 at 12:10 PM with Staff J confirmed there were no signs in either vehicle and Staff J revealed there never had been. Interview on 3-21-17 at 12:35 PM with the SW (Social Worker) revealed the signs were made at the time of the incident by the SW. The SW thought either the ADM (Administrator) or the DON (Director of Nursing) had posted them in the vehicles. Interview on 3-21-17 at 2:20 PM with the DON confirmed the DON did not post the signs and confirmed no education was provided to any of the other staff who drove the van or bus after the incident. Review of the policy Before Operating a Vehicle with Wheelchair Lifts, Wheelchair Securement Systems and/or Seat Belt Systems dated 5/2013 revealed a Vehicle Knowledge Checklist form (GSS: Good Samaritan Society #655) should be completed prior to a driver transporting resident in a wheelchair. A Transporting Residents in Wheelchair Checklist (GSS #359) shall be satisfactorily completed prior to a staff person driving and annually thereafter. Interview on 3-21-17 at 2:22 PM with the Administrator confirmed there were 4 staff trained to drive the van/bus to transport residents and per the policy the competencies should be completed annually. The ADM confirmed last van competencies completed on the staff were in (YEAR) and not done in (YEAR) or yet in (YEAR). Review of personnel files revealed : 1) Staff J last competency on driving the facility van/bus was completed 12-28-15. 2) SW last competency on driving the facility van/bus was completed 12-29-15. 3) DON last competency on driving the facility van/bus was completed 5-26-15. 4) Staff K last competency on driving the facility van/bus was completed 1-20-17. C) Observation on 3-8-17 at 08:50 AM on the SCU (Special Care Unit) revealed the Dirty Utility room door, located by the Bath House, was shut but not secured/locked. When the door was gently pushed, it opened. Observation inside the room revealed a spray bottle of Virex, a disinfectant cleaner, on top of the counter. Observation on 3-8-17 at 8:50 AM on the SCU in the Bath House revealed the door to the room was wide open and no staff was in view of the door. In the Bath House was a cabinet with the doors wide open and a spray bottle of Virex sat on the shelf. Interview on 3-8-17 at 8:50 AM with Staff X revealed Staff X had been giving baths this morning before breakfast, then stopped to assist at the breakfast time and was back to start to give baths again. Observation were conducted on 3-8-17 at 8:52 AM of a cupboard in the SCU in the DR (dining room) above the hand wash sink. The cupboard had locks on both cabinet doors but the doors were unlocked. The cupboard contained a full bottle of Wax Glue-Max. The DR contained 14 residents sitting around at various chairs and wheelchairs. One resident, Resident 82, was wandering in the halls. At 8:55 AM, Resident 82 entered into the Bath House, as the door was wide open and was beside the cabinet which held the Virex. Staff P came out of the room directly across from the Bath House and redirected the Resident 82 out of the Bath House and shut the door. Observation on 3-8-17 at 11:45 AM on the SCU revealed the Utility Room located by the Bath House. The door was shut but not secured/locked. Inside on the counter was the bottle of Virex disinfectant. In a cupboard on the bottom shelf, there was several Isolyser LTS spill kit packets. On the packets was 'Precaution: Not for Internal Use.' Observation of the bathhouse next door revealed the door was shut but the door was not secured and, with a gentle push on the door, the door opened. Inside the room, the cabinet that had previously been opened was secured shut with a padlock. Observed on top of the cabinet was a clear basket full of fingernail polish and a full bottle of fingernail polish remover. Observation on 3-8-17 at 11:50 AM revealed the Staff GG exit the Dirty Utility room and shut the door but did not pull it shut to ensure the door was secured. At 11:51 AM, a gentle push on the door opened the door. No residents were in the hallway wandering at this time. Observation on 3-8-17 at 12:25 PM revealed the cupboard in the SCU DR above the hand wash sink had unlocked cabinet doors. The cabinet had been cleaned and the Wax Glue-Max was gone. Observation on 3-8-17 at 12:39 PM revealed the door to Bath House was open about 12 inches and no staff was in sight of the room. Observation on 3-8-17 at 1:50 PM revealed the door to the Bath House was open about 1/2 inch. Inside the room was the basket at head height of fingernail polish and full bottle of fingernail remover. The whirlpool on the bottom right side had a door with a lock on it. The door opened and inside was the whirlpool disinfectant concentrate hooked up to the hose to the tub. The door was not locked. Observation on 3-9-17 at 10:30 AM revealed the Dirty Utility room door was shut but not latched secure. With a gentle push on the door, the door opened and observation revealed a bottle of Virex disinfectant spray on the counter. Observation on 3-9-17 at 10:38 AM revealed Resident 6 in the Dining Room in the SCU, which was located 1 room away from the Bath House and Dirty Utility room. Resident 6 was exit seeking with attempts to push open the exit door to the courtyard door several times At 3-9-17 at 1:45 PM, Resident 6 was across the hall from the Bath House rummaging through some dresser drawers in the resident room. Review of the MSDA (Material Safety Data) sheets of the chemicals observed revealed they were classified as harmful for oral consumption, skin corrosion/irritation, and serious eye damage/eye irritation. Interview on 3-9-17 at 4:00 PM with the ED (Executive Director) revealed the expectation was to have the doors shut and secured at all times when a staff was not in the room when chemicals are in the room. Interview with the SW (Social Worker) on 3-22-17 at 3:30 PM revealed 11 residents who live on the SCU rummaged and were independent with locomotion. | 2020-01-01 |
| 5468 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 431 | K | 1 | 1 | HUVK11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, record review and interviews; the facility failed to ensure medications were secured at all times on both units (the SCU: Special Care Unit and general population) with the potential for imminent harm for 18 residents on the SCU. The facility census was 59. Findings are: A Observation on 3-15-17 at 7:39 PM revealed Staff A prepared medications in the med room (medication room) on the SCU (Special Care Unit: a secured unit for residents with dementia) for Resident 50. When Staff A went to administer the medication to the resident, Staff A partially closed the med room door but left it open 2 inches. Staff A went around the corner and administered the medications to the resident. Staff A's back was to the med room door and access to the med room was not within the sight of Staff [NAME] Observation revealed Resident 75 stood at the refrigerator and kitchen counter rummaging through cabinets, drawers, and the refrigerator. The refrigerator was located directly beside the medication room door. - Observation on 3-16-17 at 4:25 PM revealed Nurse [NAME] in the medication room preparing eye drops to administer to Resident 36. Nurse [NAME] exited the med room and left the med room door wide open. The nurse walked away from the med room and the nurse's back was towards the med room the entire time during the administration of the eye drops. When the nurse turned around to go back to the med room, Resident 32 was observed in the resident's wheelchair in the med room with (gender) hands on top of the counter grabbing at items on the counter. Nurse [NAME] hurried back to the med room and intervened and took the resident out of the med room. The resident did not appear to have opened any medications. There were no medications sitting on the counter. The medicaiton room had a countertop with open shelves above the counter to hold stock bottles of multi-dose medications including Tylenol, MOM (Milk of Magnesia: a laxative), and constipation medications. Underneath the cabinet were drawers without locks which held the residents' medications in punch cards. the medications included: Antipsychotic medications: [REDACTED] - Antidepressant medications: [REDACTED] - Antianxiety medications: [REDACTED] - Antihypertensive medication: Midodrine, Vasotec, Spironloactone, Lisinopril, Capoten, Atenolol, - Antiseizure medications: [REDACTED] - Cardiac medications: [REDACTED] - Diuretic medication: Lasix - Anticoagulant (blood thinner) medication: Coumadin Observation on 3-20-17 at 3:21 PM revealed Nurse [NAME] was in the medication room on the SCU. Nurse [NAME] exited the med room and partially closed the door except for approximately 2 inches. Nurse [NAME] asked NA- G (Nurse Aide) to watch the med room as Nurse [NAME] had to leave the SCU to fax the Physician. NA-G was beside the med room working in the refrigerator and verbally agreed. Nurse [NAME] exited the SCU. Resident 52's TABs alarm sounded and NA-G had (gender) back to the med room door while assisting the resident on the other side of the dining room by the office door. NA-H stepped out of a resident room from the far end of the hall by the SCU entry door and asked NA-G to give another resident a root beer which NA-H had forgotten to do. NA-G proceeded to do this. When at 3:23 PM, the TABS alarm sounded again as Resident 52 started crawling out of the chair. NA-G responded and assisted the resident into a different chair. During this time, NA-G's back was toward the med room. While NA-G was assisted Resident 52 and still had (gender) back to the med room, Resident 81 ambulated from the hallway and entered into the dining room directly by the med room door. Resident 63 got up from the activity table and started towards the refrigerator. NA-G finished with the other resident and approached Resident 63. NA-G stood in between the resident and the refrigerator with (gender) back towards the med room and informed the resident it was too early for more chocolate milk. This started an argument between the resident and NA-G. While they were engaged in conversation, Nurse [NAME] returned to the SCU at 3:26 PM and entered into the medication room. Nurse [NAME] exited the med room and closed the door. Nurse [NAME] informed NA-G of the nurse's return. Interview on 3-08-17 at 2:40 PM with Nurse FF revealed Residents 81 and 75 rummage in other residents' rooms, the dining room cupboards, anywhere and whatever they can get their hands onto. Both residents are independently ambulatory. B) Observation on 3-9-17 at 5:18 PM revealed the med cart (medication cart) was located in the 200 hall near the nurses' station was unlocked. The medication drawers on the med cart opened easily and medications in punch cards were observed. No staff were observed in sight of the med cart. Observation at 5:19 PM revealed Nurse C arrived from around the corner and worked on the medication cart. At 5:21 PM, without locking the med cart, Nurse C entered into the medication room out of sight of the med cart. The medication room door was closed shut. Observation on 3-15-17 at 2:35 PM revealed the medication cart was located in the 200 hall near the nurses' station. The medication drawers on the cart opened easily and medications in the punch cards were observed. At 2:36 PM, both of the nurses were observed around the corner in the medication room and the medication cart was not within their view. Observation on 3-15-17 at 5:15 PM revealed the medication cart was located in the 200 hall near the nurses' station and was unlocked. No staff observed in the area. Observation at 5:17 PM revealed Nurse C returned to the med cart from a resident's room. Observation on 3-15-17 at 5:37 PM revealed Nurse C at the med cart located in the 200 hall by the Nurse' Station. Nurse C left the med cart unlocked while Nurse C entered into the medication room to prepare insulin for Resident 22. At 5:40 PM, Nurse C exited the medication room and left the door open without another nurse or Medication Aide in the view of the door. Nurse C entered into Resident 22's room to administer the insulin. The resident was not in the resident's room, so Nurse C went to the Dining Room and brought the resident back the resident's room. Nurse C then left the unit and entered into the SCU (Special Care Unit - a secured unit behind a locked door) to have another nurse check the insulin. During this time, the medication cart and medication room remained unlocked on the 200 hall. No other nurses or medication aides were observed in view of the medication cart or medication room. Observation at 5:46 PM revealed Nurse C returned to the unit to administer the insulin and shut the medication room door but did not lock the medication cart. Observation on 3-15-17 at 8:40 PM revealed the med cart located in the 200 hall by the Nurse's Station was unlocked and the medication drawer opened easily. On top of the med cart was 2 plastic medication cups, 1 with 10cc (cubic centimeters) of a white, milky liquid and the other cup with 10 cc of a light orange liquid in it. Around the corner in the medication room, Nurse C was observed in a cupboard with the nurse's back to the door. The medication cart was not in view when the nurse was inside the medication room. Residents were in the solarium by the nurses' station, but none were wandering. Observation at 8:43 PM revealed Nurse C came out of the medication room to the med cart. Interview on 3-16-17 at 10:52 AM with Nurse D revealed the nurse's understanding of the facility policy was anytime the medication cart or medication room was not within eyesight, it should be locked. The immediate jeopardy was abated to an [NAME] level on 3-20-17 at 6:15 PM when: 1) The facility educated all the nursing staff that the medication room must be locked at all time when the person passing the medications without exception was not inside the medication room. 2) All medication carts were to be locked when not in direct view of the person passing the medications. 3) A sticker strip was placed on the medication counter that stated lock medication room door in the SCU medication room. 4) A sticker strip was placed on the medication carts in the general population that stated lock the medication cart and on the door of the medication room to keep the door closed and locked. 5) All Nurse Aides were educated they were not allowed into the medication room and the staff mail boxes were relocated to the staff break room to alleviate opportunities for staff to be in the medication room unattended. 6) Auditing of medication administration passes and the doors began on 3-20-17 by the DON and the Corporate Nursing and QA Consultants and will continue through the facility QA daily for 1 month, then weekly for 1 month, then monthly for 10 months. Audits will be reviewed by the QA Consultant weekly for 3 months to ensure substantial compliance. | 2020-01-01 |
| 5470 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 490 | K | 1 | 1 | HUVK11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based observation, record review, and interview; the facility failed to maintain administrative programs to address areas of repeat deficiencies and to oversee the facilities compliance with regulations. This had the potential to affect all 59 residents. Findings are: The facility was found to be deficient in the following areas of regulatory compliance after the annual survey was completed on 1-26-2016. Please reference the specific tags in regard to detailed findings: -F314 Facility failed to prevent and provide ongoing monitoring for pressure ulcers. -F332 medication error rate was at 12%. -F431 Facility failed to ensure medications were secured at all times. -F441 Infection control failed to maintain an Infection Control program and failed to prevent cross contamination in the unit refrigerators. -F520 Quality Assurance failed to develop and implement plans of actions to correct issues of deficient practice. The facility was also cited with the year prior annual survey on 12-23-14 at F 314 and F 441. Additional tags cited on this survey with an exit of 3-22-17 included: F157, F159, F179, F223, F225, F226, F248, F253, F256, F309 F323, F329, F334, F425, F428, F431, F490, F497, F498, and F520. Observation, record review, and interviews during the survey revealed 4 0ther tags cites at a Scope and Severity of Immediate Jeopardys (IJ's) at -F223 Facility failed to ensure residents were not subject to physical abuse. -F323 Facility failed to provide supervision during bathing and prevent accidents during van transportation. -F431 Facility failed to ensure medications were secured at all times. - -F520 Quality Assurance failed to develop and implement plans of actions to correct issues of deficient practice. Interview on 3-22-17 at 4:00 PM with the Executive Director (ED) revealed that ED had been overseeing the facility but had no idea the facility was having these issues. Review of the undated facility Job Description for Administrator revealed, Job Summary: Responsible for the overall leadership and management of the location, ensuring regulatory and organization compliance | 2020-01-01 |
| 5473 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 520 | K | 1 | 1 | HUVK11 | > LICENSURE REFERENCE NUMBER 175 NAC 12-006.07 Based on record review and interviews; the facility's Quality Assurance Committee (QA) failed to develop and implement plans of actions to correct issues of deficient practice relevant to resident care and services and the facility failed to implement effective plans of action to maintain correction for 5 areas of deficient practice identified on the 1-26-2016 survey, including: F314, F332, F431, F441, F520. This survey also had had 4 other IJ's (immediate jeopardies) cited during the survey at F223, F323, F431, and F490. This had the potential to affect all residents that reside in the facility. The facility census was 59. Findings are: Record review of the Statement of Deficiencies for the annual survey completed 1-26-2016 revealed citations at -F314 Facility failed to prevent and provide ongoing monitoring for pressure ulcers. -F332 medication error rate was at 12%. -F431 Facility failed to ensure medications were secured at all times. -F441 Infection control failed to maintain an Infection Control program and failed to prevent cross contamination in the unit refrigerators. -F520 Quality Assurance failed to develop and implement plans of actions to correct issues of deficient practice. The facility was also cited with the year prior annual survey on 12-23-14 at F 314 and F441. Additional tags cited this survey 3-22-17 included: F157, F159, F179, F223, F225, F226, F253, F309 F323, F 329, F329, F334, F425, F428, F431, F490, F497, F498, and F520. Observation, record review, and interviews during the survey revealed 4 other IJ's at -F223 Facility failed to ensure residents were not subject to physical abuse. -F323 Facility failed to provide supervision during bathing and prevent accidents during van transportation. -F431 Facility failed to ensure medications were secured at all times. -F490 Failed to have an effective Administration to oversee the facilities compliance with regulations. Interview on 3-22-17 at 3:39 PM with the interim Administrator revealed the Administrator had only been there since (MONTH) 6, (YEAR). The QA committee met monthly but currently did not have any PIPs (process improvement plans) in process. | 2020-01-01 |
| 6414 | LYONS LIVING CENTER | 285301 | 1035 DIAMOND STREET | LYONS | NE | 68038 | 2018-05-10 | 600 | K | 1 | 0 | 2CLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(9) Based on observation, record review and interview; the facility failed to protect residents from residents with adverse behaviors. This affected all residents (Residents 1, 2, and 10) who were residing on the Memory Support Unit (an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). The sample size was 14 and the facility census was 23. Findings are: A. Review of the facility policy titled Preventing Resident Abuse dated 12/13/16 revealed a facility goal to achieve and maintain an abuse free environment. The abuse prevention/intervention program included the following: -assisting or rotating staff working with difficult residents; -training staff to understand and manage a resident's verbal, physical and sexual aggression; -assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict; -assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behaviors; -involving qualified psychiatrists and other mental health care professionals to help the staff manage difficult or aggressive residents; and -striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met. B. Review of the facility policy Resident to Resident Altercations dated 12/13/16 revealed all altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Director of Nursing (DON) and the Administrator. If 2 residents are involved in an altercation the staff will: -separate the residents and institute measures to calm the situation; -identify and implement interventions to prevent reoccurrence; -update the resident's care plans; and -report the incident and corrective measures to the appropriate state agencies. C. Review of the facility policy titled Protecting Residents during Abuse Investigations dated 12/13/16 revealed if the alleged abuse involves another resident, the accused resident's representative, and Attending Physician were to be informed of the incident. In addition, the accused resident was to be restricted from visiting other resident's rooms. Within 5 working days of the alleged incident, the facility was to give the state agency a written report of the findings of the investigation and a summary of corrective action taken to prevent the incident from recurring. D. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed the resident was admitted on [DATE] from an acute care hospital. The resident's cognition was severely impaired and the resident had a behavior of wandering identified. The wandering placed the resident at significant risk for getting into a potentially dangerous area but did not significantly intrude on the privacy of other residents. The MDS identified a [DIAGNOSES REDACTED]. Review of the resident's undated current Care Plan revealed the resident had impaired decision making skills with memory loss related to a [MEDICAL CONDITION] from a suicide attempt in (MONTH) of (YEAR). The resident had poor decision making skills with a short attention span and made occasional inappropriate comments. No interventions were identified on the residents' plan of care related to cognitive loss or the resident's occasional inappropriate comments. Review of Resident 1's Nursing Progress Notes revealed the following: -2/28/18 at 12:43 PM, (late entry for 2/27/18) the resident was admitted to the Memory Support Unit. The resident was exit seeking but redirected easily. -3/5/18 at 4:56 AM, the resident was wandering in the Unit with an occasional attempt to exit seek. -3/7/18 at 7:45 AM, the resident approached the Nurse's Station and asked if the nurse wanted to have sex. Behavior was easily redirected. -3/19/18 at 3:00 AM, the resident was found in the resident's room with Resident 2. Resident 2 was seated on the side of the bed and Resident 1 was on knees, in an inappropriate position between Resident 2's legs. Both residents were covered with a blanket. The residents were immediately separated and the DON was notified of the incident. Review of Resident 1's medical record revealed no evidence the resident's care plan had been updated regarding the inappropriate sexual behaviors and/or new interventions developed to address the resident's behaviors. Review of Resident 1's Nursing Progress Notes revealed the following: -3/29/18 at 5:20 AM, the resident was making perverted, sexually inappropriate comments to the staff. -4/5/18 at 6:13 AM, the resident has made sexual comments to the staff, asking if staff was a virgin. The resident later came out of the resident's room with the resident exposed and asked the staff member if the resident could stick it up the staff's ass. -4/7/18 at 11:00 PM, the resident was thrusting hips behind a staff member's back. -4/9/18 at 2:40 AM, the resident pulled pants down below buttocks and stated come on to the staff. -4/10/18 at 5:06 AM, the resident came up to staff and stated I want to [***] you. -4/11/18 at 3:30 AM, the resident asked staff if the resident could stick it up the staff member's ass. -4/12/18 at 4:17 AM, the resident was identified as making sexual comments to the staff. Resident asked to eat out the staff member. -4/12/18 at 5:38 PM, the resident asked staff repeatedly about whether or not the staff member was a virgin. -4/12/18 at 6:00 PM, the resident answered the phone on the Memory Support Unit. Staff removed the phone from the resident. The resident then asked if the resident could f--k (obsenity) the staff member in the butt. -4/12/18 at 8:32 PM, the resident had been sexually harassing the staff throughout the shift. The resident came out of the resident's room exposed. The resident asked staff if the resident could f--k (obsenity) staff in the ass. The resident continued to make sexually inappropriate comments and threw a plastic cup at staff. -4/13/18 at 12:45 AM, two Nursing Assistants (NA) entered the Memory Support Unit to assist with rounds. The resident came up behind one of the staff members, placed a hand over the staff member's mouth and used the other arm to grasp the staff member's body and to pull staff up against the resident. The staff member exited the Unit when released and refused to return. -4/13/18 at 4:48 AM, the resident asked staff if the resident could f--k (obsenity) the staff member in the ass. -4/13/18 at 5:13 AM, the resident continued to make sexual comments and gestures to the staff. The resident became angry when the staff attempted to redirect. -4/13/18 at 8:08 PM, the resident swatted the staff's backside 3 times throughout the shift. An appointment was made with the resident's primary physician. -4/16/17 at 3:50 PM, the resident was identified as asking staff inappropriate, sexual questions, requesting sex and inappropriately touching staff on multiple occasions. On 4/18/18 at 3:15 PM a facsimile (fax) was sent to the resident's physician to notify of the sexually inappropriate behaviors toward the staff. The fax indicated the resident had covered a staff member's mouth after coming up behind the staff and was then humping the staff member. The fax further indicated this had happened numerous times. An order was received for [MEDICATION NAME] (medication used to treat anxiety and depression) 300 milligrams (mg) three times a day to help control inappropriate behaviors. Review of Nursing Progress Notes revealed the following: -4/18/18 at 4:26 PM, the resident was kicking the window. The resident identified a desire to get out of the facility. The resident was exposed and asked staff if the resident could stick it in the staff member's vagina. -4/19/18 at 1:48 AM, the resident continued to make sexually inappropriate comments and walked around exposed. -4/20/18 at 1:50 AM, the resident was identified as having 2 episodes of sexually inappropriate behaviors throughout the shift. -4/20/18 at 2:40 PM, the resident continued to display sexually inappropriate behaviors throughout the shift. -4/21/18 at 5:44 AM, the resident came out of room without wearing any pants or underwear. -4/21/18 at 12:30 PM, the resident was identified as having inappropriate behaviors and the resident's physician ordered the resident to be placed in Emergency Protective Custody (EPC-part of the mental health commitment act which permits law enforcement officers to take into custody a mentally ill, dangerous person that is likely to harm themselves or others before a mental health commitment hearing can be held). The resident was taken to Oakland Mercy Hospital. Review of a Nursing Progress Note dated 4/27/18 at 7:00 AM revealed the resident was readmitted to the Memory Support Unit. New interventions were identified to have 2 staff working in the unit at all times and for staff to provide and document every 15 minute checks of the resident. Review of Resident 1's Nursing Progress Notes revealed the following: -4/30/18 at 11:15 PM, the resident attempted to open the exit door and when the door would not open, the resident exposed self and walked through the hallway. -5/1/18 at 12:05 PM, the resident came out of the resident's room and asked staff can I f--k (obsenity) you?' and can you f--k (obsenity) me?. -5/1/18 at 2:00 AM, the resident came to the Nurse's Station and told staff it's time to f--k (obsenity). -5/1/18 at 2:08 AM, the resident was in the bathroom. The resident began to yell out for the staff. When asked what the resident needed the resident responded your pussy. -5/1/18 at 4:00 AM, the resident came out of the resident's room completely naked. -5/1/18 at 5:04 PM, an order was identified for the resident to receive psychiatric evaluation at Fremont Behavioral Health and for psychiatric counseling. -5/2/18 at 5:48 PM, The resident and another resident were discovered by staff about to fight with each other. No physical altercation occurred. After being redirected from the other resident, Resident 1 came up behind a staff member and asked staff if they wanted to f--k (obsenity). Resident redirected to room but remained in the hallway with hands in the resident's pants and touching self. -5/3/18 at 4:20 AM, the resident was at the Memory Support Nurse's Station completely naked. -5/5/18 at 11:35 PM, resident was walking around unit with no pants and private area exposed. Review of the resident's medical record from 5/1/18 through 5/8/18 revealed no evidence an appointment had been scheduled for a psychiatric evaluation or that the resident had received any psychiatric counseling despite the resident's continued behaviors. Review of Resident 1's Nursing Progress Notes revealed the following: -5/9/18 at 5:06 AM, the resident asked the staff do you want to f--k? (obsenity) -5/9/18 at 1:41 PM, the resident asked staff if resident could see the staff's pussy. The resident was redirected and told this was an inappropriate comment. The resident then stated let me stick it in your ass. -5/9/18 at 4:06 PM, the resident told staff all you need to do is open your legs or bend over. E. Review of Resident 2's MDS dated [DATE] revealed the resident had short and long term memory loss with severely impaired decision making skills. The resident had behaviors which included hallucinations and wandering. But wandering did not place the resident at significant risk of getting to a potentially dangerous place and wandering did not intrude on the privacy of others. The resident had [DIAGNOSES REDACTED]. Review of Resident 2's undated current Care Plan revealed the resident could become angry or anxious at times related to Alzheimer's dementia. An intervention was developed to document all behaviors and mood issues and to keep the charge nurse updated. Review of Resident 2's Nursing Progress Notes dated 3/19/18 at 3:45 AM revealed the resident was found in the room of another resident on the Memory Support Unit at 3:00 AM. Resident 2 was seated on the edge of the bed and Resident 1 was on knees in an inappropriate position between Resident 2's legs. A blanket covered both of the residents. The blanket was removed and the residents were separated. Review of facility investigations of potential abuse/neglect from 12/1/17 to 4/1/18 revealed no investigation had been completed regarding the incident which had occurred between Resident 1 and Resident 2 on 3/19/18; the incident had not been reported and no interventions were put into place to protect Resident 2 from any potential ongoing sexual abuse. Review of a facility investigation dated 4/26/18 revealed on 4/21/18 at 11:58 AM, the staff had walked into a vacant room on the Memory Support Unit and had found Resident 1 and Resident 2 with their pants down and with their perineal area fully exposed. Resident 1 was holding Resident 2 in a bent over position so the resident's torso was on the bed. Resident 1 was attempting to have anal sex with Resident 2. Resident 2 appeared frightened and Resident 1 was resistive when the staff attempted to remove the resident from the situation. The report indicated Resident 1 had a recent increase in sexual comments towards the staff but had displayed no sexual tendencies toward other residents. An order was received for Resident 1 to be EPC'd and staff remained with Resident 1 until the police arrived. The resident was taken to Oakland Mercy Hospital and then to the Lancaster Mental Health Crisis Center. The resident returned to the facility on [DATE] and was readmitted to the Memory Support Unit. New interventions were identified for staff to provide and to document every 15 minute checks on Resident 1. Resident 1 was to be seen by a psychiatrist and was to receive counseling. In addition, the facility was to pursue more appropriate placement for Resident 1. Review of a Nursing Progress Note for Resident 2 dated 4/27/18 at 10:50 AM revealed staff were made aware that Resident 1 was to be readmitted . Staff to complete and document every 15 minute checks of the residents. The resident's family was notified and indicated they would trust the facility to make sure Resident 2 was not in any danger. F. Review of Resident 10's MDS dated [DATE] revealed the resident's cognition was severely impaired. The resident had behaviors which included resistance with cares and wandering and had [DIAGNOSES REDACTED]. Review of Resident 10's undated current Care Plan revealed the resident had cognitive loss due to [DIAGNOSES REDACTED]. Review of staff documentation related to the 15 minute checks of the residents on the Memory Support Unit revealed the following on 5/2/18: -9:30 AM, Resident 10 walked into Resident 1's room. Resident 1 told Resident 10 to get out. Resident 10 refused and Resident 1 stated, I will punch you and drew back fist. The residents were separated by the staff. -11:00 AM, Resident 10 was standing in the doorway to Resident 1's room. Resident 1 was at the end of the hallway, saw Resident 10 outside of room and came down the hallway with fists drawn. The residents were again separated. Review of a Nursing Progress Note for Resident 10 dated 5/2/18 at 5:55 PM revealed the resident tried to get into a physical altercation with another resident. G. Observations of the Memory Support Unit on 5/7/18 from 9:00 AM to 12:30 PM revealed the following: -9:07 AM, Resident 1 was lying on the resident's bed with eyes closed. Resident 10 entered the resident's room and stood next to Resident 1's bed. -9:11 AM, NA-B entered Resident 1's room and led Resident 10 away from Resident 1's bed. NA-B assisted Resident 10 to the bathroom in Resident 10's room. NA-B closed the door to Resident 10's room while assisting the resident with toileting. NA-B was unable to visualize Resident 1 and Resident 2 and no other staff was available on the unit. -9:11 AM, Resident 2 ambulated out of the dining room and into Resident 1's room and closed the door. -9:11 AM to 9:22 AM, Resident 1 and Resident 2 remained in the room with the door closed. NA-B remained in Resident 10's room with the door closed. -9:22 AM, NA-B exited Resident 10's room and looked in the dining room and then in the corridor for Resident 2. NA-B opened the door to Resident 1's room and assisted Resident 2 out of the room. NA-B closed Resident 1's room door. NA-B led Resident 2 to the Living Room area and placed a movie on the television for Resident 2 to watch. -9:22 AM, Resident 10 entered Resident 1's room and closed the room door. -9:25 AM, Resident 10 opened the door to Resident 1's room but remained in the doorway of the room. Resident 10 glanced up and down the corridor, re-entered Resident 1's room and again closed the room door. NA-B remained in the Living Room with Resident 2. No other staff was available on the Memory Support Unit to monitor the residents. -9:29 AM, NA-B approached Resident 10's room and when unable to locate Resident 10, opened the closed door to Resident 1's room. Resident 10 was again assisted out of Resident 1's room and was taken into the Living Room to watch a movie with Resident 2. -9:30 AM to 12:30 PM, NA-B was the only staff member working on the Memory Support Unit. During an interview on 5/7/18 from 1:30 PM to 2:00 PM, NA-B identified the following: -Resident 1 started having an increase in sexual behaviors about 2 weeks after the resident was admitted to the facility; -when Resident 1 was re-admitted on [DATE] the Memory Support Unit was to be staffed with 2 Nurse Aides. However, the facility is short staffed and after the first couple of days, there has never been more than 1 Nurse Aide at a time scheduled on the unit; -staff are to complete and document every 15 minute checks on Resident 1, Resident 2 and Resident 10. These are the only residents on the unit; -staff have been instructed to keep Resident 2 and Resident 10 out of Resident 1's room. However, both residents try repeatedly each day to gain access and it takes up the whole day just redirecting the residents; -Resident 2 requires 1-2 staff for an every 2 hour check and change schedule for incontinence; -Resident 10 requires cues and assistance every 2 hours for toileting and incontinence cares; and -when assisting Resident 2 or Resident 10 with cares, there is no one available to monitor the remaining residents to assure no abuse occurs. During an interview with the Provisional Administrator on 5/7/18 from 2:00 PM to 2:30 PM the following was confirmed: -incident on 3/19/18 at 3:00 AM between Resident 1 and Resident 2 was not reported or investigated and this incident occurred prior to the current Administrator and DON's start dates and both were unaware of the incident. -no interventions were developed or implemented to protect Resident 2 after the incident which occurred on 3/19/18; -Resident 1 had escalating sexual behaviors directed at the staff. The resident made inappropriate sexual comments, exposed self and touched staff inappropriately; -on 4/21/18 Resident 1 was found with Resident 2 in an empty room on the Memory Support Unit. Both residents were exposed and Resident 1 was attempting to have anal sex with Resident 2; -the resident's physician was notified and an order was received for the resident to be EPC'd. -the resident was taken to Oakland Mercy Hospital and was evaluated in the emergency room . The resident was found to be medically stable and was cleared to return to the facility. -the facility felt they were unable to meet the resident's needs as not enough staff available to have 1:1 with the resident. The resident's family drove the resident from Oakland Mercy Hospital to Lincoln per request of the Administrator and was to be admitted to Bryan East Medial Center for an inpatient psychiatric evaluation; -upon arrival in Lincoln the family contacted Bryan Medical Center who indicated no availability for the psychiatric evaluation and refused to admit the resident; -the resident was taken home with the family until the resident had inappropriate sexual behaviors with a minor child in the home; -the resident was then taken to the Lancaster Mental Health Crisis Center by the police where the resident remained until he was readmitted to the facility on [DATE]; -with the residents readmission the facility was to ensure 2 staff were scheduled for the Memory Support Unit at all times and staff were to conduct and document every 15 minute checks on the residents; -Resident 1 continues to have inappropriate sexual behaviors; -the facility was unable to schedule 2 staff at all times for the unit as not enough staff were available; -as of 5/7/18 the facility had not made an appointment for Resident 1 to be seen for Psychiatric Evaluation or an appointment made for the resident to receive counseling; and -was unaware of the resident to resident altercation between Resident 1 and Resident 10 on 5/2/18 and no further interventions had been into place to maintain the residents safety and to protect the residents from potential abuse. G. ABATEMENT STATEMENT Based on the following, the facility removed the immediacy of the situation and the Immediate Jeopardy situation was abated: 1). Memory Support Unit to have 2 staff members scheduled around the clock. One of the staff assigned to the Unit was to be with Resident 1 at all times. If the other staff member needed assistance with completing cares for Resident 2 or 10, then they needed to call off the Unit for a third staff member. 2). New form was developed for the staff to document the 15 minute checks on the residents. The Form must be used by all the staff on the Unit and must be filled out completely each shift. 3). Education provided to all staff working on the Memory Support Unit to assure the staff's safety when working with Resident 1. Education included the following: -never turn your back to Resident 1; -always carry a walkie-talkie with you to maintain communication with other staff; -Charge Nurse to check on staff working on the Unit every hour; and -if feeling threatened to immediately call for help. 4). Nursing schedule completed to assure adequate coverage for the Unit. 5). Resident was seen by Advanced Practice Nurse Practitioner on 5/9/18 with a new order for [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorders) 5 mg at bedtime. The immediacy had been removed, however, the deficit practice was not totally corrected. Therefore, the scope and severity was been lowered to an E. | 2019-03-01 |
| 6423 | LYONS LIVING CENTER | 285301 | 1035 DIAMOND STREET | LYONS | NE | 68038 | 2018-05-10 | 835 | K | 1 | 0 | 2CLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record review and interview, the administration failed to ensure the facility resources were utilized in a manner to ensure provision of care and services for residents. This deficient practice provided the potential to affect all residents of the facility. The sample size was 14 and the facility census was 23. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance which required an extended partial survey related to substandard quality of care. The following issues related to systems failure and/or failure to follow standards of care resulted in patterns of, or widespread failure in the facility and included the following citations: -F 600. The facility failed to protect residents from residents with adverse behaviors. This affected all residents (Residents 1, 2, and 10) who were residing on the Memory Support Unit (MSU-an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). Resident 1 displayed sexually inappropriate behaviors toward Resident 2 on 3/19/18. There was no evidence interventions were developed or implemented to protect Resident 2 from sexual abuse by Resident 1. Documentation revealed Resident 1 attempted sexual contact with Resident 2 on 4/21/18. New interventions were to have 2 staff working in the MSU at all times and for staff to provide and document every 15 minute checks of the resident. Observations during the survey revealed there were not 2 staff working in the MSU at all times. In addition, Resident 1 displayed threatening behaviors towards Resident 10 on 5/2/18. There were no interventions to prevent altercations between Resident 1 and Resident 10. -F 609. The facility failed to report, investigate and submit an investigation to the State Agency, regarding potential sexual abuse involving Resident 1 and Resident 2 which occurred on 3/19/18. The facility had a policy which indicated all altercations would be reported and investigated with the results of the investigation submitted to the State Agency within 5 working days of the alleged incident. The Provisional Administrator confirmed the incident had not been reported or investigated. -F 689. The facility failed to protect residents from potential accident hazards. Smoking safety assessments were not completed for Residents 3, 6 and 7 who were allowed to smoke. There was no evidence the residents were assessed to determine capability to smoke in a safe manner. Observations conducted during the survey revealed facility protocols related to safe smoking were not followed. Residents 3 and 4 were not assessed for risk of wandering and/or interventions were not implemented to prevent elopement (leaving the facility unattended and without staff knowledge). There was no evidence Resident 7's use of a motorized wheelchair was addressed in the current Care Plan, or that nursing interventions related to safety and the prevention of accidents and injury were implemented. Interview with the Occupational Therapist verified Resident 7 had incidents of running into other residents and/or items during transfers in the motorized wheelchair. The environment was not maintained in a manner to prevent potential accidents as windows in residents' rooms were not secured to prevent elopement, hazardous chemicals were observed unsecured and unattended in the Laundry Room and on the Housekeeping Cart, the Boiler Room was left unlocked and unattended, and the Maintenance tool storage utility cart was observed unattended and unsecured in a resident room. The Provisional Administrator confirmed during interview that the windows in the facility were supposed to be secured so they would open no more that 2 to 4 inches and would not allow access to the outside of the building. The Provisional Administrator further verified the Boiler Room was to be locked when unattended, the utility cart of tools was to be locked up when not in use, and the Laundry Room was supposed to be locked when the room was unattended. -F 725. The facility failed to ensure sufficient numbers of staff were available to monitor the MSU in order to protect Resident 2 and Resident 10 from Resident 1 who displayed adverse sexual and threatening behaviors. The facility developed interventions to have 2 staff working in the MSU at all times and for staff to provide and document every 15 minute checks of the resident. Observations during the survey, record review and interview confirmed there were not 2 staff working in the MSU at all times. In addition the facility failed to provide assistance with activities of daily living for Residents 1, 2, 4 and 6 which was related to insufficient numbers of staff. -F 677. The facility failed to provide bathing assistance for Residents 1 and 2, feeding and bathing assistance for Resident 4 and transfer assistance for Resident 6. F 656-The facility failed to ensure individualized Care Plans were developed to address Residents 6 and 3's smoking needs, Resident 4's elopement (leaving the facility unattended and without staff knowledge) risk and Resident 1's adverse behaviors. F 761. The facility failed to ensure Medication Administration Records matched current MEDICATION ORDERS FOR [REDACTED]. -F 607. The facility failed to complete criminal background, Nurse Aide (NA) registry, Adult Protective Services/Child Protective Services (APS/CPS), sex offender registry and reference checks as a condition of employment for 4 of 8 employees. Interview with the Provisional Administrator confirmed employee files were incomplete. -F 839. The facility failed to ensure 2 professional staff were licensed in accordance with applicable State laws. 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN) were not licensed in the state where they resided. The Provisional Administrator confirmed both staff were currently employed by the facility but was not aware of the requirement for RN's and LPN's to be licensed in the state where they resided. -F 842. The facility failed to ensure medical records contained completed information regarding Smoking Safety Screens for Residents 7, 3, and 6, Nursing Admission Assessments for Residents 4 and 6 and Elopement (leaving the facility unattended and without staff knowledge) Risk Assessments for Resident 3. Interviews with the Director of Nurses and/or Provisional Administrator confirmed these assessments had not been completed. -F 947. The facility failed to provide staff training which included dementia management training. This had the potential to affect Residents 1, 2 and 10 who resided in the locked Memory Support Unit (an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). -F 732. The facility failed to post the daily nurse staffing information as required which prevented families, residents and visitors from having access to information regarding the census and numbers of direct care staff providing care in the facility. | 2019-03-01 |
| 6919 | GOOD SHEPHERD LUTHERAN HOME | 285148 | 2242 WRIGHT STREET | BLAIR | NE | 68008 | 2015-08-27 | 323 | K | 1 | 0 | PN1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility failed to ensure residents were free from a potential injury of a scald from hot liquids. This finding constituted an Immediate Jeopardy situation. This had the potential to affect Residents 61, 63, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79 and 80. The facility census was 77. Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. An interview of Registered Nurse 30 (RN 30) was conducted on 8/27/15 at 5:40 AM and a temperature test of the hot liquids was verified by RN 30. A test of the temperature of the liquid dispensed on 8/27/15 at 5:40 AM from the automatic hot drink dispenser revealed the cappuccino and hot chocolate liquid dispensed was 161 degrees Fahrenheit. The hot coffee was tested for a temperature of 163 degrees Fahrenheit. RN 30 was advised of the serious and immediate concerns by the survey team. RN 30 verified the drink dispenser and the coffee maker were located in an area accessible to residents on the dementia unit and the area was unsupervised. RN 30 unplugged the hot beverage dispensers and left the unit. Interview of Licensed Practical Nurse 40 (LPN 40), who was working the secure care unit on 8/27/15 at 6:00 AM, identified the following residents as confused residents who wander on the secure unit: R61, R63, R70, R71, R72 and R73 and was advised of the serious concerns for potential injury to residents by the liquids dispensed from the hot beverage machines in an unsupervised area. Observation of two facility staff Certified Nursing Assistants (CNAs) on 8/27/15 at 6:05 AM revealed they plugged the units back in to an electrical outlet and turned the hot beverage machines on and made coffee. The two CNAs then walked out of the dining area, leaving the two drink dispensers unsupervised and back in operation. The facility failed to provide supervision in the area of the hot beverage dispensers. The facility administrator and the Director of Nursing were notified of the serious concerns by the survey team on 8/27/15 at 9:30 AM. The facility Administrator was notified of the recommendation of Immediate Jeopardy in the area of accident hazards on 8/27/15 at 9:50 AM. The Immediate Jeopardy was removed on 8/27/15 at 11:00 PM and continued at a lower severity level when the facility completed the following corrective actions: 8/27/15 at 10:00 AM, all hot fluid machines were disconnected and moved to the main kitchen away from resident accessibility 8/27/15 at 10:20 AM, six dietary staff were educated. A new procedure was put in place regarding hot liquids. All hot fluids were to be placed in carafes and taken to the dining rooms. The dietary staff would measure the temperature of the liquids and make certain the fluid temperature would not scald a resident if contact was made with skin. Dietary staff would document the temperatures of liquids sent to the resident dining area on a flow sheet in order to ensure temperatures of hot liquids remained at a level below 120 degrees Fahrenheit The Quality Assurance Committee representative would review all documentation related to fluid temperature monitors to ensure safety daily for seven days, weekly for four weeks and monthly for six months. All documentation would be reviewed quarterly through the next annual survey On 08/27/15 at 2:00 PM, 6:00 PM and 10:00 PM, all staff would attend a mandatory meeting and would be educated on the awareness of hot fluids and safety of the residents. Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. Staff interview of Certified Nurse Assistant 81 (CNA 81) on 8/27/15 at 6:10 AM revealed the hot beverage dispensers were for the use of residents and visitors. CNA 81 stated residents were able to get a beverage if they wished. Further observation of the hot beverage dispensers was continued to determine if residents used the dispensers without staff supervision. Observation of R63 on 8/27/15 at 7:08 AM revealed the resident walked into the dining area and obtained a cup of coffee with cappuccino mixed. The cup was filled to the top. The resident spilled a portion of the hot beverage on her hand as she attempted to carry the drink to a table. The resident stated ouch, ouch, ouch and wiped her hand with a paper towel. Review of the clinical record for R63 revealed the resident had a [DIAGNOSES REDACTED]. The assessment documented the resident wandered daily. The assessment documented the resident required supervision for eating. Interview of Medication Aide 90 (MA 90) on 8/27/15 at 8:12 AM verified the hot beverage center was available for use by residents on the 200, 300 and 400 units. Observation of the beverage center off the main dining room on 8/27/15 at 8:12 AM revealed a hot beverage dispenser for coffee and hot chocolate. A test of the temperature of the liquids dispensed revealed the coffee was 158 degrees Fahrenheit and the hot chocolate was 160 degrees Fahrenheit. Residents identified by Registered Nurse 100 (RN 100) on the facility units 200, 300 and 400 at risk for injury by the hot liquids dispensed from the beverage center located in the main dining room with a [DIAGNOSES REDACTED]. Observation of the kitchenette area on 8/27/15 at 10:00 AM and the beverage center off the main dining room verified all hot liquid beverage machines had been removed from unsupervised areas accessible to residents who were confused and mobile. On 8/27/15 at 2:00 PM, the facility Administrator provided the first in-service of staff, which was also attended by the state surveyor, who was observing the survey. The education presented to staff included the risk of burn with hot fluids and the process regarding how to reduce the risk of scald. The Administrator explained how the facility was going to ensure the coffee was not served too hot to protect the residents from burns. The dietary staff were to ensure the coffee had cooled to 120 degrees Fahrenheit and were to ask the residents if the coffee temperature was acceptable. The facility planned to complete hot liquid assessments on all residents to assess their risk. The facility planned to complete a care plan for the residents at risk of hot liquid spills. The staff were instructed to use coffee cups with lids. There were 70 staff members at the first in-service on 8/27/15 at 2:00 PM. The Administrator planned to hold additional in-services on 8/27/15 at 6:00 PM and at 10:00 PM. The in-service was mandatory education for all staff. Interview of the facility staff on 8/27/15 between 2:30 and 3:00 PM following the in-service held at 2:00 PM included seven Certified Nurse Assistants (CNA), the Activity Director and five Registered Nurses. All staff evidenced knowledge of the procedure put in place on 8/27/15 to ensure residents' safety in relation to hot liquids. During the staff interviews, facility staff voiced a concern regarding the hot beverage machine on the Secure Care Unit previous to the identification by the surveyor team, but revealed no action had been taken by the facility. This included interviews with two nurses and three CNAs who wished to remain anonymous. | 2018-08-01 |
| 6921 | GOOD SHEPHERD LUTHERAN HOME | 285148 | 2242 WRIGHT STREET | BLAIR | NE | 68008 | 2015-08-27 | 520 | K | 1 | 0 | PN1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of the facility's policy and procedure for the Continuous Quality Improvement (QCI) Committee and staff interview, the facility failed to ensure residents were free from a potential injury of a scald from hot liquids. This finding constituted an Immediate Jeopardy situation. This affected 13 of 77 residents with a [DIAGNOSES REDACTED]. (R61, R63, R70, R71, R72, R73, R74, R75, R76, R77, R78, R79 and R80). Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. An interview of Registered Nurse 30 (RN 30) was conducted on 8/27/15 at 5:40 AM and a temperature test of the hot liquids was verified by RN 30. A test of the temperature of the liquid dispensed on 8/27/15 at 5:40 AM from the automatic hot drink dispenser revealed the cappuccino and hot chocolate liquid dispensed was 161 degrees Fahrenheit. The hot coffee was tested for a temperature of 163 degrees Fahrenheit. RN 30 was advised of the serious and immediate concerns by the survey team. RN 30 verified the drink dispenser and the coffee maker were located in an area accessible to residents on the dementia unit and the area was unsupervised. RN 30 unplugged the hot beverage dispensers and left the unit. Interview of Licensed Practical Nurse 40 (LPN 40), who was working the secure care unit on 8/27/15 at 6:00 AM, identified the following residents as confused residents who wander on the secure unit: R61, R63, R70, R71, R72 and R73 and was advised of the serious concerns for potential injury to residents by the liquids dispensed from the hot beverage machines in an unsupervised area. Observation of two facility staff Certified Nursing Assistants (CNAs) on 8/27/15 at 6:05 AM revealed they plugged the units back in to an electrical outlet and turned the hot beverage machines on and made coffee. The two CNAs then walked out of the dining area, leaving the two drink dispensers unsupervised and back in operation. The facility failed to provide supervision in the area of the hot beverage dispensers. Interview with the Director of Nursing on 8/27/15 at 8:45 AM revealed the CQI (Continuous Quality Improvement) committee met monthly with the facility staff and quarterly with the facility staff, Medical Director, and the Pharmacist. She also revealed the committee had identified problems in the Secured Care Unit for falls and skin and had developed plan to correct the problems. The CQI committee failed to identify the issue with the hot beverage dispensers in the facility located in areas accessible to confused residents with no supervision and the potential for injury to these residents. The facility Administrator and the Director of Nursing were notified of the serious concerns by the survey team on 8/27/15 at 9:30 AM. The facility Administrator was notified of the recommendation of Immediate Jeopardy in the area of accident hazards on 8/27/15 at 9:50 AM. The Immediate Jeopardy was removed on 8/27/15 at 11:00 PM and continued at a lower severity level when the facility completed the following corrective actions: 8/27/15 at 10:00 AM, all hot fluid machines were disconnected and moved to the main kitchen away from resident accessibility 8/27/15 at 10:20 AM, six dietary staff were educated. A new procedure was put in place regarding hot liquids. All hot fluids were to be placed in carafes and taken to the dining rooms. The dietary staff would measure the temperature of the liquids and make certain the fluid temperature would not scald a resident if contact was made with skin. Dietary staff would document the temperatures of liquids sent to the resident dining area on a flow sheet in order to ensure temperatures of hot liquids remained at a level below 120 degrees Fahrenheit The Quality Assurance Committee representative would review all documentation related to fluid temperature monitors to ensure safety daily for seven days, weekly for four weeks and monthly for six months. All documentation would be reviewed quarterly through the next annual survey On 08/27/15 at 2:00 PM, 6:00 PM and 10:00 PM, all staff would attend a mandatory meeting and would be educated on the awareness of hot fluids and safety of the residents. Findings include: Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. Staff interview of Certified Nurse Assistant 81 (CNA 81) on 8/27/15 at 6:10 AM revealed the hot beverage dispensers were for the use of residents and visitors. CNA 81 stated residents were able to get a beverage if they wished. Further observation of the hot beverage dispensers was continued to determine if residents used the dispensers without staff supervision. Observation of R63 on 8/27/15 at 7:08 AM revealed the resident walked into the dining area and obtained a cup of coffee with cappuccino mixed. The cup was filled to the top. The resident spilled a portion of the hot beverage on her hand as she attempted to carry the drink to a table. The resident stated ouch, ouch, ouch and wiped her hand with a paper towel. Review of the clinical record for R63 revealed the resident had a [DIAGNOSES REDACTED]. The assessment documented the resident wandered daily. The assessment documented the resident required supervision for eating. Interview of Medication Aide 90 (MA 90) on 8/27/15 at 8:12 AM verified the hot beverage center was available for use by residents on the 200, 300 and 400 units. Observation of the beverage center off the main dining room on 8/27/15 at 8:12 AM revealed a hot beverage dispenser for coffee and hot chocolate. A test of the temperature of the liquids dispensed revealed the coffee was 158 degrees Fahrenheit and the hot chocolate was 160 degrees Fahrenheit. Residents identified by Registered Nurse 100 (RN 100) on the facility units 200, 300 and 400 at risk for injury by the hot liquids dispensed from the beverage center located in the main dining room with a [DIAGNOSES REDACTED]. Observation of the kitchenette area on 8/27/15 at 10:00 AM and the beverage center off the main dining room verified all hot liquid beverage machines had been removed from unsupervised areas accessible to residents who were confused and mobile. On 8/27/15 at 2:00 PM, the facility Administrator provided the first in-service of staff, which was also attended by the state surveyor, who was observing the survey. The education presented to staff included the risk of burn with hot fluids and the process regarding how to reduce the risk of scald. The Administrator explained how the facility was going to ensure the coffee was not served too hot to protect the residents from burns. The dietary staff were to ensure the coffee had cooled to 120 degrees Fahrenheit and were to ask the residents if the coffee temperature was acceptable. The facility planned to complete hot liquid assessments on all residents to assess their risk. The facility planned to complete a care plan for the residents at risk of hot liquid spills. The staff were instructed to use coffee cups with lids. There were 70 staff members at the first in-service on 8/27/15 at 2:00 PM. The Administrator planned to hold additional in-services on 8/27/15 at 6:00 PM and at 10:00 PM. The in-service was mandatory education for all staff. Interview of the facility staff on 8/27/15 between 2:30 and 3:00 PM following the in-service held at 2:00 PM included seven Certified Nurse Assistants (CNA), the Activity Director and five Registered Nurses. All staff evidenced knowledge of the procedure put in place on 8/27/15 to ensure residents' safety in relation to hot liquids. During the staff interviews, facility staff voiced a concern regarding the hot beverage machine on the Secure Care Unit previous to the identification by the surveyor team, but revealed no action had been taken by the facility. This included interviews with two nurses and three CNAs who wished to remain anonymous. Review of the facility policy for CQI, dated 6/15/14, revealed the facility will establish and maintain CQI to perform quality assessment activities and oversee the identification in handling of quality issues. There was no evidence the QCI committee identified the dangerous safety hazards related to the hot beverage dispensers on the Secured Care Unit and in the Beverage Center located in the main dining. The dispensers were assessable to all 13 residents identified with a [DIAGNOSES REDACTED]. | 2018-08-01 |
| 7411 | PREMIER ESTATES OF CRETE, LLC | 285170 | 830 EAST 1ST STREET | CRETE | NE | 68333 | 2015-04-21 | 223 | K | 1 | 0 | GGVC11 | Licensure Reference Number: 175 NAC 12-006.05 (9) Based on record review and interview, the facility failed to provide interventions to protect four residents (Residents 3, 7, 8 and 11) that voiced feelings of fearfulness related to the administrator yelling profanity towards staff in a manner that could be witnessed by all residents. The facility had a census of 59 residents. Findings are: A. Review of a Concern Form dated 3/13/15 filed by Resident 3 revealed the following, To: DON (Director of Nursing) Tonight before supper what (the administrator) did was uncalled for yelling on the walkie (at) all the nurses in a drill sergeant tone telling you to get off your (profanity) should've at least closed the door to your office You need to call corporate and ask for a different boss because (administrator) is very unprofessional because of cussing and yelling .(the administrator) does not treat you guys right and needs to go. Further review of the same Concern Form revealed, describe the Action that has been taken: 3/16/15 faxed/scanned to (Human Resources) and 3/19/15 Ombudsman here. Interview with Resident 3 on 4/7/15 at 9:38 AM revealed a few staff were always grouchy towards residents but that Resident 3 felt it was because of the way the administrator treated them. Resident 3 went on to describe an incident that occurred on March 13th in the afternoon. The administrator came into the facility and noticed call lights were going off and had not been answered. The administrator had an outburst and started yelling and using profanity towards staff. Resident 3 continued to report that several residents overheard this exchange because they were gathered outside of the dining room waiting for the next meal to be served. Resident 3 continued to state that this was not an isolated incident and that Resident 3 had personally heard the administrator yell and use profanity while walking the hallways at the facility. Resident 3 described feeling scared and living in a hostile environment. Resident 3 stated someone from the corporate office did call and interview (Resident 3) about these concerns. Resident 3 stated after the phone call (Resident 3) was afraid of causing problems. Resident 3 further stated that the administrator was scheduled to transport Resident 3 somewhere the following day and that Resident 3 felt nervous to be alone with the administrator. B. Review of a Concern Form dated 3/13/15 filed by Resident 7 revealed, continued verbal assaults against the staff will cause ramifications in the future, such as, lower moral, lowered ability to care for the clients on March 13th, 2015 (the administrator) shouted at one particular (staff) passing meds (medications) to the point of (staff) breaking down and crying .I will likely need to talk to (the administrator's) supervisor because this is one incident that is snowballing and will continue. (The administrator's) iron fisted way of running a nursing home is beyond belief. Further review of the same Concern Form revealed, describe the Action that has been taken: 3/16/15 faxed/scanned to (Human Resources) and 3/19/15 Ombudsman here. Interview with Resident 7 on 4/7/15 at 10:00 AM revealed the administrator dresses down the staff in front of the residents. When asked if the administrator had ever spoken to a resident in that manner, Resident 7 responded, (the administrator) doesn't have to, (the administrator) just makes sure we overhear (the administrator) doing it to the staff. Resident 7 explained that overhearing this makes Resident 7 nervous about what the administrator will do if any of the residents do something wrong at the facility. Resident 7 further explained that the administrator had been overheard yelling at staff on more that one occasion but over time it had gotten worse. Resident 7 recalled an incident that occurred on the 13th of March. Resident 7 stepped into the hallway after hearing the administrator yell at a staff member. Resident 7 then followed the administrator down the hall towards the (administrator's) office. The administrator went into the office and slammed the door. Resident 7 ended the interview by stating I want to get out of here. C. Review of a Concern Form dated 3/20/15 filed by Resident 8 revealed, in my opinion (the administrator) acted unprofessional, rude and demeaning to the aides, the DON and to the residents. (The Administrator) also said what the (profanity) is all these call lights on in (this hallway). Further review of the same Concern Form revealed, describe the Action that has been taken: 3/20/15 fax/scanned to (Director of Customer Service). On 4/7/15 at 9:12 AM, Resident 8 was interviewed to determine if any abuse had ever occurred at the facility. Resident 8 responded, mentally, the administrator had been abusive by the way (the administrator) treated the staff in front of the residents. Resident 8 went on to recall an incident when the administrator was yelling in the hallway and using profanity towards staff members and in general when walking the hallways. Resident 8 heard the administrator use profanity while standing directly outside of Resident 8's room. Resident 8 reported feeling fearful every time the administrator went on another tirade which occurred almost on a daily basis. Resident 8 reported the administrator should not be allowed to talk to staff in that manner in front of the residents at the facility. D. Review of a Resident Council Concern form dated 3/26/15 revealed several residents were inquiring about the administrators behaviors and being allowed to yell like that in the hallways. Resident 11 requested that some one apologize to a family member visiting that overheard the administrator using profanity towards a staff member and was upset. The form also stated, Action Taken: (corporate employee) given a copy. Interview with the State Long-Term Care Ombudsman on 4/7/15 at 8:10 AM revealed a group of resident's had requested to meet to discuss concerns they had regarding the facility administrator. Residents voiced at this meeting that the administrator used vulgar language towards staff and all residents present reported feeling fearful of the administrator. E. Review of a Concern Form dated 3/31/15 filed by Resident 11 revealed, Description of Concern: (The administrator) yelling out loudly at (staff member) Interview with Resident 11 on 4/7/15 at 12:45 PM revealed the administrator had yelled and called staff names in front of a family member that was visiting Resident 11. Resident 11 reported feeling embarrassed and fearful of the administrator. Resident 11 went on to say the most recent episode of the administrator yelling out at staff had just occurred earlier that same day. Resident 11 continued on to say, I am going to move because when (the administrator) is here everyone is uptight and it just feels different when (the administrator) is around. Review of the facility's Abuse and Neglect Prohibition policy revised June 2013 reveals, Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Interview with the Division Director of Operations on 4/7/15 at 4:45 PM revealed the corporate office was aware of these concerns the resident's had made and had concluded that the staff were the only ones that were being affected. The Division Director of Operations further reported the facility administrator had been suspended while an internal investigation could be conducted. The immediate jeopardy was abated when observation on 4/7/15 at 4:50 PM revealed the facility administrator had left the facility grounds. | 2018-04-01 |
| 10209 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 309 | K | 0 | 1 | NRZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D Based on record review, staff interview, and observations; the facility failed to assess residents' change in condition, failed to assess residents pain and effectiveness of medications, the facility failed to assess lab results, failed to assess the cause of skin conditions and failed to assess causes and develop nonpharmaceutical interventions for residents anxiety. (Residents 19, 22, and 32). The faciltiy census was 30 and the survey sample size was 26. Findings are: A. Review of the DISCHARGE AND DISCHARGE SUMMARY SHEET revealed the resident was admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident 19's MDS (a federally mandated comprehensive assessment tool used for care planning) dated 4/12/2012 revealed the following information about the resident: -the BIMS (Brief Interview for Mental Status) score was 5 of 15 (a score of 0 to 7 indicates severe cognition impairment), -The resident experienced short and long term memory issues, -The MDS addressed no behaviors, -Limited assist of one person physical assist for bed mobility, locomotion on unit and personal hygiene, -The resident required an extensive assist of one person physical assist for transfers, walk in the room, walk in the hall and dressing,, -The resident was dependent on two staff physical assist for toilet use, -The medication review was coded as the resident received an antianxiety one day in the assessment period and an antidepressant every day for the 7 days during the assessment period. Review of the Long Term Care Communication with the Provider, dated 6/28/2012 revealed increased episodes of agitation, biting, hitting, and kicking, wants to go home. PA (Physician Assistant) wrote an order for [REDACTED].>Review of the Laboratory Report dated 6/28/2012 for Resident 19 revealed a hand written note waiting for C & S (culture and sensitivity) along with PA initials. Review of the Physician Telephone Orders dated 7/5/2012 revealed an order to check [MEDICATION NAME] level in 1 week on 7/12/2012. Review of the medical record found no documented evidence of results from a [MEDICATION NAME] level. Interview with the DON and RN-S (Registered Nurse) on 7/25/2012 at 10:30 AM revealed no [MEDICATION NAME] level was available. Also said no culture and sensitivity available for the urinalysis performed on 6/28/2012. Resident received [MEDICATION NAME] (antibiotic) while in the hospital. Review of the UA from the hospital dated 7/4/2012 was sent for culture and sensitivity with final growth of [MEDICATION NAME], faecalis treated with [MEDICATION NAME]. Review of the Initial review and investigation dated 7/3/2012 revealed resident was seen at the clinic for lethargy and sounding gurgly. She was admitted to the hospital . No definite pneumonia was noted. She was treated with [MEDICATION NAME] for possible narcotic overdose. Review of a Clinic Note dated 7/3/2012 revealed resident was brought to the clinic because the resident was lethargic. She had a [MEDICATION NAME] 25 mcg (microgram) patch added by the PA on 6/28/2012 and bumped [MEDICATION NAME] to 150 mg (milligram) daily and added [MEDICATION NAME] 2.5 mg bid (two times a day). Resident basically unresponsive and very lethargic. Resident was gurgling and not able to respond to voice but to pain only. Resident had abnormal lung sounds bilaterally and it sounds like she is not handling her secretions. I suspect the resident may have a narcotic overdose from the [MEDICATION NAME] and maybe aspirated. Review of the admission notes dated 7/3/2012 showed an admission [DIAGNOSES REDACTED]. The reason for admission from long term care was she was not handling her secretions and was non-responsive. [MEDICATION NAME] was administered 2 (two) times and [MEDICATION NAME] was started for low grade fever and bandemia. Review of the nurses notes revealed the following: 6/28/2012 --10:00 AM resident agitated, wanting to ambulate without assistance hitting, kicking, biting unable to redirect the resident. --11:00 AM resident still agitated. Refusing assistance hitting kicking and yelling she wants to go home. --12:00 PM resident out to lunch, calmer but still restless. --2:00 PM resident restless, biting, hitting staff. 1:1 with staff unable to redirect. --2:45 PM PA informed of increased agitation, combative, and restless new orders received [MEDICATION NAME] 2.5 mg po bid and urinalysis sent to the Lab urine was cloudy and amber. --(no time of entry) [MEDICATION NAME] and [MEDICATION NAME] started as ordered. --6/29/2012 --1:10 AM drowsy and difficult to arouse. O2 88-92 % loose cough. **No documentation from 6/29/2012 at 1:10 AM until 4 PM on 6/30 approximately 30 hours after documentation of difficult to arouse. 6/30/2012 --4:10 PM resident restless making attempts to stand without assistance intervention 1:1 hitting, biting. --5:30 PM continued behaviors of agitation,yelling , biting, --7:00 PM agitated PA here new orders for [MEDICATION NAME] .5 mg bid. --11:00 PM resting in bed. 7/1/2012 No documentation of behaviors from 6/30/2012 at 11:00 PM until 7/1/2012 --1:45 PM approximately 14 hours . --1:45 PM sleepiness, denies pain hoarse voice. --2:15 PM hitting, scratching staff, wanting to go home. --2:30 PM PA here dc'd (discontinued) [MEDICATION NAME] resident agitated new order for ABH gel 1 ml topical TID --2:50 PM continues combative, biting, hitting. Obtained skin tear left hand. --3:30 PM continues combative, hitting, biting --6:20 PM daughter here less anxious. **No documentation from 7/1/2012 at 6:20 PM to 8:00 AM on 7/2/2012 about 8 hours reference behaviors. 7/2/2012 --8 AM BP (blood pressure) 218/95, pulse 77, respirations 16, temperature 98.4 no O2 (oxygen) saturation drowsy incontinent of urine. [MEDICAL CONDITION] right side of body down arms/face. Accepted meds and drank, no breakfast. --12:00 PM BP 172/88, pulse 60, respiration 17 afebrile no O2 saturation awakens consumes 25 % of meal and medication. verbal report to PA. --1:00 PM [MEDICAL CONDITION] less on right side of body. --6:00 PM lethargic combative with cares ate 50% of meal with much encouragement, being fed. --8:00 PM [MEDICAL CONDITION] less refuses HS (bedtime) meds, in bed. 7/3/2012 --10 PM - 6 AM cooperative with staff 7/3/2012 --9 AM very lethargic no VS documented, drank well at breakfast opens eyes and tries to speak. --2:00 PM OOF (out of facility) to Dr. appointment. --1:30 PM nurse called to the room CNA stated resident hard time coughing and couldn't cough up phlegm assisted with mouth swabs and suctioned. --2:30 PM admitted to acute care --2:45 PM daughter notified of admit to acute care. Review of the Initial review and investigation dated 7/3/2012 revealed resident was seen at the clinic for lethargy and sounding gurgly. She was admitted to the hospital . No definite pneumonia was noted. She was treated with [MEDICATION NAME] for possible narcotic overdose. Review of a Clinic Note dated 7/3/2012 revealed resident was brought to the clinic because the resident was lethargic. She had a [MEDICATION NAME] 25 mcg patch added by the PA on 6/28/2012 and bumped [MEDICATION NAME] to 150 mg daily and added [MEDICATION NAME] 2.5 mg bid. Resident basically unresponsive and very lethargic. Resident was gurgling and not able to respond to voice but to pain only. Resident had abnormal lung sounds bilaterally and it sounds like she is not handling her secretions. I suspect the resident may have a narcotic overdose from the [MEDICATION NAME] and maybe aspirated. Review of the admission notes dated 7/3/2012 showed an admission [DIAGNOSES REDACTED]. The reason for admission from long term care was she was not handling her secretions and was non-responsive. [MEDICATION NAME] was administered 2 times and [MEDICATION NAME] was started for low grade fever and bandemia. Interview with the DON on 7/25/2012 at 11:03 PM stated staff were borrowing medication when the DON started working at the facility and had been told to borrow meds so were re-educated to never borrow medications. Review of the Medication Record dated June 2012 revealed that the staff administered the following medications: [REDACTED] On 6/28/2012 -[MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg every HS -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] 2.5 mg bid started at 1700 [MEDICATION NAME] 25 mcg change every 72 hours for pain applied On 6/29/2012 [MEDICATION NAME] 500 mg daily at 1400 -Harriet 10 mg every HS -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] XR 150 mg daily at 0800 [MEDICATION NAME] 2.5 mg bid 1200 and 1700 [MEDICATION NAME] 25 mcg change every 72 hours for pain On 6/30/2012 [MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg every HS -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] XR 150 mg daily at 0800 [MEDICATION NAME] 2.5 mg bid 1200 and 1700 [MEDICATION NAME] 25 mcg change every 72 hours for pain On 7/1/2012 [MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg every HS -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] XR 150 mg daily at 0800 [MEDICATION NAME] 2.5 mg bid 1200 and 1700 [MEDICATION NAME] 25 mcg change every 72 hours for pain changed [MEDICATION NAME] .5 mg bid at 0800 and 1400 ABH gel PRN applied at 1430 On 7/2/2012 [MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] XR 150 mg daily at 0800 [MEDICATION NAME] 2.5 mg bid 1200 [MEDICATION NAME] 25 mcg change every 72 hours for pain On 7/3/2012 [MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] 2.5 mg bid 1200 [MEDICATION NAME] 25 mcg change every 72 hours for pain Review of the medical record for Resident 19 revealed no documented evidence the resident was assessed for pain before the [MEDICATION NAME] Patch was started. Reference Nursing 2012 Drug Handbook revealed the following medication that had possible adverse consequences: --[MEDICATION NAME]--therapeutic class--anticonvulsant--peak time 15 minutes to 6 hours--black box warning--facial [MEDICAL CONDITION], weakness, and lethargy. --[MEDICATION NAME]--therapeutic class--anti-Alzheimer--peak time 3-4 hours--adverse effects--monitor the resident for [MEDICAL CONDITION] because of potential vagotonic effects. --[MEDICATION NAME]--therapeutic class-Anti-Alzheimer--peak time 3-7 hours-- adverse effects--aggressiveness, agitation, anxiety, confusion, [MEDICAL CONDITION], may impair renal function. --[MEDICATION NAME]--therapeutic class---antidepressant--peak time 1-2 hours--adverse effects--monitor blood pressure as drug therapy may cause sustained dose dependent increases in blood pressure. --[MEDICATION NAME]--therapeutic class--antipsychotic--peak time 6 hours--black box warning sedation including coma or [MEDICAL CONDITION], overdose agitation, aggressiveness, reduced level of consciousness, aspiration. --[MEDICATION NAME] Patch--therapeutic class--opiod [MEDICATION NAME]--peak time 1-3 days--black box warning life--threatening hypoventilation between 24 to 72 hours after initial application, overdose signs and symptoms depression , respiratory depression , apnea, [MEDICAL CONDITIONS]. --[MEDICATION NAME]--therapeutic class--antipsychotic--peak time 1 hour--adverse reactions--drowsiness, sedation, [MEDICAL CONDITIONS]. --[MEDICATION NAME]--therapeutic class--anxiolytic--peak time 2 hours--adverse reactions drowsiness, sedation, agitation, weakness, unsteadiness, disorientation. --[MEDICATION NAME]--[MEDICATION NAME]--adverse reactions--peak time 1-4 hours--adverse reaction--drowsiness, sedation, sleepiness, dizziness, confusion, [MEDICAL CONDITION], tachcardia. --[MEDICATION NAME]--therapeutic class--antipsychotic--peak time--3-6 hours--adverse reaction--sedation, drowsiness, lethargy, confusion. --[MEDICATION NAME]--therapeutic class--antidote (may displace opiod [MEDICATION NAME] from their receptors)--adverse effect [MEDICAL CONDITION], tremors. The common adverse reactions the resident experienced were agitation and aggressiveness. Further review found the facility was not tracking behaviors and reviewing the effectiveness of the medication that was being administered to Resident 19. B. Resident 22 was admitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. Observation on 7/23/2012 at 9:00 AM revealed that Resident 22 had a large purple bruise on the right elbow and another large bruise on the inner side and the outer side of the left elbow. Review of Resident 22's Nurse's Notes dated 7/14/2012 at 7:45 AM revealed that a skin tear was discovered to Resident 22's right elbow. Documentation revealed that the skin tear measured 1.5 cm (centimeter) in length and 0.5 cm in width. Resident 22 stated that the elbow was bumped on the door when exiting the restroom. Further review of Resident 22's Nurse's Notes from 7/14/2012 to 7/24/2012 did not reveal any documentation of bruises to the left elbow. Observation on 7/24/2012 at 2:57 PM of Resident 22 along with the DON (Director of Nursing and LPN (Licensed Practical Nurse) D revealed that they were unaware of the large bruises on both the right and left elbows. Both the DON and LPN D stated that the large purple bruises to both elbows had not been reported so there had not been any assessment as to the cause or to prevent further bruises from occurring. C. Review of an ADMISSION AND DISCHARGE SUMMARY dated 7/10/12 revealed Resident 32 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident 32's CARE PLAN dated 7/16/12 revealed (Resident 32) is displaying behaviors of social inappropriateness by arguing with staff and name calling: - 1) Arguing with staff related to anxiety & confusion, 2) Calling staff names; - Approaches were -- 1. Redirect to another activity; -- 2. 1:1 activity; -- 3. change in activity; -- 4. return to room for change of area (do not leave alone); -- 5. take to toilet; -- 6. offer food; -- 7. offer fluid; -- 8. change position; -- 9. adjust temperature of room; -- 10. offer back rub; -- 11. medication intervention (last resort); and -- 12. other. The care plan did not describe behaviors displayed when Resident 32 was anxious or which situations or circumstances caused the anxiety. Interventions did not explain how or where to redirect Resident 32. During an interview on 7/26/12 at 8:30 AM, the Social Service Director (SSD) revealed Resident 32 displayed anxiety by using the call light frequently. The SSD explained Resident 32 would feel the call ling was on for a long time, when it wasn't, then Resident 32 would get more and more anxious. The SSD revealed at times Resident 32 would wake up during the night and want to get up, which added to the resident's anxiety. The SSD stated the staff would try to encourage Resident 32 to go back to sleep, but if the efforts were unsuccessful, staff would assist the resident to get up and sit in the recliner. The SSD revealed this intervention was not on the care plan. The SSD revealed some family dynamics also played a part, as some family members had told said the resident could go home and other had told the resident (gender) could not. The SSD revealed Resident 32 would call staff names and staff were to ignore the behavior and not take it personally. The SSD revealed the family dynamics and the intervention to ignore name calling were not included in the care plan. The SSD revealed there was no documentation that explained what triggered Resident 32's anxiety and interventions on the care plan were not specific in how or where to redirect Resident 32. The SSD stated there was not documentation whether or not interventions tried were successful and 1:1 interventions were not documented. Review of physician's orders [REDACTED]. | 2016-02-01 |
| 11105 | GOLDEN LIVINGCENTER - SORENSEN | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2012-01-05 | 309 | K | 1 | 1 | 9QU611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09 Based on record review and interview; the facility staff failed to assess 5 residents ( Resident 1, 7, 11, 13, and 27) of 27 sampled and 7 non-sampled residents who had fallen, on an ongoing basis to identify potential changes in condition. The facility staff identified a census of 61. Findings are: A. Record review of the facility Neurological Check Policy and Procedure dated ,[DATE] revealed the following: -It is the policy of GLC (Golden Living Center) Sorensen to perform neurological checks when the following occurs: -MD orders the neuro (neurological) checks. -Change in mental status. -Residents sustains an un-witnessed fall, is unable to state whether he/she hit their head and it is not clear that the resident did not hit their head. -1. Check every 15 minutes x 4 for 1 hour. -2. Check every 30 minutes x 2 for 1 hour. -3. Check every hour x 4 hours. -4. Then check every 8 for 72 hours. Record review of a Admission Record dated [DATE] revealed Resident 27 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Resuscitation Orders sheet dated [DATE], revealed Resident 27 had documentation for "no CPR". Record review of Resident 27's Minimum Data Set (A federally mandated comprehensive assessment tool used for care planning) dated and signed on [DATE] revealed the facility staff assessed the following about the resident: -Resident 27 had short and long term memory problems. -Decision making was severely impaired. -Required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. -Balance during transitions and walking was assessed as " not steady, only able to stabilize with human assistance". -Frequently incontinent of bowel, bladder and having falls since admission. Additional [DIAGNOSES REDACTED]. Record review of Resident 27's Progress Notes dated [DATE] revealed Resident 27 was "... found on the floor in mdr (main dining room)... Slid out of w/c (wheelchair) because of improper positioning". Record review of a Change in Condition Report (COCR) -Post Fall/Trauma report dated [DATE] revealed Resident 27 had fallen in the MDR. The report contained information Resident 27 had impaired safety awareness/judgement/unaware of position. The COCR contained an area to be checked if the neuro checks were completed. The neuro section was not marked as being completed at the time of the fall. Further review of Resident 27's Progress notes did not contain evidence that Resident 27 had neuro checks assessments completed after the fall. Record review of Resident 27's Progress Notes dated [DATE] revealed Resident 27 was "... found in MDR on floor, other resident reported res (resident) slid out of chair... Red abrasion notes to back of head quarter size...". Resident 27's medical record did not contain evidence neuro assessments had been completed after the fall with the resulting abrasion to the back of the head. Record review of Resident 27's Progress Notes dated [DATE] revealed Resident 27 was found on the floor next to the wheelchair. According to the progress note dated [DATE], Resident 27 was assisted into the wheelchair, taken to (gender) room and assisted into bed. There was not any evidence that neurological assessment had been completed for Resident 27. The progress note contained information that Resident 27 had been found without a pulse,respirations and emesis (vomit) of brownish coffee color. Resident 27's physician was informed and pronounced that Resident 27 had expired. Interview with Resident 12 revealed the following: -Resident 12 was Resident 27's roomate at the time Resident 27 died . -After Resident 27 was put to bed on [DATE], Resident 12 heard different kinds of noises such as gurgling coming from Resident 27's side of the room. -Resident 12 turned on the call light and nobody answered the call light. -Residednt 12 started to yell for help and after about 30 minuites a staff responded. On [DATE] at 1:35 PM an interview was conducted with Licensed Practical Nurse (LPN) B. During the interview, LPN B reported (gender) was informed that Resident 27 was on the floor. According to LPN B, LPN B entered the MDR were Registered Nurse (RN) C was in attendance of Resident 27. According to LPN B, LPN B checked to evaluate if Resident 27 had any injuries. LPN B reported completing the neuro check as part of the "assessment". LPN B confirmed Resident 27's record did not contain evidence of the neuro checks being completed. Interview on [DATE] at 2:30 PM, Nursing Consultant (NC) A confirmed that neuro assessments are to be completed on any resident who had un-witnessed falls. On [DATE] at 2:40 PM a follow up interview was conducted with NC A. During the interview NC A stated " no neuro checks had been completed" for Resident 27's un-witnessed falls. An interview was conducted on [DATE] at 2:43 PM with RN C. During the interview, RN C reported that (gender) was returning from break when responding to Resident 27 being found on the floor. According to RN C, another resident was attempting to help Resident 27 up from the floor. RN C reported intervening. RN C reported that (gender) was not sure if Resident 27 had hit (gender) head. RN C reported checking for bumps. When asked if neuro assessment had been completed for Resident 27, RN C stated "no". According to RN C, Resident 27 did not have any injuries and was taken to (gender) room. RN C reported that LPN B was instructed to complete the neuro checks. On [DATE] at 6:20 AM a follow up interview was conducted with LPN B. During the interview when asked if LPN B knew the facility policy and procedure for neuro checks, LPN B stated "no". When asked if LPN B knew what the standard in the community for neuro checks were, LPN B stated "no". When asked how long neuro checks were to be completed for a resident, LPN B stated "I think every 15 minutes for 24 hours." When asked if this was completed for Resident 27, LPN B stated "no". An interview with the Director of Nursing (DON) was completed on [DATE] at 8:20 AM. During the interview, the DON confirmed that neuro checks assessments had not been completed for Resident 27 after the falls noted on [DATE], [DATE] and [DATE]. During the interview the DON confirmed that ongoing assessments of the falls for Resident 27 had not been completed. the DON stated "yes" when asked if Resident 27 should have had completed ongoing assessments after the falls. On [DATE] at 10:45 AM an interview was conducted with NC A. During the interview, NC A reported there were "inconsistency with what staff believe the policy was for or how often to do neurochecks". An interview with the DON on [DATE] at 11:00 AM. The DON reported the policy had not been established for neurochecks until yesterday ([DATE]). When asked what the expectation was for completing neurochecks were prior to [DATE], the DON stated "We used the rule of 4". The DON reported that the rule of 4 wasn't written down or was there a policy. When asked what the expectations were for completing the neurocheck assessments, the DON stated" would expect neurochecks for any unwitnessed falls or of hitting of head". According to the rule of 4 for neuro checks would be the following: -Neurochecks every 15 miniutes x's 4. -Neurochecks every ,[DATE] hour x's 4. -Neurochecks every hour x's 4. -neurochecks every 8 hours x's 4. B. Record review of an Admission Record sheet dated [DATE] revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's MDS signed and dated [DATE] revealed the facility staff assessed the following about the resident. -Resident 1 had short and long term memory problems. -Severely impaired decision making. -Required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. -Frequently incontinent of bladder and always incontinent of bowel. -No fall history was identified for Resident 1. Record review of Resident 1's Progress Notes dated [DATE] revealed Resident 1 "...had fell out of bed during this shift". Resident 1's record did not contain evidence that a neuro assessment had been completed or that an ongoing assessment of Resident 1's neurological status had been conducted. Record review of a Verification of Investigation sheet dated [DATE] for the occurrence dated [DATE] at 9:10 AM revealed Resident 1 had been seen on the floor by a Therapist. According to the information in the investigative report, the DON assessed the resident and did not identify any injuries. According to the investigation report, Resident 1 was identified with swelling on the right side of the face at a 11:00 PM on [DATE]. Resident 1 was sent to the hospital and returned with a fracture to the right periorbital area ( right eye area). Record review of Resident 1's Progress notes dated [DATE] revealed Resident 1 "rolled out of bed". Resident 1's medical record did not contain evidence that a neuro assessment had been completed or that an ongoing neuro assessment was conducted. Record review of Resident 1's Progress notes dated [DATE] revealed a late entry for [DATE] of Resident 1 being found on the floor "around 7:15 AM with a bruise to the left side of Resident 1's head. Record review of a Neurological Flow sheet revealed 2, 15 minutes checks had been completed with documentation identifying that Resident 1 was in therapy from 8:00 AM through 9:30 AM. There was not evidence the neuro assessment had been completed at those times. An interview was conducted on [DATE] with NC A. During the interview, NC A confirmed neuro assessments had not been completed for the incidents on [DATE] and [DATE] and was not completed for the incident on [DATE]. When asked if the neuro assessments should have been completed, NC A stated "yes". C. Record review of Resident 7's Admission Record dated [DATE] revealed an admitted [DATE]. Resident 7's History and Physical dated [DATE] revealed a [DIAGNOSES REDACTED]. of abnormal movements overall and moderate incapacitation due to abnormal movements. Observation on [DATE] at 12:02 PM revealed Resident 7 seated in a wheelchair and exhibited upper and lower extremity and trunk involuntary movements while in a wheelchair in the dining area of the facility. Record review of Resident 7's Nurses Note dated [DATE] revealed a note that read " *late entry for [DATE] ,[DATE] shift.*" The nurses note late entry revealed that Resident 7 had been found on the floor at 7:15 AM and that Resident 7 stated that the fall had occurred while trying to go to the bathroom. The nurses note identified that Resident 7 had a laceration above the left eye and complained of a headache. The nurses note indicated that crani checks (a neurological assessment used to evaluate the condition of a resident after a fall with a head injury) were documented on a crani check sheet. Record review of a Neurological Assessment record dated [DATE] for Resident 7 revealed that neurological assessments were started at 7:30 AM on [DATE] and continued every 15 minutes times 2 hours, then every 30 minutes times 2 hours, then hourly times 2 hours. There was no further documentation present in Resident 7's record of neurological assessment performed after 1:30 PM , 6 hours after Resident 7's fall, on the day of Resident 7's fall with a head injury. Interview on [DATE] at 10:45 AM with NC A confirmed that neurological checks for Resident 7 were not performed according to facility policy and that there was no documentation of neurological assessment performed for Resident 7 after 1:30 PM on the day of the fall. D. Based on Resident 13's face sheet, Resident 13 was admitted to the facility on [DATE]. Based on Resident 13's MDS dated [DATE], Resident 13 had the following Diagnoses: [REDACTED]. Review of the Facility Incident Log revealed Resident 13 fell out of bed on [DATE]. Review of the Change of Condition Report states the resident fell out of bed at 23:22 (11:23 PM) . Record review of Resident 13's Nurses Notes did not indicate Resident 13 fell . There is no entry at the time of the fall or no entry of what assessments or interventions were conducted in Resident 13's record. In an interview on [DATE] at 10:15 AM, RN Consultant-A confirmed none of these items were on the record. RN-Consultant-A stated that,based on the information in the record and what information is known about the incident, it is not believed that cranial checks were done or further ongoing assessment was done immediately following the fall. In an interview with LPN-C, it was confirmed that LPN-C was the nurse on duty when the fall occurred. LPN-C stated that Resident 13 was found on the side of the bed and had no apparent injuries so Resident 13 was returned to bed. E. Review of Resident 11's medical record revealed Resident 11 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 11's MDS dated [DATE] revealed Resident 11 required limited assist of 2 staff assistance for transfers. Review of the computerized Interdisciplinary Progress Notes (IPN) revealed on [DATE] Resident 11 was "observed on floor in (gender) room, next to bed". No documentation was found in the nursing notes to indicate if resident hit head. Review of Resident 11's Neurological assessment dated [DATE] revealed neurological checks were initiated after Resident 11 was found on the floor and were done every 15 minutes for 4 times, every 30 minutes for 4 times, 1 additional time, then no further checks were done as specified in the facility policy. Review of the computerized Interdisciplinary Progress Notes (IPN) revealed on [DATE] Resident 11 was "observed on floor in (gender) room next to bed, a few feet from w/c (wheelchair)". No documentation was found in the medical record to indicate if Resident 11 hit head. Review of Resident 11's Neurological assessment dated [DATE] revealed neurological checks were initiated after Resident 11 was found on the floor and were completed every 15 minutes for 4 times, every 30 minutes for 4 times, then 1 hour for 1 time but were not continued for the 72 hours per facility policy. Interview on [DATE] at 11:30 am with RN A confirmed that neurological checks were not completed per facility policy for Resident 11's falls on [DATE] and [DATE]. Review of Resident 11's Interdisciplinary Progress Notes (IPN) revealed on [DATE] Resident 11 was "observed on floor next to bed and w/c with legs straight out." No documentation was in the medical record to indicate if Resident 11 hit head. IPN states "crani checks" (another term for neurological checks) initiated. Review of Resident 11's medical record revealed no ongoing neurological assessments were completed. Interview with RN A revealed no ongoing neurological assessments were completed for Resident 11's fall on [DATE]. As outlined by the Administrator of the facility on [DATE] at 6:00 PM the facility initiated the following plan to address the immediacy of the situation. The facility will educate all nurses on fall management/clinical guidelines that were to include causal factors, cognitive status of residents, assessment of residents and the implementation of interventions. Nurses were to be educated on the facility Neurological assessment, in addition all staff were to be educated on call lights and responding to residents yelling out. All nurses were to be educated prior to allowing them to work. All falls were to be reviewed daily with the daily startup. Audits of all falls will be conducted x's 4 weeks, then 3 x's weekly x's 4 weeks and monthly thereafter. With the above interventions initiated, the scope and severity of the deficiency was lowered to an "E". | 2015-08-01 |
| 11273 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 323 | K | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and staff interviews; the facility failed to assure residents were free of injury from hot liquid spills. Resident 28 was not assessed for risk of hot liquid spills and sustained a burn after spilling coffee. In addition, hot water temperatures were not monitored to ensure residents who received showers were protected from potential burn injury. This affected 23 residents (Resident 35, 10, 12, 4, 17, 6, 34, 28, 37, 33, 1, 29, 15, 9, 18, 40, 36, 23, 2, 24, 39, 43, and 38). Facility census was 33. Findings are: A. Review of facility Hot Beverage Safety Guideline policy (revision date 4/2013) revealed residents were to be assessed using the Hot Beverage Safety Evaluation upon admission, quarterly and as needed to determine ability to independently consume hot beverages safely. Staff were to ensure supervision and assistance was provided as identified by the Hot Beverage Safety Evaluation and witnessed unsafe practices associated with the consumption of hot beverages were to be reported to the Nursing Department Manager/Designee with interventions implemented as required. B. Review of Resident 28's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/18/14 revealed [DIAGNOSES REDACTED]. Review of a facsimile (fax) dated 11/21/14 at 7:52 PM revealed Resident 28's physician was notified of a "...burn from hot coffee." The resident spilled coffee and sustained reddened skin areas on the inner left thigh from groin to knee and a 3 centimeter (cm) area on the left inner foot. Documentation further indicated that 45 minutes later the redness to the resident's inner thigh had decreased to "...mid inner thigh approx. (approximately) 5 cm" and the reddened area to the foot had " ...decreased as well." Review of Resident 28's medical record revealed no evidence to indicate a Hot Beverage Safety Evaluation was completed until 11/24/14 (3 days after the resident was burned). Review of Resident 28's Care Plan dated 11/24/14 (3 days after the resident was burned by spilled coffee) revealed an intervention started on 11/21/14 to allow Resident 28's coffee to cool down before serving. The Care Plan did not specify what temperature the coffee was to be cooled down to before serving. There was no evidence in Resident 28's medical record to indicate Resident 28's coffee was cooled before serving or to indicate coffee and hot liquid temperatures had been monitored from 11/21/14 to 11/24/14. On 11/24/14 at 1:30 PM, Nursing Assistant (NA)-B was observed assisting Resident 28 out of bed. The resident had an open skin area on the left inner thigh from a blister that had popped. The area was not measured at that time but the approximate size was larger than a 50 cent piece. (Review of a Weekly Wound Record dated 11/25/14 revealed Resident 28 had a wound on the left inner thigh that measured 3.8 cm by 4.7 cm.) Observation on 11/24/14 at 1:40 PM revealed the coffee when served from the coffee carafe in the kitchen was 158 degrees Fahrenheit (F). Interview with the Director of Nurses (DON) on 11/25/14 at 8:50 AM revealed Hot Beverage Safety Evaluations were completed on all residents on 11/24/14. The DON further indicated 3 residents (Residents 28, 2 and 9) were identified at risk for hot liquid spills with an intervention to place lids on cups of hot liquids. Observation of the breakfast meal on 11/25/14 at 8:55 AM revealed Residents 2 and 9 were served coffee in regular coffee cups without lids. Interview with the Dietary Manager (DM) on 11/25/14 at 9:30 AM revealed hot liquid temperatures were not checked following Resident 28's coffee burn on 11/21/14 and were not checked until 11/24/14. The DM verified Resident 2's hot liquids were not served in accordance with the plan of care. The DM was not aware Resident 9 was to have hot liquids served in a cup with a lid. ABATEMENT STATEMENT Based on the following, the facility removed the immediacy of the situation: 1.) Assessments regarding risk for hot liquid spills were completed on all residents and written plans were in place to address each resident ' s needs. 2.) All staff educated regarding policy for hot liquid assessments and prevention of hot liquid spills. All staff educated on following individual plans of care to assure residents received correct interventions to prevent hot liquid spills. 3.) Assigned a staff member to monitor and document each meal to assure hot liquids were served safely and in accordance with plans of care. 4.) Continue to monitor and record temperatures of hot liquids served at every meal. Although the immediacy was removed due to facility intervention, Resident 28 sustained a burn injury. Therefore, the scope and severity was lowered to H. C. Record review of the Long Term Care Regulation Appendix PP, F323 Guidance to surveyors revealed water temperatures at 120 degrees F could result in third degree burn (penetration of the entire thickness of skin with permanently destroyed tissue) within 5 minutes of exposure. Water temperatures at 127 degrees F could result in a third degree burn within 1 minute of exposure. Water temperatures at 133 degrees F could result in a third degree burn in 15 seconds of exposure. D. Observations on 11/19/14 of hot water temperatures in residents' bathrooms revealed the following: -8:20 AM in room 22 on Hallway 3 the temperature was 139.1 degrees F. -8:24 AM in room 11 on Hallway 3 the temperature was 130.3 degrees F. During an interview on 11/19/14 from 8:42 AM to 8:45 AM, NA-B confirmed residents had been receiving showers since 6:00 AM that morning. NA-B identified no water temperatures were checked prior to giving any residents a shower stating, "We have never been expected to check water temperatures before giving showers. I regulate the water temperature by feel and will adjust the temperature if the resident's complain". NA-B further identified a concern about the water getting hotter this morning but had not notified anyone about the excessive hot water. During an observation on 11/19/14 at 2:08 PM the water temperature of the hand-washing sink of the Activity Room was measured at 133.2 degrees F. Hot water temperatures were reported to the Registered Nurse (RN) Consultant on 11/19/14 at 2:13 PM. The RN Consultant indicated facility staff completed and documented hourly hot water temperatures, and on the last checks, water temperatures were above 130 degrees on all 3 hallways. The RN Consultant further indicated a plumber was working at the facility at this time. The RN Consultant identified a plan was in place to continue to monitor and document hot water temperatures, all staff had been educated regarding excessive hot water temperatures, signs had been placed in all the residents' bathrooms regarding excessive hot water temperatures, and a log was placed in the shower room for staff to use to monitor and document water temperatures before all showers. Review of the facility shower/bath schedules dated 11/20/14 through 12/1/14 revealed 23 residents (Residents 35, 10, 12, 4, 17, 6, 34, 28, 37, 33, 1, 29, 15, 9, 18, 40, 36, 23, 2, 24, 39, 43 and 38) received a total of 38 showers. Further review revealed no documentation of hot water temperatures prior to completion of the 38 resident showers. During an interview on 12/1/14 from 12:20 PM to 12:25 PM, the DON verified NA-B was the only staff scheduled for baths/showers 11/20/14 through 12/1/14. During an interview with NA-B on 12/2/14 from 9:10 AM to 9:20 AM, NA-B confirmed no other staff had been scheduled to complete baths/showers between 11/20/14 to 12/1/14. NA-B further confirmed no hot water temperatures had been checked or documented before completion of the 38 resident showers from 11/20/14 to 12/1/14. E. On 12/1/14, the facility Hourly Hot Water Temperature Checks record was reviewed for the days the majority of showers were provided to residents in the facility, and during the hours that baths would have been provided. The following elevated hot water temperatures were recorded: - 11/19/14 at 4:30 PM, Hall 3, Room 23/24 - 135.9 degrees F - 11/25/14 at 7:30 AM, Hall 3, Room 25 - 129.1 degrees F - 11/29/14 at 8:00 AM, Hall 1, Room 3/4 - 130.9 degrees F; Hall 2, Room 8/9 - 130.0 degrees F; and Hall 3, Room 17/18 - 133.2 degrees F. | 2015-07-01 |
| 1139 | ARBOR CARE CENTERS-O'NEILL LLC | 285108 | PO BOX 756, 1102 NORTH HARRISON | O' NEILL | NE | 68763 | 2016-11-21 | 309 | J | 0 | 1 | QLXM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to provide diet modifications to prevent potential aspiration for Resident 57 and to provide assessment and monitoring for Residents 31 and 39 who were receiving [MEDICAL TREATMENT] (A method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood). The sample size was 43 and the facility census was 68. Findings are: [NAME] Review of the facility policy and procedure titled Thickened Liquids with a revision date of 3/9/15 revealed the following: - Thickened liquids will be served to residents as ordered by the physician. - The Food Services Director will record the ordered consistency on the resident's tray card. - Pre-thickened liquids will be used whenever possible. - For beverages which must be thickened, the beverage will be thickened by the dietary staff prior to leaving the kitchen. Review of an undated facility policy titled, Thickened Liquids revealed there were 3 types of thickened liquids: -Nectar Consistency- a consistency of nectar, or milkshakes; -Honey Consistency- a consistency of honey and thicker than nectar consistency; and -Pudding Consistency- the thickest of the three consistencies and the consistency of pudding. B. Review of a Hospital Progress Note dated 9/14/16 revealed Resident 57 was admitted to the hospital on [DATE]. Further review revealed Resident 57 aspirated after being admitted to the hospital with [REDACTED]. Review of Resident 57's Progress Note dated 9/21/16 at 4:51 PM revealed the resident returned to the facility from the hospital on [DATE] at 2:15 PM. Review of Resident 57's Order Summary Report revealed an order for [REDACTED]. Review of a Telephone Order dated 9/23/16 revealed Resident 57's diet was changed to a full-liquid diet with liquids thickened to honey consistency due to difficulty swallowing. Review of Resident 57's Progress Note dated 9/23/16 at 1:51 PM confirmed Resident 57's diet was changed to a full liquid diet with honey consistency. Review of the Resident 57's Progress Note dated 9/24/16 at 2:57 PM revealed after lunch the resident became more gurgly and wet sounding and was unable to cough or clear throat. Oxygen saturations (the concentration of oxygen in the blood, normal levels are 95-100 percent (%)) were checked and in the low 80 %. The resident was moaning and appeared to be in respiratory distress. Upon assessment the resident's lung sounds were very wet with audible wheezes heard. The facility was unable to get the resident's oxygen saturations above 81-82% on 3 Liters of oxygen and the resident's extremities were cool to the touch. The resident was transferred to the hospital. Review of a Hospital Progress Note dated 9/25/16 revealed the resident came into the hospital hypoxic (a condition in which the body or a region of the body is deprived of oxygen) on 9/24/15. The resident was found to have a mouthful of food and once this was suctioned the oxygen saturations improved. Review of the Hospital Diagnostic Imaging report dated 9/25/16 showed infiltration (presence of a substance more dense than air) at the left lung base. Review of Resident 57's current Care Plan with a revision date of 9/26/16 revealed the resident was on puree liquefied diet which was honey thickened in consistency. Review of Resident 57's Progress Note dated 9/27/16 at 3:35 PM revealed the resident returned to the facility from the hospital on [DATE] at 12:50 PM. Review of Resident 57's Progress Note dated 9/28/16 at 2:09 PM confirmed the resident's diet upon return from the hospital was to continue the full-liquid diet with honey thick consistency. Review of Resident 57's Progress Note dated 10/13/16 at 1:54 PM revealed the resident had a choking episode at lunch and vomited. Review of Resident 57's diet cards dated 11/15/16 and 11/16/16 indicated the resident was on a liquefied puree diet with nectar thick liquids, although the actual diet order was for honey thick consistency full-liquid diet. Review of the communication board posted in the kitchen on 11/15/16 at 12:30 PM revealed a note regarding Resident 57 which indicted the dietary staff were not to thicken the resident's liquids for meals. Observations of meal preparation revealed the following: -On 11/15/16 from 11:18 AM to 11:45 AM, Cook-X pureed the turkey. An unmeasured amount of broth and milk was added to the turkey to further liquefy the food. Cook-X then pureed the stuffing and added an unmeasured amount of broth and milk to the stuffing to further liquefy the food. No recipe was used. -On 11/15/16 at 11:51 AM Dietary Aide (DA)-Y prepared pureed cake using a recipe. Then DA-Y prepared the liquid cake by adding an unmeasured amount of milk. During an interview on 11/15/16 at 12:30 PM, Cook-X- stated Resident 57 was on an all liquid diet with thickened liquids. Cook-X stated the dietary department had the resident's dietary consistency listed as nectar thick, but nursing would tell them the resident should receive honey thick consistency so Cook-X did somewhere in between. Cook-X stated this was so the liquids did not set up too much, which was difficult for the resident to swallow. Further interview revealed the nursing staff could add thickener at the table if the nursing staff felt the drinks needed more. Cook-X confirmed recipes were not used when preparing the puree and liquids diets. Nursing Assistant (NA)-Q was observed assisting Resident 57 with the noon meal on 11/15/16 at 12:50 PM. The resident was observed to have a small cough after taking drinks of the liquefied turkey, stuffing, and cake. During an interview on 11/15/16 at 3:00 PM, Cook-Z revealed dietary staff had been notified by nursing that they (dietary) were not to thicken Resident 57's liquids anymore because the liquids were getting too thick and instead nursing would thicken them at the table before giving them to the resident. Cook-Z stated the resident was supposed to receive honey thick liquids but confirmed the diet card listed nectar thick consistency. During an interview with the Dietary Manager (DM) on 11/15/16 at 3:30 PM, the DM confirmed there were discrepancies in Resident 57's diet consistency regarding whether it should be nectar or honey thick, but confirmed it was to be honey thick. The DM confirmed the dietary staff would not thicken the drinks all the way (to honey thick) because the drinks were getting too thick so dietary would leave them thinner and then nursing could adjust them as needed. During an interview on 11/15/16 at 4:05 PM, NA-Q was unsure what consistency Resident 57's liquids should have been at the noon meal on 11/15/16. NA-Q thought the liquids were to be nectar thick but was not sure. During further interview NA-Q revealed the kitchen thickened the liquids, but nursing would adjust the liquids at the table if they felt it was too thick or too thin. During an interview with NA-AA on 11/15/16 at 4:32 PM, NA-AA did not know what consistency Resident 57's liquids were supposed to be and stated the kitchen thickened them. NA-AA was not aware of nursing being responsible for thickening the resident's liquids instead of the dietary staff. NA-AA was not sure if Resident 57's diet was actually a liquid diet or more a puree consistency that could be drank. NA-AA indicated the diet served to Resident 57 sometimes had chunks in it', like pieces of broccoli. Observation on 11/15/16 at 6:03 PM revealed Resident 57 was served a glass of non-thickened orange juice. The Administrator was notified and the Administrator indicated the orange juice would be thickened before offering it to the resident. During an interview with the Administrator on 11/15/16 at 6:29 PM, the Administrator confirmed the NA's had not had any training on thickening liquids and the different diet consistencies. Observation on 11/16/16 at 8:00 AM revealed Resident 57 was served a glass of non-thickened orange juice. Further observation revealed a container of powdered thickener setting on the table in front of the resident. Licensed Practical Nurse-H observed the non-thickened orange juice and requested a thickened glass of orange juice from dietary. During an interview on 11/16/15 at 8:45 AM, DA-W confirmed Resident 57 was provided non-thickened orange juice at breakfast. DA-W confirmed nursing had been thickening the resident's liquids and DA-W had not been notified of any changes. During an interview on 11/16/16 at 10:00 AM, NA-D was aware Resident 57 was on an all liquid diet, but thought the consistency was to be pudding thick. Observation on 11/16/16 at 12:10 PM revealed Resident 57 was served orange juice that appeared pudding thick as it was so thick that it did not spill out of the cup when the cup was tipped over. NA-P was notified and NA-P stated the liquid would be returned to dietary and a new orange juice would be requested. During interviews on 11/16/16 at 12:10 PM, NA-M and NA-P confirmed they had not had any training on thickening liquids and the different diet consistencies. The immediate jeopardy was abated to a D level on 11/16/16 at 5:30 PM when: 1) Residents receiving thickened liquids and liquefied diets were identified and diets were confirmed. 2) Dietary staff were instructed to thicken all liquids according to diet orders. 3) A plan was created to train all dietary staff members prior to them adjusting diet and/or liquid consistencies. This training consisted of education and demonstrations. Training of the dietary staff will be completed by the DM, who was trained by the Registered Dietician (RD) on 11/16/16. 4) Liquids to be thickened just prior to being sent out of the kitchen to prevent the consistency from changing. 5) Nursing staff will be in-serviced regarding policy of dietary responsibility for thickening liquids, and educated so the nursing staff can help identify incorrect diet orders. 6) A dietary communicating slip will be used for any new dietary or supplement order to improve communication between dietary and nursing. 7) Speech therapy recommendations will be given to nursing and dietary and signed by both departments. 8) Any new dietary orders will be monitored in Clinical Start-Up (a daily meeting Monday through Friday). 9) The DM, RD, Administrator, and the DON will take turns completing audits of each meal to check dietary tickets against correct diet and liquids for 2 weeks to ensure each resident on thickened liquids are receiving the accurate diet. 10) The plan of correction will be reviewed by the Quality Assurance Committee for the next 3 months. 11) Recipes are to be used whenever possible and dietary staff trained to adjust consistencies as needed as the recipes may not always produce the correct results. 12) The facility placed an order from their supplier for pre-thickened liquids. 13) The facility placed an order from their supplier for liquid thickener, which does not change consistencies over time (instead of the powdered thickener). C. Review of the facility policy titled [MEDICAL TREATMENT] Management ([MEDICAL TREATMENT]) dated 9/2013 revealed the following related to [MEDICAL TREATMENT] provided at an off-site [MEDICAL TREATMENT] Center: - Assure facility completed [MEDICAL TREATMENT] Communication form accompanies the resident to [MEDICAL TREATMENT] on treatment days, to communicate resident information and to coordinate care between [MEDICAL TREATMENT] Center and the facility. - Post [MEDICAL TREATMENT], staff to assess the [MEDICAL TREATMENT] every hour for 4 hours, documenting any bleeding, pain, redness and swelling. - Maintain and record fluid restrictions, as ordered. - Evaluate and document arteriovenous (AV- joining of an artery and a vein under the skin in the patients arm and used to access the patient's blood for [MEDICAL TREATMENT]) fistula daily for thrill (A thrill is checked by lightly placing fingertips over the fistula site and feeling for vibration of blood circulating through the fistula.) and bruit (A bruit is checked by placing a stethoscope over the fistula area and listening for blood flow.) and monitor for any signs and symptoms of infection. Evaluate central venous (CV-tubes placed in a vein in the neck, groin or back. Each central venous catheter has two openings; one takes blood from your body to be cleaned by the [MEDICAL TREATMENT] machine and the clean blood returns to your body through the other) catheter daily for signs and symptoms of infection and document. - Manage dietary restrictions as ordered. D. Review of Resident 31's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/25/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was receiving [MEDICAL TREATMENT]. Review of Resident 31's current Care Plan with revision date 8/15/16 revealed the resident was receiving [MEDICAL TREATMENT] 3 times weekly on Mondays, Wednesdays and Fridays. Nursing interventions included the following: - check access site (catheter) daily for signs of infection (redness, hardness, swelling, pain, drainage, elevated body temperature and body chills); - observe for post [MEDICAL TREATMENT] hang over-vital signs, mental status, excessive weight gain between treatments, nausea, vomiting, weakness, headache or severe leg cramps; and - 1800 milliliter (ml) fluid restriction, 480 ml at meals, 150 ml during the day and evening shifts and 60 ml on the night shift. Review of [MEDICAL TREATMENT] Communication Forms (a form completed with each [MEDICAL TREATMENT] treatment and used to communicate information and recommendations between the facility and the [MEDICAL TREATMENT] center) for Resident 31 from 10/1/16 through 11/16/16 revealed the section to be completed by the Nursing facility prior to the resident's [MEDICAL TREATMENT] treatment was missing documentation related to assessment of the [MEDICAL TREATMENT] and the resident's vital signs for the following dates: 10/3/16, 10/5/16, 10/7/16, 10/10/16, 10/12/16, 10/14/16, 10/19/16, 10/21/16, 10/26/16, 10/28/16, 10/31/16, 11/2/16 and 11/4/16. Review of Resident 31's medical record revealed no documentation to indicate assessments of vital signs and condition of the [MEDICAL TREATMENT] were completed by the facility upon Resident 31's return from [MEDICAL TREATMENT] treatments in accordance with the Care Plan and facility policy. Review of Resident 31's Treatment Administration Record (TAR) dated 11/2016 revealed the resident was to be on an 1800 ml fluid restriction per 24 hours. The resident was to receive 480 ml of fluid with each meal, 150 ml of fluid during the day and evening shifts and 60 ml of fluid on the night shift. Review of a Resident 31's TAR for 11/2016 revealed no documentation to indicate the amount of fluids the resident consumed each meal and during each shift were monitored and recorded to maintain the resident's fluid restriction. Interviews on 11/15/16 from 11:39 AM until 5:00 PM revealed the following: - NA-P was aware the resident was on a fluid restriction, however, NA-P indicated the nursing staff was no longer recording fluid intake after meals or throughout the shifts. - The Director of Nursing (DON) confirmed the Charge Nurse assigned to Resident 31 on the days the resident went to [MEDICAL TREATMENT] was responsible for completing the [MEDICAL TREATMENT] Communication Form and for assessing and documenting the resident's condition after [MEDICAL TREATMENT]. In addition, the nursing staff should be documenting the resident's fluid intake after each meal and with each shift to assure compliance with the resident's fluid restriction. E. Review of Resident 39's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 39's current Care Plan with revision date 9/24/16 revealed the resident was receiving [MEDICAL TREATMENT] 3 times weekly. Nursing interventions included the following: -Check access site-catheter-AV Fistula-for signs of infection; -Diet and fluid restrictions as ordered. Review of Resident 39's medical record revealed no evidence that assessments of the [MEDICAL TREATMENT] were completed. Review of Resident 39's TAR dated 11/2016 revealed the resident was on a 2000 ml fluid restriction; however, there was no evidence to indicate the amount of fluids the resident consumed each shift was monitored and recorded. Interview with the DON and Licensed Practical Nurse (LPN)-H on 11/14/16 at 3:50 PM confirmed there was no documentation regarding Resident 39's fluid intake. In addition, the DON and LPN-H confirmed Resident 39's [MEDICAL TREATMENT] was supposed to be assessed every shift and results of the assessment were to be recorded on the TAR. Interview with DA-W on 11/15/16 at 1:07 PM revealed DA-W poured and served Resident 39's fluids for the noon meal that day. DA-W was not aware Resident 39 was on a fluid restriction. Interview with the Dietary Manager on 11/15/16 at 3:58 PM confirmed the dietary department was not aware Resident 39 was on a fluid restriction. | 2020-09-01 |
| 2438 | WAKEFIELD HEALTH CARE CENTER | 285209 | 306 ASH STREET | WAKEFIELD | NE | 68784 | 2019-01-16 | 689 | J | 1 | 0 | QW7C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER ,[DATE].09D7 Based on observations, record reviews and interviews, the facility failed to: 1) ensure interventions were in place for the prevention of elopement (when a resident leaves the premises or a safe area without authorization and/or supervision) for Residents 1, 3, 8 and 9; and 2) develop interventions for the prevention of elopement for Resident 2. The sample size was 9 and the facility census was 22. Findings are: [NAME] Review of the facility policy titled Wander Guard monitoring system dated ,[DATE] revealed the facility utilized an elopement prevention system known as Wander Guard (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door). The policy included the following: -Nursing staff were to determine at the time of admission, which residents were at risk for wandering. A wandering risk assessment was to be performed on the day of admission; -Residents determined to be at high risk to wander (scoring 8 or above on the wandering assessment) would have a signaling device applied to their dominant wrist. Due to certain conditions alternate placement of the signaling device might be necessary; -The 90 day signaling device would be checked daily to ensure it was functioning; and -Problems with the Wander Guard signaling devices would be immediately reported to the Director of Nursing (DON and the Administrator and the Care Plan would be updated to reflect additional safeguards. B. Interview with Licensed Practical Nurse (LPN)-A on [DATE] at 4:40 PM revealed 6 residents currently residing in the facility wore Wander Guards. LPN-A indicated the following: -Resident 1's Wander Guard was not functioning; -Resident 1's Wander Guard could not be replaced as there were no additional Wander Guard bracelets available in the facility. C. Review of Resident 1's Wandering Risk assessment dated [DATE] revealed the following regarding Resident 1: -forgetful/short attention span; -experiencing feelings of anger/fear of abandonment; -known wanderer/history of wandering; and -the wandering risk score was 9 which indicated the resident was at moderate risk for wandering. Review of Resident 1's current Care Plan dated [DATE] revealed the resident was at risk to wander and a goal was developed that the resident would not wander away from the facility unattended. Interventions included the following: -anticipate and meet basic daily needs in an effort to deter exit seeking; -if exit seeking/wandering occurs try using distraction to get resident to return/remain in facility; -monitor Wander Guard signaling device placement and battery function daily; and -Wander Guard signaling device on at all times and replaced every 90 days and as needed. Review of Resident 1's Medication Administration Record (MAR) dated ,[DATE] revealed an order to change the Wander Guard signaling device every 90 days. Documentation indicated the Wander Guard signaling device was changed on [DATE]. Review of Resident 1's MAR dated ,[DATE] revealed the Wander Guard signaling device was due to be changed on [DATE]. Documentation on [DATE] indicated the Wander Guard was not replaced and a 9 (refer to progress notes) was documented on the MAR. Review of Resident 1's Progress Notes dated [DATE] revealed no progress notes regarding the Wander Guard Signaling device. Interview with LPN-A on [DATE] at 4:40 PM revealed LPN-A was not aware if additional interventions had been developed for the prevention of elopement by Resident 1 other than watching the resident more closely. Interview with the DON on [DATE] at 6:45 PM confirmed Resident 1's Wander Guard signaling device had not been changed as required on [DATE] due to unavailability of additional devices. The DON confirmed additional interventions for the prevention of elopement had not been developed for Resident 1. At 7:00 PM on [DATE] LPN-A was observed to test the functioning of Resident 1's Wander Guard signaling device. The device was functioning at this time. Interview with LPN-A at 7:00 PM on [DATE] confirmed Resident 1's Wander Guard signaling device was expired and the device needed to be replaced every 90 days to assure reliability. D. Review of Resident 3's MAR dated ,[DATE] revealed an order to change the Wander Guard signaling device every 90 days. Documentation indicated the Wander Guard signaling device was changed on [DATE]. Review of Resident 3's Wandering Risk Assessment completed [DATE] included the following regarding Resident 3: -forgetful/short attention span; -disturbed by environmental noise levels, recent medication change; -known wanderer/history of wandering; and -the wandering risk score was 8 which indicated the resident was at moderate risk for wandering. Review of Resident 3's current Care Plan dated [DATE] revealed the resident was at risk for wandering. Interventions included the following: -anticipate and meet basic daily needs in an effort to deter exit seeking; -if exit seeking/wandering occurs try using distraction to get resident to return/remain in facility; -monitor Wander Guard signaling device placement and battery function daily. It is kept on wheelchair so the resident cannot remove it; and -Wander Guard signaling device on at all times (on the wheelchair) and replaced every 90 days and as needed. Review of Resident 3's MAR dated ,[DATE] revealed the Wander Guard signaling device was due to be changed on [DATE]. Documentation on [DATE] indicated the Wander Guard was not replaced and a 5 (which meant hold) was documented on the MAR. Further review of the MAR from [DATE] through [DATE] revealed no evidence the Wander Guard was replaced. Review of Resident 3's MAR dated ,[DATE] and ,[DATE] revealed the Wander guard signaling device was checked every evening to ensure it was functioning. A 9 was documented on the MAR on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (which meant to refer to progress notes). Review of Resident 3's Progress Notes from [DATE] through [DATE] revealed no documentation regarding the functioning of the Wander Guard signaling device. Review of Resident 3's MAR dated [DATE] through [DATE] revealed no evidence the Wander Guard signaling device was replaced (the last replacement was [DATE] which was over 90 days). Interview with the DON on [DATE] at 6:45 PM confirmed Resident 3's Wander Guard signaling device was not changed on [DATE]. The DON confirmed additional interventions were not developed for the prevention of elopement. At 7:09 PM on [DATE], Licensed Practical Nurse (LPN)-A tested the battery of Resident 3's Wander Guard signaling device and noted the device was not functioning. Interview with LPN-A at 7:09 PM on [DATE] confirmed Resident 3's Wander Guard signaling device would not be replaced as there were no devices available. E. Interview with the Administrator on [DATE] at 6:05 PM and 7:30 PM revealed additional Wander Guard signaling devices were ordered by facility staff on [DATE]. The Administrator indicated there had been a discrepancy with the billing from the supplier of the Wander Guard signaling devices and after this was resolved the supplier was paid on [DATE]. The Administrator reported the Wander Guard signaling devices were supposed to arrive on [DATE] but as of [DATE] the devices had not arrived. The Administrator reported being unaware that any of the Wander Guard signaling devices currently in use were not functioning. F. The immediate jeopardy identified on [DATE] was abated to a D level on [DATE] at 8:00 PM when: -15 minutes checks were implemented and documented beginning at 6:00 PM for Resident 1 and at 6:30 PM for Resident 3 on [DATE]; -motion sensors were placed by the doorways to Resident 1 and Resident 3's rooms to alert staff when the resident's exited their rooms; -daily checks of all Wander Guard signaling devices would continue; and -15 minutes checks and room door motion sensors would be implemented if the daily Wander Guard checks determined additional signaling devices were not functioning. [NAME] Review of a Wandering Risk assessment dated [DATE] revealed Resident 2 was admitted to the facility that day. Documentation further indicated the following regarding Resident 2: -forgetful/short attention span; -recent experiences included admission with the last month, transfer from one unit to another and surgery; -ambulates with 1 assist; -[MEDICAL CONDITION]; -Taking antidepressants; and -the wandering risk score was 7 which indicated the resident was at moderate risk for wandering. Review of Resident 2's Interim Admission Care Plan dated [DATE] indicated a goal that the resident will not wander from facility unattended. Further review of the Interim Admission Care plan revealed there were no interventions related to this goal. Review of the current Care Plan dated [DATE] revealed no evidence the resident's moderate risk of wandering was addressed and there were no interventions developed for the prevention of wandering and/or elopement. Observation at 6:35 PM on [DATE] revealed a handwritten note taped to the desk at the Nurses Station which indicated Resident 2 needed a Wander Guard when the supplies arrived. Interview with the DON on [DATE] at 7:30 PM revealed Resident 2 was currently not considered an elopement risk as the resident required assistance with transfers and mobility. The DON confirmed there was no documentation related to this assessment. Review of Resident 2's Progress Notes dated [DATE] at 1:39 PM revealed the resident scored at a moderate risk to wander. Documentation further indicated the resident was unable to ambulate without assistance, had an unsteady gait and therefore a Wander Guard was not to be placed at this time. There was no evidence additional interventions for the prevention of elopement were developed. Review of Resident 2's Progress Notes dated [DATE] at 5:59 PM included the following: -the resident was last seen in the room at 4:30 PM; -at 5:05 PM staff reported the resident was not in the room and the resident could not be located in the facility; -at 5:25 PM staff located the resident outside within the immediate block and at a house on the southwest corner. The resident was assisted back into the facility; and -the buttock area of the resident's pants was noted to be wet and muddy. The resident sustained [REDACTED]. H. Interview with the Administrator on [DATE] at 9:00 AM revealed the Wander Guard policy was revised and residents who were determined to be at moderate risk and high risk for wandering/elopement would have a Wander Guard. The Administrator reported additional Wander Guard signaling devices were delivered to the facility on [DATE] and were placed on Residents 1, 2 and 3. The Administrator reported there were 3 additional Wander Guards available for resident use and the plan was to keep some Wander Guards in stock. I. Review of the revised policy Wander Guard monitoring system dated [DATE] revealed .Residents determined to be at a moderate or high risk to wander will have a signaling device applied to their dominant wrist. [NAME] Interview with the DON and Registered Nurse (RN)-E on [DATE] at 9:47 AM revealed the following regarding the Wandering Risk Assessments: -Residents with a score of ,[DATE] were low risk for wandering/elopement; -Residents with a score of 5 or above were at moderate risk for wandering/elopement; and -Residents with a score of 11 were at high risk for wandering/elopement. K. Review of Resident 8's Wandering Risk assessment dated [DATE] revealed the resident's wandering risk score was 5 which indicated the resident was at moderate risk for wandering. Review of Resident 8's current Care Plan dated [DATE] revealed no interventions to address the resident's moderate risk for wandering/elopement. Observations of Resident 8 on [DATE] at 8:25 AM revealed the resident was not wearing a Wander Guard although the resident was identified at moderate risk for wandering/elopement. L. Review of Resident 9's Wandering Risk assessment dated [DATE] revealed the resident's wandering risk score was 7 which indicated the resident was at moderate risk for wandering. Review of Resident 9's current Care Plan (undated) revealed no interventions to address the resident's moderate risk for wandering/elopement. Observations of Resident 9 on [DATE] at 9:30 AM revealed the resident was not wearing a Wander Guard although the resident was identified at moderate risk for wandering/elopement. M. Interview with the DON and RN-E on [DATE] at 9:47 AM confirmed Resident 8 and 9 were not wearing Wander Guards and alternate interventions for the prevention of elopement had not been developed. The DON and RN-E further indicated the current Wandering Risk Assessments were most likely not accurate regarding the resident's risk for wandering/elopement. N. The immediate jeopardy identified on [DATE] was abated to a D level on [DATE] at 3:15 PM when: -The Wandering Risk Assessment form was revised to more accurately assess each resident's risk of wandering/elopement; -All residents of the facility were reassessed using the revised Wandering Risk Assessment form; -Care Plans for all residents identified at risk for wandering/elopement were revised and interventions for the prevention of elopement were developed and implemented; -All Wander Guards in use were functioning properly and additional Wander Guard signaling devices were available for use; -A plan was developed to routinely audit Care Plans and ensure interventions for the prevention of wandering/elopement were implemented; and -Provision of staff education regarding wandering assessments, implementing Care Plan interventions and monitoring to ensure interventions were in place for prevention of wandering/elopement. | 2020-09-01 |
| 2439 | WAKEFIELD HEALTH CARE CENTER | 285209 | 306 ASH STREET | WAKEFIELD | NE | 68784 | 2019-01-16 | 835 | J | 1 | 0 | QW7C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].02 Based on observations, record review and interview, the Administration failed to ensure effective management of facility resources to: 1) ensure the safety of 6 residents who were identified at risk for elopement (when a resident leaves the premises or a safe area without authorization and/or supervision) and utilized Wander Guards (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door); and 2) failure to maintain an effective plan of action to prevent resident elopement with Resident 2 subsequently eloping from the facility on [DATE]. The sample size was 9 and the facility census was 22. Findings are: Review of deficient practice identified during the survey revealed the following: -F 689. [NAME] On [DATE] Wander Guard signaling devices for 2 residents (Residents 1 and 3) were expired and Resident 3's Wander Guard signaling device was not functioning when tested . There were no additional replacement Wander Guard signaling devices available in the facility. Additional interventions for the prevention of elopement were not developed. B. Facility interventions developed [DATE] for the prevention of resident elopements were ineffective as Resident 2 eloped from the facility on [DATE]. Resident 2 was identified at moderate risk for elopement, however interventions for the prevention of elopement were not developed prior to the resident eloping from the facility on [DATE]. C. Failure to ensure a safe environment for residents identified at risk for wandering was cited during the annual survey on [DATE]. The facility plan of correction indicated a Wander Guard monitoring device was installed at the entrance of the east hallway to the Assisted Living portion of the building. While this device was observed in place during the complaint survey, the alarm would not be activated if the Wander Guard signaling device worn by the resident was not functioning. | 2020-09-01 |
| 3020 | OMAHA NURSING AND REHABILITATION CENTER | 285240 | 4835 SOUTH 49TH STREET | OMAHA | NE | 68117 | 2019-11-26 | 755 | J | 1 | 0 | K9BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > State Licensure tag 175 NAC ,[DATE].10. Based on interview, observation and record review; the facility failed to administer medications for Residents 1 and 2 using the 5 Rights of medications administration. This affected 2 of 2 sampled residents. The facility identified a census of 63 at the time of the survey. Findings are: The 5 Rights of medication administration are The Right Medication The Right Dose The Right Time The Right Route The Right Patient The five rights, as stated, focus on the performance of individuals and do not reflect the fact that drug safety is a culmination of efforts of professionals from several disciplines, the responsibility for accurate drug administration lies with multiple individuals and reliable systems. Some of the factors contributing to a medical team's failure to accurately verify the five rights, despite their best efforts, include: Poor Lighting [NAME] An interview with the DON (Director of Nurses) at [DATE] at 10:48 AM revealed; that the staff had done a sweep of the property and found a bottle of Smirnoff Vodka 375ml. This was found in the front of Entrance of the building in a trash can. In the interview with the DON confirmed; that the medication administration for Resident 1 and Resident 2 was done outside the building. The DON reported that they did not know how well lit the area was at the time of medication administration. The DON confirmed that both Resident 1 and Resident 2's medication were delivered at the same time, outside. An interview on [DATE] at 10:48AM with RN (Registered Nurse) at UNMC (University of Nebraska Medical Center) revealed; Resident 1 was positive for opioid and alcohol. Resident 1's BAC (Blood Alcohol Concentration) was 239. The specific opioid and [MEDICATION NAME]. Record review of Resident 1's MAR (Medication Administration Record) revealed; No record of [MEDICATION NAME]. Record review of Resident 1's Quarterly MDS (Material Data Set- a comprehensive federally mandated process for clinical assessment to determine the functional and health care needs of residents) dated [DATE] revealed; Section C BIMS (Brief Interview for Mental Status-is a calculator that checks the residents cognitive impairment and whether further intervention is required for dementia diagnosis.) Score of 13, a score of 13 shows intact cognition. Section D Total Severity Score was 03 with Section [NAME] Little interest or pleasure in doing things ,[DATE] days section G trouble concentrating on things such as reading the newspaper or watching television ,[DATE] days. Section [NAME] Behaviors: indicates no behaviors. Section G Functional Status: indicates toilet use one assist, set up. Requires supervision for bed mobility, walking in corridor, locomotion off the unit, eating and toilet use. Section G 0300 Balance during transitions and walking-was steady at all times. Section I Diagnosis: [REDACTED]. Section J Health conditions- No pain, has had a fall with no injury, Section K: Nutrition: 5'1 and weight was 156 Section M: medications: [REDACTED]. Record review of Resident 1's Lab reports from UNMC dated [DATE] revealed; the toxicity screen for Resident 1 showed that the positive results for: Opiates and [MEDICATION NAME]. Record review of Initial Visit Critical Care Medicine dated [DATE] at 1:18Am revealed Resident 1 had a history of [REDACTED]. Resides at Nursing Home and was found unresponsive and purple. CPR was performed for 3 minutes. There was a pulse when paramedics arrived and was given [MEDICATION NAME] without effect. Resident 1 reported nonsmoking and had quit 8 months ago. Resident 1 reported no drug use. Physical exam revealed: Alert, appears stated age, cooperative, no distress and sedated and on a ventilator. Record review of UNMC Assessment and Plan dated [DATE] revealed; the principle problem was [MEDICAL CONDITION], elevated lactic acid level, acute [MEDICAL CONDITIONS], altered mental status, Insulin dependent diabetes mellitus. Record review of Attending Neurology dated [DATE] revealed; Resident 1 had a history of [REDACTED]. Resident 1 required resuscitation and CPR. Resident 1 was found to have an alcohol level over 200. Resident 1 continued to be intubated, alert and cooperative. Resident 1's parent was concerned about further [MEDICAL CONDITION]. Record review of Resident 1's Medication Admin Audit Report dated [DATE] the medications were documented at 23:53PM (11:53PM) [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) Tablet 500mg BID, [MEDICATION NAME] (benzodiazepines used to treat anxiety disorders) Tablet 0.5mg at HS, [MEDICATION NAME] (used to treat certain mental/mood conditions (such as [MEDICAL CONDITIONS] disorder, episodes [MEDICAL CONDITION] depression)Tablet 25mg at HS, [MEDICATION NAME] (a natural hormone associated with sleep onset) Tablet 3 mg 1 tablet at HS for sleep, Jolessa (a combination hormone medication used to prevent pregnancy) Tablet 0.15mg-0.03mg 1 tablet at HS, and [MEDICATION NAME] (medicine that helps lower LDL cholesterol) Tablet mg at HS. (RESIDENT WAS ALREADY OUT TO THE HOSPITAL AT THE TIME THE MEDICATIONS WERE GIVEN) [MEDICATION NAME] (a man-made rapid acting insulin for adults with diabetes) Flex Pen Sliding scale documented at 00:14AM (12:14AM) [MEDICATION NAME] Flex Pen Inject 5 units SUBQ. B. An interview with Resident 2, on [DATE] at 4:30PM revealed, that (gender) felt like the facility was blaming them for Resident 1's incident. Resident 2 reported if they would have known Resident 1 was drinking they would have got the nurse. Resident 1 had laid on Resident 2's bed, head on the pillow. Resident 2 reported Resident 1 started to snore. Resident 1 had told Resident 2 they did not snore so Resident 2 thought it was cute. Resident 2 reported that about 2 minutes later Resident 2 observed that Resident 1 was no longer snoring and assisted Resident 1 onto back. Resident 2 reported Opened Resident 1's eye lid was dilated, Lips turned blue did a sternal rub. Resident 1 did not respond, so Resident 2 went to the nurse told the nurse that it was a code, Resident 2 reported the nurse started chest compressions and within a minute they got Resident 1 back. Resident 2, who was visibly upset and reported that Resident 1 spoke about drinking all the time. Resident 2 encouraged Resident 1 not to drink and reported that the parents would not have put Resident 1 here if it was not necessary. Resident 2 reported had started smoking since the stress- 5 people have died at the facility since admission and had starting smoking related to that. Resident 2 reported that (gender) told the nurses Resident 2 thought (gender) did not get their own medications. There were not enough medications in the cup. Resident 2 reported the nurse questioned whether or not the residents were given each resident the right medications. Resident 2 requested for the nurse to check the medication administration sheets and the nurse refused telling Resident 2 that the right medications had been given. Resident 2 reported that in the cup of medications were only 3 small round pills, and there should have been more pills. Resident 2 reported that Resident 1 had already swallowed the medications. Resident 2 felt if brought to the attention of the nurses the medications were mixed that Resident 1 could have been given [MEDICATION NAME] to reverse the effects. Resident 2 reported that (gender) approached the nurse about the mix up of medication and the nurse would not check to see if the medication was given. Resident 2 reported that (gender) had some medical training. Resident 2 reported that Resident 1 called 8:13 and next time at 9pm and they followed Resident 1 outside and had a smoke. No words were slurred. Reported that the medication were given was 20 minutes with the time lapse Resident 2. Resident 2 reported that for some the Administrator wanted someone to observe Resident 2 is outside, sign out write the time. It is something they do if they sign out supposed to sign out and Resident 1 never does. Resident 2 pointed out the area both residents were sitting in and reported that area was not well lit and Nurse A delivered both residents medications at the same time. C Record Review of Administrator notes interview with Nurse A: Nurse A indicated that Resident 1 and Resident 2 were seen to be exiting the facility shortly before 8PM on [DATE]. Nurse A reported that Resident 2 told the nurse that (gender) would get medication is a little while. Resident 1 and 2 were noted to be in the garden area. Nurse A reported when it was time for medication administration, Nurse A prepared Resident 1 and 2 medications and took them outside and delivered the medications to each of them. Nurse A reported picking up cups that were outside with Resident 1 and 2. Nurse A reported that there was an energy drink present and described it as looking like red bull. Nurse A reported smelling something strange and in hindsight thinks this could have been alcohol, but at the time assumed it was water. Nurse A reported it was roughly 10 pm when Resident 1 and 2 came inside and stopped at the nurse's desk on the way to Resident 2's room. Nurse A reported after 10pm nurse arrived, Resident 2 came out of their room and reported Resident 1 was not breathing. Nurse A rushed to the room, confirmed no pulse/respirations and called for nurses from other floor to come down. Nurse B came in and placed the board under Resident 1 and began compressions. Nurse C called 911 and entered the room and began compressions to Resident 1. Nurse A reported prepared oxygen and suction machine for use if needed. Shortly after compression and respirations Nurse B and C were able to restore a pulse and breathing. Shortly after EMT arrived and took over. An interview with Nurse B on [DATE] revealed; Nurse B reported that they were finishing documentation and giving report to the night shift nurse when heard the page for stat response to 1st floor. Nurse B reported they used the stairs and rushed to 1st floor and was directed to go to Resident 2's room where she encountered Nurse A preparing to respond to code. Nurse B reported that Resident 1 had no pulse of respirations. Nurse B placed that code board under Resident 1 and coordinated with Nurse C to support rescue breathing while Nurse B did compressions. Nurse B reported that Resident 1's respirations and pulse were restored. | 2020-09-01 |
| 5456 | GOOD SAMARITAN SOCIETY - WOOD RIVER | 285198 | 1401 EAST STREET | WOOD RIVER | NE | 68883 | 2017-03-22 | 223 | J | 1 | 1 | HUVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (9) Based on record review, observation, and interview; the facility failed to ensure residents were not subjected to physical abuse. This violation effected one of five sampled residents, Resident 40. The facility census was 59. Findings are: A review of the Facility's policy and procedure titled ABUSE AND NEGLECT, last revised 11/16, revealed the purpose of the policy was to ensure residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals A review of the facility's documentation of Investigation of ABUSE, NEGLECT, OR MISAPPROPRIATION dated 2/22/17, revealed that on 2/9/17, Resident 81 was observed by staff to be hitting Resident 40 on the head with a hairbrush. The residents, who resided in the same room on the facility's Special Care Unit (SCU)-for Memory Care, were immediately separated. Resident 81 was sent out to an area Hospital's Behavioral Unit for evaluation and returned to the facility on [DATE] . The outcome of the facility investigation was to continue to monitor Resident 81's interactions with roommate as well as other residents, and make a room change when one was available. A review of Nurses Notes for Resident 40 revealed a note dated 2/9/2017 at 12:41 which documented that the resident was struck with a hairbrush on the resident's head by roommate (Resident 81). Two staff members were in the resident's room when incident occurred. Residents 40 and 81 were immediately separated and no injuries are noted at the time for Resident 40. The documentation indicated that Safety precautions are being advised. Further review of Resident 40's Nurses Notes, dated 2/9-3/5/17, revealed no further documentation related to the incident on 2/9/17 nor interventions which were put into place to ensure Resident 40's safety following readmission of Resident 81. A review of MDS (Minimum Data Set-a mandatory comprehensive assessment tool used for care planning) information for Resident 40 revealed an Annual assessment, dated 1/31/17, which indicated: BIMS (Brief Interview for Mental Status)=03 (scores=00-07 indicate severe impairment), the resident exhibited behaviors not directed at others 1-3 days of the assessment period. Resident 40's behaviors had worsened since the previous review and significantly interfered with the residents participation in activities or social interactions, intruded on privacy/activity of others, and was disruptive to care and the living environment. The resident required: extensive assist of two staff members for bed mobility, transfers, and personal hygiene; extensive assist of one for dressing, eating, and toilet use; walking in room occurred once or twice, walking in corridor was dependent with 1 assist, and a wheelchair was used for most locomotion both on and off the unit. A review of Resident 81's Care Plan printed on 3/6/17 revealed the resident: had impaired cognitive function (dementia or impaired thought processes), had a mood problem of anxiety and major [MEDICAL CONDITION] evidenced by tearful episodes about not being able to go back home, and exhibited behavior symptoms toward roommate and staff. The resident wandered into others rooms. The resident would swear/yell at staff, hit, and use care equipment as weapons by swinging items toward others in a defensive manner. Documented interventions included: provide a structured environment in the SCU, consult with Psychiatric Advanced Practice Registered Nurse (APRN) related to behaviors and use of antipsychotic medications, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention and remove from situation, and offer diversionary activities such as folding towels, dusting, sorting items. Revisions dated 2/22/17 were: continue to monitor interactions with roommate and other residents throughout the day to ensure others' safety, consult with pharmacy and health care provider to consider dosage reduction when clinically appropriate, and redirect with conversation and a walk in the fenced in area of the Special Care Unit if weather permitted . The Care Plan did not include new interventions put into place to protect Resident 81's roommate (Resident 40) from further physical abuse upon Resident 81's readmission on 2/14/17. . An interview on 3/6/17 at 1:30 PM with Nursing Assistant (NA)-DD revealed Resident 40 was dependent upon staff for ADLs (Activities of Daily Living), yelled out/verbalized almost constantly during cares, was unable to voice needs, required a sit/stand mechanical lift for transfers, used tilt in space w/c for locomotion, was assisted with toileting every 2 hrs. and laid down in bed after meals. Continued interview with NA-DD revealed the NA was unaware of any new interventions put into place following the readmission of Resident 81 (Resident 40's roommate) to ensure no further abuse occurred. The NA reported staff were aware of the need for increased supervision in the SCU and tried to keep one staff member in the commons area with any residents who were there. The other scheduled staff member would monitor the hallway and resident rooms. An interview on 3/6/17 at 1:15 PM with Medication Aide (MA)-EE revealed Resident 40 (Resident 81's roommate) was cognitively impaired and dependent upon staff for ADLs. Resident 40 also did a lot of screaming or calling out, which seems to upset Resident 81. The MA reported that since Resident 81 returned to the facility following psychiatric evaluation, some medication changes have been made, and things seem to be better with the resident's roommate. A motion alarm was in place in the room shared by Resident 40 and 81, which alerted staff to when Resident 81 crossed to the roommate's side of the room. The motion alarm was not a new intervention and the MA denied knowledge of new interventions put into place to protect Resident 40 following Resident 81's readmission to the facility and room [ROOM NUMBER]. MA-EE reported that Resident 81 spent a lot of time in the commons area and ambulated independently throughout the Special Care Unit. An observation on 3/6/17 at 1:30 PM revealed room [ROOM NUMBER] was shared by Residents 40 and 81. A motion sensor alarm was noted at the edge of the floor mat near the privacy curtain splitting the room. The Immediate Jeopardy was abated and the severity lowered to a 'D' level in the late afternoon of 3/6/17. The facility assessed all residents that could be at risk for ongoing abuse. The facility interviewed all interviewable residents and also interviewed the family members of non-interviewable residents. Staff were educated on abuse/neglect reporting and protection of residents from abuse situations. Residents were moved to separate rooms and staff monitoring of the aggressive resident was increased to ensure that no other resident was being targeted by the aggressor. The aggressive resident's behavior monitoring plan was revised to include immediate staff interventions for the resident's behaviors. | 2020-01-01 |
| 5522 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2016-11-14 | 309 | J | 1 | 0 | 7EEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].09 Based on record review and interview, the facility failed to assess and provide emergency treatment as needed for Resident 1. Sample size was five residents. The facility Census was 66 The facility policy titled Clinical Health Status Version# 5, dated with an effective date of [DATE] revealed: The process for identification of change of condition included gathering objective data and documenting assessment findings, resident and physician and family notification. A record review of the Admission Record, dated (MONTH) 3, (YEAR), revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a Nurse's note dated [DATE] at 10:30 AM by Registered Nurse (RN) B revealed Resident 1's vital signs were a temperature of 97.2 degrees Fahrenheit. Resident 1's blood pressure had been ,[DATE] and a pulse was 108. Resident 1's respiration rate was 18 breaths per minute and had an oxygen saturation of 96% on room air. Resident 1 was alert and oriented. Resident 1 was independent with transfers and ambulated with a walker. Resident 1 was independent with activities of daily living (ADL's). Resident 1 had no shortness of breath and did not require oxygen. Resident 1 had no complaints of pain and was using the telephone and talking with family and friends. A record review of Resident 1's medical record, titled Progress Note dated [DATE] at 6:00 AM, written by Licensed Practical Nurse (LPN) A, revealed that Resident 1 was yelling and was having trouble breathing. The on-duty, Nursing Assistant (NA) requested that the nurse report to Resident 1's room. Resident 1's oxygen saturation was 84% (Lippencott's Nursing Center states that SpO2, or pulse oximetry, is normal when in the range of 97 to 99 percent). Resident 1 presented with good color and was assisted to bed. An assessment of Resident 1's lungs revealed clear sounds in the upper lungs bilaterally and diminished sounds in lower lungs bilaterally. Oxygen was applied by nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory assistance) at 2 liters. Resident 1's oxygen saturation was then 91%. Resident 1 was reassured and made comfortable in bed. Resident 1 had voiced no additional distress. An interview with LPN A on [DATE] at 4:40 PM revealed that Resident 1 had been under the care of LPN A for three nights. LPN A revealed that Resident 1 had initially, called for help due to having problems breathing at 3 AM. LPN A confirmed that Resident 1 had called for help three times from 3:00 AM till 5:15 AM. LPN A revealed that NA C called over to the west nursing station at 5:15 AM and informed staff that Resident 1 needed help right away and Resident 1 was having difficulty breathing The NA stated that Resident 1 was screaming that Resident 1 was unable to breathe. LPN A revealed at 5:15 AM a check of Resident 1's oxygen level had been performed and it was 84% but came up to 91% after oxygen had been applied. LPN A confirmed that Resident 1 did not have an order for [REDACTED]. LPN A confirmed that no vital signs except the oxygen saturation had been performed on Resident 1 during the three visits to Resident 1's room, for respiratory distress. LPN A confirmed the inhaled medication that was administered to Resident 1 was not documented and that the time it was administered could not be recalled. LPN A confirmed that Resident 1's physician was not notified of the Resident's change in condition. Interview with NA C on [DATE] at 3:40 PM revealed that Resident 1 had turned on the call light at 3:00 AM. Resident 1 had requested an inhaler. NA C revealed that LPN A had arrived within 5 minutes and was observed administering Resident 1's inhaler. NA C revealed that Resident 1 called again and complained of feeling sick and unable to breathe. NA C revealed that LPN A did come at 3:50 AM but another resident had required assistance and NA C had left the room. Resident 1 came out into the hall at 5:15 AM and was screaming. Resident 1 was not feeling good and had trouble breathing. NA C revealed that LPN A had come back to Resident 1's room and checked an oxygen level, and applied some oxygen. Interview with RN D on [DATE] at 12:08 PM revealed that Resident 1 had stopped breathing during RN D's shift on [DATE] at 7:15 AM. RN D revealed that NA [NAME] had called for assistance and that Resident 1 had been found on the toilet and was not responsive. RN D revealed that Resident 1 was without pulse, not breathing, and cool in extremities. RN D revealed that the NA was told to stand-by while RN D had gone to the EMR to check on Resident 1's Code Status (to perform Cardio [MEDICAL CONDITION] Resuscitation (CPR) or Not to perform CPR). RN D revealed that the EMR stated that Resident 1 was a Full Code (Do perform CPR). RN D revealed that NA [NAME] was told to perform CPR and that RN D called 911. RN D revealed that upon looking into the paper chart there had been a document that had been signed by Resident 1's family, and that it stated Resident 1's wish had been Do Not perform CPR. RN D revealed that while checking the chart the 911 crew had arrived and RN D told the 911 crew that Resident 1 did not wish to have CPR. The NA [NAME] was told to stop CPR. RN D stated that the resident had not been revived with the CPR. Interview on [DATE] at 12:18 PM with the Director of Nursing (DON) confirmed that when vitals were recorded it would be found in the nursing notes of the nurse who had taken the vitals. The DON confirmed that no vitals other than oxygen saturation had been performed on Resident 1 on [DATE] from 3 AM to time of death at 7:15 AM. The DON confirmed that an assessment/evaluation would be expected of the nursing professional when a resident was having difficulty breathing or respiratory distress. The DON confirmed that the assessment/evaluation for Resident 1 would have been expected to include blood pressure, pulse rate, respiration rate, temperature, and a head to toe assessment. The DON confirmed that a notification to physician and family should have been done and that this did not occur for Resident 1. The Immediate Jeopardy was abated on [DATE] after the following interventions were put in place: - A Head-to-Toe assessment cheat sheet was put in place. - All licensed nursing staff on duty were educated on acceptable clinical assessment procedures as well as resident change in condition procedures. - All licensed nursing staff were to be educated on acceptable clinical assessment procedures as well as resident change in condition procedures before working their next shift. | 2019-11-01 |
| 5817 | SIDNEY REGIONAL MEDICAL CENTER-EXTENDED CARE | 285290 | 549 KELLER DRIVE | SIDNEY | NE | 69162 | 2016-09-27 | 226 | J | 1 | 0 | CZTZ11 | > Licensure Reference Number 175 NAC 12-006.05 (9) Based on record reviews and interviews, the facility failed to ensure that staff reported allegations of staff to resident abuse immediately to administrative staff to protect the resident from further opportunities of abuse for one sampled resident (Resident 1). The facility census was 50. Findings are: Review of the facility Investigative Report Incident/Unusual Occurrence, completed by the DON (Director of Nursing), revealed that on 9/9/16 at 3:00 PM NA (Nursing Assistant) - A reported that NA - B was too rough with Resident 1 during cares on 9/2/16. Further review revealed that NA - A reported that during the cares the resident stated to NA - B don't be so rough that hurts and get out of here I don't want you in here and NA - B continued with the resident's cares. NA - A reported that NA - B bent over and got into the resident's face and prayed over the resident and stated in a mocking way God bless your angry hateful soul and sung taunting like songs over the resident. When the cares were completed NA - A tried to report the incident to a charge nurse who was on the phone and told NA - A to find (gender ) after break. Later, in the dining room, NA - A reported that NA - B was tauntingly blowing kisses and making comments to the resident during the meal. NA - A and another staff member assisted the resident later in the evening and the resident stated that (gender) didn't want NA - B in the room again. Further review of the report revealed that RN (Registered Nurse) - C, Charge Nurse, stated that NA - A reported the incident at approximately 6:00 PM on 9/2/16. RN - C instructed NA - A to write out concerns and put it under the DON's office door. RN - D, Charge Nurse, stated was aware of the incident at approximately 7:30 PM - 8:00 PM from NA - B. Review of the nursing Schedule revealed that NA - B was not suspended pending an investigation to protect the resident from potential further abuse. NA - B worked the evening shift on 9/9/16 , the day shift on 9/10/16 and 9/12/16. Review of the facility policy Suspected Patient or Resident Abuse or Neglect, not dated, revealed the following including: Purpose: . To ensure that the patient's safety and rights are protected. Investigation Procedure: 1. When a person has reasonable cause to believe, or has observed a condition which would result in abuse, staff be responsible for reporting the incident to their supervisor and assisting with the documentation of the incident. 2. The supervisor/DON is responsible to: i: Assist the employee to complete a variance reports(s). ii. 'Clock-Out' the employee observed violating the abuse policy and send home pending an investigation if appropriate. iii. Report the incident to the Director of Nursing and Administrator on call. iv. Document the events, patient's condition, interventions, and other relevant information in the clinical record. v. Monitor the patient's condition and follow up as needed. Protection Procedure: Any employee who suspects or observes that a patient is being or has been abused or neglected will immediately report his/her concerns or observation to the Charge Nurse on duty. The nurse on duty must immediately assess the situation, the patient/resident's condition . The Director of Nursing and Administrator must be contacted immediately.If it is a staff to patient the staff will be interviewed, incident or written detail obtained and they they will be clocked out and sent home . Interview with the Administrator on 9/13/16 at 11:40 AM confirmed that the 1) staff did not report the allegations of staff to resident abuse immediately to the administrative staff and 2) the administrative staff did not suspend the staff member immediately for an investigation when they were notified of the allegations of staff to resident abuse. Further interview confirmed that the staff were to follow the facility abuse prohibition procedures to ensure that residents were protected from potential further abuse. Prior to the survey team exit on 9/13/16, the Administrator set up inservices for all staff on duty to review the facility abuse prohibition procedures, including how to protect the resident from further abuse. The Administrator planned to provide the inservice for the employees on the next two shifts and then provide a mandatory inservice for all staff. Due to these measures, the Immediate Jeopardy was abated and the scope and severity of the deficiency was lowered to a D. The staff inservices were completed on 9/15/16. | 2019-09-01 |
| 5887 | SORENSEN CARE AND REHABILITATION CENTER, LLC | 285107 | 4809 REDMAN AVENUE | OMAHA | NE | 68104 | 2016-08-16 | 223 | J | 1 | 0 | ROML11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number : 175 NAC 12-006.05 (9) Based on observations, record review and interviews; the facility failed to protect Resident 2 from residents with sexual behaviors. The facility census was 69. Findings are: A. Review of the facility investigation dated 8/1/2016 revealed Resident 2 reported to the Social Services Designee(SSD) that Resident 1 came into the sunroom where Resident 2 was reading and Resident 1 exposed genitals to Resident 2. Resident 1 then attempted to kiss Resident 2, at which time, Resident 2 told resident 1 to leave and kicked at Resident 1 who did leave. However, Resident 1 returned to the room dancing with genitalia exposed. Review of Resident 2's most recent MDS (Minimum Data Set: a federally mandated assessment tool used for care planning) dated 5/26/2016 revealed Resident 2 score was 15, indicating Resident 2 was cognitively alert and oriented and able to make decisions. Interview on 8/3/2016 at 10:00 AM with Resident 2 revealed Resident 2 confirmed the same information that was in the facility report. Resident 2 revealed that the incident with Resident 1 was really creepy and made Resident 2 very uncomfortable. Resident 2 stated (gender) did not want Resident 1 around. Resident 2 revealed a similar incident had happened about 1 1/2 years ago and Resident 1 had touched Resident 2 which that was uncomfortable also. Record review of Resident 2's medical record revealed an untitled document dated (MONTH) 27, (YEAR), indicating that Resident 2 was concerned about another resident coming into Resident 2's room. Interview on 8/3/2016 at 2:30 PM with the Administrator revealed the other resident referred to in the document was Resident 1. Interview on 8/3/2016 at 11:30 AM with the Director of Nursing (DON) revealed that Resident 1 did walk outside in the fenced in area and had been seen looking in Resident 2's window before Resident 2 was moved to the current room. Review of Resident 1 MDS dated [DATE] revealed Resident 1 scored an 8 on the cognitive assessment indicating Resident 1 was moderately cognitively impaired. Review of Resident 1's care plan dated 7/26/2016 revealed resident had exhibited behaviors including inappropriate touching toward facility staff and required redirection from staff regarding inappropriate behaviors. Interview on 8/3/2016 at 10:15 AM with the Assistant Director of Nursing (ADON) revealed that, when informed of the allegation by the SSD, the staff were instructed to start 15 minute checks on Resident 1. Record review of Resident 1's facility form titled 15 minute checks revealed no sheet for checks on 8/1/2016, no documented checks from midnight until 6:00 AM on 8/2/2016 and no documented checks from 1:30 PM on 8/2/2016 until 6:00 AM on 8/3/2016. Observation on 8/3/2016 completed of Resident 1's room between 9:15 AM until 10:00 AM revealed no staff opened Resident 1's door to visualize Resident 1 during the 45 minute period. Review of the facility document titled 15 minute checks dated 8/3/2016 for Resident 1 revealed Licensed Practical Nurse (LPN) V documented checks were completed during the 9:15 AM until 10:00 AM timeframe. Interview on 8/3/2016 at 10:10 AM with the DON revealed the expectation for 15 minute checks were that the staff visualize the resident to assure the residents location. The DON stated the staff document on the facility form titled 15 min(minute) checks after checking on the resident. The DON stated, if they did not enter the room or open, Resident 1's door, the staff did not complete the checks. If the 15 minute check form was not completely filled out, it would be considered the checks were not done. Interview on 8/3/2016 at 11:30 AM with LPN-V revealed LPN-V documented Resident 1 was checked because Resident 1's door was shut and Resident 1 usually did not get up until 10:30 or 11:00 AM. When asked if LPN V visualized Resident 1 by opening the door and looking in the room, LPN V stated No . Interview on 8/3/2016 at 4:00 PM with the Administrator revealed the staff were not monitoring Resident 1 in a manner to protect other residents from Resident 1's behaviors. B. As outlined by the Administrator of the facility on 8/3/2016 at 3:00 PM, the facility initiated the following plan to address the immediacy of the situation. Resident 1 was placed on one to one observation with an assigned staff member and staff education would begin with all staff regarding the facility abuse policy, including proper reporting, proper execution of fifteen minute checks, including proper documentation. All employees were to be educated as they reported to work, both clinical and non-clinical. All employees not scheduled to work within the next two days were to be educated in a group setting and/or over the telephone. | 2019-08-01 |
| 5896 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2016-08-31 | 284 | J | 1 | 0 | F2SC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09C2 Based on observations, interviews, and record reviews; the facility failed to develop a post-discharge plan for one sampled resident (Resident 4) including: 1) involvement of the physician; 2) determination of safety capabilities and consultation with therapy to meet physician recommended discharge requirements; and 3) pre-assess the safety of the discharge environment and acceptance of discharge by the resident's family. The facility additionally failed by aiding the resident to transport and remain in a setting incapable of meeting the resident's safety needs. The failure resulted in Immediate Jeopardy of the resident's safety and led to a resident fall and fracture culminating in hospitalization . Facility census was 27. Findings are: Record review of Resident 4's Admission Record printed on 8/30/16 revealed the resident was initially admitted to the facility on [DATE]. Among medical [DIAGNOSES REDACTED]. Record review of Resident 4's Quarterly review assessment MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) dated 8/22/16 revealed the following: - The resident's Functional Status for Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position was recorded as Extensive assistance- resident involved in activity, staff provide weight-bearing support at a minimum of three times during a seven day period. The Support provided for the activity was One person physical assist. - The resident's Functional Status for walking in and out of room was recorded as Activity did not occur. - The resident's Functional Status for Locomotion off unit- how resident moves to and returns from off-unit locations (e.g. areas set aside for dining, activities, or treatments) . how resident moves to and from distant areas on the floor. If in wheelchair, self sufficiency once in chair. The item recorded the resident received Extensive Assistance for the activity with the assistance of one staff. - Active Medical [DIAGNOSES REDACTED]. - The resident experienced pain over the last five days Frequently and rated the worst pain at 8 on a pain scale of 0-10 with 0=no pain and 10= very severe pain. - The resident experienced one fall since the prior assessment. - The resident's weight was recorded as 398 pounds. - The resident had not received any Occupational therapy since 1/6/16 and had not received any Physical Therapy since 7/26/16. Record review of Resident 4's care conference on 6/2/16 revealed the resident was invited to the conference and had not attended. The Discharge Plans for the resident at the conference were recorded as Long term. Record review of Resident 4's Care Plan initiated on 5/24/16 revealed the resident's discharge plan was recorded as I would like to make plans to discharge to a skilled nursing facility closer to my home. Further review of the care plan revealed a focus problem with Physical functioning deficit related to: Mobility Impairment, self care impairment, r/t (related to) [MEDICAL CONDITION] and recent BKA (Below Knee Amputation). The problem was initiated 5/24/16 and identified Transfer assistance of 2 staff with gait belt, extensive assist regarding interventions for the problem. Record review of a Report of Consultation with the resident's physician on 7/14/16 revealed the purpose of the visit was: 60 day- wants d/c (discharge) orders. The physician documented under Recommendations that the resident (MONTH) d/c home if can transfer to shower chair or toilet. Record review of the facility's Progress Notes for (MONTH) (YEAR) revealed the following entries: - 8/17/16 recorded at 3:10 p.m.- At 1150 (11:50 a.m.) Resident is found on floor by CNA (Nurse Aide). Resident states was transferring self from bed to w/c (wheelchair) using slide board. Resident also reports that slide board slips and causes to fall . Resident is helped up off floor via Maxi-lift and an assist of 4 onto bed . - 8/22/16 recorded at 5:04 p.m.- . (resident) stated wanted to go home . Resident has discharge to home orders per (name of physician) with the stipulation of being able to transfer self from w/c to toilet and back independently. Resident is able to perform transfer without difficulty. Resident has begun to gather belongings to leave for (name of town) tomorrow morning . Staff notified of discharge and will escort resident to home. - 8/23/16 recorded at 9:46 a.m.- Resident left facility via (facility) transportation for d/c, to be d/c to home with (family member), sent medication and medication list with resident. Resident left with w/c which will be brought back by staff, left with belongings . resident refused vital signs to be taken at this time, no questions or concerns. - 8/24/16 recorded at 6:50 p.m.- Resident went to motel instead of home. Concerned about how (resident) would get food/water and cook. Reported having family/friends/money for these things. Resident now in hospital. Discussed with DON (Director of Nursing) today. Interview with the SSD (Social Service Director) on 8/30/16 at 1:35 p.m. and Staff-B (facility van driver) on 8/31/16 at 9:35 a.m. revealed Resident 4 requested a discharge to the home of a family member and requested facility transportation to the home. The residence was in a town over two hours away. The facility provided van for transport and the SSD and Staff-B assisted the resident during the transport. They stopped at a medical supply vendor on the way and picked up a new wheelchair for the resident. The SSD stated when arriving at the town, the resident stated the family member would be sleeping and requested staff help the resident check into the motel where the resident would wait until the family member got off night shift work and would take the resident to the home. The SSD stated they assisted the resident with check in as the resident was unable to get inside the lobby due to the resident's size of wheelchair and inability to walk. Both staff then assisted the resident to the motel room. Staff-B stated the resident's wheelchair was too big for the resident to get through the door of the motel room and both the SSD and Staff-B stated the resident was unable to use a prosthetic leg to stand and transfer and requested use of a slide board which the facility brought along. Staff-B stated the resident used the slide board and staff placed one wheelchair inside the room in the doorway and the resident wheeled the other one outside the doorway and transferred into the wheelchair in the motel room with the aid of the sliding board. The resident requested they leave the slide board and the staff complied. The SSD stated they asked the resident if there were any other needs and resident stated no and the SSD and Staff-B left the resident and returned to the facility. Interview with the motel owner on 8/29/16 at 12:51 p.m. revealed the owner was in the office when Resident 4 arrived at the motel on 8/24/16 after lunch. The owner stated the facility staff came in and requested check in for the resident as the resident was wheelchair bound and oversized and unable to get into the office. The owner told the staff the motel was not equipped for handicapped individuals and the facility staff proceeded with the check in anyway. The owner stated later in the night the owner received a call from Resident 4 who stated having fallen and experiencing pain and felt this was not going to work. The owner stated Resident 4 requested transfer to a nursing home. The owner instructed the resident to contact family. Telephone interview with Resident 4's family member (identified by facility as the family member to which the resident requested discharge to) on 8/29/16 at 11:45 a.m. The family member stated not having any knowledge of the resident's intent to discharge to the family member's home and heard nothing of what happened until being notified by Resident 4 by phone while at work on the night shift on 8/24/16. Resident 4 called the family member at work and reported having been dropped off at the motel by the facility staff. Resident 4 stated having fallen and that the resident's back was hurting. The family member then planned to go to the motel at end of shift and assist. The family member stated when arriving, Resident 4 was in pain and unable to be moved without help and an ambulance was called. The family member stated it took six responders to assist the resident into the ambulance for transport to the hospital. Further interview with the family member revealed the family member was unable to provide care for Resident 4 due to the resident's size and amputated leg. The family member stated the home was not equipped for handicapped accessibility and stated if the resident were to fall, there would be no way to get the resident off the floor without extensive assistance of several persons. Observation of Resident 4's motel room conducted with the motel owner on 8/29/16 at noon revealed one entry/exit door into the room. The room was not handicapped accessible regarding the doorway size entering the room. The entry door measured 32 inches and the bathroom door entry measured 28 inches. Both of these were confirmed by the owner. There were no grab bars or assistive devices inside the room or bathroom. The telephone to the room was located across from the bed behind the television. The only water source in the room was in the bathroom. Interview with an EMT (Emergency Medical Technician) on 8/29/16 at 11:44 a.m. revealed the EMT responded to the call at the motel involving Resident 4 on 8/24/16. The EMT stated having arrived sometime between 5 a.m. and 5:30 a.m. on 8/24/16 . The resident was lying on the bed and was stoic and complaining of significant back pain. The resident stated having fallen sometime during the night. The EMT stated due to the resident's size and amputation, six personnel were required along with the use of the slide board to get the resident onto the transfer cot where the resident was transported to the hospital. Record review of Resident 4's hospital documents revealed the following: -Patient Registration Form from the hospital revealed the resident was admitted to the hospital on [DATE] at 10:10 a.m. -History and Physical Report on 8/24/16 revealed documentation the resident was released from the nursing home yesterday and fell last night at the (name of motel) hurting (the resident's) back. They waited until this morning, then called the ambulance, hurts in the high lumbar spine. (Resident 4) has had back pain before, but this was different and that it was more severe . (Resident 4) is a very poor historian. Seems to be slow mentally . The physical report assessed that the resident had an amputation on the right side below the knee. The Assessment recorded: New L1 (area of the lumbar spine) compression fracture intractable pain. - Radiology Report dated 8/24/16: Findings recorded: There appears to be loss of height at the L1 level consistent with a mild compression fracture. The fracture was not apparent on the previous study . - Hematology report on 8/24/16 revealed the resident's [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] disorders) toxicology report discovered a reading of 32.6 ug/ml (micrograms of medication per milliliter of blood) and recorded the result as H (Higher than normal with normal range for the medication between 10 and 20 ug/ml). Observation of Resident 4 in the hospital on [DATE] at 12:15 p.m. revealed the resident was in a hospital bed and had an amputated right leg below the knee. Interview with Resident 4 on 8/29/16 at 12:15 p.m. verified the resident requested discharge to a family member's home on 8/22/16 and the facility discharged the resident and assisted with the transfer on 8/23/16. The resident verified directing staff to transport the resident to a motel instead of the family member's home and that the staff honored the request and assisted the resident checking in to the motel and then into the motel room. The resident stated after being left, the resident was uncertain if this would work out and requested the motel owner to get the resident to a nursing home. The resident was told to contact family member by the motel owner. Resident 4 stated having fallen and was in a lot of pain. After the family member arrived, the resident was taken to the hospital by ambulance. The resident confirmed the family member was not consulted regarding the discharge by Resident 4 or the facility prior to the discharge. Interview with facility NA (Nurse Aide)-C on 8/30/16 at 11:15 a.m. revealed NA-C worked with Resident 4 in assisting with the resident's daily needs. NA-C stated transferring the resident was problematic due to the resident's size and amputated leg. NA-C stated the resident had not used the prosthetic leg and refused transfers with a mechanical lift. NA-C was aware staff had been injured during transfer of the resident resulting in a Physical Therapy review. After the review, the resident began transferring from the w/c to the bed with the use of a slide board but for safety reasons, staff still needed to be present during these transfers to ensure a safe transfer. Resident did not always comply with this or use the call light. Interview with the facility PT (Physical Therapist) on 8/30/16 at 11:30 a.m. revealed the PT had worked with Resident 4 when admitted following a [MEDICAL CONDITION]. The resident was discharged from therapy in (MONTH) of (YEAR) due to lack of progress and refusal to continue. The resident was again seen 7/26/16 for a wheelchair evaluation. The PT recalled the resident being seen due to size and transfer problems, staff were getting injured with transfers. A transfer board was initiated and resident was transferring with this when discharged . The PT verified therapy was not consulted after 7/26/16 to assess the resident's transfer ability and safety to return to a home setting. The PT stated the evaluation would determine if the resident could safely transfer between surfaces, evaluate the home setting to determine if doorways could accommodate size and wheelchair size, evaluate if steps were there, evaluate how the resident would get in and out of bed and mobilize from room to room. Other consideration would be how the resident would get in and out of the home. Record review of Resident 4's therapy documentation revealed the following: -PT Therapist Progress & Discharge summary signed on 1/6/16 revealed the resident was discharged as a Long term resident due to a plateau in progress and lack of motivation to participate and assist with transfers. Pt (patient or Resident 4) is unable to ambulate and cannot stand for greater than 10 seconds due to a fear of falling/walking . PT has encouraged and educated the pt to participate and assist more with transfer in order for the pt to return to prior living environment . - OT (Occupational Therapy)- Therapist Progress & Discharge Summary signed on 1/7/16 revealed documentation the resident was morbidly obese individual with a BKA who has been struggling to make progress over past several weeks. Pt is now at 372 pounds with a goal of 350 pounds in order to be a candidate for a prosthesis . - Physical Therapy Plan of Care (Evaluation Only) dated 7/26/16- revealed therapy was referred to assess and acquire a wheelchair and evaluation of posture and positioning. The therapist documented resident was on therapy case in past year following a Right BKA and was discharged due to unwillingness to continue or participate. The resident returned for the evaluation expressing desire to return home and will require a w/c for mobility. The resident was discharged to the Skilled Nursing Facility with plans to return home, however was unable to fully indicate home environment and location. Record review of facility policies regarding transfers and discharges revealed the following: an updated policy of - Transfers and Discharges number SS-705. The Purpose of the policy read: Transfers and discharges should be handled appropriately to assure proper notification and assistance to residents and family in accordance with federal and state specific regulations. - Discharge/Transfer of the Resident procedure number CLIN1300-320 dated 1/26/15 revealed the procedure purpose was To provide safe departure from the facility and to provide sufficient information for after care of the resident. The Procedure included: Explain discharge procedure and reason to resident and give copy of Transfer & Discharge notice as required. Include resident representatives. Further instructions in the policy included: The attending physician is required to write a discharge order . When calling the attending physician for a discharge order, inquire whether or not the resident's medication is to be sent with the resident . include instructions for post discharge care and explain to the resident and/or representative . Interview with the facility DON (Director of Nursing) on 8/31/16 at 1:30 p.m. verified Resident 4 had multiple co-morbidities regarding the resident's medical status. Among these were Diabetes with Diabetic [MEDICAL CONDITION] and pain, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], Chronic embolism/[MEDICAL CONDITION] history, and amputation of the right leg below the knee. The DON verified the resident had fallen five days prior to discharge using a transfer board independently, but was deemed by facility as independent to return to a home setting. The DON could not recall who specifically cleared the resident as safe for discharge and self transfers but said the administrative team discussed this. The DON confirmed the resident requested to go to a family member's home and the facility assisted with the transport without contacting the family member or determining if the family member's home could accommodate the special safety needs for the resident. The DON confirmed the physician nor the therapy department were consulted prior to the resident's discharge, regarding the discharge to determine if the resident had met the discharge safe transfer recommendation or if the resident was medically stable for discharge. The DON verified there was no documentation supporting whether the facility discussed diabetic needs, safety with [MEDICAL CONDITION] medications and monitoring labs, or any discussions regarding other medical needs with the resident or family. The DON verified the resident had a [MEDICAL CONDITION] disorder history and received daily doses of [MEDICATION NAME] for the [DIAGNOSES REDACTED]. The DON confirmed the family member was not consulted to assure the facility that the discharge to the family member's home would be safe and the resident's needs would be met. The DON confirmed the facility aided in the transport of the resident to a motel room which was not handicapped accessible without access to water or bathroom facilities and doorways capable of allowing the resident to exit the room in an emergency. Prior to the survey team exit on 8/31/16, the facility's Quality Assurance team convened and developed a plan of action to prevent re-occurrence of the violation and implement immediate changes regarding resident discharges. The plan included identifying all residents with active discharge plans and validating the environment being sent for discharge was safe before implementing the discharge. The plan provided education of facility transportation aides and the Social Service Director immediately and education to all staff on duty regarding discharge policy implementation. In addition the facility plan included assurance the physician or other interdisciplinary team members including therapy were notified of planned discharges and involved in consultation prior to the discharges. Due to these measures, the Immediate Jeopardy was abated and scope and severity lowered to a G. | 2019-08-01 |
| 6168 | NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER | 285271 | 2100 CIRCLE DRIVE | SCOTTSBLUFF | NE | 69361 | 2016-06-06 | 333 | J | 1 | 0 | VYV311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].10D Based on record reviews and interviews, the facility failed to clarify dosage calculations prior to administering a narcotic medication to one sampled resident (Resident 5). The failure resulted in overdosing the resident resulting in the resident's death. Facility census was 47. Findings are: Record review of an undated Resident Admission Record for Resident 5 revealed the resident was admitted to the facility on [DATE]. Record review of a Palliative Care Consultation document for Resident 5 dated [DATE] revealed the resident was assessed by a Palliative Care Nurse Practitioner. The Nurse Practitioner described the resident as having steadily declined in the past 2 years since the resident fractured a hip. The resident was assessed sitting in a recliner and answered simple questions. The Nurse Practitioner recorded There are no signs of acute distress at this time. Following assessment of the resident the Nurse Practitioner ordered [MEDICATION NAME] liquid 1 mg (milligram) by mouth or sublingually (under the tongue) q (every) 12h (12 hours). Prescription sent to pharmacy. Record review of an untitled document revealed 30 cc (cubic centimeters or milliliters) of [MEDICATION NAME] was received at the facility on [DATE]. Record review of an Individual Resident's Controlled Substance Record for Resident 5 revealed 30 ml (milliliters) of [MEDICATION NAME] was received on [DATE]. Further review of the record revealed MA (Medication Aide)-J administered a 0.5 ml dose at 9:00 p.m. On [DATE], MA-F administered a 1 ml dose of [MEDICATION NAME] at 8:33 a.m. On [DATE], MA-I administered a 1 ml dose of [MEDICATION NAME] at 8:00 p.m. on [DATE]. Record review of Resident 5's Resident Progress Notes between [DATE] and [DATE] revealed no entry on ,[DATE] and an entry on [DATE] recorded at 8:41 p.m. which read: Entered room @ (at) 2030 (8:30 p.m.), resident has no noted pulse or resp (respirations) Record review of the facility's Medication Error Report forms for Resident 5 revealed the errors occurred on ,[DATE] and [DATE]. Description of the errors revealed the bottle from the pharmacy was correctly labeled c with 0.1 ml per 1 mg. Someone had blacked out the 0.1 ml (on the label). 0.5 ml (5 milligrams) was given on [DATE] @ 2100 (9:00 p.m.) by MA-J and 1 ml (10 mg) at 0830 (8:30 a.m.) by MA-F on [DATE]; and on [DATE] at 2000 (8 p.m.) by MA-I. The document recorded the Outcome to resident was Patient died at 2030 [DATE]. A separate Medication Error Report form for Resident 5 described the same incident and included a handwritten statement on [DATE] from LPN (Licensed Practical Nurse)-L which recorded I (LPN-L) marked out the label to prevent someone from giving wrong dose. MA-F asked me what dose to give as (the med aide) was confused from looking at the label. Phone interview with the Palliative Care Nurse Practitioner on [DATE] at 9:15 a.m. confirmed the Nurse Practitioner consulted for Resident 5 on [DATE] and wrote orders for [MEDICATION NAME] 1 mg to be administered every twelve hours. The Nurse Practitioner stated, that following the assessment of the resident on [DATE], the resident was not in any imminent danger from the disease process and the family and resident chose palliative care for comfort. When questioned in the Nurse Practitioner's opinion, what would affect a 5 mg dose and two subsequent 10 mg doses would have on Resident 5, the Nurse Practitioner stated due to frailty and [AGE] years of age, doses at that level would probably kill (the resident). Phone interview with the pharmacist dispensing the [MEDICATION NAME] for Resident was done on [DATE] at 9:45 a.m. The pharmacist stated having re-checked all orders and labels regarding Resident 5's [MEDICATION NAME] order. The pharmacist confirmed receiving an order from the Palliative Care Nurse Practitioner on [DATE] and verified the order called for [MEDICATION NAME] 1 mg every 12 hours. The Pharmacist verified the label sent out was on a typed label and identified to give 0.1 ml or 1 mg in the instructions. The bottle also identified the strength of the medication in the bottle was 10 mg per milliliter. When asked what a 10 mg dose of [MEDICATION NAME] would result in for Resident 2, the pharmacist replied that in a frail elderly person over [AGE] years of age and as potent as this ([MEDICATION NAME]) is that the first dose would cause some sedation but with progressive dosing accumulation would occur and likely result in death. The pharmacist stated that even a healthy young individual taking a 10 mg dose would experience severe sedation at a minimum. Interview with the facility DON (Director of Nursing) on [DATE] at 2:00 p.m. confirmed the facility staff had overdosed Resident 5 on [DATE] and [DATE]. The DON stated, from investigation, that the resident's [MEDICATION NAME] was received at the facility in a 30 ml bottle on [DATE]. The DON stated, that when logged into the computer, LPN-K had incorrectly typed in the order as 5 mg/ml rather than 10 mg/ml. When MA-J compared label to logged in order, MA-J was confused and asked for direction from LPN-K. LPN-K then directed MA-J to administer 0.5 ml (5 mg) which MA-J complied with and administered the medication at 9:00 a.m. LPN-K had not contacted the pharmacy or prescribing Nurse Practitioner for clarification of the orders. The DON stated that, on [DATE], MA-F also questioned the order and asked LPN-L for directions. LPN-L proceeded to tell MA-F the label was incorrect and crossed out the label instructing to administer 0.1 ml and changed the label to 1 ml without receiving any clarification from the pharmacy or the prescribing Nurse Practitioner. LPN-L instructed MA-F to administer 1 ml (10 mg) of the [MEDICATION NAME] with which MA-F complied at 8:33 a.m. At 8:00 p.m., MA-I administered 1 ml of [MEDICATION NAME] to Resident 5 based on the label change. The DON verified the resident was overdosed by 5 times the order on [DATE] and twice was administered 10 times the order on [DATE]. The DON verified the resident expired a half hour after receiving the third dose. Prior to the survey team exit on [DATE], the facility had terminated two employees regarding the incident. In addition, the facility's nurse consultants and DON arranged for immediate education for licensed nurses including dosing calculations for liquid medications, and review of a new policy for monitoring liquid medication dosages. Due to these measures, the Immediate Jeopardy was abated and scope and severity lowered to a G. | 2019-06-01 |
| 6171 | NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER | 285271 | 2100 CIRCLE DRIVE | SCOTTSBLUFF | NE | 69361 | 2016-06-06 | 520 | J | 1 | 0 | VYV311 | > Licensure Reference Number 175 NAC 12-006.07C Based on record reviews and interview, the facility failed to ensure that the QA&A (Quality Assessment and Assurance) Committee 1) developed and implemented an action plan to reduce the risk for medication errors which were identified at the annual survey and 2) identified that medication administration competencies were not completed for seven medication aides to ensure safe medication administration. The facility census was 47. Findings are: A. Review of the survey findings from the annual survey, dated 2/4/16, revealed a deficiency cited for medication errors. The medication rate was eight percent. Review of the findings for the current survey revealed that a medication error occurred during the medication pass observations and a significant medication error resulting in resident death was cited. B. Review of the findings for the current survey revealed that medication administration competencies were not completed for medication aides currently administering medications for the residents. A deficiency was cited at F 499. Review of the facility Quality Assurance Policy, dated 8/30/05, revealed that the following: Policy: The Quality Assessment/Assurance Committee shall determine opportunities for improvement, develop mechanisms that scrutinize appropriateness, effectiveness, efficiency and safety of the service rendered. Interview with the Administrator on 6/6/16 at 2:00 PM confirmed that the QA&A Committee was responsible to ensure that identified deficiencies were corrected and that staff were competent to perform their jobs. | 2019-06-01 |
| 6433 | THE AMBASSADOR LINCOLN | 285066 | 4405 NORMAL BLVD | LINCOLN | NE | 68506 | 2016-02-29 | 328 | J | 1 | 0 | 5EYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 175 NAC 12-006.09D6 Based on interviews and record reviews, the facility failed to ensure an Oximeter (oxygen saturation monitoring device) was turned 'on' and functioning to alert staff of the declining oxygen saturation level for Resident 1. Facility census was 76. Findings are: A. Review of Admission report in the Medical Record for Resident 1 revealed an admission to the [MEDICAL CONDITION] Unit on 2/8/16. Resident 1's code status was changed to Do Not Resuscitate on 2/11/16 per Resident 1 Power of Attorney. Resident 1 had medical [DIAGNOSES REDACTED]. - Pneumonia, - Extreme [MEDICAL CONDITION], - Hypoventilatio[DIAGNOSES REDACTED] with severe obstructive sleep apnea, - History of Chronic [MEDICAL CONDITION] (an incision in the windpipe for artificial opening through the neck to allow passage of air or evacuate secretions), - History of Motor Vehicle Accident with chronic disability. - [MEDICAL CONDITION] requiring mechanical ventilation,(an appliance for artificial respiration/ breathing) - weaning protocol, guarded prognosis given the obesity hypoventilation history and [MEDICAL CONDITION] (without oxygen) [MEDICAL CONDITION], - previous [MEDICAL CONDITION] ( [MEDICAL CONDITION]), - Heart Failure, and - [MEDICAL CONDITION]. A Facsimile (FAX) communication report dated 2/16/16 to Resident 1's Pulmonologist (Respiratory tract/Lung disease specialist) revealed a request, (MONTH) we [MEDICAL CONDITION] (administration of air or oxygen through cannula tube in the patients neck opening) trials daytime. The Physician ordered that the facility would advance [MEDICAL CONDITION] trial for Resident 1 for daytime only but the resident required the [MEDICAL CONDITION] (machine for non-invasive form of mechanical ventilation therapy for sleep apnea) at night. Review of facility investigation report for Resident 1 from the incident on 2/20/16 revealed an unexpected death of Resident 1 when found at respiration check to be without pulse or lung sounds and oximeter machine was not on at time of Resident 1 being found. Interview with Director of Nursing on 2/29/16 at 10:45am revealed that Resident 1 was very sweaty and the pulse oximeter device kept slipping off of Resident 1 on 2/20/16 which was a common occurrence. The oximeter monitor device was applied to Resident 1's ear lobe as Resident 1 did not tolerate the device when applied to fingers. Review of nursing notes for Resident 1 on 2/29/16 of entries recorded on 2/22/16 revealed: - 12:30pm facial area moist, oximetry ear probe kept sliding off ear, ear was dried and probe put back on several times during the shift. The room temperature was lowered for Resident 1's comfort. - 4:00pm resident was repositioned and secretions suctioned. The Sa02 (oxygen level) monitor read 92 - 97% with FI02 (forced air with ratio of blood oxygen and inspired (breathed in) oxygen through a tube) @ at 35% [MEDICAL CONDITION]. - 5:00pm Resident 1 restless and received a pain pill and repositioning. - 5:40pm Resident 1 checked and sleeping comfortably. Review of Resident 1 medical record for treatment note charting by Respiratory Therapist from 2/20/16 revealed: - 6:20pm went to provide breathing treatment scheduled and found (Resident 1) was laying on the ear probe for the oximeter, which was turned off. Put the ear probe on ear and turned on the oximeter. While waiting for the oximeter to read SA02 (saturation of oxygen level in blood) noted was blue in the lips and not responding when change stoma pad (dressing over [MEDICAL CONDITION]). Tried to feel for a radial (arm) or carotid (neck) pulse and listened for breath sounds. Didn't hear any or feel a pulse. Quickly went to get the nurses down at the nursing station. We all went back down to room. Turned O2 (oxygen) up to 100% (was at 35% via [MEDICAL CONDITION] mask for ventilator weaning). Still not getting respirations. Pupils were fixed and dilated. Was on the cool mist Nebulizer 35% 02 since 6:55 am. The facility policy for Ventilator weaning dated (MONTH) 2014 required non -invasive monitoring including: oximetry for Sp02 (saturation of oxygen available in the blood to support respiratory function) and heart rate with the level of Sp02 to be greater than 90%. B. Review of the Facility Systems with Director of Nursing and [MEDICAL CONDITION] Unit Manager (Respiratory Therapist) on 2/29/16 between 1:30 pm and 2:45 pm revealed that the facility took the following actions to review systems to correct the immediacy of care concerns on the evening of 2/22/16 and 2/23/16 - 1. Checked all oximetry machines the evening of 2/20/16. Signed documents recorded that the facility Respiratory Therapist on the evening/night shift (6:00 pm - 6:00 am) went to each room, checked all the oximeters in all the patient's rooms, and determined all were on and in working condition including the oximeter used for Resident 1. 2. All staff including Nursing staff and Respiratory Therapists, were provided education on 2/23/16 including: Pulse Oximetry Protocols review with staff and discussion of Treatment Record recording of oximetry, Respiratory Therapy orders, exception reports and obtaining clarification orders from physicians and review of Ventilator Weaning Protocol. 3. A second inservice on Medication Errors (including oxygen) was conducted for all staff at the facility on 2/26/16. The meeting also included further information and updating on Respiratory Care Protocols. 4. Internal Investigation of Resident 1's death and resultant staff disciplinary action was given to the two professional/licensed nurses working the day shift of 2/20/16. The personnel files of Nursing Staff J and K were reviewed for this disciplinary action. 5. Facility staff obtained specific physician orders [REDACTED]. for all six residents residing on the [MEDICAL CONDITION] unit requiring ongoing oximetry. These orders included: check Oxygen Saturations twice daily and record; change oxygen site monitoring every morning; Keep Oxygen saturation greater than 90%. The newly obtained clarification orders for the oximetry readings were audited by the Respiratory Manager and also an outside Respiratory Therapist over a three week time period. 6. The Respiratory Unit staff were conducting change of shift rounds in each resident's room to review that resident specific assignment sheet criteria were in place. 7. Staff Interview with Respiratory Therapist (RT) - D on 2/29/16 at 2:58 pm revealed that the oximetry monitors were always positioned in the open metal basket above the residents' bed so the monitor readings could easily be visualized each time staff walk by the rooms. This compilation of correction methods placed the facility in compliance with correction as of 2/23/16 when all staff re-education was provided for Respiratory protocols. | 2019-02-01 |
| 6577 | PLATTSMOUTH CARE AND REHABILITATION CENTER, LLC | 285104 | 602 SOUTH 18TH STREET | PLATTSMOUTH | NE | 68048 | 2015-12-03 | 155 | J | 1 | 0 | YK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to follow the cardiopulmonary resuscitation (CPR) directive for one resident (Resident 1). The facility census was 100. Findings are: Review of Resident 1's Resuscitation Orders dated [DATE] revealed that in the event of cardiac and/or respiratory arrest Resident 1 wanted CPR initiated. Review of Resident 1's Nurses Notes, dated [DATE], revealed that the resident was found at 7:05 PM with no vitals or respiration. CPR was initiated and 911 was called, Director of Nursing (DON) was notified. During an interview with Licensed Practical Nurse A (LPN A) on [DATE] at 2:40 PM, LPN A revealed that, on the evening shift of [DATE], LPN A came up to the nurses station on the central unit while LPN B and Registered Nurse C (RN C) were having a discussion that Resident 1 had died and that they were unsure of Resident 1's CPR status. LPN A informed them that Resident 1's directive was to initiate CPR and that 911 needed to be called. LPN A stated that LPN A got the crash cart (a mobile cart carrying medical equipment used for resuscitation) and went to Resident 1's room but didn't have the key to turn the oxygen tank on and had to go back to get it. LPN A said that this all took about 5 minutes. LPN B was interviewed by telephone on [DATE] at 2:10 PM. LPN B said that on [DATE] after supper, RN C came to the nurses station and told LPN B that Resident 1 had died . LPN B said that, We kinda thought (Resident 1) was a no code. LPN B said it was ,[DATE] minutes before CPR was started on Resident 1. On [DATE] at 5:31 PM, RN C was interviewed by telephone. RN C stated that RN C found Resident 1 in room and unresponsive at 7:05 PM. RN C went to the nurses station and called LPN B and checked the resident's chart for the code status. Asked how long from the time Resident 1 was found unresponsive until CPR was initiated, RN C said, about 10 minutes. Review of the facility's CPR policy, with an effective date of [DATE], revealed that: 1) CPR sequence was to: -Check patient for responsiveness -Check for breathing or no normal breathing -Call for help -Check a pulse for no more than 10 seconds -Give 30 compressions -Open airway and give 2 breaths -Resume compressions -No more than 10 seconds hands off time 2) Compressions should be initiated within 10 seconds of recognition of the arrest. Review of a document titled Verification of Investigation (VOI) dated [DATE] revealed that another resident (Resident 2) was admitted to the facility on [DATE]. Resident 2 was alert and oriented and signed a code status at that time indicating Resident 2 wanted CPR. Under Summary And Outcome of Investigative Findings on the VOI, it stated that, (Resident 2) had a [DIAGNOSES REDACTED]. The resident's health status declined and the resident was found with no pulse or respirations at 1:15 AM. Resident was not given CPR. On [DATE] at 11:41 the DON was interviewed about Resident 2 and how the facility responded to the resident not getting CPR. The DON said that education was provided to all nursing staff on CPR policies at that time and audits were done on all charts to ensure all CPR status' were current. On [DATE] at 5:15 PM the DON agreed to immediately implement the following: -Immediately educate all direct care staff currently on duty about what do and how to respond when a resident is found unresponsive/without vitals -Initiate a plan on how the facility would educate each shift and the remaining direct care staff before the staff began their work shift. | 2018-12-01 |
| 8679 | GRETNA CARE CENTER | 285146 | 700 HIGHWAY 6 | GRETNA | NE | 68028 | 2013-12-04 | 309 | J | 0 | 1 | T6KG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D Based on observations, record review and interview, the facility failed to provide CPR (Cardiopulmonary Resuscitation) in accordance with the resident's signed and documented advanced directives for Resident 77. In addition, the facility failed to identify code status on room name plates with as identified in the facility policy for Resident 51 and Resident 31. Resident census was 57. Findings are: Resident 77 was admitted to the facility on [DATE] according to the Face Sheet. Resident was admitted for rehab and nursing support related to L knee non-displaced lateral tibial plateau fracture according to the Discharge summary under the category nursing summary/discharge instructions. Resident 77 died on [DATE]. Resident 77 was assisted with ADL's (Activities of Daily Living) and participated with activities and therapy during resident stay at the facility. A document entitled Preferred Intensity of Medical Care and Treatment dated [DATE] and signed by the resident's daughter and POA (Power of Attorney) for Healthcare stated: I have fully discussed my future options for medical care and treatment, with both my physician and the facility. I have been informed of the benefits and risks of such options, and the potential consequences, and I am fully aware of my right to determine the course of my future treatment. Having considered all of these factors, I hereby direct my caregivers to honor my intentions with respect to the following treatments, should the need arise, all of which have been explained to me. An X marked the area of Resuscitate (Full Code) and Hospitalize. The document was signed by the resident's Healthcare Power of Attorney and witnessed by a facility representative. The physician signed the document and dated it on [DATE]. Record review of the Nurses Notes dated [DATE] at 2110 revealed the Med pass nurse went into the resident's room to give HS (hour of sleep) medications and found the resident with eyes open, unresponsive and no heart rate. No respirations, poor color. RN (Registered Nurse) C was called to the resident's room to examine the resident. Resident 77 was last checked at 8:55 pm. No unusual behaviors noted and no complaints at that time. At 9:15 pm, the PA (physician's assistant) was notified and stated: [DIAGNOSES REDACTED]. The Nurses Notes did not indicate that CPR was initiated. Resident 77's family and the Sheriff were notified of the resident's death. An additional note added to the Nurses Notes and dated [DATE] at 10:35 pm stated: Additional information regarding expiration: CPR was not initiated due to condition of body when found. MD aware. Family voiced no concerns. An interview with RN C was held on [DATE] at 3:07 PM. RN C was asked to indicate what she would do if she found a resident unresponsive. RN C responded that RN C would attempt to arouse the resident if the resident was unresponsive. RN C would then check the chart for a yellow sticker which is the facility indicator to initiate CPR. RN C would tell someone to call 911, initiate CPR, and grab someone to assist. RN C revealed that RN C had experienced a recent occurrance where the resident was a full code but when RN C found the resident, the resident had no heartbeat or respirations and pupils were fixed. RN C did not initiate CPR due to the resident's condition. When the physician was notified, the physician stated that nurses would not have been able to do anything anyway. An interview with the DON (Director of Nursing) on [DATE] at 3:20 PM revealed that the expectation of the DON would be that if a resident or responsible party has signed a document requesting full code, that a full code would be initiated. The DON stated CPR class recertification touches on when to initiate CPR. The residents who have requested full code status have a yellow round sticker on the resident chart and a yellow round sticker on the nameplate of the door of the resident's room. Review of the policy number CL-NUR-1804 entitled Emergency: Initiation of Code Blue and dated [DATE] indicated the following: 1.0 Purpose - To provide an organized, systematic process to notify appropriate staff emmgers of the need for assistance during a potential life-threatening situation. 2.0 Fundamental Information Equipment - Emergency Cart, Emergency oxygen supply, telephone 3.0 Procedure - 1. Follow clinical practice guidelines for CPR 2. Utilizing the overhead paging system, announce Code Blue (location); Repeat 2 times. At minimum, the following individuals are to respond: Physician (if in facility), Director of Nurses, Charge Nurse, Respiratory Therapist (not applicable in all facilities. 3. A designated team leader will direct other staff members to assist with making phone calls, assure the emergency cart is brought to the scene and assure the safety of other residents in the area. 4. A licensed staff person must remain with the resident at all times. 5. Call 911 for emergency transfer to an acute care center. 6. Contact the resident's physician for further orders. 7. Contact the resident's responsible party to inform him/her of the change of condition. 8. Continue CPR efforts until the ambulance service arrives or until spontaneous respirations, pulse and blood pressure return. 9. Transport resident to the acute care center. 4.0 Documentation - In the progress notes, record: When and why the Code Blue was initiated If CPR was initiated, when and how long the resident received it Resident response and any complications Any interventions taken to correct complications Date, time of physician and responsible party notifications Resident disposition 5.0 Company related guidelines Perry/Potter reference manual: CPR; One-Person and/or Two-Person rescue Choking Manual ventilation (Ambu Bag) Interview with LPN (Licensed Practical Nurse) E on [DATE] at 3:45 PM indicated this LPN would initiate CPR and yell for help if (gender) were to find a resident unresponsive with the absence of respirations and a heart rate. LPN E indicated that if the resident was a full code, even if they were cold and blue LPN E would initiate CPR. LPN E received CPR training on [DATE] from the NE Safety Council. Interview with NA (Nurse Aide) F on [DATE] at 3:50 PM indicated that if NA F found a resident unresponsive, NA F would call for the charge nurse. NA F was unable to identify the significance of yellow dots found on the name plates of rooms. Observation of yellow dots indicating full code status held on [DATE] at 3:40 PM to 3:44 PM revealed yellow dots on the nameplates of the following rooms: room [ROOM NUMBER] 212, 217, 101, 108, and 117. Observation of yellow dots on charts indicating full code status held on [DATE] at 3:45 PM indicated yellow dots were present on charts 101A,107A, 108A,117A, 118A, 203B, 204B, 212B, 217A and 217B. The dots on the charts do no correspond with the dots on the door nameplates. Interview with RN H held on [DATE] at 3:45 PM indicated if RN H would enter a resident room and observed an unresponsive resident with the absence of heart rate and respirations, RN H would attempt to arouse the resident and check the chart to see if the resident is DNR( do not resuscitate) status. If the resident were a full code, RN H would attempt CPR. When questioned when CPR would not be initiated, RN H responded if a do not resuscitate order is present or unless the color has already changed and there are no signs of hope. Interview on [DATE] at 3:55 pm with NA I revealed NA I would get the charge nurse if she found a resident unresponsive and wait for them to tell her what to do. Interview with the DON held on [DATE] at 4:10 PM revealed the facility did not have a policy on how to identify DNR residents as opposed to full code written up on the yellow dot system but DON said I can type something up. Interview held with the DON on [DATE] at 4:45 PM confirmed 2 nameplates by resident rooms did not have yellow dots, Residents 31 and 51. Residents 31 and 51 were determined to be full code status. The DON indicated (gender) had typed up dot guide today.Interview with the DON indicated nurses are informed of the yellow dot system during initial orientation. The following interventions were implemented by the facility on [DATE], [DATE] and [DATE] to abate the immediacy of the situation and protect residents who wanted to have CPR. An action plan was created listing CPR as the area of concern with a goal of residents receiving CPR according to current CPR guidelines. Approaches included: Audit placement of round yellow stickers daily times 1 month, then weekly times one month, then monthly times 3 months, then reassess and schedule audits on a prn random basis. Tentative schedule developed with a completion date of [DATE]; Assess monthly with QA(Quality Assurance). The outcome was all round yellow stickers were in place on the charts and beside name on door after replacing needed stickers. Move stickers under plastic on the resident name plate by their room door with a completion date of [DATE]. The outcome was all round yellow stickers are under plastic on the resident name plates by their door. Re-educate staff concerning CPR guidelines and protocols on all 3 shifts before they work with a completion date of [DATE] and [DATE] and current staff by [DATE]. The outcome was re-education completed on all three shifts and will continue until all staff reeducated before they work. Random questioning of staff concerning CPR policies and procedures weekly times one month, monthly times 1 month, then reassess and scheduel random questioning on a prn basis. Tentative schedule developed. The completion date was [DATE] and assess monthly with QA. The outcome indicated staff questioned gave correct answers to questions asked. Code Blue drills weekly times 1 month alternating shifts and assess then continue on a quarterly basis. Completion date was [DATE]. The first drill is scheduled for [DATE] quarterly schedule completed. Room changes or code status change with completion date of [DATE] Outcome will be social worker will give notice to DON with reminder to move round yellow stickers with move, and give copy of all code status changes to DON, audit weekly. On admission, admission nurse will put round yellow stickers on chart and by door under plastic on name plate and document on admission check list. Completion date of [DATE] with outcome to audit of all admissions upon admit. The final approach is to report findings to QA meeting monthly with the next QA meeting being [DATE]. The outcome will be to address all findings. All facility nursing staff who were scheduled to work were re-educated on the CPR policy on [DATE] and [DATE]. Based on the facilities actions, the IJ status was abated on [DATE]. | 2017-03-01 |
| 9101 | HUNTINGTON PARK CARE CENTER | 285251 | 1507 GOLD COAST ROAD | PAPILLION | NE | 68046 | 2014-10-16 | 309 | J | 1 | 0 | BXXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D Based on interviews and record review, the facility failed to implement interventions to protect residents from potential harm after statements of suicidal ideation for two residents (Residents 6 and 10). The facility had a total census of 91 residents. Findings are: A. Resident 6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident 6's 9/16/14 MDS (Minimum Data Set; a comprehensive assessment used for care planning) under Staff Assessment of Resident Mood revealed Resident 6 was identified as having stated life isn't worth living, had wishes for death, or attempts to harm self for 2-6 days out of the last 2 weeks. A review of Resident 6's Care Plan revealed a focus area dated 8/1/14 regarding Resident 6's [DIAGNOSES REDACTED]. Interventions for this focus area included the following: monitor/document report as needed any risk for harm to self, suicidal plan, past attempt at suicide, risky behavior, intentional harm or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, or impaired judgment or safety awareness. A review of Progress Notes for Resident 6 revealed a note dated 9/27/14 at 5 PM that stated Resident 6 had a plan to kill self. Resident 6 would not state what Resident 6's plan was. The Progress Note stated Resident 6 told staff members to get out of the room and slammed the door behind them. According to the note, RN A (Registered Nurse) went to check on Resident 6 20 minutes later and could not open door as Resident 6 had backed wheelchair up against room door. RN A entered room through the bathroom connected to another room. Resident 6 refused to respond to RN A and spit in RN A's face. A Progress Note dated 9/27/14 at 6:50 PM stated Resident 6 was transferred to the hospital for suicidal thoughts with a plan and delusions. In an interview on 9/30/14 at 2:32 PM, RN A reported after Resident 6 told staff members to leave the room, Resident 6 was in room alone for 15 minutes while RN A contacted House Supervisor. RN A reported after checking on Resident 6 and discovering Resident 6 had placed a wheelchair in front of the room door so it could not be opened, Resident 6 was alone in room while arrangements were made to transfer Resident 6 to the hospital. RN A stated RN A did not check Resident 6's room for potentially dangerous objects. In an interview on 9/30/14 at 3:27 PM, the Director of Nursing reported Resident 6 should not have been left alone in the room when Resident 6 was making statements about harming self. The Director of Nursing reported Resident 6 should have been brought to the desk or a staff member should have stood in Resident 6's doorway. B. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 10's 8/5/14 MDS revealed Resident 10 had no thoughts of being better off dead or hurting self in some way with in the previous 2 weeks. Resident 10 had a total score of 7 on the Resident Mood Interview, PHQ-9 (an assessment of resident mood based on resident response to interview questions). A review of Resident 10's care plan revealed a focus area dated 6/17/14 related to depression due to admission with use of medication of [MEDICATION NAME] (a medication for depression) and [MEDICATION NAME] (a medication for anxiety). Resident 10's goal for this focus areas was for PHQ9 score to not exceed 6. Interventions for this focus area included the following: monitor/document report as needed any risk for harm to self, suicidal plan, past attempt at suicide, risky behavior, intentional harm or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, or impaired judgment or safety awareness. In interviews on 9/30/14 at 2:45 PM and 3:06 PM, LPN B (Licensed Practical Nurse) reported a family member of Resident 10 had found an empty insulin syringe in Resident 10's drawer and brought it to LPN B. LPN B reported the family member stated Resident 10 had kept it in case Resident 10 wanted to kill self. LPN B reported LPN B disposed of the syringe and reported the incident to the next shift. A review of Resident 10's Progress Notes revealed a note dated 9/27/14 at 5 PM. The Progress Note stated Resident 10's family member had found a syringe in Resident 10's top drawer. Resident 10 had told the family member the syring was in a drawer in case Resident 10 wanted to kill self. According to the Progress Note, the syringe was disposed of in a needle box. A Progress Note dated 9/28/14 referred to an incident in which the syringe was found in Resident 10's drawer but did not include any documentation of follow up being completed regarding the incident. In interviews on 9/30/14 at 3:20 PM and 4:17 PM, the Director of Nursing reported having heard either that morning or the evening before that a family member of Resident 10 reported there may have been a syringe in Resident 10's room. The Director of Nursing was not aware that Resident 10 had made statements of self-harm or that the nursing staff had seen the syringe. According to the Director of Nursing, no follow up had been completed regarding the incident. The Director of Nursing reported the information about the residents making the statement regarding self-harm should be kept at the desk during the day and check on the resident every 10-15 minutes at night. The resident's room should be checked for any item that the resident could harm self with. C. A review of the facility policy/procedure titled Suicide Precautions dated 10/02 stated the following: - Physician order for [REDACTED]. (Medical Doctor) and family contacts will be reflected in interdisciplinary notes. - Social Services will be contacted. - Documentation regarding behaviors and verbal clues that the resident is despondent will be reflected in the charting every shift. - The resident will be monitored every thirty minutes. - Medication administration will be monitored to make sure that all medications dispensed are swallowed. - All sharp objects will be removed from resident's room. This includes, but not limited to, safety razors, glassware, belts, shoelaces, all electrical cords, light bulbs and any self-administered medications. - Plastic silverware will be used for all meals. - All wastebasket plastic liners will be removed from the room. D. The following interventions were implemented by the facility on 9/30/14 and 10/1/14 to abate the immediacy of the situation and protect residents with potential suicidal ideation. 1. All current residents of the facility were screened for depression and suicide ideation on 9/30/14 or 10/1/14. Resident 6 was still in the hospital on [DATE]. An appointment was arranged for Resident 10 with the facility's consulting psychiatrist on 10/1/14. 2. The facility Suicide Precautions Policy was updated to state the following: - Suicide precautions will be implemented immediately once the need is determined. - A physician's written order shall be obtained within four hours of implementation of suicide precautions. - The need for suicide precautions will be reassessed daily for continued need by a physician. - If a Resident is found to have SI (Suicide Ideation) and has a plan, a designated staff member will stay with the resident for the resident should not be left alone. - Staff is to stay with resident and ensure safety by modification of the resident's environment. Remove any sharp objects such as razors, glassware, belts, shoelaces, light bulbs. Etc. -If suicide precautions are in place staff should monitor resident every 15 minutes or more frequently as needed, with no time lapse of greater than 15 minutes. 3. Education was provided to staff on the new suicide Precautions Policy starting with the evening shift on 9/30/14. Nursing staff members were educated on suicide precautions prior to start of night shift on 9/30/14 and day shift on 10/1/14. Education was provided to staff not working evening shift or night shift on 9/30/14 or day shift on 10/1/14 was provided on 10/1/14 in person or via telephones. This included activity and social services staff members. Nursing staff members on leave or who could not be reached were informed they would not be allowed to work until education was completed. | 2016-11-01 |
| 9241 | GOLDEN LIVINGCENTER - GRAND ISLAND PARK PLACE | 285105 | 610 NORTH DARR AVENUE | GRAND ISLAND | NE | 68803 | 2013-03-21 | 309 | J | 0 | 1 | FG2G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 Based on record review and interview, the facility staff failed to ensure a licensed nurse assessed the change in condition of 1 resident (Resident 09) who had become unresponsive and the facility staff failed to assess the resident after a medication error. The facility census was 55 and the survey sample size was 45. Findings are: Review of an ADMISSION RECORD dated 7/12/12 revealed Resident 09 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A. During an interview on 3/12/13 at 2:57 PM, Resident 09's child revealed that on Wednesday, 3/6/13, the child came to visit the resident during supper at about 6:00 PM. Resident 09's child revealed the resident was found in the dining room and was unresponsive even after the sternum rub (a method to check for a person's response by rubbing the sternum with the knuckles of the hand). Resident 09's child stated staff were in the area, but no one noticed, so the child took Resident 09 to the bedroom and started oxygen on the resident. Resident 09's child revealed the resident was taken to the hospital and given [MEDICATION NAME] (an intravenous medication that prevents or reverses the effects of opioids/narcotics including respiratory depression, sedation and [MEDICAL CONDITION]). Resident 09's child explained the resident returned to the facility later on 3/6/13, but the next day on 3/7/13, Resident 09 became unresponsive again and returned to the hospital. During an interview on 3/12/13 at 6:23 PM, Nursing Assistant (NA) -E revealed that, at about 6:00 PM on 3/6/13, the NA first thought Resident 09 was sleeping in the dining room. Then NA-E noticed the resident did not have oxygen (O2) on and NA-E was unable to wake the resident. NA-E described that Resident 09 had the head tilted back and the skin was bluish. NA-E revealed Resident 09's unresponsiveness was brought to Registered Nurse (RN) - F's attention. The RN was on break and RN-F told the NA to keep trying to wake Resident 09 and to pinch the resident's neck, but the RN did not go into the dining room to assess the resident. NA-E revealed that after attempts to awaken Resident 09 failed, RN-F was consulted and the NA was instructed to go get Licensed Practical Nurse (LPN) -P. NA-E revealed the NA had worked with Resident 09 for about 15 minutes. NA-E stated Resident 09 usually had O2 on and didn't go long without it. NA-E estimated Resident 09 had been without O2 for about 4 1/2 hours and then stated, if Resident 09 went too long without O2, the resident got ill. During an interview on 3/12/13 at 6:12 PM, LPN-P revealed, NA-E brought to the LPN's attention that Resident 09 wouldn't wake up on 3/6/13. LPN-P described Resident 09 was blue around the mouth and did not respond when the LPN pinched the resident's neck, but squinted when the LPN did the sternum rub. LPN-P revealed that Resident 09's child put O2 on the resident and an ambulance was called. During an interview on 3/13/13 at 1:56 PM, NA-K revealed that, at around 6:00 PM on 3/6/13, Resident 09 appeared to be sleeping at first with the head tilted back. Then Resident 09's child came in and didn't think Resident 09 looked right. NA-K revealed NA-E stated (gender) went to talk to RN-F; but RN-F did not come and look at Resident 09, but LPN-P did as soon as NA-E got the LPN. NA-K stated RN-F was the charge nurse for the dining room area, but did not see RN-F during this time, and didn't know where RN-F was. NA-K revealed Resident 09's fingers were a little blue. NA-K stated that Resident 09 did not use O2 all the times, but would sometimes later at night. During an interview on 3/20/13 at 3:35 PM, the Director of Nursing (DON) revealed Resident 09 did not have a physician's orders [REDACTED]. The DON stated even though Resident 09 did not have an order for [REDACTED]. During an interview on 3/13/13 at 11:25 AM, RN-F revealed Resident 09 had gotten sick while the RN was on break. RN-F explained NA-K came to the break room and reported staff couldn't wake Resident 09. Then RN-F told the NA to call the north nurse (LPN-P) to check on Resident 09. Then RN-F got a message that Resident 09 was being sent to the hospital, so RN-F finished the call to the ambulance and sent the LPN back to be with Resident 09. RN-F revealed (gender) did not assess Resident 09's change in condition. Review of Resident 09's Progress Notes dated 3/6/13 at 6:53 PM revealed (resident) was not responsive. upon my arrival (Resident 09) was blue in color and was gasping for air. (Resident 09) remained unresponsive even to painful stimuli. The entry was signed by LPN-P Review of the facility's VERIFICATION OF INVESTIGATION dated 3/13/13 revealed: - On 3/6/13 at approximately 6 PM resident was in West Dining Room, when staff note that (Resident 09) is difficult to arouse, staff attempt to wake resident and cannot, this information is relayed to (RN-F), whom instructs CNA's nursing assistants) in how to try to wake the resident, CNA attempts without success, and return to RN with update, at which point (the CNA) is instructed to notify the charge nurse for North Station; - interview with NA-E revealed did not know where RN-F was, but went to the break room purposely seeking the nurse. NA-E stated RN-F told the NA to go and try again, and was instructed to try pinching (Resident 09's) pressure points on shoulder. The interview revealed NA-E tried the pressure point pinching and it did not work, went back to the break room and reported concerns that Resident 09 did not respond and skin was tinted to RN-F, then NA-F only raised one eyebrow and instructed the NA to go get the LPN. B. Review of Resident 09's Progress Notes revealed: - 3/7/13 at 1:04 AM: resident returned to the facility at 2220 (10:20 PM); - 3/7/13 at 11:05 AM: Resident is asleep and difficult to arose. was lethargic, difficult to arose w/ (with) mottled hands and unable to speak clearly. sent resident to ER (emergency room ). - 3/7/13 at 6:27 PM: resident returned from ER this afternoon. Review of the EMERGENCY PHYSICIAN RECORD dated 3/7/13 revealed Resident 09: - Had been seen approximately 18 hours ago for same. [MEDICATION NAME] (patch that releases a narcotic medication to relieve pain) removed; - Clinical impression: Narcotic overdose - accidental. Review of a physician's orders [REDACTED]. Review of Resident 09's Medication Administration Record [REDACTED]. Review of Resident 09' Progress Notes revealed on 3/12/13 located fentynal patch 50 mcg on resident R (right) Back dcd (discontinued) patch at this time. During an interview on 3/13/13 at 9:05 AM, the Director of Nursing (DON) revealed the administration of the [MEDICATION NAME] to Resident 09 was a medication error and the resident should have been monitored for any adverse reactions. The DON revealed the monitoring was documented on the critical charting list, they just added (Resident 09) today (3/13/13) and hadn't done any assessment yet, but will do it later. Review of the critical charting list revealed no assessments of Resident 09's condition had been completed on 3/12/13 or during the morning of 3/13/13. Review of the facility's MEDICATION ERROR AND ADVERSE DRUG REACTION REPORTING dated 10/07 revealed Any new prescriber's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1) Inservice training with all licensed nurses on the correct procedure for taking off physician's orders [REDACTED].>2) Inservice training with all staff, licensed or certified, who administer medications regarding the process for discontinuing narcotics; 3) Implementation of a checklist to be used that includes the 6 steps on how to process a physician's orders [REDACTED].>4) Implementation of a process to verify new and discontinued physician's orders [REDACTED].>5) All resident medications were checked against current physician orders [REDACTED].>6) Inservice training with all nursing staff on the identification of a change in resident condition and how to respond in an emergency situation; and 7) Inservice training with all staff, licensed or certified, on Critical Charting documentation related to for ongoing monitoring of residents' health conditions. The immediacy has been removed, however, the deficient practice has not been totally corrected. Therefore, the scope and severity has been lowered to D. | 2016-09-01 |
| 9242 | GOLDEN LIVINGCENTER - GRAND ISLAND PARK PLACE | 285105 | 610 NORTH DARR AVENUE | GRAND ISLAND | NE | 68803 | 2013-03-21 | 333 | J | 0 | 1 | FG2G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10D Based on record review and interview, the facility failed to ensure 3 residents (Resident 09, 64, and 57) were free of significant medication errors. These failures involved the administration of narcotic and anticoagulant medications. The facility census was 55 and the survey size was 45. Findings are: A. Review of the facility's MEDICATION ERROR AND ADVERSE DRUG REACTION REPORTING dated 10/07 revealed Medication Error/Variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm; and Medication errors and adverse drug reactions are considered significant if they: a. Require discontinuing a medication or modifying the dose b. Require hospitalization c. Result in disability d. Require treatment with a prescription mediation e. Result in cognitive deterioration or impairment f. Are life threatening g. Result in death. B. Review of an ADMISSION RECORD dated 7/12/12 revealed Resident 09 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].), Cramp of limb, Chronic pai[DIAGNOSES REDACTED], and [MEDICAL CONDITIONS]. Review of Resident 09's medical record revealed the resident had been transported to the hospital emergency roiagnom on [DATE] for Decrease Level of Consciousness and on 3/7/13 for Narcotic overdose - accidental. Review of Resident 09's physician's orders [REDACTED].>- 2/20/13: [MEDICATION NAME] 50 mcg (micrograms)/hr (hour) [MEDICATION NAME] Patch at bedtime. Change every 3 days; - 3/6/13: may resume [MEDICATION NAME] 25 mcg to skin tonight; - 3/8/13: D/C (discontinue) [MEDICATION NAME] Patch. Review of the 2012 Nursing Drug Handbook revealed the [MEDICATION NAME] Patch was an opioid or narcotic medication used to treat moderate to severe chronic pain. Black box warnings revealed the [MEDICATION NAME] should be used with caution in patients with [MEDICAL CONDITION], decreased respiratory reserve, potentially compromised respiration, or [MEDICAL CONDITION] and in elderly or debilitated patients. The Nursing Drug Handbook revealed usage of the [MEDICATION NAME] could cause respiratory depression or an altered level of consciousness. Review of Resident 09's Medication Administration Record [REDACTED]. Review of Resident 09's CONTROLLED DRUG RECORD revealed 1 [MEDICATION NAME] 50 mcg/hr patch had been removed from the narcotic count on 3/10/13 at 8:00 PM. During an interview on 3/13/13 at 8:52 AM, Nursing Assistant (NA) - I revealed Resident 09 had a [MEDICATION NAME] on the right shoulder on 3/12/13 at about 2:00 PM when NA-I assisted Resident 09 with bathing. Review of Resident 09's Progress Notes revealed on 3/12/13 at 8:17 PM: located fentynal patch 50 mcg on resident R (right) Back dcd (discontinued) patch at this time. C. Review of an ADMISSION RECORD dated 2/13/13 revealed Resident 64 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a communication dated 11/27/12 with Resident 64's physician revealed admitted (with) 4 daily orders for [MEDICATION NAME]. patient states [MEDICATION NAME] is QID (4 times daily) alternating, could you please clarify 15 and 20 mg (milligrams) - 0500 (5:00 AM) 15 mg, 1100 (11:00 AM) 20 mg, 1700 (5:00 PM) 15 mg, 2300 (11:00 PM) 20 mg. The physician responded This is correct. Review of the 2012 Nursing Drug Handbook revealed [MEDICATION NAME] was an opioid [MEDICATION NAME] used for the treatment of [REDACTED]. Physicians orders dated 1/22/13 revealed [MEDICATION NAME] HCl (10 mg) 20 mg Tablet by mouth - Two times a day Every day: 20 mg PO (orally) BID (twice a day) and [MEDICATION NAME] HCl (10 mg) 15 mg Tablet by mouth - Two times a day Every day: 15 mg PO BID for pain. Review of the Resident 64's Medication Administration Record [REDACTED] - 12/6/12: 20 mg at 11:00 PM; - 12/21/12: 15 mg at 5:00 PM; - 12/24/12: 20 mg at 11:00 PM; - 12/31/12: 15 mg at 5:00 PM; - 1/1/13: 20 mg at 11:00 PM; - 1/3/13: 20 mg at 11:00 PM; - 1/6/13: 20 mg at 11:00 PM; - 1/7/13: 20 mg at 11:00 PM; - 1/11/13: 20 mg at 11:00 AM; and - 1/30/13: 15 mg at 11:00 PM. During an interview on 3/19/13 at 11:05 AM, the Director of Nursing (DON) revealed a review of Resident 64's narcotic (Narc) count sheet had no documentation on 1/22/13 that the [MEDICATION NAME]'s 11:00 AM dosage had been administered. The DON stated the Narc count sheet was showing that the [MEDICATION NAME] was not given. During an interview 3/19/13 at 1:38 PM, the Assistant Director of Nursing (ADON) stated review of Resident 64's Narc records for November 2012 through January 2013, revealed a 10 mg tablet had been signed out, but not the 5 mg tablet for the 15 mg dosage, 16 times, so (Resident 64) only got 10 mg instead of 15 mg. Also the ADON revealed only 1 - 10 mg tablets had been administered instead of 2 (10 mg administered instead of 20 mg dosage) on 12/4/12, 12/10/12, 1/22/13, 1/23/13, and 1/24/13. Review of Resident 64's Progress Notes revealed: - 12/7/12 at 9:15 PM = does have pain daily; - 12/8/12 at 10:23 PM and 12/9/12 at 10:28 PM = Complains of pain to low back; - 12/11/12 at 9:43 AM = [MEDICATION NAME] taken 7 x (times) for break through pain in the past wk (week); - 12/12/12 at 6:59 PM = has severe pain daily; - 12/16/12 at 11:57 PM = Complains of pain to low back; - 12/20/12 at 1:43 PM = C/O (complaints of) chronic back spasms, and leg and hip pain; - 12/30/12 at 9:41 PM, 1/1/13 at 3:18 AM, and 1/5/13 at 8:39* AM = Complains of pain to low back, routine [MEDICATION NAME] and prn (as needed) [MEDICATION NAME] given; - 1/8/13 at 4:37 PM = did have increased pain earlier in the shift; - 1/12/13 at 1:14 PM = Complains of 6/10 (rating of pain on a scale with 10 being the worse) to lower back; and - 1/15/13 at 9:32 AM = cont. (continue) to have increase in pain. During an interview on 3/19/13 at 2:03 PM the DON revealed nurses would be expected to review the routine Narc sheets to be sure medications were administered as ordered. D. Resident 57 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 57's admission physician orders [REDACTED]. The physician also documented to administer the [MEDICATION NAME] until the INR (International normalized ratio-a test for anticoagulant medications) was greater than 2.0. (Normal levels are 2.0-3.0 for all indications and 2.5-3.5 to prevent systemic embolism). In addition, Resident 57's physician's orders [REDACTED]. Review of Resident 57's lab work dated 1/14/2013 revealed that the INR was 2.52 which the laboratory marked as high. The physician was notified and wrote no changes and to recheck the INR in 2 weeks. However, the facility failed to verify if the [MEDICATION NAME] was to be discontinued as the physician had ordered on [DATE] when Resident 57 was admitted to the facility. Review of Resident 57's MAR (Medication Administration Record) for January 2013 revealed that the [MEDICATION NAME] was administered on 1/15, 16, 17, 18, and 19/2013 without verification from the physician to ensure that the [MEDICATION NAME] was discontinued as originally ordered on [DATE] for an INR above 2.0. In addition, the [MEDICATION NAME] was also administered to Resident 57 on those same days. Review of Resident 57's Nurse's Notes dated 1/20/2013 at 2:20 PM revealed that the resident had developed problems with labored breathing and started coughing green thick mucus and blood clots about the size of a quarter. Resident 57's pupils started to dilate and documentation revealed that Resident 57 stated (gender) felt like (gender) was going to pass out. The Physician was notified and Resident 57 was transferred to the emergency room for evaluation where the resident was admitted . Review of a facility investigation dated 1/22/2013 regarding the medication error for Resident 57 revealed that when Resident 57 was admitted to the hospital on [DATE], the INR was 6.81 and on 1/21/2013, the INR was 8.06 with a [DIAGNOSES REDACTED]. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1) Inservice training with all licensed nurses on the correct procedure for taking off physician's orders [REDACTED].>2) Inservice training with all staff, licensed or certified, who administer medications regarding the process for discontinuing narcotics; 3) Implementation of a checklist to be used that includes the 6 steps on how to process a physician's orders [REDACTED].>4) Implementation of a process to verify new and discontinued physician's orders [REDACTED].>5) All resident medications were checked against current physician orders [REDACTED].>6) Inservice training with all nursing staff on the identification of a change in resident condition and how to respond in an emergency situation; and 7) Inservice training with all staff, licensed or certified, on Critical Charting documentation related to for ongoing monitoring of residents' health conditions. The immediacy has been removed, however, the deficient practice has not been totally corrected. Therefore, the scope and severity has been lowered to D. | 2016-09-01 |
| 9487 | PREMIER ESTATES OF PIERCE, LLC | 285139 | P O BOX 189, 515 EAST MAIN STREET | PIERCE | NE | 68767 | 2013-08-06 | 323 | J | 0 | 1 | C9MJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7, 12-006.09D7a Based on observations, record review and staff interview; the facility failed to assure a safe environment was provided for residents identified at risk for falls and wandering. The outside exit door of the Activity Room was propped open and staff failed to respond to the door alarm for 3 minutes. Resident 38, who was at risk for wandering and falls, was seated in a wheelchair outside of the building on an unsecured patio and was unattended during this time. In addition, the facility failed to transport Resident 47 to the whirlpool room in a safe manner on 2 occasions. Facility census was 51. Findings are: A. Review of admission orders [REDACTED]. Review of facility policy entitled Resident Elopement with a revision date of 8/20/12 identified when an employee heard a door alarm, the employee should immediately go to the site of the alarm. Review of Resident 38's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 5/28/13 revealed [DIAGNOSES REDACTED]. The assessment indicated the resident had short and long term memory loss with severely impaired decision making skills, required limited assist of one with locomotion, used a wheelchair for mobility in the corridor and had behaviors of wandering, rejection of cares and physical behaviors directed at others 1-3 days during the 7 day assessment period. Review of Fall Risk Evaluation for Resident 38 dated 5/28/13 identified a total score of 20. A total score of 10 or above represents a high risk for falls. Review of an Elopement Risk Review for Resident 38 completed 5/28/13 indicated the resident was at risk for elopement. Review of Resident 38's Care Plan (revised 6/6/2013) indicated the resident was at risk for elopement due to mobility status, [DIAGNOSES REDACTED]. Interventions included: -Provide safe location for wandering behaviors as needed. -Check placement and function of wander-guard bracelet every shift. -Increase observation of resident during and after visitors. Care Plan also indicated Resident 38 was at risk for wandering related to [DIAGNOSES REDACTED]. Interventions included: -Evaluate resident for placement of safety/monitoring device (wander-guard bracelet) quarterly. -Observe for increased safety risks, wandering into others rooms, constant wandering without rest, and exit seeking behaviors. In addition, Resident 38 was identified as a potential for injury related to falls due to impaired cognition, Alzheimer's disease, recent falls, history of falls, ambulatory/incontinent, balance problems and poor safety awareness with frequent attempts to self-transfer. The Care Plan identified Resident 38 had 11 falls during the last quarter. Interventions included: -Check on resident frequently. -Pressure alarm (device which consists of a control unit/box and a pressure sensitive pad. An alarm sounds when a resident moves from a certain position) to bed and chair at all times. -TABs alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When the resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) to chair and bed at all times. -Fall mat to right side of bed closest to the window. -High/low bed to be kept in lowest position whenever resident in bed. -Self releasing safety belt with alarm to wheelchair. -Redirect resident if noted to be wandering down hallway to unoccupied area. -Encourage staff to answer alarms when going off and to toilet resident routinely and as needed. Review of Resident 38's Nurse's Notes revealed the following: -4/26/13 at 6:30 AM .alarm sounding, staff responds to alarm and finds resident on back beside bed. -4/30/13 at 6:30 PM .found on left side in activity room on floor. Resident had been up in wheelchair and wandered into an unsupervised area. Resident unaware of safety needs. -5/1/13 at 6 PM, Resident wanders through facility . -5/4/13 at 5 PM, Resident wandering through the hallway . -5/7/13 at 8:25 PM, Resident noted wandering about facility . -5/8/13 at 12:15 AM, Resident found lying on floor beside bed . -5/8/13 at 5:30 PM, Resident has been up in the wheelchair and self-propels around the facility. -5/9/13 at 5 PM, Resident wanders in wheelchair through facility . -5/12/13 at 11 AM, Resident has been trying to stand up multiple times this morning . -5/13/13 at 9:20 PM, Resident noted to be wandering the hallways . -5/17/13 7:00 PM, Resident noted to be walking wheelchair out of the activity room, alarms sounding . -5/17/13 at 7:45 PM, Resident found by staff sitting on the floor next to bed . -5/23/13 at 1:15 AM, Staff entered resident's room and found resident on the floor next to the bed . -5/25/13 at 5:00 PM, Resident wanders through facility halls and other areas . -5/25/13 from 8:30 PM to 11:30 PM, Resident tries repeatedly to get up out of bed . -5/26/13 at 5 PM, Resident wandering through the hallways, occasionally sets off alarms when attempting to stand up. -5/27/13 at 10 PM, Resident wanders about facility in wheelchair. -6/3/13 at 4:15 PM, Resident was found on the floor beside bed . -6/7/13 at 5:30 PM, All alarms sounding, resident found on the floor in Chapel area by the desk . -6/9/13 from 2 AM to 4 AM, Resident up and restless, makes repeated attempts to self-transfer, resident in wheelchair at Nurse's desk . -6/9/1 from 6 PM to 10 PM, Resident aimlessly wandering through facility with several attempts made to self- transfer . -6/18/13 at 6 PM, Observed resident lying on the floor on back in Room 46 with wheelchair behind resident . Intervention initiated to place resident on hourly checks to monitor whereabouts. -6/29/13 at 8:20 PM, Resident found on floor in hallway, tipped over wheelchair and lying on back. Resident to remain on hourly checks . -6/30/13 at 10:20 AM, Resident up in wheelchair wandering about . -7/1/13 at 2 AM, Resident's alarms sounding, resident attempting to get up. Resident up in wheelchair wandering the area . -7/6/13 at 4 PM, Resident continues to wander through the facility . -7/7/13 at 6 PM, Resident continues to wander through the facility . -7/25/13 at 7:30 PM, Resident is up in wheelchair and self-propels in the halls . -7/28/13 at 2:30 AM, Resident awake and restless, trying to get out of bed. Placed up in wheelchair at Nurse's Station . During an observation on 7/24/13 at 3:15 PM, Resident 38 self-propelled in a wheelchair from the Activity Room down the Wing 1 hallway to the Nurse's Station. Resident observed to have a TABs alarm, sensor alarm, and a self-releasing safety-belt in place. A wander-guard bracelet was noted to the resident's left ankle. During an interview on 7/25/13 from 8:40 AM to 8:45 AM, Registered Nurse (RN)-S verified Resident 38 was self-mobile in wheelchair and frequently wandered around in the facility. In addition, RN-S identified Resident 38 had sustained several falls over the last quarter and remained at high risk for injury related to falls and wandering. During observation of the Activity Room on 7/25/13 at 10:48 AM; the door which led to an outside unsecured concrete patio was propped open with a chair and a continuous alarm was heard sounding. No facility staff was observed in the Activity Room at this time. Further observation revealed Resident 38 was outside of the facility on the patio. Two concrete sidewalks extended off the patio. 1 sidewalk led to a road adjacent to a baseball field approximately 50 feet from the patio and the second sidewalk led to the facility parking lot which was approximately 50 feet from the patio. No facility staff was observed outside with the resident. Resident 38 had removed the self-releasing seat belt and had attempted to stand up from the wheelchair. The TABs alarm remained attached to the back of the resident's shirt but was pulled taunt, and the alarm for the self-releasing seat belt and the sensor pad were both sounding. No facility staff responded to the open door alarm or to the Resident's personal alarms which all continued to sound. At 10:51 AM (3 minutes later), the Activity Director (AD) wheeled Resident 47 out of the facility through the alarming open door and positioned the resident on the patio next to Resident 38. The Activity Director cued Resident 38 to sit down and silenced the resident's alarms, then walked back into the facility leaving both residents unsupervised outside on the patio. The AD retrieved a 2-way radio from a desk in the Activity Room and returned outside and used the radio to request staff assistance to the Activity Room. The Activity Room door remained propped open and door alarm continued to sound, but no further facility staff responded to the alarm. During an observation on 7/25/13 at 10:58 the AD removed the chair from the Activity Room door leading to the unsecured patio and closed the door silencing the door alarm. No additional facility staff responded to the door alarm during the 10 minutes the door was open and alarming. During an interview on 7/25/13 at 11:00 AM, the AD verified Resident 38 was at risk for elopement and falls. In addition, the AD indicated the door had been propped open so residents could be taken outside for an activity. When asked if AD would normally leave the door open with residents outside and unsupervised, the AD indicated it depended on whether or not there was an Activity Assistant scheduled to work. During an interview on 7/25/13 at 11:05 AM, the Administrator verified the AD should not have left the Activity Room door propped open and left Resident 38 outside unattended. In addition, the Administrator indicated all staff should immediately respond to a continuously sounding alarm. During an interview on 7/25/13 at 2:30 PM, the Administrator identified Residents 38, 6, 60, 32, 30, 54, 50, 37, 28, 44 and 15 were at risk for wandering, exit seeking and/or using a wander-guard bracelet. During the environmental tour completed 7/31/13 from 10:32 AM to 11:27 AM, the Maintenance Supervisor verified the distance from where Resident 38 was positioned on the patio was 41 feet from the road and 51 feet from the facility parking lot. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1.) Assessments regarding wandering, elopement and risk for falls have been completed on all facility residents. 2.) A list of all residents identified at risk for elopement, wearing a wander-guard bracelet and at risk for falls compiled and posted in manner to alert all staff. 3.) All staff educated on assuring the safety of residents; residents not to be left unattended outside, reviewed list of residents identified at risk for falls, elopement and wearing a wander-guard bracelet, no outside doors to be left propped open and staff to respond in timely manner to door alarms and wander-guard alarms and resident personal alarms. Education also provided to temporary staff employed by nursing pool agencies (pool staff) regarding safety of residents and the system implemented to assure pool staff were alerted to residents identified at risk for falls, elopement and wearing wander-guard bracelets. 4.) Schedule completed to assure adequate coverage for activities using Department Managers whenever an Activity Assistant not available. All Department Managers were educated on need to provide assistance as scheduled with activities. 5.) The Interdisciplinary Team updated the care management assignment cards of all residents to ensure interventions were identified for residents at risk for falls and elopement to ensure resident safety. The immediacy has been removed, however, the deficient practice is not totally corrected. Therefore, the scope and severity has been lowered to D. B. Review of the Owner's Operator and Maintenance Manual for the 1900/1900S Bath Lift (A bath lift is a type of wheeled chair which may be used for transport. The same chair is then used to lower and raise a resident into a whirlpool bathtub) dated 7/13 revealed the following .During transfer, raise the seat so the resident's feet are suspended from the floor. DO NOT roll caster base over objects such as carpet, raised carpet bindings, door frames, or any uneven surfaces or obstacles that would create an imbalance of the lift and could cause the lift to tip over. C. Review of Resident 47's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 7/8/13 MDS indicated the resident required extensive assistance for transfers. On 7/25/13 at 8:30 AM, NA-O (Nursing Assistant) was observed to wheel Resident 47, who was seated in the bath lift chair, down the corridor of Wing 2, over the raised carpet edge strip, across the carpeted area of the sitting area by the nurses' station, and over the raised carpet edge strip at the entrance of Wing 3. The bath lift chair seat was raised to a height of approximately 3.5 feet which caused the resident's feet and legs to dangle in the air. On 7/29/13 at 7:50 AM, NA-L was observed to wheel Resident 47, who was seated in the bath lift chair, down the corridor of Wing 2, over the raised carpet edge strip, across the carpeted area of the sitting area by the nurses' station, and over the raised carpet edge strip at the entrance of Wing 3. The bath lift chair seat was raised to a height of approximately 3.5 feet which caused the resident's feet and legs to dangle in the air. Interview with NA-T on 7/31/13 at 11:40 AM revealed residents were to be raised to a height where feet were just barely off of the floor when being transported in the bath lift chair. NA-T verified witnessing Resident 47 being transferred in the bath lift chair with the chair elevated to a level that was too high. NA-T was not aware the policy indicated the bath lift chair was not to be rolled over raised objects such as carpet or raised carpet bindings. | 2016-07-01 |
| 9581 | DUFF MEMORIAL NURSING HOME | 285217 | 1104 THIRD AVENUE | NEBRASKA CITY | NE | 68410 | 2015-12-09 | 323 | J | 1 | 0 | 548111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D7 Based on observations, interviews, and record reviews; the facility failed to evaluate resident risk for elopement, provide supervision to prevent elopement, and failed to intervene when the resident did not return to the facility following a leave of absence for one resident (Resident 1). The facility had a total census of 36 residents. Findings are: A. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility investigation dated 12/3/15 stated Resident 1's truck had been parked outside the facility and on 11/30/15 Resident 1's son had brought the keys to the truck. Resident 1 had requested the keys in order to be able to start the truck and sit in it while Resident 1 smoked. Resident 1 also wanted to drive to the store or Walmart to get cigarettes and gas. According to the investigation, Resident 1 was informed that Resident 1 needed to tell facility staff if Resident 1 was leaving the facility. On 12/1/15, Resident 1 could not open the door to the truck due to the truck battery being dead. The Activity Director assisted Resident 1 in getting a locksmith to come out and unlock the truck. On 12/2/15, maintenance staff jump started the truck for Resident 1 and Resident 1 left for Walmart at 11 AM to get a new battery. The Administrator was informed at 6:30 PM on 12/2/15 that Resident 1 had not returned to the facility. The Administrator texted staff stating that the Administrator was not worried and that if the resident was not back in the morning we might start worrying. At 7:24 AM on 12/3/15, the Administrator received a text stating Resident 1's son had been informed Resident 1 had tried to enter Canada via the North Dakota border and was at Pembina County Memorial Hospital in Cavalier, North Dakota. According to the report, Resident 1 reported leaving Omaha and when turning onto I 29, Resident 1 was uncertain if Resident 1 should go left or right. A review of a note written by the Social Service Director dated 12/3/15 revealed Resident 1's son was contacted at 3:45 PM on 12/2/15 when Resident 1 did not return from a trip to Walmart. Resident 1's son reported Resident 1 would leave for long periods of time and might stay out until midnight or even until the next morning. A Progress Note dated 12/3/15 at 1 AM stated Resident 1's son had called the facility to inform the facility that Resident 1 had been found at the border of North Dakota and Canada. According to the Progress Note, Resident 1 had stated Resident 1 was looking for Resident 1's son's house who lived in Nebraska City. Emergency Department Notes from Pembina County Memorial Hospital in Cavalier, North Dakota revealed Resident 1 had driven to the U.S. Port at Pembina, North Dakota. Resident 1 had been confused and had an outdated license. The Progress Note stated Resident 1 believed Resident 1 was in Canada and had told the custom's agent/deputy that Resident 1 was heading for Mexico. A Progress Note dated 12/3/15 at 3:10 AM stated a call had been received from Pembina County Hospital in Cavalier, North Dakota to inform the facility that Resident 1 was in the emergency room . A review of Mapquest Driving Directions revealed it was a total of 618.2 miles between Nebraska City, Nebraska and Cavalier, North Dakota. A review of Resident 1's MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 11/4/15 revealed Resident 1 scored 3 on the BIMS (Brief Interview for Mental Status; a screening tool used to detect cognitive impairment). A score between 0-7 is identified as the resident having severe impairment of cognition. Resident 1 was identified as independent with walking in room and requiring limited assistance of one for walking in corridor, and locomotion on and off unit. A review of Resident 1's SLUMS (St. Louis University Mental Status Exam) examination dated 10/30/15 revealed Resident 1 received a total score of 4. A score between 1 and 19 with less than a high school education indicated dementia. SLUMS Examination is used as a screening tool for orientation, memory, attention and executive functions. A review of Resident 1's Care Plan revealed a problem dated 10/28/15 of elopement risk on admission, questionable exit seeking, and wanting to go out and smoke. Interventions listed included the following: -Evaluate mobility, cognition, behavior and medications on admission, every quarter and as needed to identify any elopement risk factors. -If noting any exit seeking behavior reassess Wanderguard need (Wanderguard is a departure alert system that cause an alarm to sound when a resident wearing a bracelet attempts to exit a door equipped with a monitor.) -10/28/15; Wanderguard was placed as a precaution but removed 11/3/15 as resident had not made attempts to elope and requested Wanderguard to be off. -Monitor behavior for threatening to leave, seeking exits, pacing. 11/30/15, resident had not threatened to leave and had been able to follow smoking requirements. Resident 1's Care Plan was updated on 12/4/15 to state Resident 1 had no truck or keys at the facility and Resident 1 had a BIMS score of 8. A BIMS score between 8 and 12 was identified as moderately impaired cognition. Observations on 12/7/15 at 1:45 PM, Resident 1 reported going to get food at Walmart and ended up in Canada. Resident 1 was able to state the city that the facility was located in but was unable to state the name of the facility. Resident 1 reported that Resident 1 could go outside to smoke. Observations at 12/7/15 at 1:57 PM revealed Resident 1 seated outside of the facility on a bench in the smoking area. Resident 1 was smoking a cigarette. There was no staff members with resident and no staff members in the office where the windows looked out over the smoking area. Observations at 12/7/15 at 2:45 PM revealed Resident 1 seated outside of the facility on a bench in the smoking area. There were no staff members with the resident. In an interview on 12/7/15 at 1:54 PM, Registered Nurse A reported Resident 1's care plan had been updated. Resident 1 no longer had a vehicle or keys at the facility. Registered Nurse A reported Resident 1 still had privileges to go out and smoke alone. In an interview on 12/7/15 at 2:23 PM, Nurse Aide B reported Resident 1 was an elopement risk but didn't have keys to the truck anymore. Nurse Aide B reported Resident 1 could go out and smoke without supervision. In an interview on 12/7/15 at 2:43 PM, Nurse Aide C was not aware of any residents on the second floor at risk for elopement. In an interview on 12/7/15 at 3:09 PM, Licensed Practical Nurse D stated that starting with this shift, staff would be logging Resident 1 in and out to smoke but Resident 1 could be outside without supervision. In an interview on 12/7/15 at 3:17 PM, Nurse Aide E reported Resident 1 got cigarettes from the nurse but came and went as desired. In an interview on 12/7/15 at 2:28 PM, the Director of Nursing reported the Department of Motor Vehicles had been notified and Resident 1 would be receiving a letter regarding retaking the test for a driver's license. According to the Director of Nursing, facility policy was that the police would be contacted if a missing resident was not found after 15 minutes. The Director of Nursing reported Resident 1 was still allowed to go outside and smoke without supervision. In an interview on 12/7/15 at 2:50 PM, the Administrator reported meeting with Resident 1 and Resident 1's son regarding Resident 1 having the keys to the truck. The Administrator had gone over the requirements for checking out when leaving the facility and in the Administrator's judgment Resident 1 was okay with having the truck and keys. The Administrator confirmed that the Administrator had not reviewed Resident 1's cognitive assessment before the truck keys had been given to Resident 1. The Administrator confirmed being notified that Resident 1 had not returned to the facility at 6 PM on 12/2/15 and the Administrator made the decision to wait until morning before doing anything further. The Administrator reported going with Resident 1's son to transport Resident 1 from Cavalier, North Dakota back to the facility. On 12/7/15, Resident 1 was informed that Resident 1 would not be permitted to have the truck and keys while living at the facility. According to the Administrator, Resident 1 had stated Resident 1 did not want to stay at the facility if Resident was not permitted to have truck and keys. A review of the facility Leave of Absence Policy revised 5/17/2011 revealed the facility had a sign out book located at the first floor nursing station to record the date, time out, responsible party, destination, approximate time of return, and a reachable phone number. The Elopement Policy dated 5/17/2011 stated an elopement was defined as leaving the facility premises without following the facility's policy for leave of absence. Residents were to be assessed on admission, quarterly, and on changes of condition for elopement risk based on mobility, cognitive status, behavior and medications. A review of the facility Missing Resident policy revised on 5/17/11 stated facility staff were to contact the police when a resident couldn't be located within 15 minutes of noting that the resident was missing. B. The following interventions were initiated for Resident 1 on 12/7-8/15 to decrease Resident 1's risk for elopement and abate the immediacy of the situation -Wanderguard bracelet was applied on 12/7/15. -Elopement book was updated with Resident 1's face sheet and photo. -Resident 1 was to be given 2 cigarettes by the charge nurse for each outing and staff member was assigned to monitor Resident 1 while out of the building. -Flags were added to Resident 1's Medication Administration Record to instruct the charge nurse to assign a staff member to monitor resident while Resident 1 was outside. -Resident 1 was identified as high risk for elopement on report sheet. -Resident 1's care plan was updated with the new interventions. C. The following actions were initiated by the facility on 12/7/15-12/8/15 to abate the immediate jeopardy situation for all residents: -A Risk Assessment Elopement Decision Tree screening tool was implemented to evaluate each resident for risk for elopement. -All residents of the facility were screened using the Risk Assessment Elopement Decision Tree screening tool to determine risk for elopement on 12/7/15. -Report sheet was updated to identify residents at high, moderate, and minimal risk for elopement. -The Missing Resident policy was updated on 12/7/15 to state that if a resident did not return within 15 minutes of the time anticipated to return, the Missing Resident policy would be implemented. -The Elopement Policy was updated to include use of the elopement decision tree and to identify residents at risk for elopement on the report sheet. -Staff education on elopement and missing residents was started with the evening shift on 12/7/15 with all staff being educated prior to working their next shift. | 2016-07-01 |
| 10113 | JENNIE M MELHAM MEDICAL CENTER | 28A056 | P O BOX 250, 145 MEMORIAL DRIVE | BROKEN BOW | NE | 68822 | 2013-03-20 | 323 | J | 1 | 0 | RYUO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D7. Observation, record review and interviews revealed the facility failed to provide supervision of 1 sampled resident (Resident 37) to prevent the resident from exiting the facility through the secured door late at night. The resident was unable to return to the facility through the secured door or alert staff the resident had left the facility without the staff's knowledge. The facility census was 38 and the sample size was 5. Findings are: A. Review of Resident 37's CARE PLAN, dated 12/10/2013, revealed the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 37's CARE PLAN revealed Resident 37 was alert but had confusion. The resident experienced short and long term memory loss and was cognitively impaired in the ability to make decisions. The resident was forgetful and required cueing and supervision frequently and needed reminded of safety issues often due to his forgetfulness. Review of Resident 37's medical record on 3/7/2013 found no documented evidence an assessment for wandering with a risk for elopement had been completed. Review of the MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 12/10/12 revealed the following: -cognition showed a short term memory problems, -the BIMs (Brief Interview for Mental Status) was scored 7 out of 15, - No behaviors, -Limited one assist for bed mobility, transfer, personal hygiene, -Supervision with walking, used a wheelchair in the corridor, and -Wandered. B. Review of the facility report entitled ADULT ABUSE REPORT FOR LICENSED/CERTIFIED FACULTIES, dated 3/5/2013, revealed Resident 37 was very forgetful but alert. Resident 37 had poor eyesight, was hard of hearing, transferd self and got around the facility without assistance. Resident 37 went outside to check the weather, the door locked behind the resident and he/she couldn't get back in. The incident occurred on 3/4/2013 at 11:00 PM. The outside temperature was 23 with a windchill of 6.3 degrees (F) Fahrenheit at 10:52 PM. At 11:53 PM the outside temperature was 21.9 with a windchill of 2.9 degrees F. On 3/7/2013 about 9:45 AM, the facility security video was watched to reveal the following incident on 3/4/2013 when Resident 37 left the building: -At 2300 (11:00 PM), Resident 37 was seen self-mobile in the wheelchair through the ALF (Assisted Living Facility) door, then through it to the entry way and through the outside door. The resident was wearing a shirt, jeans, shoes, a light jacket, and a cap. -At 2303 (11:03 PM), Resident 37 was seen to enter the entry way in the wheelchair. Resident 37 pulled on the locked door. -At 2304 (11:04 PM), the resident was seen leaving the wheelchair in the entry way and walked outside. -At 2306 (11:06 PM), the resident came back into the entry way, pulled on the door, then pounded on the window of the door. -At 2307 (11:07 PM), the resident walked back outside and came back in knocking on the door. The resident was unsteady on feet looking around. -At 2309 (11:09 PM), Resident 37 walked back outside. -At 2311 (11:11 PM), Resident 37 walked back into the entry way. -At 2313 (11:13 PM), Resident 37 sat in the wheelchair in the entry way, then opened the door and looked out. -At 2314 (11:14 PM), Resident 37 checked the locked door again. -At 2318 11:18 PM), Resident 37 went out the entry way door to the outside in the wheelchair. Interview with the DON (Director of Nursing) on 3/7/2013 revealed the dispatcher indicated a call was received from a passer by notifying the dispatcher of a resident and wheelchair in the ditch. This call was received at 11:59 PM. The Sheriff arrived at the scene at 12:05 AM on 3/5/2013. The resident was brought to the emergency room at 12:15 AM on 3/5/2013. Interview with the Administrator and the DON on 3/7/2013 at 9:15 AM revealed the resident likes to go outside to check the weather. The resident always goes out the front door and this night 3/4/2013 the resident went out the ALF exit door. Also, Per the Sheriff, the resident was 3 blocks away from the facility. Based on the previous evidence from the security tape video and the DON interviewing, the resident went out the secured door of the facility on 3/4/2013 at 11:00 PM and was brought back to the hospital emergency roiagnom on [DATE] at 12:15 AM a total of 1 (one) hour and 15 minutes. Review of Resident 37's NURSES NOTES, dated 3/4/2013 at 2245, revealed the resident was noted in the hallway outside the room at change of shift. Staff talked to the resident and encouraged the resident to return to the room with personal affects. The resident was compliant with the suggestion and noted to have closed the door to the room. At 2400, a call was received from the acute care asking Are you missing anyone? The staff had not noted any missing residents. Acute responded that a resident was reported to have been seen on Memorial Drive in a wheelchair. A room search was initiated to find Residen 37 missing. At 2415, Acute phoned and stated (Resident 37) was picked up and delivered to the emergency room . At 2435, Acute phoned to state the resident would be held overnight for observation. Review of the hospital history and physical revealed Resident 37's core rectal temp was 95 degrees Fahrenheit as there was trouble getting an auxiliary or tympanic temperature. It was reading in the 92-93 range. The resident received 2 liters of warm saline. A bear hugger was used to warm the resident. The Doctor monitored the vital signs and labs before the resident returned to the Nursing Home. C. Observation of the resident on 3/7/2013 revealed the following regarding continued wandering behavior: -The resident was sitting in the wheelchair in the dining room at 9:30 AM, -At 10:15 AM, the resident was roaming in the hall down the middle hall and to the conference room in the south west corner of the building, -At 3:20 PM, the resident was in the room then self mobile in the hall and back to the conference room. Tour of 5 (five) exit doors of the facility on 3/7/2013 found no way to notify the staff that a resident was outside the secured door or for the resident to get back inside the building. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1) Assessments regarding wandering and a risk for elopement have been completed on the residents in the facility. 2) Door bells have been installed on all the exit doors to notify staff a resident needs to get back in the facility. 3) The wanderguard alarms have been changed to sound when anyone goes through the door to alert staff that a resident has gone out an exit door without staff knowledge. Because the immediacy was removed, but the deficient practice not totally corrected, the severity is lowered from a J to a D. | 2016-03-01 |
| 10214 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 333 | J | 0 | 1 | NRZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.10D Based on record review and staff interview, revealed the facility staff failed to administer medication to Resident 19 without a significant medication error. The facility census was 30 at the time of the survey and the survey sample size was 26. Findings are: Review of the DISCHARGE AND DISCHARGE SUMMARY SHEET revealed the resident was admitted on [DATE] and readmitted [DATE] with diagnoses of spinal stenosis, history of sacral fracture, hypertension, constipation, [MEDICAL CONDITION] one eye right, weakness, depression, cataract, dementia. Review of Resident 19's MDS (a federally mandated comprehensive assessment tool used for care planning) dated 4/12/2012 revealed the BIMS score was 5 of 15. The resident experienced short and long term issues. The MDS addressed no behaviors. Continued review revealed limited assist of one person physical assist for bed mobility, locomotion on unit and personal hygiene. The MDS revealed the resident required an extensive assist of one person physical assist for transfers, walk in the room, walk in the hall and dressing. The MDS revealed the resident was dependent on two staff physical assist for toilet use. Further review of the MDS revealed the medication review was coded the resident received an antianxiety on day in the assessment period and an antidepressant every day for the 7 days during the assessment period. Review of the Initial Review and Investigation dated 7/3/2012 found an entry that Resident 19 was admitted to the hospital. No definite pneumonia was noted. Resident 19 was treated with [MEDICATION NAME] (antidote may displace opiod [MEDICATION NAME] from their receptors)--for possible narcotic overdose. Review of the admitting note dated 7/3/2012 revealed the primary [DIAGNOSES REDACTED]. Was treated with [MEDICATION NAME] times 2. Review of the Physician Telephone Order dated 7/1/2012 found an order of ABH ([MEDICATION NAME]) gel 1 ml (milliliter) topical TID (three times a day) PRN (as needed) apply to hairless area. Further review of the Physician Telephone Order revealed no [DIAGNOSES REDACTED]. Review of the MAR (Medication Administration Record) dated 7/1/2012 showed an entry ABH gel 1 ml ([MEDICATION NAME] .5 mg, [MEDICATION NAME] 12.5 mg, [MEDICATION NAME] .5 mg) topical PRN TID for agitation/restlessness. Apply topically to hairless area. Review of the Pharmacy Communication Sheet--Long Term Care revealed ABH gel was not ordered for Resident 19. Review of the label on the ABH gel that was borrowed from Resident 28 and administered to Resident 19 reads ABH 1:25:1 mg/ml. This was twice the dosage written on the MAR. The Medical Chart did not reveal a dosage for the ABH gel that was administered to Resident 19. Interview with the DON on 7/25/2012 at 11:02 AM confirmed the physician order [REDACTED]. The DON stated the facility staff failed to clarify a dosage for the mixture. Interview with the DON on 7/25/2012 at 11:02 AM stated the staff borrowed medication from Resident 28 to administer to Resident 19. The DON confirmed the medication borrowed was ABH gel. Interview with LPN-T (Licensed Practical Nurse) on 7/25/2012 at 1:39 PM stated I wrote the dosage on the MAR indicated [REDACTED]. When asked if Resident 19 was on Hospice on 7/1/2012 LPN-T stated I don't remember. Interview on 7/25/2012 at 2:11 PM with LPN-R (Licensed Practical Nurse) stated the ABH gel was borrowed from Resident 28 to administer to Resident 19. Stated 1 ml was administered as was indicated on the MAR. Interview with the Pharmacist on 7/26/2012 at 9:06 AM revealed the Pharmacy formulary addressed the mixture of the ABH gel. The ABH gel mixture was [MEDICATION NAME] 1 mg/ml (milligram per milliliter), [MEDICATION NAME] 25 mg/ml and the [MEDICATION NAME] 1 mg/ml that was sent to the facility. The Pharmacist stated when there was a question on the dosage the nurse gave them the dose of the medication. Interview with the PA (Physician Assistant) on 7/26/2012 at 12:22 PM stated direction was given to the LPN to borrow ABH gel from a resident and administer it to Resident 19 did not feel one dose would hurt anything. The PA stated thought the ABH gel only came in one dose. Interview with the DON on 7/30/2012 at 9:10 AM revealed the facility had no policy on Medication Administration. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1) Inservice training with all staff, licensed or certified, to administer medication related to the Five Rights of Medications and medication error reporting and documentation; 2) All resident medications were checked against current physician orders [REDACTED]. 3. Implementation of new policies MEDICATION ERROR GUIDELINES, TAKING OFF ORDERS, and CHECKING MEDICATION IN FROM PHARMACY. The immediacy has been removed, however, the deficient practice has not been totally corrected. Therefore, the scope and severity has been lowered to D. | 2016-02-01 |
| 11563 | REGENCY SQUARE CARE CENTER | 285076 | 3501 DAKOTA AVENUE | SOUTH SIOUX CITY | NE | 68776 | 2012-01-24 | 323 | J | 1 | 0 | 8SG711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D7b Based on record reviews, observations, and staff interviews; the facility failed to assess residents' risk for burns from hot liquids and implement interventions to prevent burns from spilling hot liquids for 2 residents (Resident 1 and 3) of 5 sampled residents. The facility identified a total of 15 residents at risk for burns from hot liquid out of a total census of 61 residents. Findings are: A. On 1/9/12 at 12:50 PM, a cup of coffee was obtained from facility coffee machine in dining room of the facility. Coffee was poured into a thermal cup that the facility utilized to serve to coffee to residents of the facility. The following temperatures were recorded from facility thermometer in the presence of the Dietary Manager: -12:50 PM, just poured, 165 degrees Fahrenheit (F) -12:55 PM 156 degrees F -1 PM 144 degrees F -1:05 PM 138 degrees F -1:10 PM, 20 minutes after coffee was poured, 132 degrees F In an interview on 1/9/12 between 12:05-12:30 PM, the Dietary Manger reported the coffee machine temperature was set at 175 degrees F with coffee to be between 160-165 degrees F when poured into a cup. The coffee machine had been installed at the facility in 11/11 according to the Dietary Manager. In a follow-up interview on 1/10/12 at 8 AM, the Dietary Manager reported the facility started using the thermal cups at the about the same time as the facility installed the new coffee machine due to receiving complaints about the coffee being cold. A review of Equipment Service Invoice revealed coffee machine was installed on 11/17/11. Observations in the dining room at 2 PM on 1/9/12 revealed the coffee was on and accessible to residents. A visitor but no staff members or residents were observed in the dining room. In an interview on 1/10/12 at 8 AM, the Dietary Manager confirmed the coffee machine was on and coffee was available in the dining room at all times. B. Resident 1 was admitted to the facility on [DATE] according to Record of Admission. Resident 1's Client [DIAGNOSES REDACTED]. A review of Resident 1's MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 11/9/11 revealed the following: -Resident 1 scored 12 out of 15 points on Brief Interview for Mental Status (BIMS). -Resident 1 required supervision and setup assistance for eating Resident 1's Care Plan did not include a problem related to burns for spilled hot liquids but did include the following interventions related to potential hot liquid burns. -Resident 1 to have all meals in dining room. -Offer Resident 1 a clothing protector at each meal. Resident 1 wants a clothing protector at times. -Cool coffee with water before serving to Resident 1 (This intervention was dated 1/5/12. 5 days after Resident 1 sustained a burn from spilling hot coffee.) Therapy Screen Form for Resident 1 dated 11/21/11 stated "Nursing reports decrease function, increased frequency of falling, only eating 25%, no longer ambulating to dine." The Therapy Screen Form concluded therapy evaluation indicated for occupational therapy, physical therapy, and speech therapy. physician's orders [REDACTED]. Incident Report for Resident 1 for incident on 12/31/11 at 5 PM stated the following: "Resident was sitting at the table in the dining room waiting for supper when this med (medication) aide notice resident spilled (Resident 1) hot coffee on (Resident 1) lap. CNA (Certified Nurse Aide) and med aide took resident to (Resident 1) room. Notice redness on both thighs cool rag was applied." Non-Decubitus Skin Conditions report form for Resident 1 dated 12/31/11 identified a large blister on left inner thigh and 2-3 larger blister and several smaller blisters on right thigh. A review of physician's orders [REDACTED]. -1/1/12 Slivadene cream to blisters twice a day cover with dressing -1/3/12 Cephalexin (an antibiotic) 500 mg caps 1 orally three times per day for 10 days Non-Decubitus Skin Conditions report entry for Resident 1 dated 1/10/12 identified the following: -Area A-Resident 1's left thigh had 4 cm (centimeter) x .7 cm drying blister linear, yellow/greenish in color with no dressing, no periwound redness, no odor, and no warmth. -Area B-Resident 1's right thigh had 12.5 cm x 2 cm linear areas with bridging present. Area has 50% dry intact blister and 50% moist yellow with red flecks. -Area C-Resident 1's right thigh had 9.5 cm x 1.7 cm linear drying blister, with no warmth, no periwound odors, or drainage. Observation of and interview with Dietary Manager at 5:35 PM on 1/9/12 revealed Resident 1's coffee was cooled with water prior to service to Resident 1. Observations at 7:30 AM on 1/10/12 revealed Resident 1's coffee cooled with ice prior to service. A check of coffee temperature for coffee prepared for Resident 1 revealed a temperature of 65 degrees. A review of Resident 1's medical record did not reveal an assessment for safety with hot liquids. C. Resident 3 was admitted to the facility on [DATE] according to Record of Admission. Resident 3's Client [DIAGNOSES REDACTED]. A review of Resident 3's 12/7/11 MDS revealed the following: -Resident 3 scored 14 out of 15 on BIMS. -Resident 3 required extensive assist of one person with eating. Resident 3's Care Plan, dated 10/8/09, identified Resident 3 as eating slow and needing assist with meals. The intervention listed related to potential for spilling hot liquid was assist (Resident 3) with clothing protector for all meals per (Resident 3) request." Observations between 12:45 PM-12:56 PM on 1/9/12 revealed Resident 3 at the table in the dining room. Resident 3 was served a cup of coffee from the coffee machine with powdered creamer mixed into it. The coffee cup had no lid and a straw was placed into the cup of coffee. Resident 3 was observed with head tilted back holding cup of coffee at an angle drinking coffee from the straw. No staff members were observed to assist Resident 3 or be present at Resident 3's table at the time Resident 3 was drinking the coffee. Observations between 5-5:15 PM on 1/9/12 revealed Resident 3 being fed pureed food. Resident 3 was observed to drink pink liquid from a glass independently and spill pink liquid onto Resident 3's clothing protector. Hot Liquids Safety Evaluation dated 1/10/12, after observation of Resident 3 drinking hot liquid independently, identified Resident 3 as being at risk for injury from spills of hot liquids due to contractures of fingers/hands/wrists/elbows or shoulders and loss of mobility/reduced movement in upper extremities. New interventions to be implemented on 1/10/12 due to the evaluation included: temperature of hot liquid not to exceed 180 degrees; hot liquids drank while sitting at table only; coffee cooled with cream; wear clothing protector/lap protector; staff to assist resident with all hot liquids and resident to be seated at an assisted table. D. In an interview on 1/9/12 at 2:50 PM, the ADON reported the facility did not screen residents for safety with hot liquids. In an interview on 1/9/2012 at 3:50 PM, the DON (Director of Nursing) reported the facility did not screen residents for safety with hot liquids but that therapy did screen all new residents at the facility. In an interview on 1/9/12 at 4:12 PM, PTA (Physical Therapy Assistant) Therapy Department Head reported therapy did not do an evaluation of resident's safety with hot liquids. A review of the facility investigation revealed in-service education regarding first aide for burns would be provided to nurse aides on 1/5/12 and nurses on 1/12/12. The facility investigation stated Dietary Staff would be educated as well. In an interview on 1/9/12 at 3:50 PM, the DON confirmed an in-service would be held regarding burns on 1/12/12 for nurses. In an interview on 1/9/12 at 4 PM, the Dietary Manager reported Dietary staff would be attending an in-service regarding burn on 1/12/12. E. The following interventions were implemented by the facility on 1/10/12 to abate the immediacy of the situation and protect residents from hot liquid burns: -The coffee machine located in the dining room was shut off and no coffee was served at the lunch meal on 1/10/12. -A Hot Liquids Safety Evaluation was completed on all residents of the facility with 15 residents being identified at risk for injury from spills of hot liquids. The care plans for the 15 residents identified at risk for injury from spills of hot liquids were updated to include interventions to protect residents from injuries related to spills of hot liquids. -Staff education with an in-service at 2 PM on 1/10/12 was completed. -A list of Residents at Risk with Hot Liquids was posted in the kitchen. The following additional interventions were planned: -Coffee Machine would be moved into the kitchen where only kitchen staff would have access to it. -Lap pads were to be made available for residents at risk. -All staff members were required to read and sign "Hot Liquid Safety Guidelines" prior to staff working. -Coffee for residents at risk for injuries from hot liquids would be poured in to a carafe and cooled to a temperature between 120-140 degrees F before service to residents. | 2015-05-01 |
| 11652 | OAKLAND HEIGHTS | 285281 | 207 SOUTH ENGDAHL AVENUE | OAKLAND | NE | 68045 | 2011-11-10 | 155 | J | 1 | 0 | U8LG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC ,[DATE].09D Based on record reviews, observations, and staff interviews, the facility failed to provide CPR (Cardiopulmonary Resuscitation) in accordance with the resident's signed and documented advanced directive for 1 (Resident 1) of 7 sampled residents as a result Resident 1 passed away at the facility without receiving CPR. In addition, the facility failed to provide education to staff and clarify the facility CPR policy following the incident to prevent possible reoccurrence in order to protect 6 other residents of the facility who had requested CPR. The facility had a total census of 31 residents. Findings are: A. Resident 1 was admitted to the facility on [DATE] according to the Face Sheet. History and Physical for Resident 1 dated [DATE] listed the following [DIAGNOSES REDACTED]. A review of Resident 1's CPR/No CPR form revealed Resident 1 had marked CPR as the choice that Resident 1 wanted the facility to follow and had signed the form on [DATE]. Observation of Resident 1's medical record on [DATE] revealed Resident 1's medical record had a lime green dot on the chart indicating Resident 1 wanted CPR. A review of Resident CPR Status list maintained in facility medication room identified Resident 1 as wanting CPR. Resident 1's name had been crossed off the list. B. Undated facility policy titled "Cardiopulmonary Resuscitation (CPR) stated the following: "CPR or No CPR will be performed according to the resident's wishes. Procedure: 1. The Administration, or designee, will have the resident or resident representative sign the CPR determination form upon admission. 2. The licensed nurse will inform the physician by sending the form to the doctor. 3. The chart will be marked with a green sticker, when CPR is to be done. The resident's name, outside of the resident's room, will be underlined as an indication the resident wants to have CPR. 4. When sudden [MEDICAL CONDITION] is witnessed, on a resident who wants to have CPR, the nurse will initiate and do CPR until the ambulance arrives." C. The facility CPR/No CPR form stated the following: "To choose to have a CPR order, the resident will have CPR initiated in the event of an acute cardiac or respiratory arrest." A review of the CPR/No CPR form completed by residents to designate residents' wishes to have or not have CPR did not stated that CPR will only be provided if the [MEDICAL CONDITION] is witnessed. D. LPN (Licensed Practical Nurse) A was interviewed on [DATE] between 12:,[DATE]:17 PM. LPN A reported having CPR recertification in ,[DATE] but the training did not include information about the policy at the facility. LPN A reported residents who were a code were identified by a lime green sticker on the resident's record. LPN A reported it was facility policy that CPR be started if the [MEDICAL CONDITION] was witnessed. LPN A reported talking with Resident 1's spouse who wanted Resident 1's physician called. When LPN A went to call the physician and rescue squad, Resident 1's spouse came out of Resident 1's room and wanted someone to come to Resident 1's room. LPN A reported sending an aide to the room while LPN A got the oxygen. LPN A reported when LPN A reached Resident 1's room, Resident 1 wasn't breathing, and had no pulse or respirations. LPN A stated no CPR was started as Resident 1 wasn't breathing and there was no pulse. LPN A reported the squad arrived after LPN A got to the room. LPN A confirmed Resident 1 was a code. LPN A reported no one had discussed the incident with LPN A since it happened. E. A review of Interdisciplinary Progress Notes dated [DATE] for Resident 1 revealed the following: -At 6 PM; The resident ate 25% of supper, became nauseated, and was returned to room. -At 7:45 PM; The spouse was at bedside. -At 8 PM; Medication was given for pain. The resident was restless and trying to take clothes off. Skin was pale, warm, and dry. -At 8:15 PM; The resident was given medication for nausea. The blood glucose level was checked and registered at 91. Four ounces of orange juice was taken by the resident. -At 8:30 PM; The spouse called staff to the room and the resident was found to be unresponsive. Oxygen was started at 3 liters per nasal cannula after the physician was notified and order received. -At 9 PM; The resident had no pulse and the skin was pale and cool. The physician was notified and an order obtained to release the body to the mortuary. There was no documentation of any staff member initiating CPR during this period. F. Lack of staff knowledge of when to initiate CPR in accordance with facility policy was indicated by the following: -In an interview on [DATE] at 11:35 PM, LPN E reported lime green stickers were placed on the charts of residents who wanted CPR. LPN E reported completing CPR recertification every 2 years but did not recall any in-services regarding facility policy related to CPR. -In an interview on [DATE] at 11:45 AM, LPN B reported there is a list of residents with their code status kept in the medication room and a light green sticker is placed on the chart of residents who want CPR. LPN B reported if a resident who wanted CPR was observed taking their last breath, CPR would be started but if it had been a while since the resident had passed, CPR would not be started. LPN B reported LPN B would check the resident's color and skin temperature to make a determination. -In interviews at 12 PM and 12:20 PM on [DATE], RN C reported completing CPR recertification training last year but did not recall any in-service training regarding facility CPR policy. RN C reported there is a list of residents with code status in the medication room and a light green dot is placed on the charts of the residents who want CPR. RN C reported if a resident who wanted CPR was discovered after being deceased for awhile as indicated by color, stiffness, and mottling, RN C would not start CPR. -In an interview at 12:06 PM on [DATE], Acting DON RN D reported there is a list of residents with code status kept in the medication room and light green stickers are placed on the chart of residents who want CPR. RN D reported facility policy is only mentioned during CPR recertification training. RN D reported if a resident who wanted CPR was discovered with a cold skin temperature and purple color, RN D would not start CPR. -A review of list of in-services given in 2010 and updated proposed in-services for 2011 did not reveal any in-services regarding facility CPR policy or code status of residents. -A review of the facility policy did not reveal any specific signs or symptoms which would indicate CPR should not be started. G. A review of Resident CPR Status list maintained in the medication room revealed 6 of the current 31 residents of the facility wanted CPR. Observations of the 6 resident medical records and name tags by each resident door revealed each medical record had a lime green dot and each of resident's names were underlined in accordance with Resident CPR list. H. An interview on [DATE] at 12:18 PM, Acting DON (Director of Nursing), RN (Registered Nurse) D, revealed the ADON was not aware of any follow-up being done related to not providing CPR to Resident 1. In an interview on [DATE] at 12:34 PM, the Administrator reported the incident with Resident 1 not receiving CPR had not been brought to the Administrator's attention. Interviews with the Acting DON and the Administrator revealed no action had been taken to clarify the facility CPR policy or to educate staff members regarding the CPR policy in order to prevent a reoccurrence and protect the 6 current residents of the facility who had requested CPR be provided. I. The following interventions were implemented by the facility on [DATE] and [DATE] to abate the immediacy of the situation and protect residents who wanted to have CPR: -The facility CPR was updated to stated the following: "Policy: All residents have the choice regarding their cardiopulmonary resuscitation status Procedure: 4. When a sudden [MEDICAL CONDITION] is witnessed OR un-witnessed on a resident who desires to have CPR, CPR will be initiated by trained CPR personnel and will continue to do so until emergency medical technician (EMT) arrives and takes over care of resident 5. Nurse will direct staff to: A) Call 911 B) Gather Oxygen, backboard, ambu bag in Oxygen room C) Direct staff to be available to perform CPR as needed" -All facility nursing staff including nurse aides, LPN, and RNs were educated on the new CPR policy in-services held [DATE] at 8 PM or [DATE] at 9 AM or by telephone. -In an interview on [DATE] at 11:14 AM, Acting DON RN D reported LPN A had been suspended pending an internal investigation. -Based on the facilities actions, the IJ status was abated on [DATE]. | 2015-03-01 |
| 12923 | ARBOR MANOR | 285103 | 2550 NORTH NYE AVENUE | FREMONT | NE | 68025 | 2010-10-19 | 323 | J | RJGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.09d7B Based on observation, interview, and record review; the facility failed to assess residents risk for burns from hot liquids and implement interventions to prevent burns from spilling hot liquid for 1 (Resident 1) of 4 sampled residents. The facility had a total census of 110. Findings are: A. Resident 1 was readmitted to the facility from the hospital on [DATE] according to Face Sheet. Resident 1's History and Physical dated 9/1/10 included the following Diagnoses: [REDACTED]. A review of Resident 1's 9/18/10 MDS (Minimum Data Set; a comprehensive assessment used for care planning) revealed the following: -Resident 1 had short term memory problems. -Resident 1 had moderately impaired cognitive skills for daily decision making. -Resident 1 required set up help for eating. Resident 1's Care Plan included the following problem dated 9/17/10: " (Resident 1) needs assistance with (gender's) ADLs (Activities of Daily Living) due to weakness, impaired mobility & impaired cognition. " Approaches listed for Resident 1 included the following: - " (Resident 1) is usually able to feed (self). Provide set up help w/meals (with meals) & assist as needed. " - " Continue to provide supervision & setup (with) dining. " This approach was dated 10/4/10, after the coffee spill. - " Continue (with) use of lidded cup for hot liquids. " This approach was dated 9/30/10, after the coffee spill. Interview with the Assistant Director of Nursing (ADON) on 10/6/10 revealed that the interventions of supervision during dining and the lidded cup were in place prior to the coffee spill and were not changed after the spill. B. An incident report for Resident 1 dated 9/30/10 at 12:45 PM stated the following: " Res. (Resident) spilled coffee on (gender) @ lunch. Red area measured 19 x 15 cm (centimeter). After further assessment Res. has 5 fluid-filled blisters that measure 1 cm; 2 that are 2 cm. " The facility investigation dated 10/4/10 stated Resident 1 spilled coffee on Resident 1's abdomen from a lidded cup. The facility investigation also stated Resident 1 ". . . dozes off at meals frequently, bobbing (gender's) head, then opening (gender's) eyes." In an interview on 10/6/10 between 1:25-1:30 PM, MA (Medication Aide) A reported finding Resident 1's coffee cup in Resident 1's lap. MA A reported the left side of Resident 1's stomach and Resident 1's left leg was wet. MA A stated Resident 1's stomach was red underneath Resident 1's shirt. MA A called for the nurse and got cold washcloths to put on Resident 1. MA A reported being told to keep an eye the resident since the incident. MA A reported Resident 1 dozes off while eating. During an interview on 10/6/10 at 1:05 PM, the ADON stated that the coffee may have spilled and pooled under the resident's brief. No one observed the actual coffee spill but the Nurse Aide (NA) found the resident's clothing wet and thought the cup dropped and spilled, dripping into the upper part of the resident's incontinent brief (a disposable garment, use for urinary incontience, that is absorbent padding covered with protective plastic). The hot coffee soaking into the incontinent brief would have allowed the liquid to maintain contact with the skin longer and to cool more slowly than with regular clothing. Information from the American Burn Association shows that hot water at a temperature of 140 degrees F (Farenheit) will cause third degree burns (damage to all layers of the skin and into the tissues layers below) in 5 seconds and at 155dgrees F in 1 second. The Associations's recommendations was to mantain hot liquids that may contact the skin at 120 degrees F or less. Guidance to Surveyors at federal tag F323 stated a 3rd degree burn can occur in 1 second with a water temperature of 155 degrees F. Review of a Fax Cover Sheet dated 9/30/10 revealed the resident's physician was notified of the blistered areas on the abdomen from the spilled coffee and treatement orders for Bacitracin cream daily. Further medical record review showed Physician order [REDACTED]. Review of the Medication Administration dated October 2010 showed the Bacitracin Cream was applied from 10/1/10 thru 10/7/10. C. The temperature of the coffee was measured with the facility thermometer as 163 degrees F at 11:55 AM on 10/6/10 before the start of the meal service. Observations between 11:55 AM-12:48 PM revealed coffee and other hot liquids were served in an insulated mug that was fitted with a disposable plastic lid. Observations on 10/6/10 between 12:05 - 12:48 PM revealed residents drinking coffee from cups with disposable plastic lids. The lids covering the cups were of thin plastic with an open area on one side - similar to the lids used in fast food establishments to cover hot liquids. When a cup was tipped to the side so the open area in the lid was at the bottom, liquid poured from the open area. The lid would contain liquid from slopping over the cup edge if a resident had tremors, however, would not prevent spillage if the cup were tipped. An interview with the ADON on 10/6/10 at 1:05 PM revealed that all resdients received the disposable lids for their cups unless the resident refused the lid. The facility no longer screened residents for the potential to spill hot liquids since the facilty began using the cup lids. If a resident was at risk and refused the lidded cup, additional interventions would be care planned like putting the liquid in two cups. The ADON reported an in-service was scheduled for 10/14/10 to review the use of lidded cups and to monitor for residents with shakiness, tremors or residents removing the lids. Review of the facility's incident logs revealed no reports related to burns from hot coffee. However, without assessments for the potential for hot liquid spills, the potential for further occurrence could not be determined. In an interview on 10/6/10 between 12:35-12:41 PM, Dietary Manager C reported coffee was served to all residents in the insulated mug with the disposable plastic lid unless a resident had an order for [REDACTED]. D. Observations on 10/6/10 between 12:05-12:48 PM revealed Resident 1 seated in wheelchair at over the bed table in Dining Room B eating and drinking independently. There was no staff present at the resident's side or assisting anyone at adjacent tables at the beginning of the observation period. At times, Resident 1 would hold a glass in the air and doze off with eyes closed. Resident 1 would wake up and start eating again. At 12:26 PM, NA B began assisting a resident at the table next to Resident 1. NA B was not close enough to provide hands on assistance to Resident 1. NA B later assisted Resident 1 to eat a part of Resident 1's meal. Resident 1 was not served any hot liquids at the meal. In an interview on 10/6/10 at 12:48 PM, Dietary Manager C reported Resident 1 usually drank coffee at meals but did not receive it today. In interview at approximately 12:45 PM on 10/6/10, NA B reported being unaware of Resident 1's burn. NA B reported not having received instructions related to assisting Resident 1 since the coffee spill. E. The following interventions were implemented by the facility on 10/6/10 to abate the immediacy of the situation and protect resident s from hot liquid burns: -A self feeding screen was completed on all residents of the facility. Occupational Therapy screen was completed on all residents determined to be at risk. Thirteen residents were identified as being at risk and non-spill cups were purchases for those residents. an order for [REDACTED]. -The coffee temperatures were to be lowered to a 5 degree range high or lower than 155 degrees F. -Staff education was initiated on 10/6/10 and 10/7/10 and would continue until all staff had received the education. -The dietary service manager or designee will complete the self feeding screen on residents at admission, quarterly, and with significant change is status and PRN. -The dining room supervisor will observe at least 3 residents identified to be at risk on a weekly basis to assure that they are safely handling hot liquids. With the above interventions placed into practice by the facility, the scope was lowered to a D level. Observations between 12:00-12:40 PM on 10/7/10 revealed the following: -Hot liquids were being served from carafes until the coffee pot temperatures could be adjusted. Coffee temperature was measured at 150 degrees F. -Non-spill cups were being available and being used by residents of the facility. -Resident 1 was moved to a regular table with a staff member present at the table. | 2014-02-01 | ||
| 222 | MIDWEST COVENANT HOME | 285062 | P O BOX 367, 615 EAST 9TH STREET | STROMSBURG | NE | 68666 | 2020-02-27 | 880 | I | 0 | 1 | HGI711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C Based on observation, interview, and record review; the facility staff failed to prevent potential cross contamination by failing to follow contact precautions, failing to perform hand hygiene when indicated, failing to clean equipment used by multiple residents, and failing to ensure the facility policies for infection control, immunizations, and antibiotic stewardship were reviewed annually. The facility staff also failed to ensure that staff followed isolation precautions (the use of gloves, gowns, and hand washing to help stop the spread of germs from one person with a known infection to another) and to ensure that hand hygiene (hand washing) was performed when exiting the room of a resident under isolation precautions before entering the room of another resident. This had the potential to affect all of the facility residents. The facility identified a census of 30 at the time of survey. Findings are: [NAME] Interview with the ICC (Infection Control Coordinator) on 2/27/20 at 1:36 PM revealed the facility had 8 residents who had tested positive for CP-CRE (Carbapenem-resistant [MEDICATION NAME] (CRE) are [MEDICAL CONDITION] that that can cause serious infections and require interventions in healthcare settings to prevent spread according to the CDC (Centers for Disease Control)) and required contact precautions and 2 other residents who were discharged from the facility had also tested positive. Observation of the rooms belonging to Residents 29, 6, 14, 1, 30, 22, 31 and 29 on 2/24/20 at 4:05 PM revealed they had Contact Precautions signs and PPE (Personal Protective Equipment-gowns, gloves, face masks, shoe covers worn to protect the wearer from potential infection) on their doors. Review of the undated facility document Contact Precautions received from the DON (Director of Nursing) revealed the following: Perform hand hygiene before entering and before leaving room, wear gloves when entering room or cubicle, and when touching patient's intact skin, surfaces, or articles in close proximity, wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces, use patient-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment between patients. Observation of ES-H (Environmental Services) on 2/25/20 at 11:58 AM revealed they were distributing personal clothing to Resident 14 and Resident 1 who shared a room. Contact Precautions were posted on the door. A sign posted on the door read must wear gloves and gown before entering room. ES-H donned gloves and took the clothes into the room, opened a drawer, and placed the clothing into the drawer before closing the drawer. Resident 14 and Resident 1 were present in the room. ES-H did not put a gown on. ES-H then took the gloves off, came out of the room and scrubbed hands with hand sanitizer. ES-H then took clothes to Resident 20, Resident 26, and Resident 7 who did not have contact precautions. ES-H then took clothes to Resident 28 at 02/25/20 at 12:02 PM who had contact precautions and PPE posted on their door. ES-H put gloves on, entered the room, opened the drawer and put the clothes in. ES-H did not have a gown on. ES-H then took the gloves off and used hand sanitizer that was in the dispenser outside the door. Resident 28 was present in the room. ES-H then took clothes to Resident 3, Resident 17, Resident 16, and Resident 21. They did not have contact precautions. On 2/25/20 at 12:06 PM, NA-F (Nurse Aide) took a Styrofoam container of food into Resident 28's room and put it on the wheeled walker platform in front of Resident 28 who was sitting in the recliner then did hand sanitizer and took food to Resident 16 who did not have contact precautions. NA-F was in close proximity to Resident 28 and their belongings and did not have a gown on. On 2/25/20 at 12:09 PM, ES-G brought plastic hangers out of the room belonging to Resident 14 and Resident 1. There was a sign on the door Contact Precautions and PPE. ES-G was wearing gloves and did not have on a gown. ES-G handled the outside of a large white plastic bag marked for CRE hangers with the gloved hands, placed the hangers in the bag, then went back into the room and discarded the gloves. The bag was hanging on the end of a rolling clothes rack that had personal clothing on it that was out in the hall. Resident 14 and Resident 1 were present in the room. At 2/25/20 at 12:10 PM, ES-G had gloved hands and brought hangers from Resident 29's room and placed them in the bag marked for CRE hangers by handling the outside of the bag with the gloved hands. Resident 29 also had a sign on the door Contact Precautions and PPE. ES-G had gloves on and no gown. Resident 29 was present in the room. ES-G then proceeded to push the cart down the hall. The clothes were touching ES-G's smock. ES-G then took clothes into Resident 4's room on 2/25/20 at 12:15 PM then into Resident 2's room. Resident 4 and Resident 2 did not have Contact Precautions on their door. ES-G brought the hangers out of Resident 2's room and hung them on the rack. On 2/25/20 at 12:16 PM ES-G then took clothes in to Resident 5 and Resident 25. Their clothes had also been touching ES-G's smock. On 2/25/20 at 12:17 PM the bag marked for CRE hangers was touching the clothing belonging to Resident 27 and Resident 24 who did not have contact precautions. ES-G was also observed using bare hands when putting the clothes into the closets. On 2/25/20 at 12:19 PM ES-G hung a T shirt on the handrail outside Resident 6's door and it was touching the floor. On 2/25/20 at 12:20 PM ES-G donned gloves and took the T-shirt into Resident 6's room then brought hangers out and put them in the bag marked for CRE hangers by handling the bag with the same gloves. On 2/26/20 at 8:15 AM NA-F was observed carrying a pile of linens (sheets, pillowcases) down the hall up against their uniform. NA-F took the pile of linens into Resident 5's room and put some of the linen on the bed which was stripped. NA-F then took the remainder of the linens still carrying them up against their uniform into Resident 4's room. Interview with LHS (Laundry Housekeeping Supervisor) on 02/27/20 at 11:37 AM revealed the facility staff were supposed to be leaving the hangers in the rooms of residents who have contact precautions until they found a proper procedure for sanitizing them before they brought them out of the room. LHS confirmed they were looking for a disinfectant they could use the clean the hangers. The LHS revealed the facility staff should not be touching the resident clothing to their own clothing when they are passing clothing. If a clothing item fell on the floor or touched the floor the staff should have taken it back to the laundry to wash it. The LHS confirmed that the observations with laundry deviated from their expectations. Review of the undated Policy for Passing linens revealed no documentation of clothing not touching the staff clothing or items should be re-laundered if dropped on the floor or touch the floor. No documentation that staff should not be taking the hangers out of the rooms who had residents in isolation/contact precautions. There was also no documentation that staff should not be taking the same linens from room to room. Review of the facility policy Hallway Policy dated 3/7/2017 revealed the following: Linen carts-load your cart, pass linen and put cart away. B. Observation of the facility bath house on 02/26/20 at 1:52 PM revealed a Penner Cascade jetted tub with a lift chair. NA-E with the DON (Director of Nursing) present proceeded to clean the tub. The DON said they were done with baths for the day so they used a different cleaning procedure as all of the residents used the tub and the residents with CRE received the last baths of the day. NA-E set a timer for 10:45 seconds, dispensed the disinfectant in about 1 1/2 gallons of water into the bottom of the tub, then started wetting the surfaces. Everything was finally wet with 8:47 left on the clock. NA-E then proceeded to use a brush to scrub the tub with Penner disinfectant on the inside of the tub. NA-E said they cleaned the inside of the tub with the Penner disinfectant that was dispensed into the bottom of the tub and NA-E used a spray bottle of the Penner disinfectant the keep the surfaces wet. NA-E said the tub surface had to stay wet with the Penner disinfectant for 10 minutes. NA-E said they would use MicroKill wipes to clean the outside of the tub. NA-E did not put the sprayer or the spray hose into the tub and clean it. NA-E focused on the left side of the tub and did not consistently keep the right side of the tub wet. NA-E only scrubbed the underside of the lift seat that was in the tub 3 times. NA-E did not run the jets on the tub. NA-E said they did the procedure twice so after the 10 minute timer went off, NA-E started over again. This time NA-E put the sprayer into the tub and put the disinfectant on it with the scrub brush but NA-E did not spray the hose on the outside of the tub with the disinfectant. NA-E did not have the sprayer hose wet with disinfectant and the surfaces of the tub were not wet the full 10 minutes. NA-E demonstrated where the disinfectant came out of the floor of the tub, not the jets. NA-E said they did not run the jets when cleaning the tub. At 2:15 PM the DON said they don't have to run the disinfectant through the jets. After NA-E cleaned the tub NA-E wiped the outside of the tub and the sprayer hose with a MicroKill wipe. Observation of the tub of MicroKill wipes read it had a 1 minute wet set time. The surface did not stay wet for the full 1 minute. It was dry in 10 seconds. NA-E also wiped from the floor to the top of the tub when NA-E cleaned the outside of the tub. NA-E then wiped the cabinets which did not stay wet and the paper towel holder. NA-E then sprayed the shower chair with the Penner disinfectant 2 times but it did not stay wet 10 minutes. There was also a commode tub sitting on the shower chair which was not sprayed at all. NA-E then took their gloves off, took another pair of gloves out of the box, laid them on the sink, did hand hygiene with hand sanitizer and then put the gloves on. This was at 2:17 PM. Review of the undated The System Cleaning for whirlpool tubs revealed the following: press and hold the disinfect button #1 located on the left side of the tube. As the button is held down, the properly mixed cleaning solution is running through and disinfecting the pump and motor. Release the button after you see solution coming out of both jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. For aqua-air tubs: press and hold the disinfect button #1 located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all of the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. Use a long-handled brush to thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. Disinfect the seat by reattaching it to the lift and positioning it over the tub. Use the brush to scrub its surfaces with the remaining solution. Allow for proper disinfectant contact time (Usually 10 minutes or as recommended by the disinfectant manufacturer) and rinse the seat. Replace the seat on the Penner Transfer. Repeat the disinfecting procedure on the wet portions of the lift's upper arm and latching mechanism. Remove the plug from the drain. For Whirlpool tubs, spray water from the shower sprayer into the back outlet until clear water appears from the inlet. Repeat this procedure with the front outlet. Rinse the tub's interior surfaces thoroughly with the shower sprayer. For Aqua-Air tubs spray water from the shower sprayer to rinse out most of the disinfectant solution. Then press and hold the rinse button (32) until you see clear water (not soapy) coming out of the air jets. Release the rinse button. Finish rinsing the interior surfaces of the tub with the shower sprayer. Start the air blower by pushing the Aqua-air button #7. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. If this was the last bath of the day, allow the blower to run for 2 minutes to dry out the system. Stop the air blower by again pushing the Aqua-Air button #7. There was a picture of the tub on the document. Observation of the facility tub on 2/26/20 at 4:40 PM with the ICC revealed the tub not have any outlets and had a button for the air jets. The ICC confirmed the tub in the tub room looked similar to the tub on the document indicated as an Aqua air jet tub. Observation of the facility tub on 2/26/20 at 4:43 PM with the DON revealed the DON said it was a Cascade side entry tub and thought it looked like an Aqua air tub as there were not outlets. Review of the untitled facility documents identified by the DON as the bathing records for (MONTH) 2019 through (MONTH) 2020 revealed documentation all of the facility residents received a bath during the timeframe of the outbreak of CP-CRE, (MONTH) 2019 to the present. Review of the Penner Disinfectant Cleaner dated 7/7/2011 revealed the following: To disinfect inanimate, hard, non-porous surfaces add 2 ounces of per gallon of water. Apply solution. Allow to remain wet for 10 minutes. Review of the undated Medline Micro-Kill One Germicidal Wipes revealed the following: Exposure time for Escherichia coli and [DIAGNOSES REDACTED] pneumoniae is 1 minute at room temperature. Requested documentation of the first case of CP-CRE from the DON. On 2/27/20 at 9:17 AM Resident 31 tested positive for CRE on 12/9/2019 when they were hospitalized . Resident 31 returned to the facility on [DATE] and had been in strict contact isolation since then. The DON also provided a list of residents who tested positive for CP-CRE (Carbapenemase Producing Carbapenem-Resistant [MEDICATION NAME]-an antibiotic resistant bacteria) and the dates: Resident 29 on 12/27/2019 [DIAGNOSES REDACTED] pneumoniae; Resident 6 on 12/27/2019 eschericia coli; Resident 14 on 1/9/2020; Resident 1 on 1/29/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 30 on 1/29/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 22 on 2/12/2020 [DIAGNOSES REDACTED] pneumoniae; Resident 28 on 2/12/2020. Interview with the DON on 2/27/20 on 11:07 AM revealed Resident 31 took a shower and had their own shower chair in their room as Resident 31 was CRE positive. Resident 21 took a shower and Resident 21's was the shower chair that was in the bath house that NA-E had sprayed twice and it had not remained wet for the full 10 minutes. The DON revealed that if a resident wanted a shower, the staff just put them in the tub and used the shower attachment. Otherwise all of the other residents received a tub bath. The DON revealed they did not know if the staff were allowed to hold resident clothing and linens up against their uniforms or smocks. The DON revealed the expectation was that the staff were supposed to take linens and fill their cart. If they were going to leave it in the hallway they had to cover it. When they were going into the room they were supposed to grab everything for that resident depending on the resident and they were supposed to take 2-4 towels and washcloths. If they took linen into one room they could take it out of that room and take it into another resident's room. If they took linen into one resident's room and didn't need it had to be laundered and not used for another resident. The DON revealed the staff could not take the linen into another resident's room. The staff were allowed to keep the laundry hampers in the hall during am and pm cares so they were not dragging soiled linens down the hall. The DON confirmed that NA-F should not have entered resident rooms with the linen after they had taken the linen into another resident's room; when NA-F crossed the plane of the resident's room with the linen it should not have been taken into another residents room. That is why the facility had carts. Based on contact precautions, as long as they are not going to touch the residents (at first they were strict but they were running out of PPE) so they looked at the standard of care for contact precautions as long as they weren't going to do any direct resident contact for dropping off meals they did not have to wear a gown. Review of the undated untitled modified contact precautions provided by the DON: Contact isolation-any time you are going to come into contact with the resident or the residents belongings you must wear a (sic) isolation gown. The only time that you do not need to wear isolation gowns is: if you are going into the resident room to deliver laundry, deliver mail, deliver meal tray or just shut off a call light. When you do go in to do any of these things you must: Do hand hygiene: wash your hands or use hand sanitizer. Apply gloves. Make sure that you or your clothing does not touch the resident or the residents belongings. Deliver what you need to or do what you need to do. Remove gloves. Hand hygiene: wash with soap and water or use hand sanitizer. Interview with the DON on 2/27/20 at 12:55 PM revealed they did not have documentation of communication with ICAP/ASAP (state agencies responsible for infection surveillance when outbreaks of communicable diseases occur in facilities) when they modified the contact precautions. The DON revealed the Administrator made the decision to do the modified (no gown) contact precautions based on the contact precautions information they had. The DON pointed out the statement on the contact precautions document: Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces. The DON revealed the facility did not have a procedure in place if the staff did not wear a gown, entered a CP-CRE room and got coughed on or inadvertently contaminated their uniform. The DON revealed that the equipment and surfaces needed to be wet for the amount of time per the recommendations for the Penner Disinfectant and the Micro-Kill wipes. The DON confirmed NA-E should have performed hand hygiene before touching the gloves and the wet times were not long enough on the tub, shower chair, sprayer and sprayer hose, and the cabinets. Interview with the DON on 2/27/2020 at 1:37 PM revealed they didn't know how or when the first resident had CP-CRE or how long it could have been spread. The DON confirmed they had residents who initially were negative for CP-CRE and then were positive at a later time while they were residing in the facility. On 2/27/20 at 2:27 PM the ICC provided the list of residents who were initially negative and then had positive CP-CRE tests while they were in the facility: Resident 14 tested negative 12/27/2020 then tested positive 1/9/2020. Resident 1 tested negative 1/15/2020 then tested positive 1/29/20. Resident 30 tested negative on 1/15/2020 then tested positive 1/29/20. Resident 22 tested negative on 1/29/20 then tested positive 2/12/20. Resident 28 tested negative on 1/29/20 then tested positive 2/12/20. There was no documentation any of these residents were out of the facility in the time frames which indicated the residents were in the facility when they contracted the CP-CRE. C. Review of the facility policy Influenza, Prevention and Control of Seasonal dated 8/11/2015 revealed no documentation it had been reviewed annually. Review of the undated facility policy Infection Prevention and Control Policy and Procedures revealed no documentation it had been reviewed annually. Review of the facility policy Antimicrobial Stewardship Program dated 11/16/2017 revealed no documentation it had been reviewed annually. Interview with the DON on 2/27/20 at 2:28 PM confirmed there was no documentation the facility policies had been reviewed annually. D. An observation of the contact isolation precautions for Resident 6 revealed that a sign on gold paper and placed on Resident 6's door stated anyone entering the room must wear a gown and gloves at all times. Also on a pink sign were instruction for putting on PPE (Personal Protective Equipment) which was complete hand hygiene, apply gown, mask, goggles, or face shield and gloves. An observation on 2/24/2020 at 12:46 PM of ES-H (Environmental Services) delivering laundry into the isolation room for Resident 6 revealed that ES-H cleansed hands with hand sanitizer and walked into the room without applying a gown. An interview on 2/24/20 at 1:00 PM with ES-H revealed that the laundry staff because those staff don't come into contact with the residents only have to wear gloves into the room. An interview on 2/24/20 at 1:07 PM with ES-J revealed the type of PPE worn depends on the job you're doing at the time. Laundry staff only have to wear a pair of gloves into the room since there was no contact with the resident. Housekeeping need to wear a gown, gloves and booties into the isolation rooms. ES-J stated the staff have been doing this forever and are frazzled. Working with the Health Department and getting all kinds of instruction was overwhelming. D. Observation on 2/25/20 at 8:21 AM of NA-E who was taking a breakfast meal to Resident 6 revealed that NA-E was wearing only gloves into the room. NA-E after doing unobserved hand hygiene in the restroom because this surveyor could not get on the PPE (Personal Protective Equipment) in time, went into Resident 23's room and informed Resident 23 that the bath for this resident was ready. NA-E did not complete hand hygiene before going into Resident 23's room. NA-E then went around the room touching the closet door and dresser drawers gathering clothing for Resident 23 to put on after the bath. Review of a Sign at nurses' station that states: Midwest Covenant Home- * Contact Isolation-Any time you are going to come into contact with the resident or the residents belongings you must wear a isolation gown. *The only time that you do not need to wear isolation gowns is: 1. If you are going into the resident room to deliver laundry, deliver mail, deliver meal tray or just shut off a call light. When you do go in for these few things you must: a. Do hand hygiene wash your hands or use hand sanitizer b. apply gloves c. Make sure that you or your clothing does not touch the resident or the residents' belongings d. Deliver what you need to or do what you need to do. e. Remove gloves f. Hand hygiene wash with soap and water or use hand sanitizer. There was no documentation or education on the posting or anywhere in the facility to instruct staff what the process was or what to do if the staff not wearing a gown were touched by a resident or the residents personal items came into contact with the staff or the staff 's clothing. Observation on 2/27/20 at 11:39 AM of ES-H (Environmental Services) entering the isolation room for Resident 6 revealed ES-H reached into the pocket of ES-H uniform and removed a pair of gloves and applied them without doing hand hygiene. ES-H then entered the room without putting on an isolation gown. An interview on 2/27/20 at 1:24 PM with the DON (Director of Nursing) revealed the DON did not know what the precautions were if the staff touched items in the room without gloves on or if the resident touched the staff who did not have a gown on. The staff person then would be contaminated and if leaving the room would potentially contaminate everyone the staff person came into contact with. DON stated the staff are being instructed if the staff find out the resident needs something more than just answering the call light. The staff need to remove the gloves. Sanitize the hands and put a gown on then help the resident. Observation on 2/27/20 at 1: 42 PM of the sign outside Resident 22's room a yellow sign on the door that states When entering this room please wear a gown, gloves and mask at all times. Resident 22 had just returned from the hospital around 5:00 PM on 2/26/20 with a [DIAGNOSES REDACTED]. Observation on 2/27/20 at 1:50 PM of RN-K (Registered Nurse) entering the room for Resident 22 revealed RN-K did hand hygiene and applied gloves, gown was applied and a face mask. RN-K then turned off the nebulizer machine (machine used to administer aerosol medication) for Resident 22. Observation on 2/27/20 at 1:57 PM NA-C (Nurse Aide) getting Resident 22 ready to take to the bath revealed NA-C completed hand hygiene with hand sanitizer before applied gloves and a gown before entering the room. NA-C went about the room touching the closet door, the residents' bedside table, and the recliner that the resident was sitting in. Touching the items in the room contaminated the gloves worn by NA-C. NA-C was not wearing a face mask while in the residents' room and NA-C was within 2 feet of Resident 22. Resident 22 stated Resident 22 had to go to the restroom. NA-C got the isolation lift from the hallway by the door to Resident 22's Room and touched the lift without removing the gloves and doing hand hygiene after touching items in the room. This contaminated the handles of the lift. NA-C shut the door to take Resident 22 to the restroom. After 5 minutes NA-C opened the door and placed the contaminated lift in the hallway. NA-C then proceeded to assist Resident 22 out of the room in Resident 22's contaminated wheelchair down the hallway. NA-C was wearing the same gloves that were worn to push the lift into the hallway to push the wheelchair down the hallway. NA-C was pushing the wheelchair and pulling the lift contaminated lift that hadn't been cleaned from the hallway behind them. Resident 22 was brought down the hallway, by other residents, in the contaminated wheelchair that was in residents' room. Wheelchair was not wiped down and resident was not wearing a mask or gown. Resident 22 was wearing the same clothes Resident 22 had been wearing this morning. The door to the bath house was open and NA-C went inside with Resident 22, the contaminated wheelchair and contaminated lift which contaminated the bath house. Review of the undated CRE positive procedure for going to designated activity the process was to: cleaning the resident wheelchair (including wheels and high-touch surfaces like handles), putting on clean clothes; clean resident hands; use reasonable distance from others when positioning the residents'; paper copies of supplies (thrown away after use, i.e. song book); push to activity and push back when done. An interview on 2/27/20 at 2:15 PM with MA-L (Medication Aide) revealed that it is staff preference as to what you want to wear for mask, gown or gloves when entering Resident 22's room. Observation on 2/27/20 at 3:04 PM of Resident 22 sitting at the nurses' station within 3 to 4 feet of the other residents at the activity. Resident 22 was sitting in the same wheelchair that Resident 22 had been taken to the bath house in. Resident 22 was not wearing a mask. When other residents or staff wanted to go down the South hallway they would have to walk within 2 feet of the residents from contact isolation rooms. An interview on 2/27/20 at 3:34 PM with RN-K (Registered Nurse) revealed that Resident 22 was not coughing much at this time and Resident 22 was receiving nebulizer breathing treatments and hopefully would start to cough up some of the secretions from the lungs. Review of the CDC (Centers for Disease Control and Prevention) article Healthcare-associated Infections revealed that the Healthcare Facilities should- Ensure precautions are implemented for CRE (Carbapenem-resistant [MEDICATION NAME] ) colonized or infected patients. These include: *Whenever possible, place patients currently or previously colonized (Some people have germs on or in their body, but those germs do not cause an infection (when germs enter the body, often through medical devices like ventilators, intravenous catheters, urinary catheters, or wounds caused by injury or surgery) or infected with CRE in a private room with a bathroom and dedicate noncritical equipment (e.g., stethoscope, blood pressure cuff) to CRE patients. *Have and enforce a policy for using gown and gloves when caring for patients with CRE. *Have and enforce policies for healthcare personnel hand hygiene before and after contact with patient or their environment, and increase emphasis on hand hygiene on a unit caring for a patient or resident with CRE. *Healthcare personnel should follow standard hand hygiene practices, which include use of alcohol-based hand sanitizer or, if hands are visibly soiled, washing with soap and water. *When a patient with an unusual type of carbapenemase-producing CRE is identified in your facility, work with public health to prevent spread, including following guidance to assess for ongoing transmission. F. Record review of the history and physical documentation by the physician for Resident 31 dated 2/9/20 revealed that the resident had a urine lab test confirming that the resident's urine contained Carbapenem-resistant [MEDICATION NAME] (CRE) [DIAGNOSES REDACTED] (a type of bacteria that has become resistant to carbapenem, a class of antibiotic used to kill bacteria). Observation on 2/25/20 at 2:45 PM revealed that Nursing Assistant C (NA-C) entered the room of Resident 31 without putting on personal protective equipment (PPE) (protective clothing such as gown, gloves, or mask used to protect the wearer's body from infection). Resident 31 was in isolation precautions (requiring the use of gloves, gowns, and hand washing when in the resident room to help stop the spread of germs from one person with a known infection to another) and disposable PPE was available in a holder hanging on the resident's door for staff use. NA-C exited the room of Resident 31 carrying linens and did not perform hand hygiene. NA-C then carried linens into the room of Resident 3. Interview on 2/27/20 at 12:57 PM with the facility Director of Nursing (DON) confirmed that staff are required to wash the hands with soap and water or with alcohol based hand rub when exiting a resident room. | 2020-09-01 |
| 2917 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-06-14 | 689 | I | 1 | 0 | BBR311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.18E3 Based on observation, interview, and record review, the facility failed to protect 1 (Resident 4) of 4 sampled residents from a hot liquid burn and the facility failed to ensure that water temperatures did not present a potential scald hazard This practice had the potential to affect 37 residents who consume hot liquids, 55 residents who take baths in the facility and 32 residents of the facility who utilized the bathroom sinks in resident rooms. The facility had a total census of 57 residents. Findings are: [NAME] Resident 4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 6/13/18 at 11:45 AM revealed multiple fluid filled blisters to Resident 4's lower left arm. A review of a Skin Ulcer Non-Pressure assessment dated [DATE] revealed the following: -Chin burn, two areas in close proximity, measuring 3 cm (centimeter) in length x 2 cm in width. -Chest/left breast burn, multiple areas measured as one 22 cm in length x 16.5 cm in width. -Left arm burn, multiple areas, measured as one 16.6 cm in length x 6.2 cm in width. A review of a 6/13/18 at 6:30 AM Progress Note revealed a staff member was called to the resident's room and multiple areas were found. A review of Resident 4's Hot Liquid Safety assessment dated [DATE] revealed Resident 4 required staff set up for drinking hot liquids. Recommendations were cool beverages prior to handling/drinking. Educate resident/caregivers of hot liquids as a causative factor to prevent skin injury. Resident 4 requires a 2 handle cup and lid for hot liquids. In an interview on 6/11/18 at 10:14 AM, the Director of Nursing reported an investigation had been completed the following week due to a burn on Resident 1's foot. From that investigation, it was discovered the coffee was very hot and the coffee pot was to be replaced. Staff were provided education regarding the hot coffee. A review of the In-Service Training Report dated 6/8/18 revealed training was provided to 7 staff members that coffee had to be cooled down and hot liquids needed to be temped at 140 degrees F or lower before giving to resident. In an interview on 6/13/18 at 11:12 AM, Administrator and Director reported second [MEDICAL CONDITION] been discovered on Resident 4 that morning and the Director of Nursing had been notified at 9 AM. The Administrator reported coffee temperatures were to be checked and cooled before giving to resident. The investigation was being completed at that time and the coffee machine had been locked to prevent its use. In an interview on 6/13/18 at 12:32 PM, Dietary Aide A reported attending the in-service last week and adding ice cubes to the coffee it is too hot. Dietary Aide A reported that Dietary Aide A did not check the temperature of the coffee but could tell if the coffee was hot by feeling the bottom of the cup. In an interviews on 6/13/18 at 12:35 PM, the Administrator reported coffee was found to be 168 to 170 degrees F when coming out of the coffee machine. The Administrator had expected staff to record the temperatures of the coffee after being cooled and before service to resident but that was not being done. According to the Administrator, the current coffee machine was going to be removed and replaced with the coffee machine that the facility had previously used. B. Observations on 6/11/18 at 10:38 AM revealed a hot water temperature of 145 degrees F (Fahrenheit) in the shower on the Medical Center floor of the facility. Observations on 6/11/18 at 10:44 AM revealed a hot water temperature of 122 degrees F in the whirlpool on the Medical Center floor of the facility. Observation on 6/11/18 at 10:50 AM revealed a hot water temperature of 116 degrees F in the whirlpool and 116.6 F in the shower on the Garden level. Observations on 6/11/18 at 1:32 PM revealed a hot water temperature of 133 degrees F in the whirlpool on the Medical Center floor of the facility. In an interview on 6/11/18 at 1:32 PM, the Maintenance Director reported the water heater had been adjusted down and the water line just needed to be emptied. Observations on 6/11/18 at 1:58 PM revealed a hot water temperature of 130.2 degrees F in the bathroom sink for room [ROOM NUMBER]. Observations on 6/11/18 between 3:52 and 4:16 PM revealed the following hot water temperatures: -bathroom sink in room [ROOM NUMBER]-121.4 degrees F -bathroom sink in room [ROOM NUMBER]-125.7 degrees F -bathroom sink in room [ROOM NUMBER]-122.5 degrees F -Medical Center shower-120.2 degrees F A review of water temperature log from 6/5/17 to 6/8/18 revealed checks of hot water temperature had been checked on garden tub, medical center tub on 6/8/18, 8/25/17, and 7/27/18 In an interview on 6/11/18 at 10:52 AM, the Maintenance Director reported water temperatures are not to exceed 120 F in bathing fixture and facility water temperatures usually are between 108-110 degrees F in the facility. In an interview on 6/11/18 at 11 AM, the Director of Nursing reported all baths in the facility had been stopped. In an interview on 6/11/18 at 4:17 PM, the Administrator reported the facility was getting bids for repair of the water mixing valve. In a telephone interview on 6/11/18 at 4:34 PM, the facility Outside Contracted Plumber reported one mixing valve had been determined to be in need of repair. The hot water had been rerouted to go through the other mixing valve. The Outside Contracted Plumber reported the water temperature had been set between 115-117 F and the water temperature in the sinks and bathing areas would decrease once the water in the pipes was used. A review of 30 minute water temperature checks completed between 5:30 PM on 6/11/18 and 9 AM on 6/12/18 revealed 90 of 144 water temperatures were greater than 121 degrees F in bathing fixtures and resident bathroom sinks. In an interview on 6/12/18 at 10:19 AM, the Administrator reported signs stating not to use sink were being put on sinks with high water temperatures. In an interview on 6/12/18 at 11 AM, the Regional Director reported the hot water in the building had been shut off until one of the mixing valves could be repaired. A review of Center for Medicare and Medicaid Services guidelines effective 11/28/17 for temperatures revealed for the following: -Temperatures of 120 degrees F can cause a third degree burn within 5 minutes -Temperature of 133 degrees F can cause a third degree burn within 15 seconds -Temperature of 140 degrees F can cause a third degree burn within 5 seconds -Temperature of 148 degrees F can cause a third degree burn within 2 seconds | 2020-09-01 |
| 2918 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-06-14 | 867 | I | 1 | 0 | BBR311 | > Licensure Reference Number: 175 NAC 12-006.07C Based on record review and interview, the facility failed to have an effective Quality Assurance and Performance Improvement Plan to address facility identified concerns related to coffee temperatures. The facility had a total census of 57 residents. Findings are: A review of facility policy and procedure titled Performance Improvement revised 9/2017 identified the purpose of the plan is to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individual's highest practicable physical, mental, and social well-being. A review of Performance Improvement Plan initialed 6/8/18 identified potential out of range water temperatures on facility coffee machine in dietary. Interventions included checking the temperature in of the coffee in each cup before serving to each resident. If the coffee is too hot, staff are to cool down in a carafe or a coffee thermos without the lid. In an interview on 6/11/18 at 10:14 AM, the Director of Nursing reported an investigation had been completed the following week due to a burn on a Resident 1's foot. From that investigation, it was discovered the coffee was very hot and the coffee pot was to be replaced. Staff were provided education regarding the hot coffee. A review of In-Service Training Report dated 6/8/18 revealed training was provided to 7 staff members that coffee had to be cooled down and hot liquids need to be temped at 140 degrees F or lower before giving to resident. In an interview on 6/13/18 at 11:12 AM, Administrator and Director reported second degree burn had been discover on Resident 4 that morning and Director of Nursing had been notified. The Administrator reported coffee temperature was to be checked and cooled before giving to resident. The investigation was being completed at that time and the coffee machine had been locked to prevent its use. In an interview on 6/13/18 at 12:32 PM, Dietary Aide A reported attending the in-service last week and adding ice cubes to the coffee if it is too hot. Dietary Aide A reported that Dietary Aide A did not check the temperature of the coffee but could tell if the coffee was hot by feeling the bottom of the cup. In an interviews on 6/13/18 at 12:35 PM, the Administrator reported coffee temperature was found to be 168 to 170 degrees F when coming out of the coffee machine. The Administrator had expected staff to record the temperatures of the coffee after being cooled and before service to resident but that was not being done. According to the Administrator, the current coffee machine was going to be removed and replaced with the coffee machine that the facility had previously used. | 2020-09-01 |
| 908 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2017-08-22 | 309 | H | 1 | 1 | 2T4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) thorough skin assessments were completed at least weekly and dressings were changed as ordered to promote healing of open wounds with ongoing drainage for one current sampled resident (Resident 84), 2) pain was assessed and controlled during wound care for one current sampled resident (Resident 169), 3) ongoing severe pain was identified and managed for one current sampled resident (Resident 15), 4) pain rated severe was assessed and controlled for one closed record (Resident 173) and two current sampled residents (Resident 90 and 10), 5) a resident with an abnormal blood pressure reading was assessed and follow up completed to ensure that the resident didn't experience any adverse effects for one current sampled resident (Resident 84) and 6) a decline in behaviors was assessed and a plan to manage behaviors was developed for two current sampled residents (Residents 29 and 25). The facility census was 107 with 22 current sampled residents and three closed records. Findings are: A Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/8/17 at 11:00 AM revealed the resident seated in the wheelchair with ongoing foul odors noted from dressings at lower extremities. Interview on 8/8/17 at 11:00 AM with the resident revealed they don't change my dressings like they're supposed to. Observations on 8/9/17 at 9:30 AM revealed the resident seated in room in a wheelchair and noted a strong foul smelling odor in the room and the hallway by the resident's room. Interview with the resident on 8/9/17 at 9:30 AM revealed my legs are bleeding, they're supposed to change my dressings two times a day and put some cream on my legs and lucky to get it done every 2-3 days. Further observations revealed the resident removing the dressings from the right lower legs and noted leg swollen with clear, foul smelling weeping drainage dripping down the leg. Observations on 8/9/17 at 1:30 PM revealed the resident seated in the wheelchair in the room for the scheduled treatment and dressing changes to the legs. Noted the foul smelling drainage continued to weep from the lower legs bilaterally and the dressings were removed from the lower legs. The dressing/wraps were intact at the thighs. Further observations revealed LPN (Licensed Practical Nurse) - R, Charge Nurse (assisted by LPN - C, Unit Coordinator), while sitting on the floor in front of the resident, removed the wrap and dressings from the right thigh, cleansed the back of the thigh with a disposable washcloth and then the front of the thigh, applied [MEDICATION NAME] cream as ordered to the back and front of the thigh, wrapped gauze around the thigh and then an ace wrap. Noted that the back of the thigh was not visible to the nurse to assess the resident's skin as the treatment was done. LPN - R removed the ace wrap and dressing from the left thigh and performed the treatment in the same manner. The resident complained of soreness behind the left knee. LPN - R could not visualize the skin at the back of the thigh for an assessment. The resident stated my legs have been bleeding for two days. The resident also complained of pain at the left thigh and lower legs, moaning and grimacing, while the treatments were done at the left thigh and lower legs. Interview on 8/10/17 at 8:00 AM with LPN - R revealed that the resident often removed the dressings from the lower legs and often refused routine bathing. Observations on 8/10/17 at 8:00 AM revealed the resident seated in a recliner in room with legs elevated about ten inches, strong foul odor remained in room. Further observations at 11:00 AM and 2:15 PM revealed the resident seated in the wheelchair, legs not elevated and the strong foul odor remained in the room and into the hallway. Review of the Weekly Skin Check, dated 7/12/17, revealed that the resident had [MEDICAL CONDITION] at the right and left thighs (rear), right lower and left lower front legs, and right lower and left lower legs rear. [MEDICAL CONDITION] is a condition of abnormal accumulation of tissue fluid (potential lymph) in the interstitial spaces. The resident refused to have skin assessment completed. Review of the Weekly Skin Check, dated 7/19/17, revealed that the resident had bilateral lower [MEDICAL CONDITION], right and left thighs (rear), right and left lower legs (front and rear) and dressings were applied as ordered. The resident also had excoriation under both breasts and under the abdominal fold and a wound at the buttock which measured two by two centimeters. The resident had no other areas of concern. Review of the Weekly Skin Check, dated 8/9/17, (none received to review for 8/2/17), revealed that the resident had excoriation under both breasts and under the abdominal fold, and [MEDICAL CONDITION] to the right and left thigh (rear), right and left lower legs (front and rear). Further review revealed no measurements of the swelling to evaluate worsening or improvement. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed an order, dated 1/30/17, for compression wraps to both legs, change every 12 hours for [MEDICAL CONDITION] and [MEDICATION NAME] cream to bilateral legs every 12 hours. Further review revealed no documentation that the treatment was done on the day shift on 8/4/17, 8/5/17 and 8/6/19. The treatment was documented as refused on the day shift on 8/7/17 and on the evening shift on 8/2/17, 8/3/17, 8/4/17, 8/6/17, 8/7/17 and 8/8/17. Further review revealed an order, dated 6/6/17, to check buttocks and coccyx daily for skin breakdown and an order dated 7/20/17, for [MEDICATION NAME] cream to buttock every shift. Review of the Progress Notes, dated (MONTH) (YEAR), revealed no documentation of the resident's ongoing refusal of thorough skin assessments or treatments to the legs. Further review revealed no documentation of the ongoing foul smelling weeping drainage from the legs or the status of the open area on the buttock. Interview on 8/15/17 at 9:00 AM with LPN - C, Unit Coordinator, confirmed that complete skin assessments were not completed at least weekly to determine whether or not the treatments were effective. LPN - C confirmed that a complete assessment of the resident's skin condition could not be done while the resident was seated in a wheelchair. Further interview confirmed that the ongoing foul smelling drainage from the legs was not documented or addressed. B. Observations on 8/9/17 at 1:00 PM revealed Resident 169 resting on the bed, positioned on back for wound care. Further observations revealed LPN - Q lifted the resident's right foot to remove the protective boot and the resident complained of pain as the foot was lifted up. The resident said ouch, that is so tender and the resident grimaced and had labored breathing. The resident continued to complain of pain when the right foot was moved for the treatment on the pressure ulcer at the heel with continued verbal complaints of pain, facial grimacing and labored breathing. LPN - Q continued with the treatment and encouraged the resident to take deep breaths. LPN - Q and RN (Registered Nurse) - P turned the resident to left side to continue treatments to pressure ulcers at the right buttock and sacral area. The resident groaned again with pain when the right foot was lifted while repositioned to side. The resident also complained of hip pain when repositioned, when the treatment was done to the sacral area and when positioned again on back. Interview on 8/9/17 at 2:00 PM with the resident revealed that those treatments are so painful. Review of the Medication Administration Record, [REDACTED]. Interview on 8/15/17 at 10:00 AM with LPN - C, Unit Coordinator, confirmed that the resident should have been offered pain medication before the wound care in anticipation of pain. LPN - C confirmed that the nurses should have stopped the treatment when the resident complained of pain, medicated the resident and then continue with the treatment to promote comfort for the resident. C. Interview with Resident 15 on 8/8/17 at 11:20 AM revealed that the resident had back and neck pain. The resident stated that takes pain medications but it still hurts. Observations during the interview revealed that the resident had pained facial expressions and a clenched jaw. Observations on 8/9/17 at 9:45 AM revealed the resident seated in the wheelchair in room with tears in eyes. Further observations revealed dried dark red colored matter on the rim of the urinal on the edge of the garbage container. Interview with the resident on 8/9/17 at 9:45 AM revealed my bladder, back and kidneys hurts so bad. The resident also stated that it has been hurting for several days now with no relief from the pain pills. The resident stated pain pills don't help at all, it hurts so bad that I want to cry, having blood in my urine and I'm supposed to see a doctor. Interview on 8/9/17 at 10:00 AM with RN (Registered Nurse) - P, Charge Nurse, revealed that the resident had chronic neck pain and usually requested a pain pill in the morning. RN - P did not mention the resident's back pain or blood in urine. Observations on 8/9/17 at 11:15 AM revealed the resident seated on the toilet and complains of really bad pain. The resident stated may be passing a kidney stone or something. Further observations revealed the resident had bright red blood in the toilet. Interview on 8/9/17 at 11:30 AM with RN - P revealed that no urology appointment had been made yet to evaluate the resident. Further interview revealed would have the Nurse Practitioner check the resident. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the resident had a routine [MEDICATION NAME] (narcotic [MEDICATION NAME]). Further review revealed that the resident received [MEDICATION NAME] (Opioid [MEDICATION NAME]), ordered as needed for pain, on 8/7/17 at 8:22 AM, on 8/8/17 at 8:38 AM and 7:12 PM and on 8/9/17 at 8:43 AM for pain rated 9 (severe) on the 1-10 pain scale. Further review revealed documentation that the 8/8/17 at 8:38 AM and the 8/9/17 at 8:43 AM doses were ineffective in relieving the resident's pain. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Interview with the LPN - C, Unit Coordinator, on 8/15/17 at 10:30 AM confirmed that the medical provider should have been notified of the resident's ongoing unrelieved pain and blood with urination sooner to relieve the resident's pain. D. Review of the Admission Record, printed 8/9/17, revealed that Resident 173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident received the first dose on 7/11/17 at 1:00 AM for pain rated 7 (on a pain scale of 1-10 with 10 as the worst possible pain) for right shoulder pain per the Progress Notes. The resident received the next doses at 7:34 AM for right shoulder pain rated 8 and at 4:44 PM for all over pain rated 9. The resident received the pain medication again on 7/12/17 at 4:51 AM for pain rated 7 for right shoulder and right arm pain, at 1:11 PM for right shoulder pain rated 10 and at 9:09 PM for right shoulder pain rated 7. Review of the Progress Notes, dated 7/12/17 at 9:55 AM, revealed that the resident complained on continuous pain to the left upper extremity and the right lower extremity and pain medication offered as needed was effective for a short amount of time, but then the pain returned. The resident was to have an x-ray of the right ankle today due to severe pain. Review of the Progress Notes, dated 7/13/17 at 2:36 PM revealed a new order for [MEDICATION NAME] 10/325 milligrams every 6 hours for pain. Review of the Medication Administration Record, [REDACTED]. Further review of the Medication Administration Record [REDACTED]. Further review revealed no documentation on 7/14/17 or 7/15/17 of how the resident rated the pain. Review of the Progress Notes, dated 7/15/17 at 4:10 PM, revealed that the resident was continuously pulling on the call light cord screaming in sleep, noted body tremors, when the resident was awake was confused and hallucinating about chickens. The on call provider was notified of the resident's change in condition and stated it is probably the dosage increase of [MEDICATION NAME] and new orders were received to discontinue the routine scheduled [MEDICATION NAME] and change back to every eight hours as needed for pain. Further review revealed that at 8:00 PM, the resident continued to have episodes of twitching with [MEDICAL CONDITION] off and on during the day, was unresponsive and grimaced with pain during movement. The provider was notified and orders were received to transport the resident to hospital emergency room for evaluation and then admission. Interview on 8/15/17 at 3:00 PM with LPN - C, Unit Coordinator, confirmed that further assessments of the resident's ongoing pain should have been completed, including causal factors and non- pharmacological interventions in place to control the resident's pain. Further interview confirmed that pain assessments should have continued when the [MEDICATION NAME] was changed to routine dosing to ensure that pain was managed effectively for the resident's comfort. E. Review of the Admission Record, printed 8/9/17, revealed that Resident 90 was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview on 8/9/17 at 10:00 AM with the resident revealed that the right shoulder continued to hurt and rated pain at 7 as it still hurts a lot. Interview on 8/10/17 at 7:15 AM with the resident revealed that the right shoulder and right leg hurt and the resident was rubbing the shoulder and leg. The resident stated that the pain pills help some, but it still hurts. Review of the Medication Administration Record, [REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed that orders were received on 8/8/17 for routine [MEDICATION NAME] every bedtime. Interview on 8/15/17 at 10:40 AM with LPN - C, Unit Coordinator, confirmed that further assessments of the resident's ongoing pain should have been completed to include potential causal factors and non - pharmacological interventions to manage the resident's pain. F. Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed the resident's blood pressure was 195/75 on 7/28/17. Review of the medical record, including the progress notes, revealed no assessment of the resident on 7/28/17 or follow up blood pressure until 8/2/17 with a reading on 163/73. Interview on 8/14/17 at 1:30 PM with LPN - D, Unit Coordinator, confirmed that an assessment and follow up vital signs should have been completed and documented with the abnormally high blood pressure reading on 7/28/17. Further interview confirmed that the resident's condition should have been monitored closely to ensure that the resident's needs were met. [NAME] Review of Resident 29's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 6/10/17, revealed that the resident had no behaviors. Review of the MDS, dated [DATE], revealed that the resident had physical behaviors directed towards others one to three days during the assessment period. Interview on 8/14/17 at 2:30 PM with LPN - Z, MDS Coordinator, revealed that the resident had a documented episode of hitting and kicking staff in the nursing assistant documentation during the assessment period. Further interview confirmed that there was no documentation that the care plan team reviewed the incident, considered the potential causal factors related to the behaviors or developed a plan to reduce the risk for further behaviors. H. Review of Resident 25's MDS, dated [DATE], revealed that the resident had no behaviors. Review of the MDS, dated [DATE], revealed that the resident had physical behaviors directed towards others one to three days during the assessment period. Interview on 8/14/17 at 2:30 PM with LPN - Z, MDS Coordinator, revealed that the care plan team did not address the resident's decline in behaviors, identify potential causal factors or develop a plan to manage any further behaviors directed towards others. I. Interview with Resident 10 revealed the resident had pain that would not go away and the facility hadn't intervened to assist in alleviating the pain. Observation on 8/8/17 at 10:20 a.m. revealed the resident grimaced throughout the interview. Record review of the MDS (Minimal Data Set, a federally mandated comprehensive assessment tool utilized to develop care plans) revealed the resident was assessed with [REDACTED]. Record review of the resident's care plan revealed the resident had right knee pain. Record review of Nurses notes revealed Resident 10 had knee injections for pain on 8/9/17 at the physician's clinic. Record review of facility documentation revealed no pain assessments for Resident 10 were completed before and after knee injection on 8/9/17. Record review of Resident 10's Medication Administration Record [REDACTED]. Record review of Resident 10's electronic medical record revealed there were no formal pain assessments completed since 6/30/17. Interview with LPN (Licensed Practical Nurse)-C on 8/15/17 at 3:00 p.m. revealed LPN-C was the unit coordinator and worked routinely with Resident 10. LPN-C confirmed there were no follow up formal pain assessments or documentation for Resident's pain since 6/30/17. | 2020-09-01 |
| 912 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2017-08-22 | 323 | H | 1 | 1 | 2T4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and interviews; the facility failed to ensure that 1) interventions were in place to prevent recurrent falls and a subsequent fractured finger for one current sampled resident (Resident 26) and 2) oxygen concentrators were turned off when not in use to reduce the risk of fires for five current sampled residents (Residents 25, 66, 40, 15 and 71). The facility census was 107 with 22 current sampled residents. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7b (3) [NAME] Review of the Admission Record, printed 8/9/17, revealed that Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident also had [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 11/3/17, revealed that the resident was at risk for falls related to poor safety awareness and self-determination related to transfers. Further review revealed that the resident fell getting out of the wheelchair on 4/24/17, slid self out of the wheelchair to the floor on 6/29/17 and had an unwitnessed fall out of the wheelchair on 7/25/17. Review of the Progress Notes, dated 7/25/17 at 1:49 PM, revealed that the resident was found to be on the floor next to the wheelchair in the dining room and no injuries were noted. Further review revealed at 2:09 PM, bruising which measured 5 cm. (centimeters) by 2 cm. was noted on the 3rd digit. At 6:14 PM, swelling was noted at the finger. On 7/27/17 at 2:45 PM, an x ray showed that the resident had a fractured right third finger and orders for a splint were received. Observations on 8/9/17 at 7:40 AM revealed the resident resting in bed and a splint in place at the right third finger. Review of the Treatment Administration Record, dated (MONTH) (YEAR), revealed an order, dated 7/26/17, for Epsom salt treatment two times a day for swelling and bruising of the right hand. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed an order, dated 8/1/17, to take the splint off and check skin daily and reapply the splint daily until 9/7/17. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed that the resident received Hydrocodone - Acetaminophen (narcotic analgesic) for pain on 7/24/17 and 7/26/17. Interview on 8/14/17 at 1:45 PM with LPN (Licensed Practical Nurse) - D, Unit Coordinator, confirmed that the care plan interventions were not effective to prevent further falls from the wheelchair and the subsequent fractured finger. Licensure Reference Number: 175 NAC 12-006.09D7 B. Observations on 8/8/17 at 8:30 AM revealed Resident 15 (Room 104 B) and Resident 17 (Room 215 B) oxygen concentrators on while the residents were out of the room. Observations on 8/14/17 at 7:45 AM revealed Resident 25 (Room 220 B), Resident 66 (219 B) oxygen concentrators on while the residents were out of the room. Observations on 8/14/17 at 8:00 AM revealed Resident 40 sleeping in bed with the oxygen concentrator on and the mask on the bed. Interview on 8/14/17 at 8:15 AM with the Interim Director of Nursing confirmed that the oxygen concentrators were to be turned off when not in use to reduce the risk of accidental fires and to promote safety. | 2020-09-01 |
| 1920 | PREMIER ESTATES OF KENESAW, LLC | 285166 | P O BOX 10, 100 WEST ELM AVENUE | KENESAW | NE | 68956 | 2019-09-12 | 600 | H | 0 | 1 | WSRR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (9) Based on observation, interview, and record review; the facility failed to protect the residents from neglect by failing to ensure staff had the supplies needed to care for residents. This had the potential to affect all of the facility residents. The facility identified a census of 52 at the time of survey. Findings are: Interview with MA-O (Medication Aide) on 9/08/19 at 6:18 PM revealed the facility did not have any disposable wipes so they were using paper towels to provide perineal care to the residents as they had been directed. Observation of the facility nursing supply store room on 9/09/19 at 2:38 PM with NA-U (Nurse Aide) and NA-V revealed there were no disposable wipes. NA-U and NA-V both reported this was the storeroom they were directed to retrieve nursing supplies. NA-V revealed they had asked one of the facility staff about the wipes and they were told they had backordered. Interview with NA-U on 9/9/2019 at 2:38 PM revealed the facility never had enough disposable wipes as they frequently ran out of them. NA-U revealed they were told to use wash cloths to provide perineal care but NA-U was uncomfortable doing this as there were no wash cloths designated specifically for perineal cleansing use and NA-U felt they should not be using the same wash cloths for perineal care that the staff used to wash the residents' faces, etc. Interview with HS (Housekeeping Supervisor) on 9/11/19 at 2:27 PM revealed they were responsible for ordering nursing supplies. HS revealed there was one case of disposable wipes located in the facility. Someone had put them in the wrong storeroom. HS did not confirm or deny the facility ran out of supplies or if the storeroom was being checked regularly to ensure there were ample supplies. Review of the facility policy Central Supply issued (MONTH) 20, 2019 revealed the following: The purpose of the central supply system is to: Maintain Inventory Control. B. Observation of the facility on 9/12/19 at 12:26 PM revealed none of the residents had any hand towels or washcloths. Interview with MA-D on 9/12/19 at 12:31 PM revealed the nursing staff were supposed to pass linen at least once a shift. MA-D revealed they did not know why the residents did not have towels and washcloths. MA-D revealed they knew the facility had been low on them and they have been trying to get some more ordered. C. Interview with Resident 1 on 09/09/19 at 1:53 PM revealed it had been hot in the facility most of the summer. Interview with the MS on 9/11/2019 at 2:27 PM confirmed the AC (Air Conditioner) had not been working during the first part of the summer. It took 3 years to get fixed. The MS revealed 4 AC units had been down at one time. D. Interview on 9/09/19 at 10:07 AM with Resident 42 revealed the resident had not had a bath in the past year at times for weeks at a time. Right now the thing that really concerned the resident was during the whirlpool baths the staff were not turning on the whirlpool jets because they could not clean the jets properly because the facility was out of the proper disinfectant they needed to clean the jets in the tub. Interview on 9/10/19 at an unspecified time with Anonymous revealed the facility had been out of Penner whirlpool disinfectant for about 1 month and the staff had not been able to clean the whirlpool jets. Anonymous revealed the staff had been told in the past to never use any disinfectant in the whirlpool jets except for the Penner disinfectant or it would ruin the jets. When the facility ran out of the Penner disinfectant about 1 month ago, the facility instructed the staff to use a disinfectant from Housekeeping that was supposed to still be able to kill the germs but was not a Penner product. The staff had been cleaning the tub but not the jets so as not to ruin the jets, yet the staff were still providing baths to the residents in the whirlpools but not turning the jets on. Anonymous confirmed when giving the baths the water line was above the jet holes in the tub. Anonymous confirmed residents with catheters and wounds had been receiving baths during the time frame of the jets not being cleansed. Observation on 9/10/19 at 8:43 PM revealed NA-N performed a bath in the whirlpool on Resident 8. When done with the bath, observed NA-N cleanse the whirlpool tub and used A456II disinfectant. NA-N took the whirlpool chair seat apart and cleaned it while inside the tub and scrubbed the tub chair and the tub thoroughly. NA-N did not spray disinfectant into the jets. When done scrubbing, NA-N sprayed everything again then let it sit wet for 10 minutes. Interview with NA-N revealed the whirlpool tubs were cleansed between each resident use and there was one more bath to be given that night. NA-N confirmed the facility had been out of the Penner disinfectant that was supposed to be used to clean the whirlpool and jets and it had been approximately 1-2 weeks that they had been out. Instead the staff had been using the disinfectant A- and NA-N confirmed the staff did not put A- into the jets. NA-N revealed with the Penner disinfectant the staff sprayed it into the jets and let the jets run for 2 minutes, but now they do not disinfect the jets. They continue to bathe in the whirlpool but do not turn on the jets. Interview on 9/10/19 at 8:50 PM with the DON revealed the DON had been aware the facility had been out of the Penner disinfectant at one point but knew the facility had tried re-ordering more and thought the re-order had come in. The DON revealed the DON was never aware the staff were not cleaning the whirlpool jets. The DON revealed during the time when the DON knew the facility was out of the Penner disinfectant, the DON had checked the A disinfectant specs before using it to ensure it was approved to kill the same type of germs and could be used in regular tubs. The DON ceased any further whirlpools to be given in the facility until the facility could investigate, re-educate staff and ensure the whirlpools were cleansed appropriately before any more baths were given. The DON revealed showers would be given instead. Interview on 9/11/19 at 7:55 AM with RN-B revealed the Infection Control reports reviewed the facility had no infections in Sept or Aug of UTI's (urinary tract infection) or wound infections. RN-B provided a report which showed the only infections for the 2 months was an URI (upper respiratory infection). Review of the Product Specification Document for A- Disinfectant Cleaner revealed it was a one-step disinfectant cleaner, fungicide, virucide, mildewstat, and deodorizer to be used and then let set 10 minutes It [MEDICAL CONDITION](human immunodeficiency virus), HBV([MEDICAL CONDITION] virus), and HCV ([MEDICAL CONDITION] virus) and was a hospital use disinfectant bactericidal and had an entire list of bacteria it killed. Review of a list provided by the DON on 09/11/19 at 1:59 PM revealed 47 residents had a tub bath in the whirlpool. The residents were Residents 7, 27, 21, 4, 9, 14, 25, 44, 39, 34, 37, 53, 49, 48, 16, 33, 5, 2, 3, 38, 10, 26, 15, 11, 36, 51, 1, 8, 41, 18, 46, 6, 40, 32, 47, 45, 30, 28, 31, 43, 17, 20, 13, 50, 24, 23, and 35. Review of the facility matrix and by observation of these residents revealed out of the list provided by the DON, the following residents had a urinary catheters: Resident 53. The following residents had open wounds and received a bath in the whirlpool: Resident 5 with a pressure ulcer on the right buttocks measured on 8-19-19 at 0.5 x 0.3 x 0.4 cm (centimeters) and Resident 16 with pressure area on the ear. | 2020-09-01 |
| 2839 | BELLE TERRACE | 285237 | 1133 NORTH THIRD ST | TECUMSEH | NE | 68450 | 2017-06-08 | 353 | H | 1 | 0 | LUKH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure reference: 175 NAC 12-006.04C Based on observation, interview, and record revie;, the facility failed to ensure sufficient staff to meet resident needs as evidenced by not providing assistance to transfer in a safe manner for one sampled resident (Resident 3), failure to provide assistance with toileting for one sampled resident (Resident 9), failure to provide medications at scheduled times for two sampled residents (Resident 3 and 17), and failure to answer call lights within facility parameters for three sampled residents (Resident 3, 8, and 9). The sample size was 17 and facility census was 56. Findings are: [NAME] Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's care plan revealed a problem dated 2/22/17 of alteration in mobility with approach of Hoyer lift with 2 assist for transfer. A review of a facility investigative report dated 5/18/17 revealed on 5/14/17 at 4:50 PM Resident 3 was transferred from the wheelchair to bed by two nurse aides without using a Hoyer lift. The report stated that a popping sound was heard when the nurse aides tried to reposition the resident in to the center of the bed. Resident 3 had very limited range of motion in all joints due to severe contractures and arthritic changes according to the report. Resident 3 was diagnosed with [REDACTED]. Preventative measures put in place by the facility included staff education on safe transfers for all residents and resident education on importance of Hoyer lift due to resident condition. In an interview on 5/31/17 at 11:05 AM, Nurse Aide A reported Nurse Aide A had assisted Nurse Aide B in transferring Resident 3 without use of the Hoyer lift. When trying to reposition Resident 3 in bed a popping sound had been heard. Nurse Aide A reported that Nurse Aide A had not been trained on transferring Resident 3. Nurse Aide A confirmed Nurse Aide A was not 18 and could not operate the lift. In an interview on 5/31/17 at 1:38 PM, Nurse Aide B reported Nurse Aide B had been trained by a previous nurse aide to transfer Resident 3 utilizing a two person lift. Nurse Aide B reported hearing a pop after transferring Resident 3. Nurse Aide B confirmed Nurse Aide B was not 18 and could not operate the lift. A review of the staffing schedule as worked for 5/14/17 revealed Nurse Aide A and B were the only nurse aides working the floor between 2 PM and 6 PM along with a charge nurse and a medication aide. In an interview on 5/31/17 at 12:57 PM, the Assistant Director of Nursing confirmed Nurse Aide A and Nurse Aide B were the only aides in the building at the time of the incident and neither one of the aides were old enough to operate the Hoyer lift. The Assistant Director of Nursing reported education had been provided the nurse aides to get the charge nurse or medication aide to assist with using the lift. Census List dated 5/30/17 identified 12 residents utilizing a Hoyer lift. B. Observations on 5/30/17 at 9:31 PM revealed Resident 17 was administered [MEDICATION NAME] HCL (a medication for pain) 50 mg (milligrams) and [MEDICATION NAME]-HCTZ 10-12.5 1 tablet by Medication Aide F. A review of Resident 17's (MONTH) (YEAR) Medication Administration Record [REDACTED]. In an interview on 6/8/17 at 2:32 PM, the Assistant Director of Nursing reported the facility had a one hour window of time on either side of the scheduled time for medication administration. C. Observations on 5/30/17 at 9:36 PM revealed Resident 3 was administered [MEDICATION NAME] sodium 1 cap (a laxative), [MEDICATION NAME] 75 mg (a medication for nerve pain), Celecoxib 200 mg (a nonsteroidal anti-[MEDICAL CONDITION] medication), and [MEDICATION NAME] 150 mg (an antacid) by Medication Aide F. A review of Resident 3's (MONTH) (YEAR) Medication Administration Record [REDACTED]. In an interview on 6/8/17 at 2:32 PM, the Assistant Director of Nursing reported the facility had a one hour window of time on either side of the scheduled time for medication administration. D. In an interview on 5/30/17 at 7:38 PM, Medication Aide F reported that Medication Aide F had to pass medications to all residents of the facility. A review of the facility roster received on 5/30/17 revealed the facility had a census of 56 residents. E. In an interview on 5/30/17 at 9 PM, Medication Aide G reported having to pass medications to all residents of the facility when Medication Aide G first started but it was better now. A review of an employee list with start dates revealed Medication Aide G had started working at the facility on 5/1/17. F. Resident 9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident 9's Resident Status Sheet revealed the resident was to be checked and changed every 2-4 hours. If Resident 9 refused to be changed notify charge nurse and reoffer regularly. Observations on 5/30/17 at 10:11 PM revealed Resident 9 transferred to bed with a Hoyer lift. Resident 9's pants were observed to be wet and a urine odor was noted. In an interview on 5/30/17 at 10:11 PM, Nurse Aide C confirmed this was the first time Resident 9 had been changed since shift started at 6 PM. In an interview on 6/8/17 at 10:25 PM, the Assistant Director of Nursing reported Resident 9 should be offered toileting every 2 hours. Interviews conducted with nurse aides on 5/30/17 between 7:44 PM and 8:26 PM revealed 4 nurse aides were working on the floor. In an interview on 6/13/17 at 11:05 AM, the Director of Nursing confirmed 4 aides were working on the floor after 7 PM. [NAME] In an interview on 5/3/17 at 10:05 AM, Resident 3 reported call lights were not always answered in a timely manner and it may to take up to an hour to get a call light answered at night. A review of the call light log for Resident 3 from 5/20/17 to 5/27/17 revealed 18 times in which call light response time was greater than 15 minutes and 8 times in which call light response time was greater than 30 minutes two of which were greater than one hour. H. In an interview on 6/7/17 at 9:58 AM, Resident 8 reported that at times Resident 8 had to wait to get the call light answered. A review of the call light log for Resident 8 from 5/20/17 to 5/27/17 revealed one time that a call light response time was greater than 30 minutes. I. A review of the call light log for Resident 9 from 5/20/17 to 5/27/17 revealed 18 times the call light response time was greater than 15 minutes and 10 times greater than 30 minutes with two response times greater than one hour. [NAME] In an interview on 6/13/17 at 8:55 AM, the Assistant Director of Nursing reported it was the facility goal to have call lights answered within 10 to 15 minutes. K. In an interview on 6/13/17 at 9:52 AM, Staff Coordinator H reported Staff Coordinator H tried to staff 6 AM to 6 PM shift with 5 to 6 aides, between 6 PM-10 PM staffed with 4-5 aides with 2-3 aides being over 18, and between 10 PM-6 AM staff with 3 aides with 2 aides being over 18. | 2020-09-01 |
| 2869 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-01-02 | 686 | H | 1 | 1 | 51KH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to identify pressure ulcers and failed to implement assessed interventions to prevent development of pressure ulcers for 4(Resident 3, 36, 51 and 160) of 4 sampled residents. The facility staff identified a census of 66. Findings are: [NAME] Record review of Resident 51's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 12-06-2017 revealed the facility staff assessed the following about Resident 51: -Brief Interview for Mental Status (BIMS) was a 14. According to the MDS Manuel a score of 13 to 15 indicates a person is cognitively intact. -Required supervision with eating. -Required extensive assistance with 2 or more persons assisting with bed mobility, transfers, dressing, toilet use and personal hygiene. -Always incontinent of bowel and bladder. -Identified Resident 51 at risk for the development of pressure ulcers. Record review of Resident 51's Braden Scale (tool used for predicting pressure sore risk) dated 12-06-2017 revealed Resident 51 scored a High Risk rating. Record review of Resident 51's Comprehensive Care Plan (CCP) dated 11-24-2017 revealed Resident 51 had the [DIAGNOSES REDACTED]. Further review of Resident 51's CCP updated on 12-06-2017 revealed Resident 51 had returned from the hospital with an open wound to the sacrum and prevalon boots (type of pressure relieving foot wear) in place to both feet. According to Resident 51's CCP, the prevalon boots were worn at all times. Observation on 12-20-2017 at 2:49 PM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 at 11:00 AM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 11:22 AM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 at 1:10 PM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Further observation on 12-21-2017 at 1:10 PM revealed Resident 51's Family member was in the room with Resident 51. Resident 51's Family member stated see (gender) doesn't have (gender) boots on and with a pointing movement indicated the prevalon boots were placed in a chair in Resident 51's room. Resident 51's family member confirmed the prevalon boots were to be on Resident 51. Observation on 12-21-2017 2:00 PM with Licensed Practical Nurse (LPN) B of Resident 51's heels revealed Resident 51 had an approximately 5 centimeters (cm) roundish fluid looking blister to the left heel. On 12-21-2017 at 2:00 PM an interview was conducted with LPN B. During the interview, LPN B confirmed Resident 51 did not have the prevalon boots on (gender) feet. LPN B further reported not being aware Resident 51 had a wound to the left heel. Record review of Resident 51's record revealed there was no evidence Resident 51 had a pressure area to the left heel. Further review of Resident 51's medical record revealed there was no evidence the facility had completed daily monitoring of Resident 51's feet. Record review of a Skin Pressure Ulcer Weekly (SPUW) sheet dated 12-21-2017 with a time of 2:50 PM revealed the area to Resident 51's left heel was measured as 2.9 cm by 2.5 cm and staged as a Suspected Deep Tissue Injury ( SDTI). The description of the left heel SDTI was identified as black/brown, eschar (dead tissue). According to Woundeducators.com, a SDTI is A deep tissue injury is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. B. Record review of Resident 3's MDS dated as completed on 10-03-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 15. -Total dependence for bed mobility, transfers, dressing, eating, toilet use and personal hygiene with 2 plus people assisting with bed mobility, transfers, dressing and personal hygiene. -No pressure ulcers were identified for Resident 3. Record review of a Skin Evaluation sheet dated 12-17-2017 revealed there were not any pressure ulcers identified for Resident 3. Record review of a Braden Scale evaluation sheet dated 9-21-2017 revealed Resident 3 was evaluated as low risk for the development of pressure ulcers. Record review of Resident 3's CCP dated 10-13-2017 revealed Resident 3 was to have Prafo (type of pressure relieving boots) while in bed. Further review of Resident 3's CCP dated 12-17-2017 revealed Resident 3 had the potential for impaired skin integrity and pressure. The goal for Resident 3 was to remain free of sign and symptoms of new skin breakdown. Interventions identified were to assist with repositioning, Prafo boots while in bed, pressure reducing mattress and wheelchair cushion. On 12-21-2017 at 4:12 PM an interview was conducted with Resident 3. During the interview Resident 3 reported having a pressure ulcer to the right heel. Review of Resident 3's medical record revealed there was no evidence the facility staff had identified a pressure ulcer on the resident's right heel. On 12-26-2017 at 5:04 AM an interview was conducted with Resident 3. Resident 3 reported (gender) had a pressure ulcer to the right heel. On 12-26-2017 at 5:20 AM observation of Resident 3's right heel with Registered Nurse (RN) D revealed a had a dark purple looking area to the right heel. Record review of a SPUW sheet dated 12-27-2017 revealed Resident 3 was identified with an unstageable pressure ulcer to the right heel that measured 1.5 cm by 4.0 cm. The wound bed was identified as black/brown eschar. On 12-27-2017 at 7:26 AM an interview was conducted with Registered Nurse (RN) E. During the interview RN [NAME] reported there was no monitoring of the right heel ulcer for Resident 3. C. Record review of Resident 160's MDS dated as completed on 12-20-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 6. According to the MDS Manuel, a score of 0 to 7 indicates severe cognitive impairment. -Required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. -Resident 160 was identified at risk for developing pressure ulcers. -No pressure ulcers were identified for this resident. Record review of a Braden Scale form dated 12-07-2017 revealed the facility assessed Resident 160 as a low risk for the development of pressure ulcers. Observation on 12-27-2017 at 6:30 AM revealed Resident 160 was in bed, in a back laying position. Observation on 12-27-2017 at 7:45 AM revealed Resident 160 was in bed, in a back laying position. Observation on 12-27-2017 at 8:25 AM revealed Resident 160 was in a back laying position. Observation on 12-27-2017 at 1:35 PM with RN [NAME] revealed Resident 160 had several red areas with defined edges. Record review of a SPUW sheet dated 12-27-2017 timed at 7:47 PM revealed the facility staff assessed Resident 160 with 3, stage 1 (Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness) caused from pressure) pressure ulcer. The 3 pressure ulcers were identified as the following: -Site 1, left buttocks, stage, with measurements of 2.0 cm by 0.6 cm. -Site 2, lower left buttocks, stage 1 with measurements of 2.0 cm by 0.6 cm. -Site 3, right buttocks, stage 1 with measurements of 2.0 by 1.0 cm. C. Review of Resident 36's Comprehensive Care Plan (CCP) revealed a problem statement of: Alteration in skin integrity. Resident 36 requires assistance with repositioning. The CCP revealed on12/13/17 Resident 36 was identified as having a pressure ulcer on the coccyx (tailbone). Review of Resident 36's Comprehensive Care Plan for Bed Mobility revealed Resident 36 required extensive assistance of 1 staff to reposition and turn in bed and staff to assist Resident 36 every 2 hours and as needed. 12/27/2017 observations of Resident 36 revealed the resident was in the following positions: -6:30 AM; On back. -7:00 AM; On back -7:50 AM; On back, -8:35 AM; On back, -9:15 AM; On back, -9:40 AM; On back. Observation on 12/27/2017 at 9:40 AM of Resident 36 revealed an area on Resident 36's coccyx bony prominence was open. Interview on 12/27/2017 at 9:40 AM with the Assistant Director of Nursing (ADON) revealed Resident 36 should have been turned at least every 2 hours. Review of a facility form dated 12/18/2017 revealed Resident 36 had a pressure ulcer on the resident's coccyx identified on 10/30/2017 as unstageable which was assessed as healed on 12/18/2017. Review of wound documentation dated 12/23/2017 revealed Resident 36 had no alteration of skin integrity. Review of the facility document dated 9/2017 titled Wound Management revealed the purpose of the policy was to ensure the resident did not develop pressure ulcers unless clinically unavoidable and the facility provided care and services to prevent the development of additional pressure ulcers. Interview on 12/27/2017 at 2:00 PM with LPN-C revealed Resident 36 did have an area on the coccyx that had previously healed and did reopen and is a stage 2 area with a small unstageable area in the center. | 2020-09-01 |
| 2883 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-01-02 | 835 | H | 0 | 1 | 51KH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review, and interview; the facility failed to ensure the administrative team utilized resources in a manner to ensure provision of care and services for residents. Facility census was 66. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance with an extended survey required related to substandard quality of care. Please refer to the Tag citations for specific detailed findings. -F 550; The facility failed to ensure water temperature for bathing was at a comfortable level for resident 56 one of one resident, the facility census was 66. -F580; The facility failed to notify Resident 39's representative of fall for one of three residents. Facility census was 66 -F609; The facility failed to submit an investigation to the state agency as required, within 5 working days. Resident 48, 3, 15. -F 655; The facility failed to include information related to antipsychotic medication in initial plan of care for use for Resident 52, 160. -F 656; The facility failed to develop activity care plans for Residents 49, 36. -F 657; The facility failed to revise plan of care for assisting resident with nutritional intake for Resident 36. -F675; The facility failed to implement a bowel care regimen to prevent impaction for Resident 36. -F 676; The facility failed to ensure dentures were available for use and failed to ensure Resident 51 was assisted with dressing. -F677; The facility failed to provide assistance with morning cares and meals for Resident 39 and provide standard of care for transfer with use of gait belt for Residents 12, 21. -F 679; The facility failed to provide activities to meet resident interest for Resident 36 and 49. -F680; The facility failed to have a activity director that meets the required qualifications. This has the potential to affect all residents in the facility. The facility Census was 66. -F684; The facility failed to ensure the coordination of care for Hospice Resident Resident 36. -F686; The facility failed to identify pressure ulcers, and failed to implement interventions to prevent development/redevelopment of pressure ulcers for Residents 160, 36, 51, and 3. -F688; The facility failed to implement a specific restorative program for Resident 3. - F689; The facility failed to implement interventions to prevent falls for Resident 38, failed to provide supervision during smoking for Resident 3, and failed to utilize gait belt in a manner to prevent potential accidents for Resident 12, 21. -F690; The facility failed to ensure that residents were free of indwelling catheters for Resident 23 and 49. -F692; The facility failed to assist Resident 36 with nutritional intake. -F712; The facility failed to ensure Residents receive primary physician visits in a routine manner for Residents 47,18,39,2,12,21. -F725; The facility failed to provide sufficient staffing levels to provide Activity of Daily Living services, nutritional intake prevention of pressure ulcer development, bowel elimination and accident prevention, with the potential to affect all residents residing in the facility. The facility census was 66. -F726; The facility failed to provide training for gait belt use and specialized equipment to maintain Range of Motion. -F758; The facility failed to monitor behaviors for use of [MEDICAL CONDITION] medication use for Resident 52 and 160 -F759; The facility failed to maintain a medication error rate less than 5 % the medication error rate was 7.69. -F760; The facility failed to ensure Resident number 23 was free of a significant medication error. -F801; The facility failed to have a qualified dietary manager, this had the potential to affect all resident. -F804; The facility failed to ensure food were provided in a manner that was maintained at a temperature that was appealing to residents. This had the potential to affect all residents the Facility census was 66 -F812; The facility failed to ensure hair restraints covered all hair during food service, and failed to utilize hand washing and gloving techniques to prevent food contamination during food service. -E0015; The facility failed to ensure sufficient supply of nutritional provisions food supplies were maintained for residents, and staff in case of emergency. -F835; The facility failed to ensure administer utilize resources in a manner to ensure provision of care, provision of services for residents. -F867; The facility failed to ensure an effective quality improvement plan as evidenced by new and repeat deficient practice Interview on 1/2/18 at 9:00 AM with the Administrator revealed the management was in the process of building its team to improve quality care to the residents of the facility. The administrator and the facility consultant confirmed that the facility did need to improve areas of deficient practice and competencies of staff. | 2020-09-01 |
| 2884 | KEYSTONE RIDGE POST ACUTE NURSING AND REHAB | 285238 | 7501 KEYSTONE DRIVE | OMAHA | NE | 68134 | 2018-01-02 | 867 | H | 0 | 1 | 51KH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observations, record reviews and interviews conducted during the standard annual and extended survey process related to substandard equability of care. The facility failed to ensure an effective quality improvement plan as evidenced by new and repeat deficient practice. Facility census was 66. Findings are: Interview on 12/27/17 at 2:03 PM with the facility Director of Nursing (DON) and Nurse Consultant N revealed that the Quality Improvement Committee oversees the quality of Resident care. Nurse Consultant N confirmed the facility had not identified the current deficient practices and there were no PIP/QUAPI programs in place at this time for the following Tag citations The facility was found to be deficient in multiple areas of regulatory compliance requiring an extended survey process for substandard quality of care. Please refer to the Tag citations for specific detailed findings: -F 550; The facility failed to ensure water temperature for bathing was at a comfortable level for resident 56 one of one resident, the facility census was 66. -F580; The facility failed to notify Resident 39's representative of fall for one of three residents. Facility census was 66 -F609; The facility failed to submit an investigation to the state agency as required, within 5 working days. Resident 48, 3, 15. -F 655; The facility failed to include information related to antipsychotic medication in initial plan of care for use for Resident 52, 160. -F 656; The facility failed to develop activity care plans for Residents 49, 36. -F 657; The facility failed to revise plan of care for assisting resident with nutritional intake for Resident 36. -F675; The facility failed to implement a bowel care regimen to prevent impaction for Resident 36. -F 676; The facility failed to ensure dentures were available for use and failed to ensure Resident 51 was assisted with dressing. -F677; The facility failed to provide assistance with morning cares and meals for Resident 39 and provide standard of care for transfer with use of gait belt for Residents 12, 21. -F 679; The facility failed to provide activities to meet resident interest for Resident 36 and 49. -F680; The facility failed to have a activity director that meets the required qualifications. This has the potential to affect all residents in the facility. The facility Census was 66. -F684; The facility failed to ensure the coordination of care for Hospice Resident Resident 36. -F686; The facility failed to identify pressure ulcers, and failed to implement interventions to prevent development/redevelopment of pressure ulcers for Residents 160, 36, 51, and 3. -F688; The facility failed to implement a specific restorative program for Resident 3. - F689; The facility failed to implement interventions to prevent falls for Resident 38, failed to provide supervision during smoking for Resident 3, and failed to utilize gait belt in a manner to prevent potential accidents for Resident 12, 21. -F690; The facility failed to ensure that residents were free of indwelling catheters for Resident 23 and 49. -F692; The facility failed to assist Resident 36 with nutritional intake. -F712; The facility failed to ensure Residents receive primary physician visits in a routine manner for Residents 47,18,39,2,12,21. -F725; The facility failed to provide sufficient staffing levels to provide Activity of Daily Living services, nutritional intake prevention of pressure ulcer development, bowel elimination and accident prevention, with the potential to affect all residents residing in the facility. The facility census was 66. -F726; The facility failed to provide training for gait belt use and specialized equipment to maintain Range of Motion. -F758; The facility failed to monitor behaviors for use of [MEDICAL CONDITION] medication use for Resident 52 and 160 -F759; The facility failed to maintain a medication error rate less than 5 % the medication error rate was 7.69. -F760; The facility failed to ensure Resident number 23 was free of a significant medication error. -F801; The facility failed to have a qualified dietary manager, this had the potential to affect all resident. -F804; The facility failed to ensure food were provided in a manner that was maintained at a temperature that was appealing to residents. This had the potential to affect all residents the Facility census was 66 -F812; The facility failed to ensure hair restraints covered all hair during food service, and failed to utilize hand washing and gloving techniques to prevent food contamination during food service. -E0015; The facility failed to ensure sufficient supply of nutritional provisions food supplies were maintained for residents, and staff in case of emergency. -F835; The facility failed to ensure administer utilize resources in a manner to ensure provision of care, provision of services for residents. -F867; The facility failed to ensure an effective quality improvement plan as evidenced by new and repeat deficient practice Interview on 1/27/17 at 1:00 PM with NA(Nursing Assistant) J, revealed that NA J , worked mostly day shift, and was not able to identify any of the members of the Q A &A committee, or what current projects the committee were working on. Interview on 1/27/17 at 2: 00 PM with NA S revealed that NA S, worked mostly the afternoon shift, and was not able to identify any of the members of the Q A &A committee, or what current projects the committee were working on. Repeat tags included: (Tag numbers have changes, new and old listed) F157 on 09/06 16 survey andF580 for current survey. F225 on 9/6/16, 9/2015 and F 609 for current survey. F248 on 9/6/16 and F679 for current survey. F248 on 9/6/16 and F676 for current survey. F325 on 9/6/16 and F 692 for current survey. F332 on 9/6/16 and F759 for current survey. F371 on 9/6/16 and F812 for current survey. F520 on 9/6/16 and F867 for current survey. | 2020-09-01 |
| 2944 | RIDGECREST REHABILITATION CENTER | 285239 | 3110 SCOTT CIRCLE | OMAHA | NE | 68112 | 2018-01-23 | 692 | H | 1 | 0 | L1D311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility staff failed to identify significant weight loss and failed to implement interventions to prevent weight loss for 4 of 4 sampled residents (Resident 20, 23, 24, and 25). The facility staff identified a census of 60. Findings are: [NAME] Record review of a Face Sheet dated 8-18-2017 revealed Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 20's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed as completed on 12-26-17 revealed the facility staff assessed the following about the resident: -Totally depended for bed mobility, transfers, dressing, eating, dressing, toilet use and personal hygiene. Record review of a weight record sheet (WRS) provided by the facility revealed Resident 20's weight on 9-13-17 was 268 pounds. Further review of the WRS revealed Resident 20's weight on 11-8-17 was 233.4 pounds, a loss of 34.6 pound weight loss or 11.39% indicating a significant weight loss. Record review of a Progress Note (PN) dated 12-9-17 (a 31 day span from the significant weight loss identified on 11-8-17) revealed the facility Registered Dietician (RD) identified Resident 20 had lost weight, According to the RD PN dated 12-9-17, Resident 20 had not been hungry and Resident 20's weight loss was greater than 1 pound a week .which indicates a caloric deficit resulting in loss. Further review of Resident 20's RD, PN dated 12-9-17 revealed there was no evaluation of Resident 20's nutritional requirements, no evaluation of Resident 20's medical condition related to the weight loss or what interventions were to be implemented to stabilize Resident 20's weight. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 5-9-16 revealed Resident 20 had impaired nutritional status. According to Resident 20's CCP dated 5-9-17 with an updated intervention dated 7-7-2016 revealed Resident 20 was to have large portions of foods at meal times. Further review of Resident 20's CCP date 5-16-17 revealed there was not an indication any weight loss was planned for Resident 20. Record review of an undated dietary food tray slip revealed Resident 20 was to receive large portions. Observation on 1-9-18 at 8:07 AM revealed Resident 20 was served for breakfast, 2 pancakes, 2 link sausage, small bowel of cut up fruit and several drinks. On 1-9-2018 at 8:10 AM an interview was conducted with the Dietary Services Manager (DSM). During the interview the DSM confirmed Resident 20 was to receive large portions at meals and further confirmed Resident 20 was served a regular sized portion for breakfast on 1-9-18 at 8:07 AM. On 1-9-2018 at 4:45 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 20 had a significant weight loss and did not have interventions to stabilize Resident 20's weight. B. Record review of Resident 25's CCP dated 11-9-2013 revealed Resident 25 had the potential for a nutritional deficit. The goal identified for Resident 25 was to maintain weight. Interventions identified on the CCP included monitor weights, a lip plate and covers for drinks. Further review of Resident 25's CCP revealed on 7-24-16 a new intervention was identified to give Resident 25 finger foods. Record review of Resident 25's Dietary Card (DC) revealed Resident 25 was on a regular diet that was mechanically altered. There was no indication on Resident 25's DC that Resident 25 was to be offered or receive finger foods. Record review of Resident 25's WRS dated 10-25-17 revealed Resident 25's weight was 170 pounds. Review of Resident 20's WRS dated 12-27-17 revealed a weight of 158 pounds, a loss of 12 pounds or 7.05 percent. Record review of the WRS dated 1-8-18 revealed Resident 25's weight was 149.8, a loss of 20.2 pounds or 11.88% compared to the weight on 10-25-2017. Review of Resident 25's record revealed there was no evidence Resident 25's weight loss on 12-27-17 and again on 1-8-18 had been evaluated or any additional interventions were implemented to stabilize Resident 25's weight. Observation on 1-9-18 at 12:40 PM revealed Resident 25 was served chicken cut up, long noodles, vegetables served on a lip plate, a slice of chocolate cake and several types of drinks. The lip part of the plate had been positioned away from Resident 25. Resident 25 was not able to scoop food up against the raised part of the plate to get food resulting in food being dropped onto Resident 25 or the floor. Further observations revealed Resident 25 was in a wheelchair and positioned as if Resident 25 was sliding out of the wheelchair resulting in Resident 25 struggling to reach the lunch meal, in addition, Resident 25 did not have finger foods provided. On 1-10-18 at 9:00 AM an interview was conducted with the facility Nurse Consultant (NC). During the interview the facility NC confirmed Resident 25 had weight loss with resulting significant weight loss and did not have an evaluation completed or additional interventions implemented to stabilize Resident 25's weight. The NC further confirmed Resident 25 had not received finger foods at lunch on 1-9-18 at 12:40 PM. On 1-10-18 at 11:40 AM an interview was conducted with the facility RD. During the interview, the facility RD reported while the weight identified on 12-27-2017 .is of significant concern as (Resident 25) was trending down wards. The RD reported during the interview Resident 25 should have had an assessment completed at that time and did not. C. Record review of Resident 23's CCP dated 7-22-17 revealed Resident 23 was at risk for nutritional problems. The goal for Resident 23 was to maintain weight. Interventions identified on the CCP included large supper, magic cup and to offer snacks. Record review of Resident 23's PN dated 12-10-17 revealed the facility RD had identified interventions which included magic cup, superceral, fortified potatoes and 2 eggs at breakfast. Record review of an undated DC for Resident 25 revealed Resident 25's staff were to give Resident 23 a large meal in the evening, superceral and 2 eggs for breakfast. In addition, the DC identified Resident 23 was allergic to chocolate and tomatoes. Observation on 1-8-2018 at 6:25 PM revealed Resident 23 was served a BBQ sandwich, baked beans, cooked cabbage, desert and drinks. On 1-8-18 at 6:30 PM the NC replaced Resident 23's meal with 1 ground hamburger, soup and a new desert. Observation on 1-9-18 at 8:20 AM revealed Resident 23 was served cold cereal (cheerio type), 2 pancakes, 2 sausage with gravy and several drinks. On 1-9-18 at 8:35 AM an interview was conducted with Nursing Assistant (NA) [NAME] During the interview NA A confirmed Resident 23 did not have eggs or supercereal. On 1-10-18 at 2:40 PM an interview was conducted with the DSM. During the interview, the DSM reported a large portion would be 1 and 1/2 portions of a regular sized portion. The DSM confirmed 1 hamburger was not a large portion. D Record review of Resident 24's CCP dated 4-28-17 revealed Resident 24 was at nutritional risk. The goal identified for Resident 24 was to maintain weight. Interventions included double portions at all meals. Record review of Resident 24's DC revealed Resident 24 was to have double portions at meals. Observation on 1-8-18 at 6:27 PM revealed Resident 24 was served 1 BBQ sandwich, baked beans, cook cabbage, desert and fluids. Observation on 1-9-18 at 8:20 AM revealed Resident 24 was served 2 pancakes, 2 sausage, cereal and fluids. On 1-9-18 at 8:36 AM an interview was conducted with NA [NAME] During the interview NA A confirmed Resident 24 did not receive double portions for breakfast. Record review of the facility Policy and Procedure for Weight Assessment and intervention dated 4-2012 reveled the following information: -Analysis: -Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding: -a. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake. -c. The relationship between current medical condition or clinical situation and recent fluctuations in weight. | 2020-09-01 |
| 2950 | RIDGECREST REHABILITATION CENTER | 285239 | 3110 SCOTT CIRCLE | OMAHA | NE | 68112 | 2018-01-23 | 835 | H | 1 | 0 | L1D311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review and interview; the facility administrative staff failed to ensure the facility resources were effectively utilized to maintain or improve the physical, psychosocial and mental well-being of the facility residents. This deficient practice had the potential to affect all residents in the building. The facility staff identified a census of 60. Findings are: Review of the following information revealed the following: -F692. The facility staff failed to identify and implement interventions to prevent weight loss. This practice affected 4 of 4 residents that were reviewed for the survey. The facility staff had identified Residents 22 and 24 had weight loss and identified interventions to prevent further weight loss. Observations during the survey revealed those interventions were not carried out for Resident 22 and 24. Resident 20's care plan indicated Resident 20 was to receive large portions and Resident 20 did not during the survey, in addition, Resident 20 had significant weight loss and the loss was not evaluated. Resident 25 had weight loss without interventions and lost a significant amount of weight. -F686. The facility staff failed to identify, evaluate casual factors and implement interventions for the development of a pressure ulcer for 1 (Resident 20) of 1 residents. Resident 20 had a history of [REDACTED]. Observations during the survey revealed Resident 20 developed a pressure ulcer. The facility staff had not identified the pressure ulcer, had not evaluated casual factors or implemented interventions. -F 744. The facility failed to have specific activities for residents with Dementia who reside in a Memory Support Unit, and failed to have specific guidelines on how activity services would be provided and what staff members would be responsible for the activities on the MSU. Observations during the survey revealed individualized activities that were resident centered was not provided to 4 (Resident 21, 22, 23 and 24) of 4 residents reviewed. Observations during the survey revealed residents were not provided activities, facility staff did not engage residents and failed to have qualified staff in the MSU. Review of the Facility Assessment revealed there was criteria for admission and discharge from the Memory Support Unit, however, there was not information of how resident centered services would be provided to those residents with the [DIAGNOSES REDACTED]. -F606. The facility failed to ensure reference checks were completed on 4 of 6 employee files reviewed. The facility had a Policy and Procedure for competing background checks. During the survey an interview with the facility Human resources personal was conducted that revealed reference checks should have been completed. -F880. The facility failed to ensure gloves were worn when removing soiled meal items from the table for Resident 22. Review of Resident 22's CCP revealed management had identified Resident 22 liked to clear the table after meals and that Resident 22 was to wear gloves and wash hands. -F730. Ongoing Nursing Assistant education. Review of 34 nurse aide employee files revealed 24 nurse aide employees did not have the required 12 hours per year of continuing training. -F550. During observation 4 (Resident 20, 21, 22 and 25) dignity was not maintained. On 1-23-2018 at 10:35 AM an interview was conducted with the facility Administrator. During the interview, the administrator confirmed cited deficiencies were not identified as a problem in the facility. | 2020-09-01 |
| 3940 | VALLEY VIEW SENIOR VILLAGE | 285294 | 220 SOUTH 26TH STREET | ORD | NE | 68862 | 2018-03-21 | 686 | H | 1 | 1 | OLWQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, interview, and record review; the facility staff failed to implement interventions to promote the healing of pressure ulcers for 4 of 4 sampled residents including completing assessments, using clean technique for dressing changes, repositioning, and administering nutritional supplements as ordered. This affected Residents 3, 29, 24 and 34. The facility identified a census of 34 at the time of survey. Findings are: [NAME] Review of Resident 3's quarterly MDS (minimum data set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/7/2018 revealed an admission date of [DATE]. Resident 3 had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer that was not present at the time of admission. Review of Resident 3's admission MDS dated [DATE] revealed Resident 3 was admitted to the facility on [DATE] and had one Stage 2 pressure ulcer that was not present upon admission/entry or reentry. The date of the oldest Stage 2 pressure ulcer was 8/4/2016. Review of Resident 3's Physician Order Report for 2/6/2018-3/6/2018 revealed a [DEVICE] was being used to treat a sacral (tailbone) wound. Observation of Resident 3 on 3/14/18 at 7:31 AM, 9:28 AM, 1:36 PM, 3:17 PM and 4:20 PM revealed Resident 3 was sitting in the wheelchair. Interview with Resident 3 on 3/14/2018 at 3:17 PM revealed Resident 3 had been up in the chair since 7:30 AM and had not laid down in bed. Review of Resident 3's Resident Progress Notes for 3/14/2018 revealed no documentation Resident 3 had been offered the opportunity to change positions or educated about the risks of refusing to change positions. Observation of Resident 3 on 3/15/18 at 7:09 AM, 10:52 AM, 1:05 PM, 1:49 PM, and 3:20 PM revealed Resident 3 was sitting in the wheelchair. Review of Resident 3's Resident Progress Notes for 3/15/2018 revealed no documentation Resident 3 had been offered the opportunity to change positions or educated about the risks of refusing to change positions. Review of the undated NA (Nurse Aide) Pocket Guide revealed the following instructions for Resident 3: Lay down BID (twice) during the day. Interview with NA-U on 3/19/18 at 1:48 PM revealed the direct care staff carried pocket care plans with care instructions for the residents. Residents with pressure ulcers or who were at risk for skin breakdown were to be repositioned every 2 hours. Review of Resident 3's Medications Flow sheet for January, February, and (MONTH) (YEAR) revealed documentation that Resident 3 had wound area (pressure ulcer) pain and wound vac change pain ranging in intensity of 10/10 (worst pain you can imagine) 8 out of 10 and severe to very severe pain due to the pressure ulcer. Review of Resident 3's Wound Clinic note dated 2/16/18 revealed Resident 3's coccygeal (tailbone) ulcer went deep into the subcutaneous fat and the dressing changes were causing more discomfort. Review of Resident 3's Physician Order Sheet dated 3/7/2018 revealed the following: wound care nurse wrote a note to provider: routine wound vac changes are becoming extremely painful when wound is cleansed. Observation of RN-C (Registered Nurse) on 3/19/2018 at 11:22 AM doing dressing change for Resident 3's pressure ulcer to coccyx/sacrum (tailbone area) being treated with a [DEVICE] revealed the following: RN-C did 1 second hand scrub with hand sanitizer and applied gloves. The hand sanitizer did not cover all surfaces of RN-C's hands and RN-C's hands did not appear wet. RN-C then closed Resident 3's room curtains touching the rod with the gloved hands. RN-C then lowered the head of the bed touching the bed control with the same gloved hands. RN-C then picked the trash can up by the rim and moved it to where RN-C was working. RN-C then got more gloves out of the box in the bathroom and put them in the dressing bin. RN-C did not change gloves after touching the trash can before touching the gloves they put in with the other dressing supplies. RN-C then got supplies including [MEDICATION NAME] (pain medication) and dressings, touching them with the same gloved hands. RN-C then touched the bed control to raise the bed. RN-C then took the reservoir out of the [DEVICE] pump and removed the tubing. RN-C then removed the soiled dressings from Resident 3's pressure with the same gloves touching the wound. Resident 3 hollered out twice while RN-C was pulling the old dressing off. RN-C then rummaged around the bin of supplies with the soiled gloves and retrieved more supplies. RN-C then touched the wound edge and the dressing sponge that was in the wound with the same gloves. RN-C then discarded the sponge, put new gloves on, and squirted the [MEDICATION NAME] in the wound without performing hand hygiene. RN-C then put the new canister in the [DEVICE] pump that they had already touched with the dirty gloves. RN-C then opened the clean dressing package and touched the sponge. RN-C then took a pair of scissors out of their pocket and cut the sponge. RN-C did not clean the scissors or change gloves. RN-C then cut the transparent dressings with the scissors that were in their pocket. RN-C then washed the wound with soap and water on a washcloth and used a plain wet washcloth to rinse. RN-C then sprayed Resident 3's wound with wound cleanser and rinsed with saline, touching the canister of wound cleanser before placing it back in the bin with the remainder of the dressing supplies. The pressure ulcer to Resident 3' tailbone was deep. RN-C then changed gloves without performing hand hygiene. RN-C then got a dressing out of the tub that they had been rummaging in. RN-C then cut the sponge with the scissors they had taken out of their pocket and used without cleaning and placed it in the wound. RN-C then placed the cut transparent dressings around and over the wound and the sponge. RN-C then attached the hose to the canister after applying the adhesive dressings. RN-C then changed gloves without performing hand hygiene. RN-C then tore a hole in the dressing that was in the wound with a gloved finger. RN-C then turned the [DEVICE] pump on that was sitting on the floor. Resident 3 flinched twice after RN-C turned the [DEVICE] pump on and the suction started. RN-C then put the scissors in their pocket without cleaning them. Review of Resident 3's Wound Evaluation flow sheet dated 2/28/2018 revealed documentation that Resident 3's pressure had potential signs of infection including green slime exudate (drainage). Review of the facility policy hand hygiene revised 3/18 revealed the following: Purpose: to prevent the spread of infection through adherence of good hygiene practices. Policy: all personnel shall wash their hands with soap and water or use hand sanitizer to prevent the spread of infections. Wash hands with antimicrobial soap and water when hands are visibly soiled. Use an alcohol-base waterless antiseptic for routinely decontaminating hands when hands are not visibly soiled . When to practice hand hygiene: between resident contacts; after removing gloves; anytime hands are soiled; when going from a dirty to clean function on the same resident. Hand hygiene methods: antiseptic hand rub: apply adequate amount of alcohol-based waterless solution to palm of one hands. Rub hands together, covering all surfaces of hands and fingers, until hands are dry. Antiseptic hand wash: Moisten hands with water then apply enough soap to produce a lather. Rub hands vigorously for at least 10-15 seconds. Review of Resident 3's Wound Evaluation Flow Sheet received 3/14/2018 revealed no documentation Resident 3's pressure ulcer had been assessment since 3/5/2018. Interview with LPN-G (Licensed Practical Nurse) on 3/19/18 at 1:07 PM confirmed there was no documentation Resident 3's pressure ulcer had been assessed since 3/5/2018 (9 days). Review of Resident 3's progress notes for 3/5/2018-3/15/2018 revealed no documentation of an assessment of Resident 3's pressure ulcer. Interview with the DON (Director of Nursing) on 3/19/18 at 01:08 PM it was their expectation that wounds were assessed and documented on weekly. Review of Resident 3's Physician's Orders revealed the following: Peanut butter and jelly sandwich once a day at 3:00 PM with an order date of 10/26/2017, Ensure (dietary supplement) at each meal with an order date of 10/11/2017, and ProStat (protein supplement) 1 ounce twice a day mixed in diet soda with an order date of 3/16/2018. Review of Resident 3's Resident Supplement Chart for 2/17/18 to 3/18/18 revealed incomplete documentation of the supplement intake: PB & J (Peanut Butter and Jelly) sandwich only charted 3 days out of the month. Breakfast supplement (Ensure) was not charted on 2/17, 2/25, 3/9, 3/10, 3/11, and 3/15. Lunch supplement (Ensure) was not charted 2/17, 2/18, 2/24, 2/25, 3/4, 3/9, 3/10, 3/11, 3/15, 3/17, 3/18. Dinner supplement (Ensure) not charted on 2/19, 2/22, 2/24, 3/1, 3/2, 3/7, 3/10,3/11, 3/16, 3/17, and 3/18. Interview with the RD-O (Registered Dietitian) on 3/19/18 at 2:59 PM confirmed Resident 3 had a pressure ulcer that was not healing. RD-O confirmed the dietary supplements were not documented and should have been. RD-O revealed Resident 3 had been receiving Ensure TID (three times a day) and it was changed on 3/16/2018 to ProStat BID that is charted on the MAR (Medication Administration Record). Review of Resident 3's MAR for (MONTH) (YEAR) revealed the ProStat was started on 3/16/2018. The ProStat was documented as administered on 3/18 AM and 1700 (5 PM). It was not documented as administered any other time. B. Interview with Resident 29 on 3/13/18 at 3:22 PM revealed they were being treated for [REDACTED]. Resident 29 revealed they were supposed to go to the hospital last week and get the pressure ulcer surgically closed but it got infected so that got put on hold. Review of Resident 29's admission MDS dated [DATE] revealed an unhealed Stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) pressure ulcer 2.0 cm long; 2.0 cm wide and 2.2 cm deep. Review of Resident 29's annual MDS dated [DATE] revealed an unhealed Stage 3 pressure ulcer that was 2.7 cm log, 2.2 cm wide and 3.2 cm deep which indicated the pressure ulcer had gotten larger. Interview with LPN-G on 3/19/18 at 1:34 PM revealed Resident 29 had a Stage 4 pressure ulcer that was marked a Stage 3 pressure ulcer on the annual MDS dated [DATE]. LPN-G confirmed the MDS should have reflected Resident 29 had a Stage 4 pressure ulcer. Review of Resident 29's Wound Evaluation Flow Sheet dated 8/29/17 revealed the pressure ulcer to the left ischium (hip/buttock) measured 1.4 cm x 1.4 cm x 1.8 cm. The pressure ulcer was a Stage 3 at that time. Review of Resident 29's Wound Evaluation Flow Sheet dated 12/5/2017 revealed the pressure ulcer to the left ischium measured 2 cm x 2 cm x 2 cm. Review of Resident 29's Wound Evaluation Flow Sheet dated 2/12/2018 revealed Resident 29 had a Stage 4 pressure ulcer to the left ischium (hip/buttock) that measured 2.7 cm (centimeters) by 2.2 cm and was 3.2 cm deep. The documentation on the Wound Evaluation Flow Sheet indicated the pressure ulcer had gotten larger and deeper. Observation of pressure ulcer care for Resident 29 on 3/13/2018 at 11:33 AM revealed the following: MA-B moved Resident 29's personal belongings from the over the bed table. RN-C then placed the supplies for the dressing change on the table which included scissors, dressings, and tubing. RN-C did not clean the table or apply a barrier before putting the dressing supplies on the table. RN-C donned gloves then turned off the [DEVICE] pump that was sitting on the floor. RN-C clamped the tubing from the [DEVICE] pump to the dressing on Resident 29's left hip then removed the soiled dressing. RN-C then removed the gloves, applied hand sanitizer and rubbed hands for 2 seconds then donned another pair of gloves. RN-C then washed the wound with a washcloth they had retrieved from the bathroom. The pressure ulcer was deep to the left hip. RN-C then opened the dressing package and cut the foam and clear adhesive dressings with the scissors that had been lying on the table. RN-C then laid the cut dressings onto the outside of the dressing package and the table. RN-C then placed one of the cut foam dressings into the pressure ulcer. RN-C then applied another piece of foam dressing that had been lying on the table onto the wound. RN-C then applied the clear adhesive dressings over the foam dressings then used the scissors that had been lying on the table to cut a hole into the clear adhesive dressings. RN-C then removed the gloves, washed hands for 3 seconds then applied another pair of gloves. RN-C then used a pre-moistened wipe to wash Resident 29's back side. RN-C applied a clean brief then assisted with repositioning Resident 29 to their back by touching the turn sheet then proceeded to wipe Resident 29's front side of the perineum (bottom). RN-C did not change gloves after cleaning Resident 29's back side before touching the clean brief, turning sheet, and cleaning Resident 29's front side. RN-C then removed the gloves, donned another pair of gloves then finished dressing Resident 29's bottom. RN-C then removed the gloves then touched the bed rail and gave Resident 29 the call light cord, which Resident 29 then proceeded to touch. RN-C then picked the scissors up off the table that they had used during the dressing change and put them in their pocket. RN-C did not wipe the table off or the scissors and did not perform hand hygiene after removing gloves. Review of Resident 29's Progress Notes for 12/15/2017 to 3/15/2018 revealed Resident 29 was treated for [REDACTED]. Review of Resident 29's Wound Culture Reports dated 2/27/18, 1/9/18, 12/27/17, and 12/22/17 revealed the pressure ulcer to Resident 29's left ischium showed infection. Interview with LPN-G on 3/15/18 at 11:14 AM confirmed that Resident 29's pressure ulcer to the left ischium was infected. Review of Resident 29's [DIAGNOSES REDACTED]. Review of Resident 29's Wound Evaluation Flow sheet revealed documentation the last assessment of Resident 3's pressure ulcer was 2/27/2018. The pressure ulcer was 1.8 cm long, 3.5 cm wide and 3 cm deep. Interview with LPN-G on 3/19/18 at 1:07 PM confirmed there was no documentation Resident 29's pressure ulcer had been assessed since 2/27/2018 (14 days). Review of Resident 29's Resident Progress Notes revealed no documentation of an assessment of Resident 29's pressure ulcer. Interview with the DON (Director of Nursing) on 3/19/18 at 01:08 PM it was their expectation that wounds were assessed and documented weekly. Review of Resident 29's Physician Order Report for 1/26/2018-2/26/2018 revealed an order for [REDACTED]. Review of Resident 29's Resident Supplement Chart documentation for 2/17/2018 to 3/18/2018 for cottage cheese per RD-O revealed there was incomplete documentation on 2/17, 3/6, 3/8, 3/11, 3/12, 3/13, and 3/15. Interview with the DON on 3/19/18 at 04:08 PM revealed that standard protocol was that hands were cleaned after gloves were used. After touching a dirty area with the hands or gloved hands staff were expected to clean hands and put on clean gloves. The DON confirmed the dressing changes were to be done as a clean procedure; by clean you would go from dirty to clean. Staff were expected to use a clean surface, wash the scissors, get their stuff together first and then put their gloves on and not touch everything. Review of the facility policy Pressure Ulcer Care revised 11/29/07 revealed the following: Residents having pressure ulcers receive necessary treatment and serves to promote healing, prevent infection, and prevent new pressure ulcers from developing. The resident's plan of care will be reviewed and revised at least quarterly and more often if a decline in function is apparent. Width and depth for Stage 3 and Stage 4 will be measured weekly. The physician will be notified of any pressure ulcers and a wound consult will be ordered. The physician will be notified weekly of the healing status of the pressure ulcer. Standard precautions will be utilized during wound care. C. Interview on 3-13-18 at 11:08 AM with Resident 24 revealed the resident had skin sores on the right calf and right heel and all had a dressing on them. Record review of the Pressure Ulcer Weekly Physician Notification form for Resident 24 revealed a unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) pressure ulcer to the right heel was identified 05/11/17. The initial measurement was documented as 1 cm (centimeter) x 0.8 cm x no depth. Review of the Wound Evaluation Flow Sheet dated 2-15-18 revealed the right heel pressure ulcer had increased in size and measured at 2 cm x 1.8 cm x 0.3 cm with dark eschar with severe pain documented. No further measurements were found of the pressure ulcer on the right heel. Observation of LPN-G on 3-15-18 at 1:30 PM revealed LPN-G performed the dressing changes to Resident 24's pressure ulcer wounds to the right calf and right heel. When LPN-G went to perform the dressing to the right heel, LPN-G revealed the Theraskin was not on the right heel and should have been. Interview on 3-19-18 at 10:01 AM with the LPN-G (Licensed Practical Nurse), who was also the wound nurse) revealed the resident had seen a Physician for the wounds on 2-22-18 and the initial Theraskin (a skin graft treatment to help heal wounds) had been applied to the pressure wounds. LPN-G revealed once the Theraskin had been applied, the dressing was only to be removed one time a week. On (MONTH) 1, LPN-G revealed LPN-G assessed the wound but did not document an assessment of the wounds. On (MONTH) 8 Resident 24 went to the Physician's office and LPN-G confirmed there were no papers received from the Physician's clinic to reveal the assessment of the wound. On (MONTH) 15, LPN-G performed the dressing changed and there was no assessment documented. The only documentation was in the PN (Progress Notes) which Area to R (right) heel appears to not have Thera Skin on. Clarification sent to Physician. Record review of Resident 24's current Careplan revealed the resident was to be in the recliner after breakfast and in bed after lunch for interventions to address the pressure ulcers. Record review of the Turn Schedule dated 3-15-18 to 3-16-18 which was hung on the resident's closet door revealed the resident was not turned for 3 hours from 0600 till 0900 on 3-15-18. Interview on 3-15-18 at 09:12 AM with NA-E (Nurse Aide) revealed the resident was extensive assist with cares. Resident 24 can tell the staff what the resident needs were. NA-E revealed the resident was turned every 2 hours during the night and after breakfast and lunch was laid down. Observation on 3-13-18 at 11:08 AM revealed the Resident sitting in the wheelchair. Observation on 3-14-18 at 09:30 AM revealed Resident 24 sitting in the wheelchair at an activity. Observation on 3-14-18 at 11:30 AM revealed Resident 24 sitting in the resident's room in the wheelchair. Observation on 3-14-18 at 1:37 PM revealed Resident 24 sitting in the resident's room in the wheelchair. Observation on 3-14-18 at 3:10 PM revealed Resident 24 sitting in the wheelchair in the resident's room. Observation on 3-14-18 at 4:07 PM revealed Resident 24 sitting in the wheelchair in the resident's room. Observation on 3-15-18 at 9:10 AM revealed Resident 24 was assisted out of bed by the staff for breakfast. Observation on 3-15-18 at 11:41 AM revealed Resident 24 was sitting in the wheelchair in the resident's room Observation on 3-19-18 at 11:17 AM revealed Resident 24 sitting in the wheelchair with the resident's head slumped forward asleep. Observation on 3-19-18 at 11:54 AM revealed Resident 24 sitting in the wheelchair. Observation on 3-19-18 at 2:30 PM revealed the resident was lying down in bed on the left side. However both of the residents legs, where the pressure ulcers were, were lying flat on the mattress and no offloading of pressure was to the wounds. Interview on 3-15-18 at 1:25 PM with Resident 24 revealed the resident lays down when the staff ask the resident but they had not been asking the resident. D. Review of Progress Notes in Matrix dated 2/22/18 upon admission revealed no measurements or staging of pressure ulcers. Review of Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning purposes) dated 2/28/18 for Resident 34 revealed a BIMS (brief interview for mental status, test how you are functioning cognitively at the moment) score of 5, this indicated severe cognitive impairment. Review of undated [DIAGNOSES REDACTED]. that can cause urination difficulty), Suprapubic indwelling catheter (a surgically created connection between the urinary bladder and the skin around the umbilical region used to drain urine from the bladder), osteo[DIAGNOSES REDACTED] (bone infection), kidney disease, decubitus (pressure) ulcers (resulting from prolonged pressure on the skin), bursitis of the right hip (hip pain), [MEDICAL CONDITION] (decreased blood flow to extremities). Interview on 03/15/18 at 02:50 PM with Resident # 34 revealed, when asked, Do you lay down during the day? Resident 34 replied, Sometimes. They haven't been by to ask me to lay down yet. Interview on 03/15/18 at 03:08 PM with MA-D (Medication Aide-D) revealed staff assist the resident by helping put pants on. Resident 34 was able to do own shirt and other small tasks such as brushing teeth and combing hair. When asked about transfers MA-D stated, Resident can stand and walk pretty good. Doesn't usually lay down after meals and gets one bath a week per resident's request. MA -D confirmed resident has a sore on the the left heel and left hip. During an observation on 03/19/18 at 02:34 PM of dressing change to Resident 34's pressure ulcer on left heel and behind left ankle, RN-C did not remove soiled gloves prior to touching clean items in a plastic bag. Continued observation of the dressing change revealed RN-C placed the plastic bag of items on the floor with no barrier between the floor and the plastic bag. Bloody drainage ran onto items placed on a wash cloth on the floor for the dressing change. RN-C sat on the bare floor to complete the dressing change. RN-C did not change gloves from beginning of dressing change to the end. RN-C did not wash hand or use hand sanitizer. RN-C contaminated a pair of scissors taken from uniform pocket and replaced them into the same pocket without cleaning them. Observation on 03/19/18 at 02:34 PM during a complete dressing change on Resident 34 to left heel and back of left ankle by RN-C. RN-C washed hands. RN-C then pulled a trash can over to the side of Resident 34's wheelchair. Placed a white cloth on the floor by the wheelchair. Placed soapy clothes on the white cloth on the floor. RN-C placed a plastic bag which contained numerous items of dressings, bandages, tape, ointments, and Saline Spray on Resident 34's bed. Saline spray is used to moisten dressings to make them easier to remove when they become stuck. It is clean (sterile) since it is in a closed container. RN-C then put on gloves. RN-C sat down, on the floor, in front of Resident 34's wheelchair. The white cloth is on the floor just to her right. RN-C began to remove Resident 34's sock and shoe from the left foot. RN-C began to remove the old dressing, which was soaked with bloody drainage, from Resident 34's foot and back of ankle. RN-C then reached into the pocket of RN-C's uniform and removed a pair of scissors. The scissors were placed on the white cloth with the other clean items for the dressing change. The bloody dressing became stuck, closer to the skin. RN-C reached into the plastic bag which contained numerous supplies for dressing changes. RN-C dug into the bag several time and was unable to locate what item was needed. RN-C then slid the bag of supplies to the uncovered floor, not on the white cloth, and removed the can of Saline Spray. RN-C sprayed the soiled dressing, which began to run down and drip onto the scissors and other items on the white cloth on the floor. RN-C tried to remove the dressing and Resident 34 stated Ouch! That hurts! RN-C informed Resident 34 that the dressing was stuck. RN-C sprayed the dressing again and it came off. RN-C then took two (2) 4 X 4 gauze pads, touched the tube of [MEDICATION NAME] gel and squeezed the ointment onto the two (2) 4 X 4 gauze pads. RN-C did not change gloves, wash hands or use hand sanitizer. RN-C then placed the one (1) 4 X 4 gauze pad onto the wound on the back of the left ankle. RN-C then needed to apply skin prep (a protective coating that helps guard the skin against irritations) to the ulcer on the left heel. Resident 34 asked if it was going to burn. Resident 34 was hard of hearing and could not hear RN-C. Resident 34 replied, What did you say? RN-C stated, Hold on and applied the skin prep. Resident 34 stated, That hurts! RN-C then applied one (1) 4 X 4 gauze pad on the left heel, making no reply to Resident 34's comment about pain. RN-C reached into the plastic bag of supplies, took out a roll of Kerlix wrap and secured the 4 X 4 dressings into place. RN-C then used tape to hold the Kerlix wrap into place. The tape and [MEDICATION NAME] were placed back into the plastic bag. RN-C then placed the scissors back into uniform pocket. Resident 34 replied several time, My foot still hurts! RN-C informed Resident 34 that it was because the dressing was stuck. RN-C informed Resident 34 that the dressing and cleaning of the suprapubic catheter site would be done next. (Suprapubic catheter is a surgically created connection between the bladder and the skin used to drain urine from the bladder when a person has an obstruction (blockage) of normal urine flow). RN-C took off the gloves from the previous dressing change. No washing of hands or use of hand sanitizer was observed. RN-C gathered the supplies needed with ungloved hands. RN-C with ungloved hand moved trash can closer to the resident's wheelchair. RN-C then applied gloves, without washing them or using hand sanitizer. RN-C prepared the wash clothes to clean the catheter site. RN-C removed the old dressing and placed it into the trash can. New gloves were applied and the area around the site was cleaned. Area cleaned with soap and water, moving from inward at insertion site outward. Gloves were not changed, new dressing was applied and secured with tape. Tape placed back into plastic bag of supplies. Resident 34's clothing was adjusted and trash picked up from room. RN-C replied, I will wash my hands later. RN-C went into bath house and use hand sanitizer. Review of Treatments Flow Sheet dated 3/1/18-3/31/18 revealed dressing changes had been done 3/15/18, 3/18/18 and 3/19/18 with no measurements recorded on the, WOUND EVALUATION FLOW SHEET. Resident 34 had order for Profo Boot-offloading pressure on 3/6/18. Boots did not start getting applied until 3/16/18. Care Plan does not reveal what procedure was being done prior to Profo Boots. Review of Progress Notes dated 2/22/18 through 3/19/18 revealed no documentation since admission of resident refusing to be assisted to bed. Observation for five (5) hours from 09:15 AM until 01:50 PM revealed resident sitting in the wheelchair in various locations around the facility. Review of undated Care Plan revealed Resident 34 has no interventions that include changing positions and documenting refusals to lay down. | 2020-09-01 |
| 4844 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 689 | H | 0 | 1 | 9WK311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b Based on observations, record reviews and interviews; the facility failed to ensure that 1) causal factors were identified, assessments were completed related to a dislocated shoulder and follow up interventions were in place to reduce the risk of recurrence for one current sampled resident (Resident 176), 2) a finger injury was identified, assessed and care provided for one current sampled resident (Resident 21) and 3) interventions were in place to prevent a fall with facial fractures for one current sampled resident (Resident 76). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 2/24/18 at 7:29 PM, revealed that the resident required one staff member assist with toileting. Review of the Progress Notes, dated 2/25/18 at 12:00 PM revealed that the resident was seated on the toilet and upon rising stated ow and pointed to bicep area. The resident requested spouse be called. Spouse called and stated that the resident's shoulder was dislocated and requests the resident be sent to the emergency room per ambulance. Resident was assessed for pain and was transferred to the hospital per ambulance. Further review revealed that at 2:55 AM, the resident returned to the facility with no documentation of an assessment of the left shoulder until 2:59 PM. At that time, the resident denied pain at the left shoulder. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Final Impression: Headaches and reported shoulder dislocation; - Differential Diagnosis: [REDACTED]. - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, found that the left shoulder was dislocated and the left hand was blue, spouse reduced the left shoulder and restored circulation to the left arm. The dislocation may have occurred while trying to assist the patient off of the toilet. Review of the emergency room discharge handout Shoulder Dislocation included the following information: What causes a shoulder dislocation? - a fall on an outstretched arm, a hard pull on your arm, loose tissues around your shoulder joint that allow the joint to move more than it should. What are the signs and symptoms of a shoulder dislocation? - shoulder an arm pain that worsens with movement, redness and swelling of you injured shoulder, weakness, numbness or tingling in you injured shoulder and arm. How is a shoulder dislocation treated? - manual reduction where healthcare providers use their hands to move your dislocated arm back into place, you may need medications such as a muscle relaxer, sedative or anesthesia, - you may need a sling, splint or brace. Review of the care plan, initiated on 2/26/18, revealed that the resident required extensive assistance of two staff with bed mobility, transfer, dressing, toileting and personal hygiene. Interventions initiated on 2/27/18 included spouse indicates that the resident's left shoulder dislocates frequently and occurs with slight movements. Interview with the DON (Director of Nursing) and the Nurse Consultant on 3/5/18 at 8:50 AM confirmed that there was no assessment of the left shoulder injury on 2/24/18 including causal factors, intensity of the pain, that there was impaired circulation at the left arm or that the spouse reduced or placed the shoulder back into place. The DON confirmed that there was no documentation of the resident's condition, including shoulder pain until 2:59 PM. Further interview confirmed that the care plan was not updated with interventions to reduce the risk for recurrent dislocation of the left shoulder. B. Record review of Resident 21's Admission Record printed on 2/28/18 revealed the resident was initially admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Observation of Resident 21 on 2/27/18 at 11:43 a.m. revealed the resident's fifth little finger on the right hand was splinted and the splint was taped to the fourth and fifth fingers for mobility. Interview with Resident 21 on 2/27/18 at 11:43 a.m. revealed the resident could not recall how the finger was injured. Record review of Resident 21's Progress Notes revealed the following entries: - 2/25/18 at 1:50 p.m., RN (Registered Nurse)-G recorded: Family came to nurse's station with concern's the resident's pinky finger on the right hand was broken. this nurse went to assess and found the finger swollen and purple in color. When asked what happened, the resident said (Resident) sneaked out last night and shut it in the car door then said, I didn't tell anyone because (the resident) didn't want anyone to know (the resident) sneaked out. Resident given Tylenol 325 mg (milligrams) two (tabs) and ice placed on site. Will continue to monitor. - 2/25/18 2:07 p.m., RN-G recorded This nurse went to staff and inquired whether or not they knew of resident's injury to (the resident's) pinky. All my staff denied knowing of injury and denied it occurred on evening shift yesterday (2/24/18) (NA (Nurse Aide)-H) stated that night shift (NA-I) knew of the injury when day shift NA's (Nurse Aides) began working today (2-25-18). This nurse will discuss the injury with the night shift nurse when (the nurse) arrives. - 2/25/18 at 6:38 p.m. LPN (Licensed Practical Nurse)-J recorded the resident was assessed for bruising on 5th digit of the right hand with pain medication and ice as needed. LPN-J recorded the physician ordered for the resident to be taken to the emergency room for x-ray of the 5th digit of the right hand. - 2/25/18 at 9:46 p.m. LPN-J recorded the resident returned from the emergency room with a [DIAGNOSES REDACTED]. Orders were received for follow up with the physician in 1-2 weeks and to be seen every 1-2 weeks to check on compliance and complications. Further orders were for Tylenol 650 milligrams orally every 4-6 hours as needed. - 3/1/18- at 4:30 p.m. the Director of Nursing documented the resident's splint was removed for assessment after ice applied. Noted some swelling and bruising to the distal joint which the resident reported only hurts when I mess with it. Resident aware of injury and told the Director they called it a mallet finger. The resident was unable to recall how it happened. The splint was replaced and taped. Record review of documents from the emergency room , regarding Resident 21's injured finger, revealed the following: - Discharge Instructions revealed the resident came to the emergency roiagnom on [DATE] at 7:57 p.m. and was diagnosed with [REDACTED]. - An informational document was provided for What you need to know for a Jammed Finger. The document recorded A jammed finger is an injury to the tendon that straightens the tip of your finger. A piece of bone may be pulled away with your tendon. Your injury may take 4 to 8 weeks to heal. Record review of a facility investigation of Resident 21's finger injury incident completed on 3/1/18 revealed in the Outcome that LPN-J had cleaned the resident's fingernails during the morning of 2/25/18 around 4:15 a.m. and did not discover an injury. NA-I noticed bruising to the finger between 4:30 a.m. and 4:45 a.m. and reported the bruising to the oncoming day shift but not to the night nurse or the day nurse. The outcome of the investigation is inclusive (sic for inconclusive) as we can't determine a cause of the injury. The document recorded for preventative measures that administration that they discussed with NA-I the requirement to report any and all injuries to the charge nurse immediately to the supervising charge nurse. Interview with NA-E on 3/1/18 at 10:45 a.m. revealed NA-E recalled coming to work the morning of 2/25/18 and that NA-I reported Resident 21 sustained an injury to the right hand pinky finger. NA-E stated not reporting to the charge nurse as the day shift staff thought NA-I had already done so. Record review of Resident 21's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed a Quarterly MDS was completed on 1/29/18. The MDS recorded the resident received Extensive Assistance (Resident involved in activity, staff provide weight bearing support) for positioning in bed and transferring between surfaces such as bed to chair, toilet, or wheelchair. Interview with the Administrator and Corporate Nurse Consultant on 3/6/18 at 11:00 a.m. confirmed that during the night shift early morning on 2/25/18 the resident sustained [REDACTED]. Due to this, the injury was not assessed, physician notified, or treatment initiated until the family reported the incident on 2/25/18 at 1:50 p.m. and the resident was not seen in the emergency room until 7:57 p.m. on 2/25/18. C. Record Review of Resident 76's Admission Record printed on 2/28/18 revealed an Admision date to the facility on [DATE]. Observation on 02/27/18 at 9:30 a.m. revealed Resident 76 was sitting in their recliner with a blanket covering Resident 76's body. Resident 76 had bruising on the right side of the face and stitches over left eye. Resident 76 had a tabs monitor connected to the recliner and the shirt Resident 76 was wearing. Observation on 03/01/18 at 8:30 a.m. revealed the resident was sitting in their recliner and observing television. The resident had a bedside table next to the recliner with a mug of water sitting on it. Resident 76 had a tabs monitor connected to the recliner and Resident 76's shirt. The call light was next to the resident and was connected to resident's recliner. Resident 76's face was bruised on the right side and bruising went from under the left side of the chin to the top of the left side of forehead and stitches remained over the left eye. Record Review of Resident 76's progress note 02/21/18 at 9:44 a.m. identified Resident 76 was getting up without staff assistance and tripped over the bedside table while staff were getting Resident 76's walker. Resident 76 had a laceration above the left eye and Resident 76 complained of head pain. Resident 76's primary physician was contacted and recommended the resident be transferred by ground ambulance to SRMC ( Sidney Regional Medical Center). Resident 76 was transported SRMC Emergency Department. Record Review Resident 76's progress note dated 02/21/18 at 9:04 a.m. identified that the Emergency Department Nurse reported that Resident 76 had been admitted to the SRMC with multiple facial fractures and a hemorrhage to the brain. Record Review of Resident 76's fall risk assessment completed on 02/16/18 revealed that Resident 76 was not steady, and was only able to stabilize with staff assistance when walking and turning around when facing the opposite direction while walking. Interview with Resident 76's family on 02/27/18 at 10:30 a.m. revealed Resident 76 had a fall in the resident's room and Resident 76 had facial fractures to the left side of the face, lacerations over left eye and a brain hemorrhage. Interview with NA (Nursing Assistant)-E verified Resident 76 fell in the room and NA-E did not witness the fall as NA-had gone to retrieve a walker for Resident 76. Interview on 03/06/18 at 9:23 a.m. with LPN (Licensed Practical Nurse)-D verified there were no staff in the room at the time of the fall. Interview on 03/06/18 at 10:10 a.m. with the Administrator and Corporate Nursing Consultant verified Resident 76 did have a fall on 02/21/18 after the Fall Risk Evaluation had been completed on 02/16/18 and it had identified the resident was not steady when walking or turning around and required staff assistance to stabilize and staff were not present at the time of the fall. | 2020-03-01 |
| 4846 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 697 | H | 1 | 1 | 9WK311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) pain assessments were completed and pain was managed for one current sampled resident related to a dislocated shoulder and chronic headaches related to a [DIAGNOSES REDACTED] (Resident 176), 2) pain assessments were completed with pain levels rated severe for one current sampled resident (Resident 11) and 3) assessments were completed and interventions were in place to relieve ongoing pain related to positioning in the wheelchair for one current sampled resident (Resident 22). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 2/25/18 at 12:00 PM revealed that the resident was seated on the toilet and upon rising stated ow and pointed to bicep area. The resident requested spouse be called. Spouse called and stated that the resident's shoulder was dislocated and requested the resident be sent to the emergency room per ambulance. Resident was assessed for pain and was transferred to the hospital per ambulance. Further review revealed that at 2:55 AM, the resident returned to the facility with no documentation of an assessment of the left shoulder until 2:59 PM. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, found that the left shoulder was dislocated and the left hand was blue, spouse reduced the left shoulder and restored circulation to the left arm. Interview with the resident's spouse on 2/28/18 at 7:45 AM revealed concerns related to pain management. The spouse stated that the resident was not always reliable with communication, when asked if having pain will say no when the resident means yes. Nonverbal symptoms of pain need to be utilized, frowning, shaking head, or grimacing. The spouse stated that the resident had a long history of frequent headaches since diagnosed wih the [DIAGNOSES REDACTED] and typically took Tylenol at least a couple of times a day for lesser pain and [MEDICATION NAME] daily for more severe headaches. The spouse stated that would put hands up and the resident could point to a finger to express the intensity of pain. The spouse was concerned that the resident was having pain that wasn't identified by the staff and medications were not being administered when needed. Review of the care plan, initiated on 2/26/18, revealed no care plan to address pain. Review of the Medication Administration Record, [REDACTED]. Further review revealed that no pain medication was administered until 2/26/18. Further review of the Progress Notes included the following: - 2/26/18 at 9:00 AM [MEDICATION NAME] administered for complaints of pain all over rated 7-10 on the pain scale The pain scale is based on 1 - 10 with 8-10 considered extreme pain; - no documentation of where the pain was located or other interventions in place to manage the pain; - 2/26/18 at 10:33 AM - medication was effective with no further documentation; - 2/26/18 at 10:15 PM - medication was given pain medication earlier for headache; - 2/27/18 at 12:27 AM - [MEDICATION NAME] given for complaints of a headache, no further assessment documented including intensity or other care provided to relieve the headache; - 2/27/18 at 3:06 AM - resident states no pain; - 2/27/18 at 6:03 AM - [MEDICATION NAME] administered for pain , no documentation of the location or intensity; - 2/27/18 at 7:17 AM - medication was effective with no further assessment. Interview with the DON (Director of Nursing) and the Nurse Consultant on 3/5/18 at 8:50 AM confirmed that there was no assessment of the resident's left shoulder injury on 2/24/18 including causal factors, intensity of the pain, or that pain medication was administered to relieve the pain. Further interview confirmed that assessments should have been completed and documented related to the resident's headaches, including non verbal symptoms of pain, to ensure pain was effectively identified and managed to meet the resident's needs. B. Review of the Admission Record revealed that Resident 11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with the resident on 3/1/18 at 11:30 AM revealed that knee has been killing me and went to the doctor and has an infection in the knee. Review of the care plan, target date 4/28/18, revealed that the resident required assistance with activities of daily living including transfers, mobility, and assess for non verbal indicators of pain and encourage to verbalize pain and discomfort. Further review revealed no care plan to address actual pain and interventions to relieve pain. Review of the Medication Administration Record, [REDACTED]. Further review revealed that in addition [MEDICATION NAME] (narcotic [MEDICATION NAME]) was administered on 2/12/18 at 10:47 AM for pain rated 8, on 2/21/18 at 11:31 AM for pain rated 10 and on 2/27/18 at 12:47 PM for pain rated 10. Further review revealed that the medications were documented as effective. Interview with the DON on 3/5/18 at 3:45 PM revealed that no further assessments were completed or documented to include causal factors of pain, numerical rating to evaluate pain relief after pain medications were administered and non pharmacological interventions in place to prevent or to relieve pain. Further interview confirmed that assessments and follow up should be done to ensure that the resident's severe pain was managed to meet the resident's needs. C. Record Review of Resident 22's Admission Rcord printed on 2/28/18 revealed an admitted to the facility on [DATE]. Observation on 02/27/18 at 9:00 a.m. revealed Resident 22 was sitting in their wheelchair in their room placing clothing items in a dresser and Resident 22 verbally complained about back pain. Observation 02/28/18 at 10:30 a.m. revealed the resident was in the hallway sitting in their wheelchair and Resident 22 was in a slouching position in the wheelchair. Resident 22's back was not against the back of the wheelchair. Record Review of Resident 22's progress note completed by SSD ( Social Services Director) on 02/06/18 at 15:01 verified that Resident 22 had voiced concerns about the wheelchair. Record Review of Resident 22's MDS (Minimum Data Set) identified the resident had occasional pain and it was rated at an 8 on a scale of 0-10. Record Review of Resident 22's Care plan revealed that Resident 22's pain would be at an acceptable level through the next review. The care plan was revised on 2-21-18. Interventions included adjustments made to pain medication, Administer medication as ordered, monitor pain level per pain scale, if pain level not tolerable, notify PCP (Primary Care Physician) for medication adjustment or change. Interview on 02/27/18 at 9.00 a.m. with Resident 22 revealed the resident's wheelchair did not fit the resident correctly and it caused Resident 22 back pain. Interview on 02/28/18 at 10:00 a.m. with Resident 22 revealed when the resident was sitting in the wheelchair there were times that the resident experienced back pain and butt pain. Resident 22 reported the chair was causing the pain. Interview on 03/05/18 at 1:55 p.m. with the SSD ( Social Services Director) confirmed that Resident 22 complained about the wheelchair causing pain and requested to have the wheelchair re-evaluated. The SSD reported it was unclear where PT (Physical Therapy) was with this process but was also unclear who was responsible for the follow up on the wheelchair which may be causing the resident pain. Interview on 03/05/18 at 2:16 p.m. with PTA (Physical Therapy Assistance)-K verified they were not aware about Resident 22's wheelchair not fitting correctly. PTA-K reported that Resident 22's wheelchair had not been reassessed and also had stated the wheelchair was fairly new and was not sure if Medicaid would pay for a new wheelchair. PTA-K reported it was not clear if the wheelchair was causing Resident 22 pain and that the DOR (Director of Rehabilitation)-L would have to be the person to assess Resident 22 and see if the wheelchair was causing the pain. PTA-K reported that DOR-L had not completed another wheelchair assessment since Resident 22's chair was so new and no one had requested to have it re-evaluated. Interview on 03-06/18 at 12:06 p.m. with Resident 22 revealed the wheelchair had not been reassessed to see if this was causing the resident's back and hip pain. Interview on 03/06/18 at 12:23 p.m. with LPN (Licensed Practical Nurse)-D verified there were no orders to have Resident 22's wheelchair reassessed to determine if this was the root cause of the resident's back pain. Interview on 03/06/18 at 2:04 p.m. with the Administrator and Corporate Nursing Consultant verified that follow up had not been completed on the resident's wheelchair to see if this was the root cause of the resident's pain. | 2020-03-01 |
| 4851 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 755 | H | 1 | 1 | 9WK311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.12A Based on record reviews and interviews, the facility failed to ensure that medications were available to administer as ordered 1) on admission for two current sampled residents (Residents 176 and 175), 2) for an antifungal medication to treat a skin disorder for one current sampled resident (Resident 20) and 3) for antibiotics to treat a urinary tract infection for one current sampled resident (Resident 24). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed that the following medications were not administered as ordered on admission: - [MEDICATION NAME] daily for Major [MEDICAL CONDITION], start date 2/24/18 and not administered until 2/25/18; - [MEDICATION NAME] Ointment apply daily to wound on upper back, start date 2/24/18 and not applied until 2/25/18; - [MEDICATION NAME] tapering doses, two times a day for Malignant Neoplasm of Brain and Cerebral [MEDICAL CONDITION] (swelling), ordered 2/23/18 and not administered until 2/25/18; - [MEDICATION NAME] every four hours as needed for pain, ordered 2/23/18 and not administered until 2/26/18; - [MEDICATION NAME] every four hours as needed for pain, ordered 2/23/18 and not administered until 2/27/18. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Final Impression: Headaches and reported shoulder dislocation; - Differential Diagnosis: [REDACTED]. Examination showed that the patient has difficulty understanding and following commands at this time, spouse reports that since the [MEDICAL CONDITION] the patient has times periods of being alert and oriented and answers questions to period where the patient cannot follow commands, respond well, can't answer questions. The patient acts like is trying to answer but is unable to get the words out. - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, found that the left shoulder was dislocated, and left hand was blue, spouse reduced the left shoulder and restored circulation to the left arm. The dislocation may have occurred while trying to assist the patient off of the toilet. The spouse reported that the resident had not received the ordered doses of steroid since admission to the facility for cerebral [MEDICAL CONDITION] (brain swelling) prevention and was increasingly lethargic and sleeping much more than normal, 18 hours today. The resident was given a dose of steroid and orders for tapering doses. Interview with the resident's spouse on 2/28/18 at 7:45 AM revealed concerns related to pain management. The spouse stated that the resident has a long history of frequent headaches since diagnosed wih the [DIAGNOSES REDACTED] and typically took Tylenol at least a couple of times a day for lesser pain and [MEDICATION NAME] daily for more severe headaches. The spouse was concerned that the resident was having pain and medications were not being administered when needed. The spouse also stated concerns related to the missed doses of the steroid ordered on admission which may have contributed to the increased lethargy sleeping all day on 2/24/18 and being so out of it on 2/25/18. Interview with the Nurse Consultant on 2/28/18 at 3:00 PM confirmed that the resident's medications listed above were not received from the pharmacy on admission and were not administered until available as documented on the Medication Administration Record. B. Review of the Admission Record revealed that Resident 175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, dated (MONTH) (YEAR), revealed that the following medications were not administered as ordered: - [MEDICATION NAME], ordered on [DATE] every evening for Diabetes, not administered until 2/20/18; - Latanoprost eye drops to both eyes for [MEDICAL CONDITION], ordered 2/18/18 and not administered until 2/21/18; - Terozosin every bedtime related to [MEDICAL CONDITION], ordered 2/18/18 and not administered until 2/20/18; - [MEDICATION NAME] daily for [MEDICAL CONDITION] Fibrillation, ordered 2/19/18 and not administered until 2/20/18; - [MEDICATION NAME] two times a day for Partial Intestinal Obstruction, ordered on [DATE] and not administered until evening dose on 2/20/18; - [MEDICATION NAME] ordered two times a day for Diabetes, ordered 2/19/18 and not administered until 2/20/18; - Potassium Chloride ordered two times a day, ordered 2/18/18 and not administered until evening dose on 2/20/18; - Risamine ointment to reddened groin two times a day, ordered 2/18/18 and not applied until the evening dose on 2/20/18; - [MEDICATION NAME] R injections per sliding scale four times a day for Diabetes, ordered 2/18/19 and not administered until 2/20/18. Interview with the Director of Nursing on 3/5/18 at 9:40 AM confirmed that the medications listed above were not received from the pharmacy on admission and were not administered as ordered until available as documented on the Medication Administration Record. C. Review of Resident 20's Medication Administration Record, dated (MONTH) (YEAR), revealed an order, dated 2/10/18, for [MEDICATION NAME] (antifungal) daily for [DIAGNOSES REDACTED] (reddened and chaffing skin) which was not administered on 2/10/18, 2/11/18 and 2/12/18. Further review revealed an order, dated 2/13/18, for [MEDICATION NAME] daily for until 2/20/18 which was not given 2/13/18 through 2/16/18. [MEDICATION NAME] was ordered again on 2/17/18 to be administered daily until 2/23/18. Further review revealed that it was administered daily as ordered on [DATE] through 2/23/18. Interview with the Nurse Consultant on 3/5/18 at 3:00 PM confirmed that there was a mix up with the pharmacy orders and the medication was not available until 2/17/18. Further interview confirmed that the resident's were to receive their medications as ordered which did not occur due to issues with the pharmacy and staff not following the procedures for ordering medications for the residents. D. Record review of Resident 24's Admission Record printed on 2/28/18 revealed the resident was initially admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 24's Progress Notes revealed the following entries: - 2/13/2018 at 5:34 p.m. LPN (Licensed Practical Nurse)-C recorded: Received new orders for UTI (Urinary Tract Infection). [MEDICATION NAME] (antibiotic) 100 mg (milligrams) 2 x (two times) day for 7 days . - 2/14/2018 at 7:38 a.m. MA (Medication Aide)-F recorded the [MEDICATION NAME] was not given due to on order. - 2/15/18 at 4:44 p.m. LPN-D recorded the [MEDICATION NAME] was not given due to waiting to be delivered. - 2/16/18 at 11:59 p.m. LPN-D recorded the [MEDICATION NAME] was not given to the resident due to waiting for delieery (sic for delivery). - 2/16/18 at 1:55 p.m. LPN-D recorded: [MEDICATION NAME] 100 mg first dose started today for UTI. Record review of Resident 24's Medication Administration Record for (MONTH) of (YEAR) revealed [MEDICATION NAME] 100mg was ordered on [DATE] with instructions to administer the medication twice a day for Urinary Tract Infection. Further review of the document revealed the medication was not administered to the resident until 5:30 p.m. on 2/16/18 revealing that five potential doses of the medication were delayed from being administered to the resident as ordered. Interview with the Director of Nursing on 3/5/18 at 3:00 p.m. confirmed Resident 24 was ordered [MEDICATION NAME] on 2/14/18 for a urinary tract infection and the medication was not administered to the resident until 5:30 p.m. on 2/16/18. | 2020-03-01 |
| 4857 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 835 | H | 0 | 1 | 9WK311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.01 (4) Based on observations, record reviews, and interviews, the facility administration failed to identify and correct issues to maintain compliance and ensure the provision of care and treatment for [REDACTED]. Facility census was 27. Findings are: Entrance to the facility on [DATE], the facility provided a personnel form which identified the facility employed a full-time licensed Administrator responsible for managing the facility and day to day operations. Due to risk of retaliation by the company or the administration of the facility, various staff members, residents, and families were interviewed under requests for anonymity. These interviews were conducted during a complaint drop in visit conducted on 2/23/2018 between 1:25 p.m. and 3 p.m. and during the annual survey conducted beginning on 2/27/18 through 3/6/18. These interviews resulted in the following concerns being expressed: - shortages in direct care nursing staff resulting in delays of call lights, bathing not being done as scheduled, no restorative nursing program, delays in attending to resident condition changes, and lack of response by administration in dealing with concerns and issues brought to administration attention. During the survey conducted from 2/27/18 through 3/1/18, the facility was cited for the following issues related to systems failure or standards of care breaks resulting in patterns of, or widespread failure in the facility: - F561- bathing not provided for residents as requested. Interviews with staff and residents revealed this was related to nurse staffing shortages. - F684- Activity programs being canceled related to one employee in the department being pulled to do resident transport duties to and from medical and other appointments in addition to performing Social Service duties four days a week. In addition, the facility was not employing a full-time Activities Director as specified in the Facility Assessment Tool. - F689- Accidents resulting in harm to residents due to systems failures in nursing assessment and care planning. - F725- Inadequate direct care staffing related to mechanical lift transfers being done without a second person per standards of practices and individualized care planning. Interviews with staff and residents attribute this practice due to lack of direct care staffing on the floor. No restorative program verified by interviews with staff, therapy, and administration. Medication error rates attributed to being rushed to complete medication duties and charge nurse duties. Bathing not being completed based on interviews with staff and residents attributing this to staff shortages. - F727- The Director of Nursing hired on 2/8/18 had been working 24-36 hours per week in the capacity of night shift charge nurse resulting in failure to devote the required 35 hours per week to directing nursing care for the facility. This resulted in no direction or supervision over nursing staff resulting in additional deficiencies cited for medication errors, Infection Control programming, Pain management, accidents, medication labeling, and medications and nutritional supplements being obtained for administration as ordered. Medication being unavailable resulted in increased changes in condition, pain, and additional medical attention. - F745- Lack of providing essential social services for residents. Wheelchair issues brought to the attention of administration and Social Services were not addressed verified by care plan documentation, progress notes, and family interview. In addition, the facility was not employing a full-time Social Service Director as specified in the Facility Assessment Tool as they were employing the Social Services Director one day per week and additional hours were being supplemented by the Activity Director consisting of an average of 2 hours per day four days per week. - F809 failure to address repeated Resident Council concerns regarding evening snacks. - F837- Essential services including Medical Director, Consulting Pharmacist, Pharmaceutical suppliers, food suppliers, medical equipment suppliers, Fire and Safety inspections, Generator rental, and plumbing contractors not being paid and all with past due accounts. Some of these issues have resulted in delays or refusal to provide further services. Interviews and past due accounts and invoices were reviewed supporting the lack of payment. - F841- The Medical Director had not been supplied a current contract identifying policies and services required for the position. The specific observations, record reviews, and interviews related to these deficiencies may be referenced in support of the dificiencies that were patterned or widespread. | 2020-03-01 |
| 4860 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 865 | H | 0 | 1 | 9WK311 | Licensure Reference Number 175 NAC 12-006.07C Based on observations, record reviews and interviews; the facility failed to ensure that the QA (Quality Assurance) and QAPI (Quality Assurance and Performance Improvement) Committees identified and corrected quality of care issues. The facility census was 27 and this failure has the potential to effect all of the residents. Findings are: Review of the findings during the annual recertification survey, dated 3/6/18, revealed the following deficient areas identified including: Emergency Preparedness: - 0001 failed to establish an emergency program as required; - 0015 failed to include subsistence needs for patients and staff; - 0029 failed to include a communication plan; - 0030 failed to include names and contact numbers; - 0035 failed to include the required components for sharing information from the emergency plan to residents, families or resident representatives; Recertification deficiencies identified at a scope higher than isolated: - F 561 failed to ensure that resident choices for bathing choices were honored; - F 665 failed to ensure that baseline care plans were developed for newly admitted residents; - F 656 failed to develop and implement comprehensive care plans as required; - F 658 failed to ensure that medications were administered per standards of practice; - F 679 failed to ensure that the activities program was in place to meet the residents' needs; - F 684 failed to provide care and treatments related to a change in condition, ongoing diarrhea and to prevent skin breakdown to ensure that the residents' needs were met; - F 686 failed to provide care and treatment to address limitations in range of motion and have a restorative nursing program in place; - F 689 failed to provide care and treatment related to a dislocated shoulder, finger injury and to prevent a fall with fractures; - F 697 failed to ensure that nutritional supplements were available and administered for residents with nutrition issues; - F 697 failed to provide effective pain management to meet the needs of the residents; - F 725 failed to provide sufficient nursing staff to meet the needs of the residents; - F 727 failed to ensure that the Director of Nursing worked the required full time hours; - F 732 failed to ensure that daily staff postings were accurate and maintained as required; - F 745 failed to provide medically related Social Services to meet the needs of the residents; - F 755 failed to ensure that medications were available and administered on admission and new orders for antibiotic therapy; - F 757 failed to obtain monitoring lab work and vital signs as indicated to ensure the therapeutic benefits of medications; - F 759 failed to ensure a medication error rate less than 5%; - F 761 failed to ensure that prescription labels matched current medication orders; - F 809 failed to ensure that bedtime snacks and fresh water were provided; - F 812 failed to maintain sanitation in the kitchen; - F 835 failed to ensure that the administration identified and corrected issues to maintain compliance and ensure the provision of cares and treatments through systems and policies which resulted in substandard quality of care and actual harm cited for deficient practice; - F 837 failed to ensure that outside agencies and businesses providing goods and services were being paid; - F 841 failed to ensure that a contract was in place with the Medical Director to identify responsibilities and requirements to coordinate medical care for the residents; - F 880 failed to have an infection control program in place to provide surveillance and audits and to prevent infection control issues related to handling of laundry, wound care, urinary catheter care, respiratory equipment and hand washing to reduce the risk of cross contamination. Review of the facility policy Quality Assurance and Performance Improvement, dated (MONTH) (YEAR), revealed the following including: Policy: It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Interview with the Administrator, QAPI Coordinator, on 3/6/18 at 11:30 AM confirmed that the QAPI Committee was not effective in identifying or developing a plan to address quality of care issues in the facility. | 2020-03-01 |
| 4861 | SIDNEY CARE AND REHABILITATION CENTER, LLC | 285113 | 1435 TOLEDO STREET | SIDNEY | NE | 69162 | 2018-03-06 | 867 | H | 0 | 1 | 9WK311 | Licensure Reference Number 175 NAC 12-006.07C Based on observations, record reviews and interviews; the facility failed to ensure that the QAPI (Quality Assurance and Performance Improvement) Committee developed and implemented a plan of correction to maintain compliance for deficiencies cited at the last annual recertification survey. The facility census was 27 and this failure had the potential to effect all of the residents. Findings are: Review of the recertification survey, dated 4/19/17, compared to the current recertification survey, dated 3/6/18, revealed that the following deficiencies were cited and not corrected: - F 157 (F 580) failed to notify the physician of a change in condition as indicated; - F 241 (F 550) failed to ensure that residents were treated with dignity; - F 279 (F 656) failed to develop a comprehensive care plan to address residents' needs; - F 323 (F 689) failed to identify potential accident hazards and prevent accidents; - F 332 (F 759) failed to ensure a medication error rate less than 5%; - F 371 (F 812) failed to ensure dietary sanitation practice; - F 431 (F 761) failed to ensure that prescription labels matched current medication orders; - F 425 (F 755 and F 658) failed to ensure medications were administered per standards of practice and that medications were available for administration; - F 441 (F 880) failed to ensure infection control procedures were in place to reduce the risk of cross contamination; - F 520 (F 865 and F 867) failed to ensure that the QAPI Committee 1) identified quality of care issues and had a plan to correct the issues and 2) ensure that the plan of correction for previous deficiencies was effective to obtain and maintain regulatory compliance. Review of the facility Quality Assurance and Performance Improvement policy, dated (MONTH) (YEAR), revealed the following including: . 11. Governance and leadership - . b. Governing oversight responsibilities include, but are not limited to the following: . vi. Ensuring that corrective actions address gaps in systems, and are evaluated for effectiveness. Interview with the Administrator, QAPI Coordinator, on 3/6/18 at 11:30 AM confirmed that, based on comparison of the current survey findings and the previous annual survey findings and identified repeat deficiencies, the QAPI Committee was not effective in obtaining or maintaining regulatory compliance. | 2020-03-01 |
| 5186 | EL DORADO MANOR NURSING HOME | 285253 | 71434 HWY 25, BOX 97 | TRENTON | NE | 69044 | 2016-11-08 | 223 | H | 0 | 1 | 8A4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (9) Based on observation, record reviews and interviews, the facility failed to protect residents from abuse by failing to: 1) suspend employees after receiving reports of alleged verbal, psychological, and physical abuse; and 2) immediately initiate an investigation of these allegations. This affected 3 of 6 sampled residents (Residents 15, 16, and 18). The facility identified a census of 37 at the time of survey. Findings are: [NAME] Review of Resident 15's annual MDS (Minimum Data Set-a comprehensive resident assessment tool used to develop a resident's care plan) dated 12/24/2015 revealed an admission date of [DATE] and a BIMS (Brief Interview for Mental Status) score of 14 which indicated Resident 15 was cognitively intact. Interview with Resident 15 on 11/01/2016 at 11:40 AM revealed that the facility Administrator had verbally intimidated Resident 15 and Resident 16 by stating if you don't like it you can leave after they brought up concerns they felt the facility needed to address. Resident 15 also revealed that the Administrator accused Resident 15 of violating HIPAA laws because they got permission from Resident 16 to bring up an issue about Resident 16 not being able to get a haircut. Resident 15 revealed that the Administrator told Resident 16 that they should not be paying for a ride to go to their house when they did not have money to pay for other things. Resident 15 stated feeling psychologically abused and bullied by the Administrator. Interview with Resident 15 on 11/01/2016 at 11:59 AM revealed that, when Resident 15 inquired about a facility staffing change, the administrator said in an antagonistic way it's all taken care of. Resident 15 had reported to the facility staff feeling psychologically abused and bullied by the facility Administrator. Interview with the DON (Director of Nursing) on 11/02/2016 at 9:55 AM revealed the facility Administrator was brash and short with people. The DON further revealed that the governing entity for the facility had been notified about the concerns with the facility Administrator; the DON confirmed that the facility Administrator continued to work in the facility. Observation of the facility during the survey period of 10/31/2016 to 11/8/2016 revealed the facility Administrator was working in the facility. B. Review of Resident 16's annual MDS dated [DATE] revealed an admission date of [DATE] and a BIMS score of 15 which indicated that Resident 16 was cognitively intact. Interview with Resident 16 on 11/01/2016 at 10:58 AM revealed that the facility administrator had threatened to make Resident 16 move out of the facility on 3 separate occasions. Interview with Resident 16 on 11/02/2016 at 2:06 PM revealed that the facility Administrator had called them bad and had taken away their tools. Resident 16 also reported that the facility staff member had said Resident 16 was evil and that the facility had called the cops because Resident 16 had made a joke that was taken out of context. Resident 16 expressed that the facility Administrator just did not know when to stop and constantly told Resident 16 about stuff Resident 16 did wrong. Resident 16 reported that the facility Administrator told them if you don't like it here you can leave when Resident 16 brought up concerns and Resident 16 had heard the facility administrator threatening other facility staff. They threaten everybody. Resident 16 reported that living at the facility felt like prison and they felt like they could not come and go as they pleased. Resident 16 also reported that the facility staff did not make arrangements to take the residents on outings and prevented Resident 16 from making an attempt to retrieve some personal belongings from a residence that Resident 16 had previously owned. Resident 16 reported that they had saved money to pay for public transportation to take them to a prior residence to retrieve some personal belongings, but the administrator refused to let them leave the building and told them they weren't going to bring anything else into this building. Interview with the DON on 11/02/2016 at 9:55 AM confirmed that Resident 16 had made their own arrangements to retrieve some belongings of theirs that may have been at a residence previously owned by Resident 16 and that the administrator intervened. The DON revealed they did not know if the Administrator had made any effort to assist Resident 16 with retrieving their belongings. Interview with the administrator on 11/03/2016 at 4:26 PM revealed that Resident 16 had made arrangements to go to their previously owned home and retrieve some belongings. The administrator confirmed that they told Resident 16 they should not be going. The administrator revealed they did not contact the current owners of the residence to make arrangements for Resident 16 to retrieve their belongings. The administrator revealed they did not document the issue and was aware that Resident 16 was upset about not being able to go to the house and retrieve the belongings. C. Interview with NA-H (Nurse Aide) on 11/03/2016 at 1:15 PM revealed that NA-H had worked with NA-J who had been rude, mean, and rough with the residents. NA-H revealed that the facility administrator knew about it for a while and did not do anything about it. Interview with NA-H on 11/03/2016 at 1:59 PM revealed that they had reported NA-J being rude, mean, and rough with the residents 3 weeks ago to RN-C (Registered Nurse). NA-H reported that RN-C had them write out a statement and put it under the administrator's door at that time. NA-H revealed that NA-J continued to work in the facility after that and NA-J provided directed resident care. NA-H revealed that a couple of residents refused to allow NA-J to care for them. NA-H revealed that a couple other residents also had issues with NA-J after that and that NA-J continued to work. NA-H revealed that last Tuesday (10/25/2016) a couple of residents said they didn't want NA-J to take care of them and felt that NA-J was hurting them. NA-H revealed they had reported the concerns regarding NA-J again to RN-C on 10/25/2016. NA-H revealed that the DON found out about it on Wednesday (10/26/2016) and NA-J was finally fired. Interview RN-C on 11/03/2016 at 2:07 PM confirmed that they had received reports from staff and residents that NA-J was rough with the residents. RN-C revealed that they had left a note for the DON and had called the DON. RN-C revealed they had not reported the allegations to the facility administrator. Interview with LPN (Licensed Practical Nurse)-L on 11/03/2016 at 2:16 PM revealed that it had been brought to their attention several times that NA-J was abrasive with and rude to the residents. LPN-L confirmed that Resident 18's family member had reported to them that NA-J had been rough with Resident 18 and that NA-J had continued to work. LPN-L reported that they had left a note on the DON's door regarding the concerns about NA- [NAME] LPN-L revealed that RN-C had left a note on the DON's door about the concerns with NA-J when it was first reported to them. LPN-L revealed being unaware if the DON was contacted by phone or if the administrator had been notified. Interview with Resident 18's family member on 11/07/2016 at 12:29 PM revealed that Resident 18 had reported to them about 2-3 weeks ago that NA-J had been rough with Resident 18. Resident 18's family member revealed that NA-J had left bruises and a fingernail mark on Resident 18's hands. Resident 18's family member revealed that they had reported this to the nurse aides and they told them to report it to LPN-L. Resident 18's family member revealed that staff said they had left a note under the door for the nurse for Monday. Resident 18's family revealed they were never contacted by the facility regarding the incident. Interview with the DON on 11/03/2016 at 3:01 PM revealed that NA-M reported to them on (MONTH) 26th, that Resident 18's family had reported that NA-J was rough with Resident 18. The DON revealed having no prior knowledge of the allegations regarding NA-J as the DON was on leave from the facility for a week prior to that and that they had not been contacted by phone. The DON revealed that, when they returned from leave on (MONTH) 26th, the DON immediately ordered NA-J to leave the facility. Then the DON contacted the agency that NA-J worked for and terminated their contract. The DON revealed that NA-J would not be allowed to work in the facility. Interview with the facility Administrator on 11/03/2016 at 4:26 PM revealed that the administrator was aware of incidences with NA-[NAME] The administrator revealed that NA-J had been rough and mean with some of the residents. The facility administrator revealed that there was no documentation that an investigation into the allegations regarding NA-J had occurred and the administrator revealed the state agency had not been contacted about the allegations. The facility administrator revealed that NA-J was terminated on 10/26/2016 at 4 PM and there had been no prior corrective action taken to address the allegations of abuse regarding NA-[NAME] The facility administrator revealed that it was the expectation that the staff let the DON and administrator know right away if there are allegations of abuse. Review of the nursing staff schedule for (MONTH) (YEAR) revealed documentation that NA-J worked on (MONTH) 13, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, and 26, providing direct resident care for 12 days after allegations of abuse were first reported. Interview with the DON on 11/03/2016 at 3:00 PM revealed that it was the expectation that, if there is an allegation received that a staff member has been rough with or abusive to a resident, that staff member would immediately be removed from caring for residents. Review of the facility policy titled Abuse and Neglect Policy and Procedure dated 6/5/2008 revealed the following: -It is the policy of this facility that reports of abuse, mistreatment, neglect, and/or misappropriation of resident property be promptly and thoroughly investigated. -An employee witnessing an act in violation of these policies shall report the incident immediately and directly to the Administrator (or, in the Administrator absence, to a designee). -When an incident or suspected incident of abuse is reported, the administrator will appoint a representative to investigate the incident or complete the investigation themselves. -The results of the investigation shall be documented and retained with the report from and maintained in the administrator's office. -Results of the investigation shall be reported to the Department of Health and Human Services within five working days. -All steps shall be taken to protect residents from harm upon alleged abuse and during an investigation. Any staff witnessing abuse shall intervene and report to a charge nurse or supervisor of their suspicions immediately. -If the preliminary findings indicate probable abuse/neglect the accused employee may be, and in the case of physical abuse, will be placed on suspension without pay and/or terminated and required to vacate the premises until final disposition of the case. a. If the charges are not substantiated, the suspended employee will be reinstated. b. If the charges are proven correct, termination of the accused employee shall take place with appropriate documentation in the employee's personnel file. The Administrator shall document any variance from this action. -All alleged staff to resident violation and all substantiated incidents shall be reported to the state agency and all other agencies required. The law enforcement agency and/or Abuse-neglect hot line and the Nebraska DHHS shall be notified within 24 hours of a report of abuse or neglect if preliminary finding indicate potential abuse or neglect. | 2020-02-01 |
| 5204 | EL DORADO MANOR NURSING HOME | 285253 | 71434 HWY 25, BOX 97 | TRENTON | NE | 69044 | 2016-11-08 | 520 | H | 0 | 1 | 8A4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].07 Based on record reviews and interviews; the facility failed to re-evaluate prior plans of correction to correct and maintain correction for previously cited deficient practice related to: dignity, housekeeping/maintenance, sanitation in the kitchen and accident hazards for residents and resolution of resident and/or family grievances. The facility failed to ensure that the Quality Assurance/Assessment Committee identified quality of life and quality of care issues, related to the abuse prohibition policies and procedures, to ensure that staff followed the procedures to protect Residents from abuse. The failures resulted in potential deficiencies affecting all 37 residents. The facility census was 37 at the time of the survey. Findings are: Record review of previous complaint and annual survey deficiencies for the facility revealed the following: -F241 The facility failed to treat residents in a dignified manner by entering resident rooms without permission, posting personal care information in a conspicuous place, exposing a resident's medical condition, and failing to cover a resident that was exposed in the dining room. -F253 The facility failed to 1)fix the doors to the room, bathrooms and closet doors that were chipped and marred, 2) clean the ceiling vents in the bathrooms, 3) replace the linoleum that has holes or a cut by equipment, 4) replace linoleum that has stains in bathrooms, holes, or scrapes, 5) paint the window frames, 6) clean the windows with a brown debris, 7) fix the ceiling light fixture hanging from the ceiling, 8) fix the cracks in the resident room between the dry wall and the cinder blocks, 9) failed to remove screw and nails that were a harm to the residents, 10) fix the dry wall with scrapes or holes and 11) fix the resident's recliner for the resident to use. -F280-The facility failed to update and revise the care plan to reflect a resident's pressure ulcer. -F371-The facility staff failed to restrain their hair and keep the range hood clean to prevent possible food contamination. -F323-The facility failed to maintain side rails to prevent a potential entrapment hazard. The facility failed to store drugs and biologicals secured away from the availability of residents. -F431-The facility failed to ensure that biologicals for resident use were not expired. F441-The facility staff failed to change gloves after they were contaminated and failed to cleanse a pressure ulcer to prevent potential cross contamination during a dressing change. -F520-The facility failed to protect residents from abuse by failing to: 1) suspend employees after receiving reports of alleged verbal, psychological, and physical abuse ; and 2) immediately initiating an investigation of these allegations Interview with the Quality Assurance Coordinator on [DATE] at 3:40 PM revealed the committee had been working on skin care issues, infection control issues, and spot checking on cleaning. Monthly in-services were conducted with various topics like infection control, resident rights, severe weather, harassment and abuse/neglect. Review of the facility form entitled the Facility Quality Assurance Plan, no date of origin), revealed the Standard Quality Assurance was an organized structure, process, and procedures designed to ensure that care practices were consistently applied and the facility meets or exceeds an expected standard of quality. The quality deficiency was meant to describe a deficient or an area for improvement. | 2020-02-01 |
| 6995 | NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2014-12-11 | 323 | H | 0 | 1 | 9RWM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09d7 Based on observation, record review and interview; the facility staff failed to implement interventions and re-evaluate interventions to prevent falls for 3 residents (Resident 28, 41 and 46) and failed to secure medications and chemicals on the secured unit. The facility staff identified a census of 50. Findings are: A. Record review of an Admission record sheet dated 3-10-2014 revealed Resident 41 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 41's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9-19-2014 revealed the facility staff assessed the following about the resident; -BIMs (Brief Interview for Mental status) revealed Resident 41 scored a 5. According to the MDS Manuel, a score of 0 to 7 indicated severe impairment. -Required extensive assistance with transfers, bed mobility, dressing, personal hygiene and toilet use. -Falls occasionally. Record review of Resident 41's Quarterly Interdisciplinary Resident Review (QIRR) sheet dated 10-19-2014 revealed Resident 41 scored a 13 on the section that was identified a Devices, Restraints and Falls. According to the information on the QIRR sheet revealed a total score of 10 or above deemed the resident at risk. Record review of a Balance Assessment Screen (BAS) dated 10-19-2014 revealed Resident 41 scored a 3. According to the information on the BAS form, a score of 3 indicated a standing balance test could not be completed without physical help. Record review of Resident 41's Comprehensive Care Plan (CCP) reviewed on 9-10-2014 revealed Resident 41 was identified at risk for injury or falls related to weakness, dementia, poor balance and a history of falls. The goal was Resident 41 would not have any fall related injury requiring hospitalization . Intervention identified on the CCP included Foot wear to prevent slipping, Bed and wheelchair alarm. According to the CCP, this intervention was initiated on 6-09-2013 and reviewed on 9-09-2014. Further review of Resident 41's CCP revealed Resident 41 was incontinent with a goal to prevent Urinary Tract Infections (UTI) and a goal listed here dated 6-13-2013 was to use a chair alarm. Resident 41's CCP had a hand written entry dated 10-20-2014 that identified Resident 41 had a fall with a resulting laceration to the head that required staples. Record review of a Fax sheet dated 10-20-2014 revealed the facility had informed Resident 41's physician that Resident 41 had been sent to the hospital and received 3 staples. Record review of Resident 41's Verification of Investigation (VOI) dated 10-20-2014 revealed Resident 41 was found on the floor with a laceration and contusion noted to the right side of (the) head. According to the VOI dated 10-20-2014, Resident 41 was not able to verbalize what had happened due to impaired cognition related to dementia. Further review of the VOI revealed a section that had an area for staff to specify recommendations/interventions taken to prevent reoccurrence included a low bed, sensor alarms in the w/c (wheelchair) and bed. The VOI did not indicate if the alarm had been attached and sounding with the fall on 10-20-2014. On 12-09-2014 at 11:20 AM an interview was conducted with the Director of Nursing (DON). During the interview, Resident 41's CCP and the VOI dated 10-20-2014 was reviewed with the DON. The DON confirmed that according to Resident 41's CCP, Resident 41 should have had an alarm on prior to the fall on 10-20-2014. According to the DON, the alarm was removed as Resident 41 had not recently fallen. When asked if an evaluation to remove the alarm had been completed, the DON stated no. B. Record review of an Admission Record sheet dated 12-8-2014 revealed Resident 46 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 46's MDS dated [DATE] revealed Resident 46 was identified as independent with Activities of Daily living and required supervision with bathing. Record review of a VOI dated 10-17-2014 revealed Resident 46 had attempted (to) crawl out of the bath tub over the side of the tub instead of opening the tub door and fell . Accord to to the information in the VOI, Resident 46 was sent to the hospital for an evaluation. Further review of the VOI dated 10-17-2014 did not contain information that Resident had been supervised prior to the fall. An interview was conducted with the DON on 12-09-2014 at 2:41 PM. During the interview the DON reported the Bath Aid had set the resident up for the bath and left the room and stepped outside the door. The DON confirmed an evaluation had not been completed for independently bathing for Resident 46. C. Record review of the care plan for Resident 28 revealed: Resident 28 was admitted on [DATE] with the following diagnoses-Dementia, unspecified, with behavioral disturbance; other and unspecified [DIAGNOSES REDACTED]; unspecified essential hypertension; Obstructive chronic bronchitis without exacerbation. Record review of the admission Clinical Health Status record dated 11/06/2014 revealed: Resident 28 scored a 6 on the fall scale. A score of 10 or above deems resident at risk. Record review of the care plan dated 12/01/2014 revealed: At risk for falls related to: Wandering, Use of Medications, New environment, History of falls. Goal-No fall related injuries requiring hospitalization . Interventions-Assess for pain, provide medication or non-pharmacologic pain relief methods and appropriate, assess effectiveness. Assess that wheel chair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, anti-tippers. Call light or personal items available and in easy reach or provide reacher. Footwear to prevent slipping. Keep environment well lit and free of clutter. Observe for side effects of medications. Orientation to new room and roommate. Therapy services as ordered. Toilet schedule; assist resident to toilet in AM, before/after meals or activities, at HS (bedtime) and PRN (as needed). Provide incontinence cares as needed. A review of the VOI for Resident 28 revealed Resident 28 had fallen on 11/19/2014. Further review of Resident 28's VOI revealed there was no evidence of any new interventions implemented to prevent Resident 28 from further falls. Interview with the ACU (Alzheimer Care Unit) Director on 12/10/2014 at 7:35 AM revealed the following: confirmed that there were no new interventions identified nor were any new interventions care planned. D. During initial tour of the facility Alzheimer's Secured Unit on 12/01/2014 at 12:13 PM revealed the door to the bath house unlocked and the chemicals, Lemon-Eze and Neutral Disinfectant Cleaner, were located in an unlocked cabinet. Record review of the Safety Data Sheet dated 02/18/2014 from Ecolab for Lemon-Eze revealed: -Do not get in eyes, on skin, or on clothing. -Causes serious eye damage. -Keep out of reach. Record review of the Safety Data Sheet dated 02/18/2014 from Ecolab for Disinfectant Cleaner revealed: -Causes digestive tract, eye and skin burns. -Harmful if absorbed through skin or if swallowed. -Causes Respiratory tract irritation. -Corrosive to eyes and skin. -Causes burns to mouth, throat, and stomach. Interview with Alzheimer's Care Unit (ACU) Director on 12/01/2014 at 12:15 PM confirmed that the bath house door on the secured unit was left unlocked as well as the cabinet that contained the chemicals in it was also left unlocked. ACU Director also confirmed these chemical should be locked up and not accessible. E. During observation of meal service in the Alzheimer's Secured Unit on 12/04/2014 from 11:50 AM to 11:55 AM, in a small room connected to the main dining room, Resident 11 was sitting at the dining room table with a medication cup, containing 4 pills, sitting in front of the resident. No staff were in attendance in the small room. Resident 54 was sitting across the table from Resident 11. During this observation Resident 17 entered the room from the main dining room, walked around the table of Resident 11 and Resident 54, and exited the room going back into the main dining area. Observation on 12/04/14 at 11:55 AM revealed Resident 11 picked up the medication cup, dumped the pills in their hand and put the pills in Resident 11's mouth. Resident 11 picked up a glass of juice and took a drink. Observation on 12/04/2014 at 11:57 AM Licensed Practical Nurse (LPN) G walked into the small room adjoining to the dining room and revealed Resident 11 was given pills a few minutes ago and that Resident 11 was independent with medication administration but staff should stay with Resident 11 until Resident 11 took the pills. Interview with LPN G on 12/4/2014 at 11:57 AM, LPN G confirmed that Resident 11 should not be left alone with pills sitting in front of Resident 11 with wandering residents in the area. LPN G also revealed that staff should have stayed with Resident 11 until the pills were swallowed. Interview with the ACU Director on 12/04/2014 at 12:25 PM confirmed that medications were not to be left in front of a resident, unattended, at the dining room table with wandering residents in the area. The ACU director also confirmed that the expectation was to observe the resident swallow the medication | 2018-07-01 |
| 7001 | NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2014-12-11 | 490 | H | 0 | 1 | 9RWM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on record reviews, observations and staff interviews; the facility administration failed to maintain a system to prevent non-compliance with Federal and State regulations related to assuring residents were protected from injury due to hot water temperatures in resident care areas, Maintanance of the resident environment related to the condition of the facility and failed to implement interventions to prevent accidents. The facility census was 50. A. Record review of an unused and undated Maintenance Director Orientation information check list revealed at the section titled: Water Temperature revealed the following: -Notify the Executive Director immediately of any water Temperature above 110 degrees Fahrenheit. -Water must be shut down so that residents can not utilize in the affected area, until the temperature is returned to 110 degrees Fahrenheit. Record review of a Preventative Maintenance (PM) rounds sheet dated 9-15-2014 revealed the following information: -Bathing water temperature on the skilled side of the facility was 117.8 degrees. There was no temperature of the bathing water on the secured unit of the facility. Record review of a PM rounds sheet dated 11-27-2014 revealed the following information: -Bathing water on the skilled side of the facility was 117.8 degrees. There were not any temperature of the bathing water in the secured unit of the facility. Record review of a PM rounds sheet dated 12-02-2014 revealed the following information: -Bathing water on the skilled side of the facility was 123.5 degrees. There were not any temperatures obtained of the bathing water on the secured unit of the facility. -room [ROOM NUMBER], the handwashing sink water temperature was 123.5 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 123.2 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 124.5 degrees. -room [ROOM NUMBER], the handwashing sink water temperature was 124.8 degrees. Observation of water temperatures in the residents' handwashing sinks revealed the following: - 12-02-2014 at 12:08 PM, room [ROOM NUMBER],handwashing sink water temperature was 124.9 degrees. -12-02-2014 at 2:03 PM, room [ROOM NUMBER],handwashing sink water temperature was 128.4 degrees. -12-02-2014 at 12:09 PM, room [ROOM NUMBER], handwashing sink water temperature was 124.1 degrees. -12-02-2014 at 2:08 AM, room [ROOM NUMBER], handwashing sink water temperature was 129.2 degrees. -12-02-2014 at 12:13 PM, room [ROOM NUMBER]. handwashing sink water temperature was 127.2 degrees. An interview with the facility Maintenance Director (MD) was conducted on 12-02-2014 at 12:35 PM. During the interview, the MD reported having been employed at the facility about a year. When asked if (gender) had an orientation to the position and what the water temperatures should be for both, handwashing skins and bathing, the MD stated no. When asked what the water temperature should be for bathing and for resident handwashing sinks, the MD stated I'm not sure. A follow up interview was conducted with the MD on 12-02-2014 at 1:18 PM. During the interview, when asked about the bathing water temperatures in the secured unit , the MD stated I don't do that shower. On 12-03-2014 at 8:20 AM an interview was conducted with the facility Administrator. During the interview, the administrator reported the MD had been employed prior to the current Administrator. When asked about the MD orientation, the facility Administrator reported there was not any check list to indicate what the MD had been educated on in the facility. B. Observation the facility during an environmental tour on 12/09/2014 between 8:30 AM - 11:00 AM conducted with the facility Administrator and MD revealed the following areas: -Ventilation system not functioning in resident rooms were not functioning. -Urine odors noted in rooms: 115, 103, 113, 320, 324, and 325. -Caulking peeling or cracked behind the sink in the bathrooms and around toilet bases in resident rooms. -Kick guards of door chipped and or peeling away from the door of residents rooms. -Bolt sticking out of wall where old toilet paper hanger was located in residents rooms. -Rotting boards under heating/cooling unit in room [ROOM NUMBER]. -Behind the main nurses ' station, sink had coving and caulking coming away from the wall and caulking stained. Dark spots located on ceiling above the chart rack and red spots on wall above counter top to the left of the chart rack. -Alzheimer ' s unit kitchenette had sheet rock crumbling off the wall behind the sink and laminate bubbled and peeling off the back splash of counter behind the sink. Wall paper was peeling off the south wall by the window. An interview with Administrator and Maintenance Director on 12/09/2014 at 11:04 AM confirmed these findings during the environmental tour. C. Record review of Resident 41's Comprehensive Care Plan (CCP) reviewed on 9-10-2014 revealed Resident 41 was identified at risk for injury or falls related to weakness, dementia, poor balance and a history of falls. The goal was Resident 41 would not have any fall related injury requiring hospitalization . Intervention identified on the CCP included Foot wear to prevent slipping, Bed and wheelchair alarm. According to the CCP, this intervention was initiated on 6-09-2013 and reviewed on 9-09-2014. Further review of Resident 41's CCP revealed Resident 41 was incontinent with a goal to prevent Urinary Tract Infections [MEDICAL CONDITION] and a goal listed here dated 6-13-2013 was to use a chair alarm. Resident 41's CCP had a hand written entry dated 10-20-2014 that identified Resident 41 had a fall with a resulting laceration to the head that required staples. Record review of a Fax sheet dated 10-20-2014 revealed the facility had informed Resident 41's physician that Resident 41 had been sent to the hospital and received 3 staples. On 12-09-2014 at 11:20 AM an interview was conducted with the Director of Nursing (DON). During the interview, Resident 41's CCP and the VOI dated 10-20-2014 was reviewed with the DON. The DON confirmed that according to Resident 41's CCP, Resident 41 should have had an alarm on prior to the fall on 10-20-2014. According to the DON, the alarm was removed as Resident 41 had not recently fallen. When asked if an evaluation to remove the alarm had been completed, the DON stated no. | 2018-07-01 |
| 7005 | NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC | 285109 | 1420 NORTH 10TH STREET | NEBRASKA CITY | NE | 68410 | 2014-12-11 | 520 | H | 0 | 1 | 9RWM11 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interview; the facility Quality Assurance Plan failed to identify ongoing issues relevant to F166, F226, F242, F248, F250, F252, F272, F309, F323, F329, F353, F411, F431, F497, F499, 517 and implement effective plans of action to identify and correct the deficient practice. The Quality Assurance Plan failed to ensure the repeated deficiencies at F 253 and F371 were corrected and the correction maintained. The facility staff identified a census of 50. Findings are; A. An interview was conducted with the facility Administrator on 12-10-2014 at 7:13 AM. During the interview the facility Quality Assurance Program was reviewed with the Administrator. During the interview when asked if the facility staffing or hot water had been identified in the facility as a problem, the Administrator stated no. B. An interview with Licensed Practical Nurse (LPN) E was conducted on 12-10-2014 at 8:12 AM. During the interview, when asked what the Quality Assurance committee was and what the committee was working on, LPN E stated I don't know what they are working on. I don't know anything about it. C. An interview was conducted on 12-10-2014 at 8:16 AM with LPN F. When asked what the Quality Assurance committee was working on. LPN F stated I don't know. D. On 12-10-2014 at 8:20 AM an interview was conducted with Nursing Assistant (NA) K. During the interview, when asked what the Quality Assurance Committee was working on, NA K stated I don't know. E. On 12-10-2014 at 8:23 AM an interview was conducted with LPN L During the interview when asked what the Quality assurance committee was working on, NA L reported not being aware of what the committee was working on. | 2018-07-01 |
| 10210 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 318 | H | 0 | 1 | NRZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09D1, 12-006.09D1a Based on observation, record review and interview the facility failed to provide restorative services to residents with limited range of motion in order to prevent the further decline in range of motion. The facility had a census of 30 and a survey sample of 26. This affected Residents 12, 06 and 32. Findings are: A. According to the 6/18/12 ADMISSION and DISCHARGE SUMMARY Resident 12 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Observation on 07/23/2012 at 9:44 AM revealed that Resident 12 had bone deformities of the fingers and hands bilaterally. Review of the 2/17/12 MDS (Minimum Data Set -a federally mandated comprehensive assessment tool used for care planning) revealed the following assessment of Resident 12's ability: Toilet use - extensive assistance of one person, Personal Hygiene - extensive assistance of one person. Review of the 5/19/12 MDS revealed the following assessment of Resident 12's ability: Toilet use - limited assistance of one person, Personal Hygiene - limited assistance of one person. Resident 12 had improvement in toilet use and personal hygiene from 2/17/12 to 5/19/12. Review of an ADL FLOWSHEET (Activities of Daily Living) for the period of time 7/17/12-7/25/12 confirmed that the nurse aides were providing the following assistance for Resident 12: Toilet use - full staff performance of one person, Personal Hygiene - full staff performance of one person. Interview on 7/26/12 at 10:19 AM with MA-JM (Medication Aide) confirmed that Resident 12 was dependent on staff to assist with toileting, incontinence care and brushing teeth. Resident 12 required the assistance of one person for dressing. Resident 12 had decline in toilet use and personal hygiene from the 2/17/12 and 5/19/12 MDS assessments to the 7/17/12 documentation of actual care provided by the nursing staff. Review of the 6/1/11 CARE PLAN for Resident 12 revealed that Resident 12 was identified as a risk for development in functional joint mobility related to [MEDICAL CONDITION] Arthritis. The identified goal was for the resident to maintain current level of functional ability through the next review - 9/6/12. The interventions included: restorative program 1-5 times weekly, passive ROM (Range of Motion) to upper extremities 10 repetitions, Nu-step 10 minutes, monitor for increased pain with exercise, medicate as needed, praise the resident, report and document decline in abilities, refer to therapy as needed and may vary activities. The CARE PLAN had been revised and updated 3/8/12 and 6/6/12. Interview on 7/25/12 at 9:07 AM with Resident 12 about the CARE PLAN interventions revealed the resident was doing the following: ride the Nu-step twice a week (about 45 minutes each time), whirlpool two times a week, walk a mile twice daily, put hands under hot water and pull on the fingers to exercise them (unassisted by staff), fold aprons and exercise to the music at meals. The activities reported by Resident 12 did not match the CARE PLAN. Interview with NA-TB (Nurse Aide doing Restorative Care) on 7/25/12 at 7:47 AM confirmed that Resident 12 was on a restorative program. NA-TB reported that the documentation of implementing the restorative program was on RESTORATIVE CARE sheets. Review of the May, June and July, 2012 RESTORATIVE CARE sheets confirmed the following were being monitored and documented by NA-TB: Restorative Care 1-5 times a week, Chair Dance Tape, ROM to upper extremities - times 10 repetitions, Nu-Step for 10 minutes, Aprons, and Total minutes spent in restorative. The RESTORATIVE CARE monitoring and documentation did not match the CARE PLAN or the plan stated by the resident. The Chair Dance Tape was being monitored, however, Resident 12 reported on 7/25/12 at 9:07 AM that the resident had not watched a dance/exercise tape for 4-5 years. NA-TB reported that slash marks on the RESTORATIVE CARE sheets represented times when the activities did not occur. For the three months reviewed, the Chair Dance Tape never occurred, and the Apron folding occurred 4 times. The resident went without having ROM from May 1-21, June 1-19 and June 21-July 9. The facility failed to implement any of the restorative program on July 1-9. Interview with NA-TB on 7/25/12 at 7:47 AM confirmed that NA-TB was on vacation for the first 9 days of July and the facility had no staff assigned to implement the restorative programs when NA-TB was gone from the facility for any reason. Interview on 7/26/12 at 11:11 AM with the DON (Director of Nursing) confirmed that the facility had no method of ensuring that restorative programs were implemented in the absence of NA-TB. Review of a 7/11/12 monthly summary, documented by RN-S (Registered Nurse and MDS/Care Plan Coordinator) revealed that Resident 12 had no decline in functional ability and the resident ' s involvement in the restorative program was limited due to the resident's participation in activities. RN-S documented that the facility would continue to encourage and continue the present plan of care. RN-S failed to recognize that Resident 12 had documented declines in functional abilities such as toilet use and personal hygiene. RN-S failed to assess how Resident 12's restorative care could be implemented while allowing the resident to participate in desired activities. Interview on 7/26/12 at 9:06 AM with RN-S confirmed that the assessment of the extent of limited range of motion was evaluated by a medical practitioner and physical/occupational therapist. Resident 12 had the initial assessment of range of motion when admitted to the facility in 2004. Any declines in range of motion would be judged against that initial assessment. Another physical/occupational therapy evaluation could be done if the staff noticed declines in the resident's abilities. RN-S reported that Resident 12 had remained the same for many years so no further assessments from the therapists had been done. RN-S was unaware of the documented decline that Resident 12 had in toilet use and personal hygiene from the 2/17/12 and 5/19/12 MDS assessments to the 7/17/12 documentation of actual care provided by the nursing staff. Interview on 7/26/12 at 11:11 AM with the DON revealed resident 12 had not been evaluated by physical/occupation therapists for a long time. B. Review of an ADMISSION AND DISCHARGE SUMMARY dated 7/10/12 revealed Resident 32 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident 32's CARE PLAN dated 3/8/12 revealed the resident was to receive Restorative care 3-5 x a week or as tolerates. Review of RESTORATIVE CARE for July 2012 revealed no documentation that Resident 32 had received restorative care during the week of July 1-7, 2012. During an interview on 4/26/12 at 8:59 AM, NA-TB revealed no restorative care was done with Resident 32 the first week in July, as NA-TB was on vacation. NA-TB stated there was no one available to do restorative care when NA-TB was no working. C. Review of an 10/12/11 CARE PLAN revealed Resident 06 was admitted to the facility on [DATE]. The CARE PLAN also revealed Resident 06 had [DIAGNOSES REDACTED]. Observations on 7/19/12 at 2:49 PM revealed contractures present at the first joint of the fingers of both Resident 06's hands. During an interview on 7/19/12 at 11:47 AM, Resident 06 stated I don't due any exercises now. I do walk to meals and to activities. They haven't offered any exercises since I've been here, I've always done it myself. Resident 06 revealed arthritis caused the contractures in the fingers & I can't do anything about that. Review of the 11/10/11 MDS revealed the following assessment of Resident 06's ability: - Bed mobility - independent; and - Functional Limitation in Range of Motion - impairment on one side. Review of the 5/12/12 MDS revealed the following assessment of Resident 06's ability: - Bed mobility - limited assistance of one person; and - Functional Limitation in Range of Motion - impairment on one side. Review of an ADL FLOW SHEET for the period of time 5/6/12 - 5/12/12 confirmed Resident 06 received staff assistance with dressing and toilet use. Review of an ADL FLOW SHEET for the period of time 7/17/12 - 7/25/12 confirmed Resident 06 received staff assistance with dressing, toilet use, personal hygiene, and oral hygiene. During an interview on 7/25/12 at 720 AM, Licensed Practical Nurse-D revealed with the contractures in Resident 06's fingers, the resident would probably benefit from some therapy balls. During an interview on 7/25/12 at 8:10 AM, RN-S reviewed restorative services had been discussed with Resident 06 during the care plan meeting on 5/23/12 and Resident 06 had expressed (the resident) did not want to be involved in any therapy, and that Resident 06 did fine on (gender) own. Review of the Care Plan Conference Summary dated 5/23/12 revealed Restorative Therapy: Does not participate per (Resident 06's) choice. The summary did not explain what restorative services were offered to the resident or the reason Resident 06 did not want to participate in restorative. During an interview on 7/24/12 at 11:43 AM, Resident 06 revealed every once in a while the resident had used therapy balls and worked with them. Resident 06 stated it helped my fingers limber up. During an interview on 7/26/12 at 7:30 AM, MA-MJ revealed Resident 06 required assistance with applying poly-grip on (gender) dentures and with putting the resident's shoes and socks on. | 2016-02-01 |
| 10220 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 490 | H | 0 | 1 | NRZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.02 Based on observations, record reviews, and interview, the facility administration failed to utilize facility resources in a manner to achieve and maintain the highest practical physical, mental, and psychosocial well-being of each resident by 1) the failure to implement an effective plan of action to maintain correction for a previously cited area of deficient practice, and 2) the failure to ensure the facility identified and developed plans of action to identify multiple issues of deficient practice. The facility census was 30 and the survey sample size was 26. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance after the tacks of the annual standard survey was completed. Please reference the specific tags in regard to detailed findings: - F156 Failed to inform residents of items and services not covered by Medicaid benefits; - F157 Failed to notify residents' families of change in condition; - F159 Failed to ensure resident personal funds accounts were available on evenings and weekends, failed to pay interest on accounts over $50, and failed to provide quarterly statements; - F161 Failed to secure a surety bond for assurance of residents' financial security; - F166 Failed to address residents' grievances; - F176 Failed to assess residents for the ability to self-medicate; - F224 Failed to protect residents belongings; - F225 Failed to report to the State agency and investigate allegations of abuse, neglect, misappropriation and injuries of unknown origin; - F226 Failed to screen new employees and failed to protect residents during abuse/neglect investigations; - F242 Failed to honor the residents' right to choose what time to get up in the morning; - F248 Failed to plan and implement activities of residents interests; - F253 Failed to provide a clean and well-maintained environment; - F258 Failed to provide comfortable sound levels; - F272 Failed to complete comprehensive assessments of residents needs; - F279 Failed to develop comprehensive care plans that addressed residents needs; - F280 Failed to revise the comprehensive care plan to reflect the actual care provided to residents; - F281 Failed to follow standards of practice for medication administration, following physicians orders, and accurate documentation; - F309 Failed assess and identify causal factors for change in condition, pain, skin conditions, and anxiety in residents; - F318 Failed prevent the decrease in residents' range of motion; - F323 Failed to implement intervention to prevent resident falls; - F327 Failed to monitor residents' fluid restrictions; - F329 Failed to ensure resident medications had indications for usage and failed to implement non-pharmacological interventions prior to the use of psychoactive medications; - F333 Failed to ensure residents were free of significant medication errors; - F334 Failed to ensure residents pneumococcal immunization were current; - F356 Failed to ensure the posting of nurse staffing was accessible, visible and accurate; - F406 Failed to provide psychological services; - F428 Failed to ensure the consultant pharmacist identified and reported irregularities in residents medication regimen; - F441 Failed to follow infection control program related to hand hygiene and the tracking and trending of infections; - F492 Failed to ensure compliance with applicable Federal and State laws and regulations; - F496 Failed to receive Nurse Aide Registry verification prior to nurse aide employment; - F497 Failed to complete Nurse Aide performance reviews and competence in-service training; - F498 Failed to ensure Nurse Aides were able to demonstrate competency in skills needed to care for residents; - F500 Failed to have agreements with outside sources for the provision of services; - F501 Failed to ensure the Medical Director provided oversight for the coordination of resident care; - F503 Failed to obtain a contract for the provision of laboratory services; - F506 Failed to obtain an agreement for the transportation of residents to laboratory services; - F509 Failed to obtain a contract for the provision of radiology services; - F512 Failed to obtain an agreement for the transportation of residents to radiology services; - F514 Failed to ensure accurate and completed documentation in residents medical records; - F520 Failed to maintain an effective Quality Assurance Program. B. The facility administration failed to maintain corrections of the following tags cited during the previous annual survey completed 7/14/11: F253, F333, and F441. C. The facility administration failed to provide the Medical Director required documentation to fulfill the Medical Director's duties. D. Review of the facility's undated policy Long Term Care Continuous Quality Improvement Plan (CQI) revealed: Authority: 2. The administrator has been delegated responsibility for assuring the CQI Program of this facility is in compliance with federal, state , and local regulatory agency requirements. E. During an interview on 7/31/12 at 8:45 AM, Administrator revealed policies and procedures for the Long Term Care had disappeared when the past Director of Nursing (DON) had left the facility in December 2011. The Administrator revealed the policies and procedures hadn't all been replaced. The Administrator revealed no knowledge whether or not the Long Term Care policies and procedures were on the computer or if they could be reprinted. The Administrator stated it wouldn't make a difference because if the past DON had written policies and procedures on a computer program, they would be password protected and the facility wouldn't have access to them. F. During an interview on 7/31/12 at 9:10 AM, Director of Nursing revealed the past DON had left the facility in [DATE] and the new DON began employment on March 12, 2012. The DON revealed when (gender) started the DON was unable to find any policies or procedures for the Long Term Care. The DON revealed staff had reported they did not have access to any of the policies or procedures, and explained the past DON would just pull a policy out of a notebook from the DON's office if one was needed. The DON revealed a policy and procedure manual had not been placed at the nurses station so staff could have access to them. | 2016-02-01 |
| 10232 | KEARNEY COUNTY HEALTH SERVICES | 2.8e+298 | 727 EAST 1ST STREET | MINDEN | NE | 68959 | 2012-08-01 | 520 | H | 0 | 1 | NRZX11 | LICENSURE REFERENCE NUMBER: 175 NAC 12-006.07C Based on observations, record review, and interviews conducted during the annual standard survey; the facility failed to ensure the Quality Assessment and Assurance Committee (QA&A) failed to identify areas of deficient practice. The QA&A committee also failed to develop and implement plans of action to correct multiple issues of deficient practice relevant to resident care and services The facility failed to implement plans of action to maintain correction for previously cited areas of deficient practice identified during survey on 9/27/11, 7/14/11, 11/9/10, 5/5/10, 5/27/09, 12/23/08, and 6/4/08. The facility census was 30. Findings are: A. Review of the facility's undated policy Long Term Care Continuous Quality Improvement Plan (CQI) revealed: - Policy Statement: This facility shall develop, implement, and maintain an ongoing program designed to monitor and evaluate he quality of resident care, pursue methods to improve quality care, and to resolve identfied problems. - Authority: 2. The administrator has been delegated responsibility for assuring the CQI Program of this facility is in compliance with federal, state, and local regulatory agency requirements. - Goals of the Committee: 1. To monitor and evaluate the appropriateness and quality of care provided within the framework of the CQI Plan; and 2. To provide a means whereby negative outcomes relative to resident care can be identified and resolved through an interdisciplinary approach, and positive outcomes can be reinforced through education and monitoring. - Committee Actions: 1. The committee will develop and implement plans of action to correct identified negative care outcomes. B. The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the annual standard survey were completed. The facility failed to maintain corrections for the regulations identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the areas identified below. Please refer to the Tag citations for specific detailed findings: - F156 Failed to inform residents of items and services not covered by Medicaid benefits; - F157 Failed to notify residents' families of change in condition; - F159 Failed to ensure resident personal funds accounts were available on evenings and weekends, failed to pay interest on accounts over $50, and failed to provide quarterly statements; - F161 Failed to secure a surety bond for assurance of residents' financial security; - F166 Failed to address residents' grievances; - F176 Failed to assess residents for the ability to self-medicate; - F224 Failed to protect residents belongings. Previously cited on 9/27/11 and 5/27/09; - F225 Failed to report to the State agency and investigate allegations of abuse, neglect, misappropriation and injuries of unknown origin; - F226 Failed to screen new employees and failed to protect residents during abuse/neglect investigations; - F242 Failed to honor the residents' right to choose what time to get up in the morning; - F248 Failed to plan and implement activities of residents interests; - F253 Failed to provide a clean and well-maintained environment. Previously cited on 7/14/11 and 6/4/08; - F258 Failed to provide comfortable sound levels; - F272 Failed to complete comprehensive assessments of residents needs; - F279 Failed to develop comprehensive care plans that addressed residents needs; - F280 Failed to revise the comprehensive care plan to reflect the actual care provided to residents. Previously cited on 12/23/08; - F281 Failed to follow standards of practice for medication administration, following physicians orders, and accurate documentation. Previously cited on 5/5/10, 5/27/09, and 12/23/08; - F309 Failed assess and identify causal factors for change in condition, pain, skin conditions, and anxiety in residents. Previously cited on 11/9/10; - F318 Failed prevent the decrease in residents' range of motion; - F323 Failed to implement intervention to prevent resident falls. Previously cited on 5/27/09 and 6/4/08; - F327 Failed to monitor residents' fluid restrictions; - F329 Failed to ensure resident medications had indications for usage and failed to implement non-pharmacological interventions prior to the use of psychoactive medications; - F333 Failed to ensure residents were free of significant medication errors. Previously cited on 7/14/11 and 6/4/08; - F334 Failed to ensure residents pneumatically immunization were current; - F356 Failed to ensure the posting of nurse staffing was accessible, visible and accurate; - F406 Failed to provide psychological services; - F428 Failed to ensure the consultant pharmacist identified and reported irregularities in residents medication regimen; - F441 Failed to follow infection control program related to hand hygiene and the tracking and trending of infections. Previously cited on 7/14/11, 5/27/09, and 6/4/08; - F492 Failed to ensure compliance with applicable Federal and State laws and regulations; - F496 Failed to receive Nurse Aide Registry verification prior to nurse aide employment; - F497 Failed to complete Nurse Aide performance reviews and competence in-service training; - F498 Failed to ensure Nurse Aides were able to demonstrate competency in skills needed to care for residents. Previously cited on 5/27/09; - F500 Failed to have agreements with outside sources for the provision of services; - F501 Failed to ensure the Medical Director provided oversight for the coordination of resident care; - F503 Failed to obtain a contract for the provision of laboratory services; - F506 Failed to obtain an agreement for the transportation of residents to laboratory services; - F509 Failed to obtain a contract for the provision of radiology services; - F512 Failed to obtain an agreement for the transportation of residents to radiology services; - F514 Failed to ensure accurate and completed documentation in residents medical records. Previously cited on 6/4/08; - F520 Failed to maintain an effective Quality Assurance Program. C. During an interview on 7/26/12 at 4:02 PM, the Quality Assurance Coordinator (QA-C) revealed the QA&A Committee receives concerns and problems from a lot of sources including incident reports, resident council meetings, care plan meetings, audits on resident rights, hand washing audits, past surveys, and nursing home compare website. The QA-C revealed a lot of medication errors, documentation problems, medication omissions had been identified, and felt was a problem with a lack of accountability. The QA-C revealed the QA&A Committee had not identified or addressed the following issues: - investigations to ensure they were completed and not addressed the need for education; - review Long Term Care policies and procedures; - orientation for new employees to ensure lift education was adequate for staff to use the lifts, splint, and other equipment ; - schedule of physical or occupational therapy interfering with resident activities; - documentation issues, including the accuracy of documentation; - usage of the mechanical lifts (2 staff employed for 6 months didn't know how); - resident trust accounts; - infection control and hand washing was one of our first studies in January. The QA-C stated I don't know if direct care staff know how to access the QA committee. The QA-C revealed no one had looked at education about documentation for a long, it was probably more than 5 years ago. . During an interview on 7/26/12 at 3:00 PM, Medication Aide (MA)-MM stated I don't' think they have a QA Committee. MA-MM revealed the MA didn't know who was on the QA&A committee. An interview with Nurse Aide (NA)-KS on 7/26/12 at 3:10 PM, revealed if the NA-KS had a concern, the NA would tell Registered Nurse-S or the Director of Nursing (DON), but was not sure whether or not they were on the committee. NA-KS revealed sometimes the facility would have changes in process or the way to do things, but those were signed by the DON and didn't know if the QA&A Committee was involved in those changes or not. An interview with NA-HB on 7/26/12 at 3:15 PM, revealed NA-HB thought the facility had a QA&A committee, but was not sure who was on it or how to access the committee. | 2016-02-01 |
| 11269 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 309 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on observations, record review and staff interview; the facility failed to provide care and treatment to promote healing of wounds for Residents 17, 28, and 35. Facility census was 33. Findings are: A. Review of facility policy for Actual Impaired Skin Integrity (no date indicated) revealed residents with impaired skin integrity as a result of pressure ulcers, vascular ulcers, rashes, skin tears, surgical sites and diabetic/neuropathic ulcers were to receive interventions which included the following: -Medications and treatments as ordered -Encouragement and assistance to turn and reposition every 1 - 2 hours -Measure/assess wound and skin check every week -Notify physician of signs and symptoms of impaired skin integrity -Notify physician as needed for lack of response to treatment if no improvement noted within 2-4 weeks as indicated/appropriate -Monitor status of surrounding skin every day and notify physician as needed of noted impairment -Monitor for signs/symptoms of infection or other complication and notify physician as needed B. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/27/14 indicated the resident was admitted to the facility 2/19/14 with [DIAGNOSES REDACTED]. Review of Resident 17's Treatment Flowsheet (a record of treatments provided by nursing) for 2/2014 revealed a physician's order dated 2/19/14 for saline wet-to-dry dressings (A gauze pad soaked in saline and placed on the surface of a wound bed, followed by a dry dressing pad placed on top of the wet dressing) to left lateral ankle BID (2 times daily) at 10:00 AM and 10:00 PM. Documentation revealed the 10:00 AM dressing change to Resident 17's ankle was not documented from 2/19/14 to 2/25/14 (6 of 13 dressing changes in 7 days). Review or Resident 17's Care Plan dated 2/25/14 indicated the resident had an open wound to the left lateral ankle and included the following interventions: - dressing changes 3 times weekly by Physical Therapy (PT) assisted by the Case Manager (a nurse employed by the facility), - area monitored by PT and Case Manager, - area measured by PT with every dressing change, and - measure the area weekly with skin assessments and document. Review of Treatment Flowsheets dated 2/2014 and 3/2014 revealed the 10:00 AM dressing change to Resident 17's ankle was not documented on 2/26/14, 2/27/14 and 2/28/14, and the 10:00 PM dressing change was not documented on 2/27/14, 2/28/14 and 3/5/14 (6 of 16 dressing changes in 8 days). Review of a Visit Summary by Resident 17's physician dated 3/5/14 indicated an order to continue dressing changes BID, and "should be as close to q (every) 12 hours as possible". The physician further ordered the wound to be measured weekly. Review of Treatment Flowsheets for 3/2014 and 4/2014 revealed the following: - On 3/5/14 the wound measured 5.4 cm (centimeters) x (by) 2.2 cm (This was the first documentation of the size of the wound since the resident was admitted on [DATE].) - The wound was measured weekly on 3/12/14, 3/19/14, 3/26/14 and 4/2/14 with a decrease in size noted. - There was no documentation of measurement of the wound after 4/2/14. - The 10:00 AM dressing change was not documented on 17 of 56 days, and the 10:00 PM dressing change was not documented on 3 of 56 days (20 of 112 dressing changes in 56 days). Review of PT Evaluation and Daily/Weekly Progress Notes dated 2/20/14 through 5/22/14 revealed no evidence to indicate PT measured the wound or completed dressing changes 3 times weekly. Review of the Treatment Flowsheet dated 5/2014 revealed the following: - Measurements of Resident 17's wound were not recorded. - The 10:00 AM dressing change was not documented on 3 of 5 days from 5/1/14 through 5/5/14. - Documentation indicated "new times start 5/6/14", and the morning dressing change was to be done between the hours of 6:00 AM and 2:00 PM and the evening dressing change between the hours of 6:00 PM and 11:00 PM. - From 5/6/14 through 5/31/14, Resident 17's morning dressing change was not documented on 6 of 26 days, and the evening dressing change was not documented on 1 of 26 days (7 of 52 dressing changes in 26 days). - There was no documentation to indicate the actual time of the dressing change within the ranges specified in order to assure a 12 hour interval between dressing changes as recommended by the physician. Review of Resident 17's medical record revealed no physician's order to change the timing of dressing changes. Review of a Referral Form dated 6/2/14 indicated Resident 17's wound to the left lower leg was treated since admission and had improved, however, "in the last week it has declined and the overall size has increased". A physician's order was obtained for PT to evaluate and treat the resident's wound. Review of a Wound Assessment Tool completed by the PT and dated 6/4/14 indicated Resident 17 ' s wound on the left lower leg measured 4.7 cm x 1.6 cm x 0.1 cm (depth). This was the first recorded measurement of the wound since 4/2/14 and represented an increase in size of the wound. The PT recommended daily wound dressing changes to be performed by nursing staff using [MEDICATION NAME] gauze or xeroform gauze (non-adhering mesh dressings used to treat wounds) to the wound bed followed by a non-adhesive pad, cotton bandage and tape. Documentation indicated PT would inspect the wound weekly and make further recommendations as needed. Review of an Addendum to Wound Assessment Tool completed by PT and dated 6/5/14 revealed PT would work with Resident 17 on left lower leg wound care 3 times weekly for 4 weeks. Documentation further indicated PT would provide guidance and instruction to nursing staff regarding wound care and dressing changes for the days PT did not perform the wound care. Review of the Treatment Flowsheet dated 6/2014 indicated the following: - Beginning 6/8/14 the dressing change would be done 3 times weekly on Monday, Wednesday and Friday by PT, and nursing was to complete dressing changes on the other 4 days of the week to assure daily dressing changes were completed. - There was no evidence to indicate nursing staff changed the dressing on Thursday 6/12/14, Saturday 6/14/14, Sunday 6/15/14, Thursday 6/19/14, Saturday 6/21/14, Sunday 6/22/14, and Thursday 6/26/14. Review of Daily/Weekly Progress Notes by PT dated 7/1/14 through 7/30/14 revealed PT performed wound dressing changes and measurements 3 times weekly. Review of Nursing Progress Notes dated 7/1/14 through 7/31/14 revealed nursing staff performed the wound dressing 1 time on 7/19/14 (which indicated the dressings were not changed daily as ordered). Review of a PT Discharge Summary dated 7/30/14 indicated Resident 17's left lower leg wound measured 3.0 cm x 1.1 cm x 0.1 cm which was a decrease in size. Review of the Treatment Flowsheet for 8/2014 revealed a physician's order dated 8/1/14 to dress Resident 17's leg wound as recommended by PT. The physician's order included the following: -Change the dressing every other day (qod) -Measure and document the wound length, width and depth qod -Cover the wound bed with [MEDICATION NAME] (a type of dressing used to treat wounds) cut slightly smaller than wound margins to allow granulation tissue (new tissue that forms on the surface of a wound during the healing process) to close inward -Cover the [MEDICATION NAME] with [MEDICATION NAME] (a non-adhesive dressing) and secure with kerlix (a gauze dressing) and Ace wrap (an elastic bandage) Review of a Medication Error report dated 8/5/14 revealed Resident 17's treatment to left lower leg was incorrectly performed by nursing staff on 8/3/14. Documentation indicated the wound measured 5.0 cm x 3.0 cm x 0.1 cm (an increase in size from measurements 7/30/14) because the [MEDICATION NAME] was not cut smaller than the wound margins as instructed, and therefore, "ruined healthy healed skin surrounding" . Documentation on the Treatment Flowsheet revealed the dressing change was performed qod except Friday 8/29/14. Review of Weekly Skin Integrity Action Tool (skin sheet used by nursing to document assessment and measurements of wounds) for 8/2014 revealed the following: -Resident 17's wound was not measured and assessed qod with dressing changes as ordered as no measurements were recorded on 8/1/14, 8/3/14, 8/7/14, 8/9/14, 8/11/14, 8/17/14, 8/21/14, 8/23/14, 8/25/14, 8/29/14 and 8/31/14. -The wound measured 3.2 cm x 1.7 cm on 8/13/14 and 4 cm x 2.4 cm on 8/27/14 (the depth of the wound was not documented) -The size of the wound had increased Review of the Treatment Flowsheet for 9/2014 indicated a physician's order dated 9/3/14 to change the treatment to saline wet-to-dry dressings to left lower leg wound BID at 7:00 AM and 8:30 PM. Documentation indicated the dressing change was performed BID from 9/3/14 through 9/15/14. Review of Weekly Skin Integrity Action Tool for 9/2014 revealed Resident 17's wound was not assessed or measured by nursing staff. Review of a PT Evaluation form dated 9/15/14 revealed Resident 17's leg wound measured 3.4 cm x 1.8 cm x 0.1 cm. Documentation further indicated the wound was being treated by nursing staff per PT recommendations, however, the treatment "was not followed exactly" . During interview on 12/1/14 at 5:00 PM, the Director of Nursing (DON) verified wound dressing changes on Resident 17's left lower leg were not performed in accordance with physician's orders and PT recommendations. The DON further verified assessments and measurements of the resident's wound were not completed by nursing staff in accordance with the plan of treatment. C. Review of Resident 28's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of a facsimile (fax) dated 11/21/14 at 7:52 PM revealed Resident 28's physician was notified of a "...burn from hot coffee." The resident spilled coffee and sustained reddened skin areas on the inner left thigh from groin to knee and a 3 cm area on the left inner foot. Cool water was applied to the site followed by [MEDICATION NAME] (topical cream used to treat burns). Documentation further indicated 45 minutes later the redness to the resident's inner thigh had decreased to "...mid inner thigh approx.(approximately) 5 cm" and the reddened area to the foot had "...decreased as well." No further treatment was ordered by the physician other than to "Observe". Review of Resident 28's Progress Notes revealed no evidence to indicate the burn injury was monitored and treated until 11/23/14 at 2:37 AM (over 24 hours later). Documentation stated "...Blistering showing in leg burn yesterday that occurred during supper time. [MEDICATION NAME] applied". The location of the blistered skin areas of the leg were not identified and measured. There was no evidence to indicate assessment and monitoring of the burn until 11/24/14. Review of Resident 28's Progress Notes dated 11/24/14 at 2:52 AM documented "...burn to left inner thigh, blister the size of quarter has popped and skin is very red, superficial, open wound noted. Area around wound is red, area to left inner knee red, and left foot is red. When asked what happened to resident, aide tells this nurse that resident spilled coffee on (self) on 11/21/14". Documentation indicated a plan to notify the physician for orders for ointment or some type of dressing. On 11/24/14 at 1:30 PM, Nursing Assistant (NA)-B was observed assisting Resident 28 out of bed. The resident had an open skin area on the left inner thigh from a blister that had popped. The area was not measured at that time but the approximate size was larger than a 50 cent piece. During interview on 11/25/14 at 10:40 AM, the Director of Nursing (DON) verified Resident 28's left inner thigh wound had not been measured. The DON indicated the physician was notified for treatment orders on 11/24/14 and the physician ordered application of [MEDICATION NAME] to the wound 2 times daily. Review of a Weekly Wound Record initiated 11/25/14 revealed Resident 28 had a wound on the left inner thigh that measured 3.8 cm x 4.7 cm on 11/25/14. On 11/30/14 the wound measured 3 cm x 3.8 cm. D. Review of Resident 35's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident had moisture associated skin damage. Review of Transfer and Referral Record from the hospital dated 9/17/14 revealed Resident 35's coccyx was slightly reddened. Review of Resident 35's Progress Notes dated 9/17/14 at 4:02 PM revealed the resident's skin was described as "....warm dry and intact". There was no evidence to indicate the resident's coccyx or buttock area was reddened. Review of Admission and Weekly Skin Integrity Action Tool dated 9/24/14 revealed no evidence to indicate Resident 35 had a skin integrity problem. Review of Admission and Weekly Skin Integrity Action Tool dated 10/6/14 and 10/13/14 revealed Resident 35's buttocks were reddened and [MEDICATION NAME] (topical medication containing menthol and zinc oxide which protects skin from moisture and minor irritation) cream was applied after incontinent brief changes. There was no further assessment regarding the resident's reddened buttocks area. Review of Physician Orders dated 10/16/14 revealed orders for [MEDICATION NAME] (topical medication used to treat minor skin irritation by forming a barrier on the skin to protect it from irritants/moisture) cream as needed and [MEDICATION NAME] cream as needed. Review of Resident 35's Medication Flowsheet dated 10/2014 revealed an order for [REDACTED]. Review of the Admission and Weekly Skin Integrity Action Tool dated 10/20/14 revealed Resident 35's buttocks were red and [MEDICATION NAME] was used with incontinent brief changes. There was no documentation on the Admission and Weekly Skin Integrity Action Tool dated 10/27/14 regarding Resident 35's skin condition. Review of the Admission and Weekly Skin Integrity Action Tool dated 11/3/14, 11/10/14 and 11/17/14 revealed no assessment or documentation regarding Resident 35's reddened buttocks area. Review of progress notes dated 11/19/14 at 7:15 PM indicated the resident was seen by the physician due to possible yeast infection beneath the resident's breasts and lower abdominal folds and "...Do show MD residents bottom". There was no assessment or documentation regarding the skin condition on the resident's buttocks/coccyx area. Review of Resident 35's Medication Flowsheet dated 11/1/14 through 11/24/14 revealed no evidence to indicate [MEDICATION NAME] or [MEDICATION NAME] creams had been used. Review of the Admission and Weekly Skin Integrity Action Tool dated 11/24/14 revealed no assessment or documentation regarding Resident 35's buttocks area. Nursing Assistants A and E were observed to provide Resident 35's perineal hygiene on 11/25/14 at 7:35 AM. The skin on the resident's buttocks, coccyx and rectal areas was red and excoriated. Nursing Assistant (NA)-E stated the reddened excoriated areas had "gotten better then gets worse again" and "it comes and goes". NA-A and NA-E indicated [MEDICATION NAME] (topical cream containing menthol and zinc oxide) was applied each time incontinent care was provided. | 2015-07-01 |
| 11271 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 314 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record review and staff interviews; the facility failed to identify the presence of pressure sores and/or to provide identified interventions for the prevention and treatment of [REDACTED]. Facility census was 33. Findings are: A. Review of facility policy titled "Pressure Sore Prevention and Monitoring Guidelines" (revised 6/13) revealed the goal of the facility was to maintain skin integrity. If a resident developed a pressure sore, the resident was to receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Upon identifying a pressure sore the licensed nurse was to perform the following procedures: -Notify the physician for orders to treat each pressure sore identified. -Notify resident's responsible party and physician regarding change in condition. -Ensure pressure sores are identified with goals and interventions to be addressed on the resident's Care Plan. -Schedule weekly head to toe skin assessments. -Notify the Dietary Manager and the Registered Dietician for recommendations to ensure adequate caloric and protein needs as applicable. -All pressure sores will be assessed weekly. B. Review of facility policy titled "Dressing-Non-sterile Treatment" (revised 6/13) revealed the policy of the facility was to perform treatments and dressing changes per physician orders. The licensed nurse was to follow the following procedure: -Review physician treatment orders. -Prepare clean field. -Create a barrier for dressing supplies and place on the clean field. -Wash hands. -Apply clean gloves -Remove soiled dressing and place in a biohazard container. -Remove gloves and wash hands. -Apply clean gloves. -Clean wound per physician order. Clean wound from the center to the outer borders using a circular motion (area of most contamination to the area of the least). Ensure you do not contaminate the wound bed. -Remove gloves and wash hands. -Apply clean gloves. -Apply dressing as ordered. -Remove gloves and wash hands. C. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/14 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 38 had the following pressure sores identified: -Two Stage 2 pressure sores (The staging system is a method of summarizing certain characteristics of pressure sores, including the extent of tissue damage. Stage 2 refers to partial thickness skin loss that presents as an abrasion, blister or shallow crater). -Two Stage 3 pressure sores (full thickness skin loss with damage to subcutaneous (under the skin) tissue). -One unstageable pressure sore (unstageable refers to a full thickness tissue loss in which the base of the sore is covered by slough and/or eschar (dead tissue) in the wound bed). -One unstageable pressure sore with suspected deep tissue injury (pressure related injury to subcutaneous tissue). The MDS identified use of pressure reducing devices to chair and bed, a turning and repositioning program, nutritional and hydration interventions, pressure sore care and application of non-surgical dressings. Review of Resident 38's admission physician orders [REDACTED]. Review of Resident 38's "Wound Assessment Tool" dated 10/8/14 revealed the resident had a 9.5 centimeter (cm) by 5.7 cm pressure sore with 10 cm depth to gluteal sacral area (lower back above the buttock crease) and a 4 cm by 3.7 cm pressure sore with 3 cm depth to left [MEDICATION NAME] area (upper back). Review of Resident 38's "Weekly Pressure Sore Record" dated 10/8/14 revealed the resident had a stage 3 pressure sore (no measurements) to the left heel which was debrided (removal of eschar to promote healing). Review of Resident 38's Care Plan with revision date 10/8/14 reflected the resident had a stage 3 pressure sore to sacral gluteal area and a stage 3 pressure sore to [MEDICATION NAME] area. The following interventions were identified: -[DEVICE] to [MEDICATION NAME] and gluteal pressure sores with dressing change to be completed by PT 3 times per week. -Case Manager to update physician on wound progress. -Avoid shearing skin when repositioning resident. -Conduct a skin inspection weekly. -Observe and report signs [MEDICAL CONDITION] or osteo[DIAGNOSES REDACTED]. -To wear heel pressure booties at all times to bilateral feet. -High protein diet. Further review of the resident 38"s Care Plan revealed no documentation related to the presence of a stage 3 pressure sore to the resident's left heel. Review of Resident 38's "Wound Assessment Tool" dated 10/10/14 and completed by PT revealed Resident 38's gluteal sacral pressure sore measured 11.0 cm by 5.6 cm with 5 cm depth (1.5 cm increase of wound length from measurements on 10/8/14). review of the resident's medical record revealed [REDACTED]. sacral pressure sore. Review of Resident 38's Progress Notes dated 10/10/14 at 4:30 PM revealed PT dressed the areas to the resident's left foot with Vaseline gauze (non-adherent absorbent dressing impregnated with white [MEDICATION NAME]). Review of Resident 38's medical record revealed no further documentation or assessment of the pressure sore to the resident's left heel. Review of Resident 38's "Wound Assessment Tool" completed by PT revealed the following measurements and assessments for the pressure sore to Resident 38's gluteal sacral wound: -10/13/14- 9.0 cm by 5.6 cm with 6 cm depth. -10/15/14- 10.4 cm by 4.5 cm with 5 cm depth (1.4 cm increase of wound length from measurement on 10/13/14) -10/17/14- 8.7 cm by 5.4 cm with 3 cm depth. -10/20/14- 9.9 cm by 5.2 cm with 3.7 cm depth ( 1.2 cm increase in length and .2 cm increase in depth since measurement on 10/17/14) -10/22/14- 5 cm by 8.5 cm with 2.7 cm depth (3.3 cm increase in width since measurement 10/20/14) -10/24/14- 5.2 cm by 10 cm with 2.7 cm depth (1.5 cm increase in width since measurement on 10/22/14) -10/26/14- Increased odorous drainage noted to dressing when removed. Review of Resident 38's medical record from 10/13/14 to 10/26/14 revealed no documentation to indicate the resident's physician was notified of the increased measurements and of the increased odorous drainage to the resident's gluteal sacral pressure sore. Review of Resident 38's "Wound Assessment Tool" completed by PT on 10/24/14 revealed due to increased odor and drainage the therapist debrided necrotic area to left heel pressure sore. The wound was covered with Vaseline gauze and secured with [MEDICATION NAME] and gauze. Review of Resident 38's medical record revealed no further documentation or assessment of the pressure sore to the resident's left heel. Review of Resident 38's Medication Administration Record [REDACTED]. Further review revealed the resident only received a snack on 10/26/14 and 10/27/14 (2 out of 24 days). Review of the Registered Dietician's Progress Note dated 11/5/14 at 12:52 PM (8 days after Resident 38 was admitted to the facility) revealed the resident was receiving an extra glass of milk and large portions of meat with all meals for added protein. Further review of the Registered Dietician's documentation revealed no documentation of Resident 38's caloric or protein intakes and no further assessment or recommendations for the resident's needs. Review of the Resident 38's medical record from 10/25/14 to 11/7/14 revealed no further assessment or documentation to the pressure sore on the resident's left heel. Review of Resident 38's "Wound Assessment Tool" completed by PT revealed the following measurements and assessments for the pressure sore to Resident 38's left heel: -11/7/14- 1.2 cm length by 1.3 cm width with 0.3 cm depth. The pressure sore had minimal drainage and minimal odor. -11/10/14- assessment revealed the pressure sore continued to have drainage with minimal odor and skin surrounding wound bed was red and swollen. Therapist used [MEDICATION NAME] (ointment used to treat a bacterial infection) on wound and covered the pressure sore with [MEDICATION NAME] (dressing which is used to help control the growth of bacteria) dressing and gauze wrap. -11/12/14- 1.5 cm length by 1.3 cm width and 0.3 cm depth. (.3 cm increase in length since measurements on 11/7/14) -11/17/14- assessment revealed maceration (break down of skin resulting from prolonged exposure to moisture) to skin surrounding wound bed with an increased odor. Review of Resident 38's medical record from 11/10/1 4 to 11/17/14 revealed no documentation that the resident's physician was notified of the change in the left heel pressure sore. During observations on 11/17/14 from 7:01 AM to 8:21 AM, Resident 38 was observed in the resident's room with no pressure relieving devices to bilateral feet. During observations on 11/20/14 from 11:56 PM to 12:55 PM, Resident 38 was observed seated in a wheelchair with no pressure relieving device to the right foot and the right heel resting directly on the surface of an unpadded foot pedal. Observation of the dressing change to Resident 38's pressure sores to gluteal sacral area, [MEDICATION NAME] area and left heel on 11/24/14 from 9:10 AM to 10:15 AM, revealed PT-J removed the [DEVICE] dressing to the resident's gluteal sacral wound. Without removing soiled gloves, PT-J measured the pressure sore, cleansed the skin approximately 6 inches on all sides around the perimeter of the wound with alcohol, applied a skin protectant to the skin around the wound bed and applied several strips of the transparent drape approximately 6 inches away from the wound, right up to the wound edges. PT-J removed soiled gloves but without washing or cleansing hands, donned clean gloves and proceeded to pack the wound bed with strips of foam which had been cut and shaped to fit the wound bed. PT-J applied [MEDICATION NAME] ointment to the foam used to pack the center of the wound bed followed by application of additional transparent drape over the foam packing. While still wearing soiled gloves, PT-J used a pair of tweezers to tuck the sides of the drape into the borders of the wound bed, cut a 2 cm hole in the center of the transparent drape directly over the top of the pressure ulcer, attached a pad with tubing over the hole and attached the tubing to the canister of the [DEVICE]. PT-J removed soiled gloves but did not wash or cleanse hands before donning clean gloves. PT-J removed the soiled dressing to the resident's [MEDICATION NAME] pressure sore, palpated the edges of the wound with gloved fingers, measured and cleansed the wound and applied a border foam (absorbent foam) dressing before removing soiled gloves and washing hands. PT-J donned clean gloves and removed the soiled dressing to the resident's left heel with odor noted immediately after removal of dressing. PT-J indicated the pressure sore had increased maceration to the edges of the wound and stated the heel was "mushy". PT-J measured, cleansed and applied calcium alginate to the wound bed and covered with a border foam dressing before removing gloves and washing hands. Before leaving the resident's room, PT-J again identified the left heel was looking worse and indicated the dressing should be changed at least on a daily basis. Review of "Wound Assessment Tool" dated 11/24/14 revealed a recommendation by the PT to change the dressing to Resident 38's left heel daily. Review of Resident 38's "Wound Assessment Tool" completed by PT on 11/24/14 revealed the pressure sore to Resident 38's left heel measured 1.5 cm in length by 1.0 in width and 0.5 cm depth. The resident had identified increased pain with treatment, and the therapist documented increase of maceration to skin surrounding the wound bed with continued odor. Therapist changed the treatment to calcium alginate (absorbent dressing which aids in debridement and is used for wounds with increased drainage or infection) to the wound bed followed by a border foam dressing. During observations on 11/24/14, Resident 38 was observed seated in a wheelchair with no pressure relieving device to the right foot and the right heel resting directly on the surface of an unpadded foot pedal from 11:16 AM to 12:32 PM, from 2:14 PM to 2: 48 PM and from 4:30 PM to 5:30 PM. During an observation on 11/24/14 at 5:15 PM, Resident 38 was served a meal which consisted of a bowl of vegetable soup, one half of a corn beef sand-which and one glass of milk. Resident 38 was not provided with an extra glass of milk or with an additional portion of meat. Review of Resident 38's MAR from 11/1/14 to 11/24/14 revealed Resident 38 received a high protein snack before bed from 11/7/14 to 11/13/13 and from 11/15/14 to 11/19/14 (12 out of 24 days). During an interview on 11/25/14 from 11:00 AM to 11:12 AM, the Director of Nursing (DON) and the Infection Control Coordinator confirmed PT-J should have followed the facility policy related to non-sterile dressing changes. In addition, the DON verified Resident 38's physician was not notified of the increase in measurements of the gluteal sacral wound on 10/10/14, 10/15/14, 10/20/14, 10/22/14, 10/24/14 and 10/26/14 and no assessments were completed for Resident 38's left heel from 10/10/14 to 10/23/14 and from 10/25/14 to 11/17/14. The DON further verified Resident 38's physician was not notified of the increase in size, odor, maceration and drainage to the resident's left heel pressure sore until 11/24/14. The DON identified Resident 38 was to have heel protectors to both feet at all times as assessed on the resident's Care Plan and confirmed Resident 38's Care Plan did not address the pressure sore to the resident's left heel. Review of "Wound Assessment Tool" dated 11/25/14 to 12/1/14 revealed the dressing to Resident 38's left heel was changed on 11/26/14 and 11/28/14 and 12/1/14 (3 out of 7 days) instead of on a daily basis as recommended by the PT. During an interview on 12/1/14 from 10:20 AM to 10:40 AM, the DON confirmed the dressing change on Resident 38's left heel was not completed on 11/25/14, 11/27/14, 11/29/14 and 11/30/14. During observations on 12/1/14 at 9:00 AM and on 12/2/14 at 7:42 AM, Resident 38 was seated in a wheelchair in the dining room with no pressure relieving device to the right foot. In addition, the resident was served a breakfast meal on both days which consisted of only one glass of milk. During an interview on 12/2/14 from 8:50 AM to 9:05 AM the Dietary Manager (DM) confirmed Resident 38 was to receive an extra glass of milk and an additional portion of meat at all meals for increased protein. In addition, the DM confirmed the snack cart was not always passed in the evening due to fluctuations in staffing. D. Review of Resident 19's MDS dated [DATE] indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The same MDS indicated the resident required total assistance with activities of daily living, was at risk for the development of pressure sores, and received Hospice services. Review of resident 19's Care Plan dated 9/9/14 indicated the resident was at risk for skin breakdown related to immobility and pain. Nursing interventions included a systematic skin inspection weekly and as needed with bath, and report any signs of skin breakdown including sore, tender, red or broken areas. Review of the Weekly Skin Integrity Action Tool (a tool used by nursing to document the assessment of skin problems) dated 9/4/14 revealed "slight redness to gluteal (buttocks) folds" and "healed wound to (L) (left) gluteal" and "no open skin". Review of the Treatment Flowsheet (a record of treatments provided by nursing) for 9/2014 revealed orders dated 9/4/14 for head to toe skin assessments every week on Friday, and for [MEDICATION NAME] silicone foam dressing (a type of dressing used to treat skin breakdown) to bilateral buttock pink areas, change every (q) 3 days as needed (prn) for shearing (friction causing trauma to the skin) and skin breakdown. There was no documentation to indicate the [MEDICATION NAME] dressing was applied. Review of Hospice Plan of Care Update Report dated 9/10/14 revealed Resident 19 had a [DIAGNOSES REDACTED]. Review of Hospice Visit Note Report dated 9/11/14 indicated redness was observed to Resident 19's bilateral buttocks and [MEDICATION NAME] (a protective paste) was applied. There was no documentation to indicate the [MEDICATION NAME] dressing was applied. Review of the Weekly Skin Integrity Action Tool dated 9/12/14 indicated "no new skin issues". Review of a Nursing Progress Note dated 9/20/14 at 8:30 PM indicated excoriation was noted on bilateral buttocks and "some shallow open areas present with surrounding redness". Documentation indicated the area was cleaned and a protective barrier cream applied, and the physician was notified by facsimile (fax). There was no documentation to indicate the [MEDICATION NAME] dressing was applied as previously ordered by the physician, and there was no documentation to indicate the size or staging of the pressure sores. Review of Hospice Visit Note Report dated 9/25/14 revealed Resident 19 had a Stage 1 (a pressure-related alteration of intact skin that presents as a defined area of persistent redness or discoloration) pressure sore on the right buttock measuring 5 cm x 2 cm, and a Stage 2 pressure sore on the left buttock measuring 3.5 cm x 1 cm. Documentation indicated the Hospice nurse applied a silicone foam dressing to the areas. Review of a Physician Verbal Order dated 9/25/14 indicated Hospice notified Resident 19's physician and obtained an order for [REDACTED]. Review of Treatment Flowsheets for 9/2014 and 10/2014 revealed a physician's orders [REDACTED]. There was documentation to indicate the treatment was completed on 9/26/14 and 9/29/14, however, there was no documentation to indicate the treatment was provided 10/1/14 through 10/31/14. Review of Hospice Visit Note Report dated 10/2/14 revealed a "white pin point (sic) area to top of left second toe" and "a dark brown soft spot on top of left great toe". Review of the Weekly Skin Integrity Action Tool for 10/2014 revealed the following: -10/3/14 - reddened and abraded areas to the left buttock measuring 3 cm x 2 cm, and to the right buttock measuring 5 cm x 3 cm (This indicated the areas increased in size from the previous measurements taken 9/25/14.) -10/10/14 - 3 cm x 1.5 cm scabbed area to the left buttock and 3.5 cm x 1.5 cm reddened scabbed area to right buttock with red/purple skin surrounding both areas (This indicated worsening of the resident's skin integrity on bilateral buttocks.) -10/17/14 - excoriated areas noted 7 cm x 3 cm to left buttock and 3 cm x 3 cm to right buttock (This indicated the area on the left buttock had increased in size.) -There was no documentation to indicate staging of the areas. -There was no documentation related to areas observed 10/2/14 by hospice on the resident's left toes. Review of Hospice Visit Note Report dated 10/23/14 revealed an area of black eschar (dead tissue on top of a wound) measuring 1 cm in diameter on the left great toe. (This was the first documentation related to the left great toe since 10/2/14, 21 days prior.) Review of Resident 19's Weekly Skin Integrity Action Tool for 10/2014 revealed the following: -10/24/14 - a "new unstageable" pressure sore on the left second toe measuring 0.6 cm x 0.8 cm. (This was the first documentation of this wound since hospice noted it on 10/2/14, 22 days prior.) - 10/24/14 - buttocks "still red" and applying cream and dressings (There were no measurements or description of the area documented.) -There was no documentation related to the area of eschar on the left great toe. -There was no weekly skin assessment documented on 10/31/14. Review of Hospice Visit Note Report dated 11/3/14 revealed black eschar remained on the resident's left great toe (no measurements documented) and the surrounding area was "bright red". (This was the first documentation related to this area since first noted by hospice on 10/23/14, 11 days prior.) Documentation also indicated the presence of a pressure sore on the second toe of the left foot (no measurements or staging documented) with a raised, tender area surrounding. Review of a Physician Verbal Order dated 11/3/14 indicated Hospice notified Resident 19's physician of "scabbed area on left second toe for a couple of weeks" and "area is raised, has a white border around it, is soft, tender to touch, does have red streaks coming from area". Documentation indicated the physician ordered Bactrim (an antibiotic medication) liquid 200/40 milligrams (mg) per 5 milliliters (ml), give 20 ml 2 times daily (BID) for 7 days. There was no documentation to indicate the physician was notified of the eschar area on Resident 19's left great toe. Review of a Nursing Progress Notes for Resident 19 revealed the following: -11/3/14 at 11:40 PM - the "left great toe" had a "dime sized white area with a brown scabbed area in center oozing whitish brown thick substance." -11/4/14 at 1:48 PM ("Recorded as Late Entry on 11/05/14 02:18 PM") - resident's "left second toe" had a "dime sized white area with a brown scabbed area in center and was oozing bloody drainage", and the antibiotic ordered by the physician had not yet arrived. -11/5/14 at 2:10 AM - initial dose of Bactrim administered for infection of second great toe. Review of Hospice Plan of Care Update Report dated 11/5/14 revealed Resident 19's buttocks were "still red" and continued to be treated. Review of the Treatment Flowsheet for 11/2014 revealed there was no documentation to indicate the q 3 day [MEDICATION NAME] dressing to the resident's buttocks was completed on 11/4/14 and 11/19/14. Review of Hospice Visit Note Report dated 11/6/14 indicated Resident 19 had the following pressure sores: -left great toe - 1.0 cm in diameter and extending into the nail bed, black eschar, and surrounding skin "bright red" (This was the first documentation of size and description of this pressure ulcer since 10/23/14, 14 days prior.), and -left second toe - 1.0 cm diameter with redness extending to 2.0 cm, large amount of tan/yellow drainage, necrotic (dead) tissue present, area surrounding dark red and swollen (This was the first documentation of size and description of this pressure ulcer since 10/24/14, 13 days prior.) Review of a Physician Verbal Order dated 11/6/14 indicated Hospice notified Resident 19's physician that the area on resident's left second toe had opened and was draining dark brown, thick drainage. A physician's treatment order was received to cover the area with [MEDICATION NAME] (a non-adhesive wound dressing) and gauze after cleansing the wound daily. There was no documentation to indicate the physician had been notified of the area on Resident 19's left great toe. Review of Hospice Visit Note Report dated 11/13/14 indicated the resident had the following pressure sores: - left second toe - 1.0 cm in diameter, small amount pale red/pink drainage, no necrotic issue, area surrounding bright red and "entire toe is swollen", - left great toe - 1.0 cm diameter, black eschar extending into nail bed, surrounding tissue a white/gray pallor, and - buttocks were "white/red" with no open areas noted. Review of a Physician Verbal Order dated 11/13/14 indicated Hospice notified Resident 19's physician that the left second toe was swollen and red, but the red streaks up the foot and into the calf were resolved with administration of the antibiotic. The physician ordered a thin film of [MEDICATION NAME] (an antibiotic ointment) be applied to the area with each dressing change. There was no documentation to indicate the physician had been notified of the area on Resident 19's left great toe. During observation on 11/20/14 from 8:49 AM until 9:15 AM, Licensed Practical Nurse (LPN)-F provided treatment to Resident 19's left second toe pressure ulcer. The soiled [MEDICATION NAME] dressing was adhered to the wound bed with dried drainage and was released using a spray cleanser. The area was located on the joint of the toe and measured 1 cm in diameter. The skin surrounding the area was a purple color. LPN-F dressed the area using antibiotic ointment, [MEDICATION NAME] dressing and gauze as prescribed. There was no treatment provided to the left great toe and no measurements made. During the same observation, Nursing Assistant (NA)-E and NA-D provided incontinent care. There was no dressing on Resident 19's coccyx/buttock area, and the skin was a dark purple color. During observation of nursing care on 11/24/14 from 11:20 AM until 11:44 AM, NA-A, NA-B and NA-E provided incontinent care for Resident 19. There was a dressing on the left second toe and the left great toe was open to air. There was a dark black spot on the end of the left great toe and the surrounding skin was dry, flaky and discolored red/purple. The resident's coccyx area was open to air and was purple in color with no open areas noted. E. Review of Resident 15's MDS dated [DATE] revealed the resident was admitted with [DIAGNOSES REDACTED]. The MDS further indicated Resident 15 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and required extensive to total assistance with bed mobility and transfers. Review of Resident 15's Care Plan dated 7/31/13 revealed the resident was at risk for pressure ulcers and nursing interventions included to elevate the resident's heels while in bed, and to avoid shearing (friction that could result in trauma to the skin) during positioning, transferring and turning. The Care Plan did not indicate the frequency of repositioning for Resident 15. Review of the Braden Scale For Prediction of Pressure Ulcer Risk dated 10/23/14 revealed Resident 15 was at high risk for the development of pressure ulcers and nursing interventions included pressure reducing devices in the chair and bed, and a turning and repositioning program. During observations of Resident 15 on 11/20/14 the following were noted: - At 6:55 AM, 7:44 AM, 7:48 AM, 8:09 AM, 8:39 AM, 9:21 AM, 9:42 AM and 10:07 AM, the resident was observed seated in the dining room for the breakfast meal. - At 10:12 AM the Activities volunteer wheeled the resident from the dining room to the activity room for a music event. - At 10:34 AM the Activities volunteer wheeled the resident to room. - There were no nursing staff observed to enter the resident's room until 11:30 AM when Nursing Assistant (NA)-G was observed to wheel the resident from room to the dining room. During interview on 11/20/14 at 11:30 AM, NA-G verified Resident 15 was not toileted or repositioned prior to being wheeled to the dining room for the noon meal. (The resident was observed seated in wheelchair without repositioning for 4 hours and 35 minutes.) During observation on 11/24/14 from 9:15 AM until 9:44 AM, Resident 15 was seated in wheelchair at the dining room table for the breakfast meal. During interview on 11/24/14 at 9:44 AM, NA-B revealed Resident 15 was up since 6:30 AM to 7:00 AM. The following observations of Resident 15 were noted on 11/24/14: - At 10:00 AM the resident was wheeled directly from the dining room to the activity room for an exercise activity and remained there until 10:30 AM when the resident was wheeled directly to the dining room to attend a Bingo activity. - The resident remained in wheelchair at the dining room table for Bingo until 11:45 AM when a staff member moved the resident's wheelchair to the other side of the table for placement for the noon meal. The resident was not taken to room for toileting and/or preparation for the noon meal. - At 1:12 PM the resident was wheeled to room for toileting (3 hours and 57 minutes since first observed in wheelchair in the dining room for breakfast). During interview on 11/24/14 at 1:25 PM, NA-E indicated Resident 15 was to be repositioned every 2 hours. During interview on 11/25/14 at 9:29 AM, the DON verified Resident 15 was to be repositioned every 2 hours. F. Review of Resident 10's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 9/30/14 MDS further indicated the resident was dependent with bed mobility and transfers, was at risk for pressure sores, had moisture associated skin damage, and was on a turning/repositioning program. Review of Resident 10's Admission and Weekly Skin Integrity Action Tool for 9/2014, 10/2014 and 11/2014 revealed the following: -9/14/14-"red/purple area above coccyx, no open areas noted" -9/21/14-"red/purple area remains. No open sore" -9/28/14-"no new skin issues" -10/5/14-"no new skin issues" -10/12/14-"No new skin issues" -There was no documentation on 10/19/14 and 10/26/14 -11/2/14-"no new skin issues" -There was no documentation on 11/9/14 -11/16/14-"No new skin issues" Review of Resident 10's Care Plan dated 11/5/14 revealed a potential for skin breakdown with an intervention to turn and reposition the resident every 2 hours and as needed. NA-C and NA-D were observed to provide Resident 10's perineal hygiene on 11/19/14 at 4:32 PM. NA-C commented Resident 10 had a "little schiff" (a small open area) on the "backside" (coccyx area) which had been reported to the Director of Nurses earlier that day. A Stage 2 pressure sore was observed on Resident 10's coccyx area. On 11/20/14, Resident 10 was observed seated in a wheelchair without benefit of repositioning from 7:10 AM until 10:40 AM (3 hours and 30 minutes). NA-E voiced awareness of Resident 10's pressure sore of the coccyx during observation of care at 10:40 AM on 11/20/14. NA-E applied a barrier cream (over the counter topical medication to protect skin from moisture and minor irritation) to the resident's coccyx area upon completion of care. Review of Resident 10's Progress notes for 11/2014 revealed no evidence to indicate the pressure sore of the coccyx was assessed. Review of Resident 10's Admission and Weekly Skin Integrity Action Tool dated 11/23/14 revealed no documentation regarding the pressure sore of the coccyx. On 11/24/14, Resident 10 was observed seated in a wheelchair without benefit of repositioning from 9:16 AM until 12:13 PM (2 hours 57 minutes). NA-A and NA-B were observed to transfer Resident 10 onto the toilet at 12:13 PM on 11/24/14. Following toileting, Licensed Nurse (LN)-F examined the pressure sore on Resident 10's coccyx area and stated "It is superficial. It's from moisture." There was no evidence further assessments or measurements were completed. On 11/25/14, Resident 10 was observed seated in a wheelchair without benefit of repositioning from 6:45 AM until 9:56 AM (3 hours 11 minutes). | 2015-07-01 |
| 11274 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 325 | H | 0 | 1 | ZQ0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and staff interview; the facility failed to evaluate significant weight losses for Residents 15 and 9, and gradual weight loss for Resident 10. Interventions for the prevention of weight loss were not developed and/or revised to prevent further loss of weight. Facility census was 33. Findings are: A. Review of the facility Weight Policy (Revised 08/13) included the following: 1. All residents will be weighed monthly. 2. The charge nurse will notify the Dietary Manager (DM) and Director of Nursing (DON) of weight variances. 3. Weight variance: Calculate weight loss or gain every time a resident is weighed. Significant weight variance must be brought to the attention of the Registered Dietician (RD). (Significant weight loss/gain was defined as 5% (percent) in 1 month, 7.5% in 3 months, and 10% in 6 months.) 4. RD or designee will review information, discuss with resident and document on the medical record. 5. The physician will be called by the charge nurse regarding significant weight variances. B. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/23/14 indicated the resident was admitted with [DIAGNOSES REDACTED]. The MDS further revealed the resident had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and required extensive assistance with eating. Review of Resident 15's Care Plan dated 2/2/13 indicated the resident had a history of [REDACTED]. Interventions included to offer ice cream if not eating the meal provided; provide 2 Cal (a high calorie nutritional supplement) 4 ounces TID (3 times daily) between meals; encourage, provide cues, and/or assist with oral intake of food and fluids although resident not always receptive to this; monitor and record weight weekly; notify physician and family of significant weight changes; and monitor/record intake of food. Review of a Referral Form dated 4/22/14 indicated a request by nursing to discontinue use of 2 Cal nutritional supplement as resident refused it all but once in the last 22 days. A physician's orders [REDACTED]. There was no documentation to indicate an alternate supplement was attempted. Review of a Nutritional Assessment by the RD dated 8/4/14 revealed Resident 15 weighed 87 pounds (#). Documentation indicated the resident's ideal body weight was 85-95#, the goal body weight was 85-88#, meal intakes provided 76-100% of estimated needs, the resident was nutritionally stable and determined to be at no/low risk for nutritional problems, and no new dietary interventions were recommended. Review of the Weight Variance Report (a record of weekly weights) indicated Resident 15 weighed 87# on 8/4/14 and 82# on 9/2/14. This represented a 5.7% significant weight loss in 1 month. Review of a Weight/Skin Condition Review completed by the DON and DM on 9/4/14 revealed the following: - the resident had a significant weight change, - average meal intakes were 0-25% except for the breakfast meal, - the resident was getting a 4 ounce shake as a nutritional supplement TID, and - a new intervention was added to provide Magic Cup (a nutritional supplement) TID with meals. Review of Resident 15's Medication/Treatment Flowsheet (a record of medications and treatments provided by nursing) for 9/2014 indicated there was no documentation of administration of nutritional supplements of 4 ounce shake TID and Magic Cup TID. There was documentation of a bedtime (HS) snack offered at 8:00 PM, however, it was not indicated what the HS snack consisted of, and the resident refused it 100% of the time. Review of the Weight Variance Report indicated Resident 15 weighed 81.7# on 9/8/14, 79.5# on 9/17/14 and 82.1# on 9/24/14. Review of a Nursing Progress Note dated 9/24/14 at 1:45 PM indicated Resident 15's physician was notified of the resident's weight loss (22 days following the significant weight loss on 9/2/14). No recommendations were made by the physician. There was no documentation to indicate the RD had been notified of the significant weight loss to evaluate the need for additional dietary interventions. Review of the Weight Variance Report indicated Resident 15 weighed 80.0# on 9/29/14, and 79.3# on 10/8/14 and 10/16/14. This indicated a continued gradual weight loss. Review of a Weight/Skin Condition Review completed by the DM on 10/17/14 revealed the following: - average meal intakes continued to be 0-25%, - Instant Breakfast as a nutritional supplement (the amount and frequency were not specified), and - no additional interventions recommended. Review of the Weight Variance Report indicated Resident 15 weighed 79.2# on 10/20/14 and 78.2# on 10/29/14, a continued gradual weight loss. Review of a Weight/Skin Condition Review completed by the DON and DM on 10/31/14 revealed the following: - 10% significant weight loss in 3 months, - continued average meal intakes of 0-25%, - Instant Breakfast as a nutritional supplement (the amount and frequency were not specified), and - no additional interventions recommended. There was no documentation to indicate the RD was notified of the resident's continued significant weight loss to evaluate the need for additional dietary interventions. Review of Resident 15's Medication/Treatment Flowsheets for 10/2014 and 11/2014 indicated there was no documentation of administration of nutritional supplements of 4 ounces shake TID, Magic Cup TID and/or Instant Breakfast. There was documentation of an HS snack offered at 8:00 PM, however, it was not indicated what the HS snack consisted of, and the resident refused it 100% of the time. During observation on 11/19/14 from 9:40 AM until 9:52 AM, Resident 15 was seated in wheelchair in room with breakfast meal on bedside table that consisted of an English muffin with butter and jelly and 3 glasses of fluids in sippy cups with straws. 1 of the glasses was labeled "Ensure" (a type of nutritional supplement). The resident sat with head down and eyes closed, but responded when spoken to and stated "I need some help". Nursing Assistant (NA)-M was observed in the hallway and, upon request, entered Resident 15's room to assist with the breakfast meal. At 9:53 AM, NA-M remained in the room feeding the resident. 100% of the English muffin and 1 glass of fluid were consumed, and NA-M was attempting to give the resident Ensure. Review of an entry in the Bath Book dated 11/19/14 indicated Resident 15 weighed 80.6#. The following was observed during Resident 15's breakfast meal on 11/20/14: - The resident sat in the wheelchair at the dining room table with no food or fluids from 6:55 AM until 7:48 AM. - At 7:48 AM (53 minutes after first observed in the dining room) the resident was served water, orange juice and a pink supplement in sippy cups. The resident retrieved and drank the fluids independently. - At 9:21 AM the resident sat with head down and eyes closed, still awaiting service of the breakfast meal. The resident had consumed 100% of the pink supplement and orange juice, and 50% of the water. - At 9:54 AM (2 hours and 59 minutes after the resident was first observed in the dining room awaiting service of the meal) the resident was served a piece of toast with jelly and ate independently. - The resident was not offered anything more to eat or drink. - At 10:12 AM the resident was removed from the dining room. The following was observed during Resident 15's breakfast meal on 11/24/14: - At 9:15 AM the resident was observed seated in wheelchair at the dining room table with full plate of food consisting of a pancake with peanut butter and syrup on it, a glass of water, a glass of orange juice, and a glass of pink supplement in sippy cups with straws. - NA-B cued the resident to drink fluids but made no attempt to assist the resident with eating, and no alternates were offered. - At 10:00 AM the resident was wheeled from the dining room, having consumed less than 25% of food and fluids. The resident was not offered ice cream or other alternate as indicated by the Care Plan. The following was observed during Resident 15's non meal on 11/24/14: - At 12:29 PM the resident was served fried chicken, cabbage, potato, and a fruit cup. The resident sat with eyes closed and made no attempt to eat. - At 12:32 PM, NA-B offered the resident a bite of food which was received, then moved away from the resident's table to assist another resident. - At 12:33 PM, NA-B returned to the resident who was drinking supplement, and while the resident had the glass of supplement at mouth, NA-B offered a bite from the fruit cup. The resident shook head in refusal and NA-B left the table to assist another resident. Resident 15 put down the glass of supplement and continued to sit without eating. - At 12:47 PM the resident continued to sit without eating. NA-A returned to the resident's side and offered bites of food which were accepted by the resident. NA-A then left Resident 15's table to assist another resident. Resident 15 occasionally took sips from the glass of supplement and/or attempted to take bites of food using fingers. - At 12:52 PM the resident sat without further attempts to eat food. The pink supplement was 100% consumed, but only bites of food were eaten. - NA-A attempted to give the resident bites of food at 1:01 PM and 1:10 PM and the resident refused. The resident was not offered ice cream or other alternate considering the poor intake of the meal, and as indicated in the Care Plan. During interview on 11/25/14 at 9:29 AM, the DON verified the pink supplement served to Resident 15 at meals was Instant Breakfast. During interview on 12/2/14 at 12:48 PM, the DM verified there was no documentation to indicate administration and consumption of nutritional supplements. The DM further indicated the resident was to be offered Magic Cup instead of ice cream if meal intake was poor. C. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The same MDS indicated the resident had moderate cognitive impairment, required extensive assistance with eating and weight was 117 pounds. Review of Resident 9's Care Plan dated 10/9/14 revealed a problem (start date 7/31/12) regarding weight loss with current body weight of 131 pounds and acceptable body weight of 128 pounds. The long term goal (target date 10/10/14) indicated the resident "will maintain current body weight of 133 pounds). An intervention (started 7/31/12) was to increase portion size at breakfast meal. Further review of Resident 9's Care Plan dated 10/9/14 revealed a goal for the resident to maintain body weight plus/minus 10 percent of baseline body weight. The baseline body weight was identified as 119 pounds (which was different from the other Care Plan goal which addressed 128 pounds as the acceptable body weight). Interventions included provision of assistance at meals, encourage oral intake of food and fluids and offer available substitutes if problems with food served. Review of Weight Variance Reports from 10/3/14 through 11/17/14 and Weight and Vital Signs Monitoring Record from 10/3/14 through 11/19/14 revealed the following weights: -10/3/14-117.8 pounds -10/10/14-117 pounds -10/24/14-116.8 pounds -11/3/14-116.8 pounds -11/5/14-110 pounds -11/10/14-106.6 pounds (an 8 percent significant weight loss in 1 month) -11/16/14-111.8 pounds -11/17/14-111.8 pounds -11/19/14-112.7 pounds Review of Resident Meal Consumption Records for 10/2014 revealed Resident 9 refused breakfast on 5 occasions and there was no documentation regarding meal consumption for 2 breakfast meals. Documentation further indicated Resident 9 refused the noon meal on 3 occasions and ate less than 25 percent (%) on 1 occasion. Resident 9 refused the supper meal on 1 occasion and ate less than 25% on 6 occasions. Review of Resident Meal Consumption Records from 11/1/14 through 11/24/14 revealed Resident 9 refused the breakfast meal on 3 occasions, ate less than 25% on 4 occasions and there was no documentation regarding consumption on 3 occasions. Resident 9 refused the noon meal on 1 occasion, ate less than 25% on 8 occasions and there was no documentation regarding consumption on 3 occasions. Resident 9 refused the supper meal on 1 occasion, ate less than 25% on 3 occasions and there was no documentation on 1 occasion. Review of Resident 9's medical record revealed no evidence to indicate the significant weight loss had been evaluated and additional interventions to prevent further weight loss were not developed. At 7:41 AM on 11/19/14, NA-B was observed to wheel Resident 9 into the dining room. Resident 9 was not served the breakfast meal until 8:35 AM (53 minutes). Resident 9 made no attempt to feed self and received no eating assistance until 8:53 AM (18 minutes). On 11/24/14, Resident 9 was observed lying in bed at 11:39 AM, 12:00 noon, 1:00 PM and 2:00 PM. The resident did not receive a noon meal. NA-A indicated during interview on 11/25/14 at 10:17 AM that Resident 9 had slept through the noon meal on 11/24/14. NA-A indicated the resident was usually offered something to eat after waking, however the resident had not been offered anything to eat when NA-A went off duty at 2:00 PM as the resident was still in bed. Review of Resident 9's medical record revealed no evidence to indicate the resident was provided with something to eat after missing the noon meal on 11/24/14. Review of the Resident Meal Consumption Record dated 11/24/14 revealed there was no documentation regarding the noon meal. Interview with the DM on 11/25/14 at 10:10 AM revealed Resident 9 was receiving extra food at the breakfast meal, however no other nutritional interventions or supplements were provided. The DM was not sure if the RD had evaluated the resident's nutritional status in the past year. D. Review of Resident 10's MDS dated [DATE] and 9/30/14 revealed [DIAGNOSES REDACTED]. The 7/7/14 MDS indicated the resident's weight was 158 pounds and the 9/30/14 MDS indicated the resident's weight was 156 pounds. Review of Weight Variance Reports from 4/2/14 through 11/17/14 revealed Resident 10 had a gradual weight loss as evidenced by the following weights: -4/2/14-164.6 pounds -5/3/14-163.5 pounds -6/4/14-161 pounds -7/3/14-158.9 pounds -8/6/14-160.0 pounds -9/3/14-158.6 pounds -10/3/14-154.6 pounds -10/6/14-153 pounds Review of a Mini Nutritional Assessment completed 10/10/14 at 11:20 AM revealed Resident 10's weight was 153 pounds, a moderate decrease in food intake was noted and the assessment score indicated the resident was malnourished. Review of Resident 10's Progress Notes revealed the RD did not assess the resident's weight loss until 11/5/14. The RD made no additional interventions for the prevention of further weight loss. | 2015-07-01 |
| 11284 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2014-12-02 | 520 | H | 0 | 1 | ZQ0211 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observations, record review and staff interview; the facility Quality Assurance (QA) Committee failed to maintain correction of previously cited deficiencies regarding accident prevention, infection control, Care Plan revision and implementation, timely assistance for residents who require assist with activities of daily living, treatment and care of pressure sores, QA and staffing. This failure had the potential to affect the well-being of all residents. Facility census was 33. Findings are: A. Record review of the Quality Assurance policy and procedures (undated) revealed the purpose of the program was to ensure appropriate follow-up and ongoing tracking of identified environmental and quality of care issues. The policy further indicated the QA Committee was to develop and implement plans of corrective action for identified trends and/or deficient practices. The following areas were to be addressed monthly by the QA Committee: -Infection Control -Skin Integrity -Safety/Environment -Resident Assessment -Quality of Care B. Review of facility deficiency statement from the Quality Indicator Survey (QIS) completed 11/13/13 and QIS completed 12/2/14 revealed repeated facility noncompliance with the following Federal (F) tags: -F 323-Failure to prevent accidents -F 280-Failure to revise resident Care Plans -F 282 Failure to implement assessed Care Plan interventions -F 312 Failure to provide timely assistance for residents who required toileting and feeding assistance. -F 441-Failure of staff to remove gloves and wash hands during toileting cares, dressing changes and catheter cares in a manner to prevent cross contamination. F 520-Failure to maintain correction of previously cited deficiencies through the QA program. C. Interview with the Administrator on 12/2/14 from 7:45 AM to 8:01 AM revealed the QA Committee had discussed issues regarding infection control practices and current facility pressure ulcers at the last QA meeting on 10/22/14. However, there was no documentation to indicate previous interventions had been reviewed or additional interventions were implemented. In addition, the Administrator denied any knowledge of the deficiencies cited at the facilities previous QIS. | 2015-07-01 |
| 11361 | MONTCLAIR NURSING AND REHABILITATION CENTER | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2012-02-29 | 520 | H | 1 | 1 | IWZ611 | LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility's Risk Management/Quality Improvement Program (RM/QIP) failed to identify ongoing issues relevant to F157, F221, F225, F281, F309, F311, F315, F323, F325, F329, F332, F333, F431, F469, F490, F505 and F520 and implement effective plans of action to correct the deficient practice. The RM/QIP Committee failed to assure repeated deficiencies at F157, F253, F280, F315, F323 and F329 were corrected and the correction maintained. The sample size of the survey consisted of 26 sampled and 2 non-sampled residents. The facility staff identified a census pf 157. Findings are: Record review of the facility policy and procedure for the RM/QIP revised on 03/2011 revealed the following: -The RM/QIP is directed by the Administrator. The program is focused on minimizing risk and improving resident/patient care by implementing a process for root cause analysis ad the utilization of the Quality Improvement teams. -Procedure: -#6. Prepare a written agenda for each meeting to include the discussion of incidents, issues and concerns. -#7. Develop a action plan to improve the identified process or system. Action plan is to include goals, outcome indicators and a monitoring plan. -#8. Complete written minutes of the meeting to document items discussed and the proposed action item. -#9. Implement action plan. -#10. Collect, study and analyze the outcome data. -#11. Continue to monitor the completion and effectiveness of the action plan. Modify the action plan (if) results are not acceptable. -#12. Report results to RM/QIP committee. An interview on 2/23/2012 at 7:35 AM was conducted with Nursing Assistant (NA) C . During the interview, NA C stated (gender) was not aware of the RM/QIP committee or how the RM/QIP functioned. NA-C was not aware of what the QI (Quality Improvement) process was, did not know how to access the committee, and was not able to verbalize any specific plans of action the RM/QIP was working on. An interview on 2/23/2012 at 7:40 AM was conducted with NA-D. During the interview, NA-D reported (Gender) was not aware of the QI committee or how it functioned. NA-D was not aware what the QI process was, did not know how to access the committee, and was not able to verbalize any specific program or action plans the RM/QIP was working on. An interview on 2/23/2012 at 7:55 AM was conducted with NA-E. During the interview NA E stated (gender) was not aware of the RM/QIP or how the RM/QIP committee functioned. NA-E was not aware what the RM/QIP process was, did not know how to access the committee, and was not able to verbalize any specific plans of action described by the RM/QIP committee. In an interview on 2/23/2012 at 8:00AM, NA-F stated NA-F was not aware of the RM/QIP committee or how it functions. NA F was not able to verbalize any specific plans of action described by the QI committee. An interview with the Director of Nursing (DON) was conducted on 2/23/2012 at 9:30 AM. During the interview, the DON stated the facility RM/QIP committee was working on " routine things". When asked if the facility had identified any issues, other than routine items, The DON stated "no". When asked if any action plans were in place prior to the survey, the DON stated "no, just the routine things". An interview was conducted with the facility Administrator on 2/23/2012 at 9:45 AM. During the interview, the facility Administration was able to identify the RM/QIP process, how often the committee meets and what action plans were. When asked if the RM/QIP action plan would include, identifying the issue, implementing a plan and re-evaluation the intervention and monitoring, the Administrator stated "yes". When asked to describe an action plan the RM/QIP was currently working on, the Administrator identified resident falls was an action plan. The Administration was asked for evidence of the action plan. A follow up interview was conducted with the Administrator on 3/23/2012 at 10:25 AM. During the interview, the Administrator reported the information was not available as identified in the RM/QIP i.e. Develop an action plan, identify goals, outcome indicator, have a monitoring plan and re-evaluate your action plan as needed. The Administrator stated "we don't have it". | 2015-06-01 |
| 11370 | MONTCLAIR NURSING AND REHABILITATION CENTER | 285054 | 2525 SOUTH 135TH AVENUE | OMAHA | NE | 68144 | 2012-02-29 | 490 | H | 1 | 1 | IWZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.02 Based on observations, record review, and interviews, the facility failed to ensure effective management of facility resources to maintain the high practical well being of residents and the facility as evidenced by failure to ensure the facility identified and developed plans of action to correct deficient practices and failure to maintain correction for previously cited areas of deficient practice and failed to provide Medical Director required docuemntation to fulfill Medical Directors duties. The survey sample was 26 residents with 4 non-sampled residents. The total facility census was 157 residents. Findings are: A. The facility was found to be deficient in multiple areas of regulatory compliance. The following is a list of F tags cited, please refer to the tag citation for specific detailed findings: -F157 Failed to notify resident's physician and/or family members of changes in condition -F221 Failed to evaluate a tilt and space wheelchair as a restraint -F225 Failed to report possible abuse or neglect immediately, investigate and submit investigation in accordance with federal requirements -F253 Failed to maintain equipment and furniture in clean condition and in good repair -F279 Failed to implement comprehensive care plan -F281 Failed to follow physician order [REDACTED]. -F309 Failed to evaluate skin breakdown and implement interventions -F311 Failed to provide restorative services -F323 Failed to evaluate causal factors, implement interventions and reevaluate interventions to prevent accidents -F325 Failed to weigh residents, evaluate weight changes and implement caloric count -F329 Failed to complete behavioral monitoring for aggressive behaviors -F332 Failed to ensure medication error rate of less than 5% with a medication error rate of 18.6% -F333 Failed to ensure residents were free from significant medication errors -F371 Failed to ensure dietary staff utilized hand washing techniques and install back flow prevention device -F467 Failed to maintain ventilation system in working order -F469 Failed to maintain an effective pest control program -F520 Failed to maintain an effective Quality Assurance Program B. The facility failed to maintain correction of the following tags cited during the previous annual survey completed 3/3/11: F157, F253, F280, F315, F323, and F329. C. The facility policy titled Physician Services revised on 11/11 listed the following duties for the Medical Director: - "Review and sign all incident reports, identify hazards to health and safety, and provide recommendations to the Facility's Administrator to promote a safe and sanitary environment for residents, guests, and personnel." - "Participate in identifying the need for, developing, amending, recommending, approving, implementing and monitoring written policies governing resident care including policies related to: i. admissions transfers, and discharges ii. infection control iii. use of restraints iv. physician privileges and practices v. responsibilities of non-physician health care workers (e.g., nursing, rehabilitation therapies, and dietary services in resident care, emergency care, and resident assessment and care planning). A review of 15 facility incident reports dated between 10/4/11 and 2/6/12 did not reveal signatures from either of the facility's Medical Directors. A review of the Administrative Manual of policies and procedures did not reveal a signature from either of the facility's Medical Directors indicating the manual had been reviewed and approved. The Administrative Manual of policies and procedures was approved by the Administrator on 4/27/11 and the Director of Nursing on 5/5/11. In an interview on 2/29/12 at 11:42 AM, Medical Director GG reported Medical Director GG had not recently been provided with incident reports to review and sign or the policy and procedure manual to approve. In an interview on 2/29/12 at 12:30 PM, Medical Director HH reported Medical Director HH had not been provided with incident reports to review and sign or the policy and procedure manual to approve. | 2015-06-01 |
| 25 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-08-12 | 689 | G | 1 | 0 | 7ED911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to implement assessed interventions and failed to implement additional interventions to prevent falls for 3 (Resident 20, 21 and 23) of 4 residents. The facility staff identified a census of 225. Findings are: [NAME] Record review of Resident 20's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 6-19-2019 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 1. According to the MDS Manuel, a score of 0 to 7 indicated severe cognitive impairment. -Extensive assistance with bed mobility and transfers requiring 2 persons physically assisting the resident. -Total dependence for locomotion on the unit, toilet use and personal hygiene requiring 2 persons to physically assist the resident. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 1-29-2019 revealed Resident 20 was at high risk for falls. The goal identified for Resident 20 was no falls or no falls with injury. The interventions identified on Resident 2's CCP included 2 persons to assist with dressing, hygiene, grooming/bathing and bed mobility. Resident 20's CCP also identified Resident 20 could stand and pivot with assistance. Other interventions included a mat next to the bed and to keep Resident 20's bed in a low position. Record review of a Abuse/Neglect/Misappropriation/Crime Reporting Form (ANMCRF) dated 7-24-2019 revealed Resident 20 had .fell out of bed yesterday ,striking (gender) head on the floor sustaining an abrasion and possible head injury. Record review of a investigation report dated 7-25-2019 revealed the Nursing Assistant (NA) A had been providing care to Resident 20 when Resident 20 fell from bed. Record review of a Documentation form dated 7-24-2019 revealed NA A reported working with Resident 20. According to the Documentation report, NA A reported getting Resident 20 cleaned and dressed and when NA A retrieved Resident 20's wheelchair, Resident 20 fell out of bed. Record review of an undated Fall Root Cause Analysis (RCA) form revealed Resident 20 had sustained a laceration and hematoma to the right side of the face and had altered mental status. According to the RCA, the family chose not to have Resident 20 sent to the hospital. On 8-12-2019 at 1:50 PM an interview was conducted with Registered Nurse (RN) B. During the interview RN review of Resident 20's MDS and CCP were reviewed. RN B confirmed during the interview Resident 20's CCP and MDS indicated Resident 20 was to have 2 people assist with cares. When asked how many staff were assisting Resident 20 when Resident 20 fell on [DATE] resulting in a laceration and hematoma, RN B stated 1 staff was working with (gender). B. Record review of Resident 21's MDS dated as completed on 5-29-2019 revealed the facility staff assessed the following about Resident 21: -BIM's score was a 3. -Required supervision with bed mobility, transfers, walking on the unit and eating. -Required extensive assistance with toilet use and personal hygiene. Record review of Resident 21's CCP dated 3-04-2019 revealed Resident 21 had a fall on 7-30-2019 resulting in a laceration 2 lacerations to Resident 21's forehead. Further review of Resident 21's CCP revealed there were not specific interventions implemented in an attempt to prevent re-occurrence. Record review of Resident 21's progress notes dated 7-31-2019 revealed Resident 21 was seated at a table ,stood up and fell . On 8-12-2019 at 12:25 PM an interview was conducted with RN B. During the interview RN B confirmed no additional interventions had been implemented when Resident 21 fell on [DATE]. C. Record review of Resident 23's MDS signed as dated as completed on 7-03-2019 revealed the facility staff assessed the following about the resident: -BIM's score was a 3. -Required supervision with eating. -Required extensive assistance with transfers, dressing, toilet use and personal hygiene. Record review of Resident 23's CCP dated 12-03-2018 revealed Resident 23 was at risk for fall related to multiple falls and poor safety awareness. Further review of Resident 23's CCP revealed Resident 23 had a fall on 6-30-2019 at 1:45 PM and on 6-30-2019 at 10:30 PM. Review of Resident 23's record revealed there was not evidence the facility had implemented interventions in an attempt to prevent additional fall when Resident 23 fell , twice on 6-30-2019. Record review of Resident 23 progress note dated 7-16-2019 revealed Resident 23 had slipped from the wheelchair sustaining a laceration on the left side of the head. On 8-12-2019 at 4:00 PM a interview was conducted with RN B. During the interview RN B. During the interview review of Resident 23's care plan was completed. During the interview, RN B confirmed additional interventions were not implemented after he falls on 6-30-2019. RN B further confirmed Resident 23 had sustained a laceration to the left side of the head. RN B confirmed additional interventions should have been implemented. Record review of the facility Policy and Procedure for Fall Risk Assessment sheet revised on 9-2005 revealed the following information: -Purpose: -2. To facilitate implementation of preventative measures. -Procedure: -7. Revise the residents care plan to reflect care needs and interventions based on the residents potential for falling. -Key Points: -Interventions must be implemented to aid in the prevention of falls. | 2020-09-01 |
| 64 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 609 | G | 1 | 0 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview the facility failed to ensure that resident abuse resulting in injury was investigated for 1 resident (Resident 87) and the facility failed to ensure that misappropriation of resident property was investigated for 1 resident (Resident 86). Based on record review and interview, the facility failed to ensure incident investigations were submitted to the state agency within 5 working days. This affected 5 residents (Residents 14, 40, 69, 86, and 87) of 10 residents reviewed. The facility census was 123. Findings are: A) Interview with Resident 87 on 9/30/19 at 10:26 AM occurred in the resident room. A splint was observed in place on the resident's right pinky finger. When asked by this surveyor what happened to the resident's right pinky finger the resident responded that the resident (Resident 87) hit another resident in the head when another resident attempted to kiss the resident (Resident87). Resident 87 confirmed that this was reported to facility staff in (MONTH) (2019). Record review of the nurse progress note for Resident 87 dated 3/5/19 at 10:45 PM revealed that the resident had complained of itching to the small right finger earlier in the evening at 9:00 PM. The finger was swollen, reddish purple in color and painful to touch, ice was applied at that time and continuing to monitor for any changes. Record review of the X-Ray report for Resident 87 dated 3/6/19 revealed that the resident had a [MEDICAL CONDITION] digit (pinky finger) of the right hand. Record review of the facility policy titled Abuse Investigations dated (MONTH) 2014 revealed the Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Step 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state or local laws, with five (5) working days of the reported incident. Interview with the Clinical Services Consultant (CSC) on 9/30/19 at 11:07 AM confirmed that a state report was not completed or submitted for the resident to resident altercation that resulted in a [MEDICAL CONDITION] pinky finger for resident 87. B) Record review of the Progress note for Resident 86 dated 5/26/19 10:19 PM revealed that the family reported that the resident's watch was missing and that it was gold in color. Record review of the Progress note for Resident 86 dated 5/31/19 9:59 AM revealed that the resident's family member was here and reported that they bought the resident a new watch, gave the receipt to Social Services for reimbursement of the lost item and stated that it may have been stolen by a former employee. Record review of the facility grievances revealed an email dated 5/31/19 from the facility Social Services Director (SSD J) to the facility Grievance Officer. The email revealed that Resident 86 was missing a watch since 5/26/19. A resident family member bought a new watch for the resident on 5/31/19 and the receipt was submitted to the business office for reimbursement. Record Review of the facility policy titled Reporting Abuse to Facility Management dated (MONTH) 2014 revealed Step 2 definitions: To help with recognition of incidents of abuse, the following definitions of abuse are provided: Step 2 h. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Interview with the facility Administrator on 9/24/19 at 2:55 PM confirmed that if an item is reported as stolen, it is reported right away. If an item is missing, the facility looks for it to try and find it first. The Administrator confirmed that the facility was unable to provide documentation showing that an investigation was completed and submitted to the state agency within 5 working days. C) Review of Abuse/Neglect Investigation Report Form dated 5/30/19 revealed that on 5/25/19 Resident 14 was walking by Resident 40 when Resident 40 reached out and hit Resident 14 on the arm. No documentation related to submission of the investigation report to the state agency within 5 working days was present. Interview on 9/30/19 at 8:23 AM with the DON (Director of Nursing) revealed the facility was unable to provide documentation showing the investigation was submitted to the state agency within 5 working days. D) Review of Abuse/Neglect Investigation Report Form dated 6/12/19 revealed that on 6/7/19 Resident 69 reported NA-C (Nurse Aide) pushed Resident 69 into a wheelchair while being assisted to the bathroom. No documentation related to submission of the investigation report to the state agency within 5 working days was present. Interview on 9/24/19 at 3:24 PM with CSC (Clinical Services Coordinator) revealed the facility was unable to provide documentation showing the investigation was submitted to the state agency within 5 working days. | 2020-09-01 |
| 209 | ROSE BLUMKIN JEWISH HOME | 285059 | 323 SOUTH 132ND STREET | OMAHA | NE | 68154 | 2016-12-01 | 309 | G | 0 | 1 | W3MZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to re-evaluate pain indicators and implement interventions to manage pain for 1 (Resident 112) of 1 residents reviewed. The facility staff identified a census of 86. Findings are: Record review of Resident 112's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 9-26-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 3. According to the MDS Manual, a score of 0 to 7 indicated severe cognition impairment. -Independent with bed mobility. -Supervision with personal hygiene. -Limited assistance with on and off the unit. -Extensive assistance with dressing and toilet use. -Received as needed (PRN) pain medication or was offered and the resident declined the medication. Record review of Resident 112's Comprehensive Care Plan (CCP) dated 6-13-2016 revealed Resident 112 had back pain. The goal for Resident 112 was that Resident 112 would rate pain below a 4 on the pain scale. Typed in interventions on the CCP were to balance rest and activity, use numeric scale to rate pain, Tylenol and [MEDICATION NAME] (pain medication) PRN.[MEDICATION NAME] (pain medication) PRN. Further review of Resident 112's CCP dated 6-13-2016 revealed a hand written entry update that Resident 112 received an x-ray due to increased pain and the update dated 10-26-2016 that Resident 112 was to receive Tylenol routine for back pain. Observation on 11-30-2016 at 8:02 AM of personal care for Resident 112 revealed Nursing Assistant (NA) [NAME] and NA F washed hands and donned gloves. Resident 112 was observed to be in bed. Resident 112 yelled out Oh that hurts and was heard to moan and groan as NA F started to cleans the front peri area. Resident 112 continued to yell out stop at NA F and then started to hit at NA F. NA [NAME] assisted Resident 112 into a right laying position for further cleaning. Resident 112 yelled out Your killing me, Oh God Help me, it hurts, Daddy Daddy, oh boy that hurts. NA [NAME] and NA F positioned Resident 112 onto a back laying position and pulled up Resident 112's clothing. When asked by NA F if (gender) wanted to go to breakfast, Resident 112 reported, no. NA [NAME] and NA F did not stop the procedure when Resident 112 complained of pain to report it to the charge nurse. On 11-30-2016 during the observation of care at 8:02 AM, NA [NAME] said Resident 112 was always in pain. Observation on 11-30-2016 at 1:10 PM of Resident 112 being transferred from a wheelchair to the bed revealed NA [NAME] and NA F placed a transfer belt around Resident 112. Both NA [NAME] and NA F explained the transfer task to be completed to the resident. NA [NAME] and NA F began to transfer Resident 112 from the wheelchair and Resident 112 yelled out in pain stating ouch, that hurts and was transferred into bed. NA [NAME] and NA F pulled down Resident 112 pants and positioned the resident onto the resident ' s right side. During the repositioning, Resident 112 yelled out Oh it hurts, help me god, don't move me. NA [NAME] and NA F completed the personal care. An interview was conducted on 11-30-2016 at 1:10 PM after the personal care was completed. When attempting to ask Resident 112 to rate the pain, Resident 112 stated little bit, little bit with furrowed brows. Resident 112 was not able to state a number on a scale of 0 to 10. An interview on 11-30-2016 at 2:01 PM was conducted with Licensed Practical Nurse (LPN) B. During the interview, LPN B reported that NA [NAME] and NA F had informed (gender) about Resident 112's pain. LPN B reported Resident 112 had identified the pain as a little bit. When asked if LPN B had evaluated Resident 112's pain after being notified, LPN B stated no. Record review of The Facility Pain assessment and Treatment Program Policy and Procedure dated 7-2013 revealed the following information: -Policy: All residents will have their pain recognized, assessed and treated. Pain may manifest itself as verbal expression of pain, moaning, sleep disturbances, agitation, rocking, grimacing, withdrawal, crying, and guarding of affected area(s). -Procedure: -1. The resident will be assessed for pain by the licensed nurse at admission, re-admission, quarterly and as needed. -5. Staff will continue to monitor for verbal and nonverbal signs of pain. It may be necessary to ask the resident are you having pain?, are you comfortable?, do you have discomfort or do you ache anywhere?. The pain assessment scale will be utilized to rate the severity of pain. -6. Information regarding the resident's pain, interventions and management will be included in the resident's plan of care. This will be reviewed and modified needed. -treatment plan: [REDACTED] -1. treatment of [REDACTED]. -2. Non-Pharmacological interventions can include repositioning, music, relaxation, distraction, exercise, physical or occupational therapy and application of ice or heat. -4. It may also be necessary to administer pain medication prior to certain activities such as physical or occupational therapy or medical procedures. -5. The licensed nurse will notify the physician if the residents is not experiencing relief with the current treatment plan or are experiencing a new acute onset of pain and pain is interfering with their comfort and/or functional status. The resident will be placed on triggered charting until the resident is free of pain or the pain controlled within the resident's stated acceptance level The facility staff did not provide additional information prior to survey exit. | 2020-09-01 |
| 258 | HIGHLAND PARK CARE CENTER | 285063 | P O BOX 950, 1633 SWEETWATER | ALLIANCE | NE | 69301 | 2018-08-23 | 689 | G | 0 | 1 | EHQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b (3 and 4) Based on record reviews and interview, the facility failed to ensure that interventions were in place to prevent recurrent falls with injuries including a cervical fracture with ongoing pain and multiple abrasions with pain for one current sampled resident (Resident 54). The facility census was 53 with 22 current sampled residents. Findings are: Review of Resident 54's care plan, goal date 8/20/18, revealed that the resident had a history and potential for falls related to a history of self transfers and self ambulation, confusion, impaired gait and balance, incontinence, antidepressant and diuretic medications, was unaware of safety needs, weakness, difficulty in walking, refusal of cares and physical and verbal aggression and agitation at times. Further review revealed a focus area, dated 8/20/18, which stated that the resident sustained [REDACTED]. Other focus areas included that the resident had cognitive impairment related to both short term and long term memory troubles and the resident required assistance with activities of daily living including transfers and toileting. Interventions listed on 7/4/18 revealed that the resident often self transfers, attempts to self ambulate and will often transfer self to the bathroom unassisted. Review of the Progress Notes revealed the following including: - 7/24/18 at 7:20 PM The staff found the resident on the floor at the foot of the bed. The resident stated was going to the bathroom. The resident complained of neck and shoulder pain and refused to go to the hospital for evaluation. The resident was educated on the use of the call light; - 7/25/18 at 1:35 PM The resident was sent to the to physician for evaluation of severe neck and shoulder pain almost unbearable; - 8/2/18 at 11:00 AM The resident was readmitted from the hospital with a [DIAGNOSES REDACTED].; - 8/4/18 at 1:08 PM The resident transferred self back to bed after breakfast and staff gave frequent reminders to call for assistance, the resident required extensive assistance of two staff for all transfers; 6:47 PM The resident attempted to self transfer multiple times this shift; - 8/10/18 at 1:23 PM The provider changed pain medications from routine to as needed; - 8/14/18 at 11:10 AM The resident was unable to use legs to stand up correctly in sit to stand lift, full body lift used at this time; - 8/17/18 at 1:27 PM The nurse witnessed the resident slip to the floor from the bed, the resident frequently attempts self transfers, no injuries noted; - 8/19/18 at 2:58 PM The resident was observed on the floor at 1:15 PM, the resident stated tried to get into bed, did not use the call light for assistance. The resident was transported to the emergency room via ambulance for evaluation. The resident returned to the facility at 6:45 PM and was treated for [REDACTED]. - 8/20/18 at 3:00 PM The resident is very confused and has been attempting to self transfer since 2:00 PM, 9:48 PM The resident had been attempting multiple times to self transfer this shift and is very confused and does not call for help; - 8/21/18 at 3:50 AM The resident was confused and was observed attempting to get up from bed, legs hanging out over the side of the bed. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the resident received [MEDICATION NAME] as needed for pain related to the cervical fracture 17 times from 8/11/1- 8/20/18 for pain rated 4-7 on the 0-10 pain scale with 0 indicating no pain and 10 the worst possible pain. The resident rated pain at 4 three times, 5 seven times, 6 three times and 7 four times. Review of the facility Fall Scene Investigation Reports revealed the following including: - 7/24/18 Initial Cause (s) of the fall? The resident did not call for assistance to go to the bathroom, knocked the wheelchair over, still did not call for help and then attempted to self transfer to the bathroom. Interventions to prevent future falls and verify implementation were encourage the use of the call light, educate on the use of the call light every time staff enters room and possible placement of a fall alarm. IDT (Interdisciplinary Team) interventions added to the care plan related to the event and observe to verify implementation: 1. Place anti -tip device on the wheelchair. 2. Have therapy evaluate transfer and determine if a trapeze would be appropriate for repositioning. 3. Offer to move the bed against the wall to open up room if the residents wants to self transfer. - 8/17/18 Initial cause(s) of the fall? Bed positioning and frequent attempts to self transfer. Interventions to prevent future falls and verify implementation: Care plan update, will not position the bed with both the head and foot elevated at the same time. IDT interventions added to the care plan related to the event and observe to verify implementation: 1. Staff to monitor bed position with each encounter and reposition bed if both foot and head elevated. 2. Remove turn sheet when not in use. - 8/19/18 Initial cause(s) of fall? Attempted to self transfer. Interventions put into place to prevent future falls and verify implementation: Provider ordered transport to the hospital emergency room per ambulance for assessment. IDT interventions added to the care plan related to the event and observe to verify implementation: 1. Schedule pain medications. 2. Document pain levels two times a day and report to provider if not adequate. Review of the Non -Pressure Skin Condition Records, dated 8/23/18, revealed the following skin injuries related to the fall on 8/19/18: - Digits to the left foot have multiple abrasions in various stages of healing and pain; - Digits to the right foot have abrasions to all digits except the fifth digit. Abrasions in various stated of healing and pain; - Entire left knee is reddened, several abrasions in various shapes and sizes inside the reddened area and pain; - Entire right knee is reddened with several abrasions in various sizes and shapes throughout the reddened area and pain. Interview with the Director of Nursing on 8/23/18 at 10:35 AM confirmed that the resident had a history of [REDACTED]. Further interview confirmed that fall interventions in place were not effective to prevent self transfers and subsequent falls with injuries. | 2020-09-01 |
| 364 | PARK VIEW HAVEN NURSING HOME | 285073 | 309 NORTH MADISON STREET | COLERIDGE | NE | 68727 | 2017-09-28 | 325 | G | 1 | 1 | XTJ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview; the facility failed to revise current interventions or to develop new nutritional interventions to address ongoing significant weight loss for Resident 13. The facility census was 25 and the sample size was 27. Findings are: [NAME] Review of the facility policy Significant Weight Loss (undated) revealed a goal of identifying causes or factors contributing to significant unplanned weight loss and implementation of interventions as appropriate to stabilize weight. Review of the identified procedure revealed the following: -Review food intake records. -Interview the resident to identify possible causes and appropriate interventions. -Implement individualized nutritional interventions based on resident preferences. This may include but is not limited to; foods enhanced with extra calories or proteins. -High calorie or high protein supplements. -Possible use of an appetite stimulant if appropriate. B. Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/24/17 revealed [DIAGNOSES REDACTED]. The resident's weight was 143 lbs. (pounds) and the resident was not on a prescribed weight loss regime. Review of Resident 13's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) revealed on 5/28/17 the resident's weight was 142 lbs. Review of Resident 13's current Care Plan revised on 5/30/17 revealed the resident had the potential for nutritional problems related to pain and loss of appetite. The following interventions were identified: -Offer snacks as requested by the resident. -Provide and serve diet as ordered. -Registered Dietician (RD) to evaluate and make recommendations as needed. Review of Resident 13's Weights and Vitals Summary sheet revealed the following record of weights: 6/26/17- 138 lbs. 7/24/17- 143 lbs. 8/21/17- 134 lbs. (down 9 lbs. or a 6.3 % (percent) loss in 1 month) Review of a Nutrition Progress Note by the RD dated 8/22/17 at 1:06 PM, revealed the resident's current body weight was 133.5 lbs. with a significant weight loss of 6.8 % in 30 days. The resident was on a regular diet and had poor intakes averaging 25 to 100% at meals. The RD made a recommendation for the resident to receive Ensure (drink with added calories) 240 cubic centimeters (cc) twice a day to deter further weight loss. Review of Resident 13's Medication Administration Record [REDACTED]. Review of Resident 13's MAR indicated [REDACTED] -8:00 AM from 9/1/17 through 9/25/17 the resident consumed less than 50% of the supplement on 9/1/17 through 9/7/17, 9/9/17, 9/11/17 through 9/15/17, 9/20/17, 9/22/17, and 9/24/17 ( 16 out of 25 days) and, -12:00 PM from 9/1/17 through 9/25/17 the resident consumed less than 50% of the supplement on 9/1/17 through 9/7/17, 9/10/17 through 9/12/17, 9/15/17, 9/18/17 and 9/20/17 through 9/24/17 (16 out of 25 days). Review of Resident 13's Weights and Vitals Summary revealed the resident's weight on 9/25/17 was 121 lbs. (down 13 lbs. or 9.7% in 1 month and down 17 lbs. or a 12% weight loss in 3 months). Review of Resident 13's medical record revealed no evidence the Dietary Manager (DM) or the RD had addressed the resident's ongoing significant weight loss since 8/22/17. During an interview on 9/27/17 from 9:30 AM to 10:05 AM, the RD confirmed the following: -Resident 13 received the Ensure 240 cc only once a day from 8/23/17 through 8/31/17. The resident's intakes continued to decline and the resident was not always accepting the supplement. -Staff did increase the Ensure supplement to twice a day when the error was identified on 9/1/17 even though acceptance continued to be poor at times. -Resident 13 had not been interviewed since admission on 5/27/17 to determine dietary preferences. -No further nutritional interventions were developed or implemented despite the residents continued significant weight loss. | 2020-09-01 |
| 421 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2018-02-12 | 689 | G | 1 | 1 | B6BN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 12-006.09D7 Based on observations, interview, and record review, the facility failed to implement interventions to protect 1 (Resident 59) of 9 sampled residents with falls. The facility had a total census of 170 residents. Findings are: Resident 59 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 2/7/18 at 9:09 AM and 1:05 PM revealed Resident 59 being fed breakfast and lunch in bed by Nurse Aide I. In an interview on 2/7/18 at 1:05 PM, Nurse Aide I reported Resident 59 was not getting up in chair due to not having a cushion for Resident 59's wheelchair. Observations on 2/8/18 at 9:06 AM revealed Resident 59 being fed breakfast in bed by Nurse Aide [NAME] In interviews on 2/8/18 at 7:28 AM and 9:06 AM, Nurse Aide J reported Resident 59 had slid out of wheelchair and Resident 59 had not been getting up. Nurse Aide J reported waiting until new wheelchair came in to get Resident 59 up. In an interview on 2/7/18 at 2:06 PM, Registered Nurse N reported physical therapy was trying to find a wheelchair for Resident 59 due to sliding out of the wheelchair. A review of Post Fall assessment dated [DATE] revealed Resident 59 was observed slid down out of wheelchair with back resting against foot pedals. Resident 59 received a 5.6 x 1.9 cm (centimeter) skin tear with redden bruising around edges to left lower arm and a 4.7 x 3.5 cm skin tear with reddened bruising around edges to left arm near elbow. A review of Interdisciplinary Therapy Screen dated 1/31/18 revealed Resident 59 was identified having a potential risk related to wheelchair positioning. The comments section stated Resident 59 was appropriate for occupation therapy due to need for wheelchair positioning assessment. In an interview on 2/8/18 at 8:36 AM, Occupational Therapist K reported that a physician's orders [REDACTED]. In an interview on 2/8/18 at 10:10 AM, Physical Therapist L confirmed a screen had been completed on 1/31/18 and orders requested for an evaluation. Physical Therapist L reported no recommendation had been made for Resident 59 to stay in bed due to being unsafe in chair. A review of Occupational Therapy Initial Evaluation dated 2/8/18 revealed Resident 59 required occupational therapy services to address sitting tolerance and postural control. Occupational Therapy Initial Evaluation identified a short term goal for Resident 59 of completion of a trial in a customized wheelchair to improve postural stability and upright positioning. | 2020-09-01 |
| 424 | ST. JOSEPH VILLA NURSING CENTER | 285078 | 2305 SOUTH 10TH STREET | OMAHA | NE | 68108 | 2018-02-12 | 697 | G | 1 | 1 | B6BN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to implement and evaluate the effectiveness of the pain management program for 1 (Resident 156), and failed to evaluate the effectiveness of as needed pain medications for 1 (Resident 256) of 5 sampled residents. The facility staff identified a census of 170. Findings are: [NAME] Record review of a Face Sheet dated 1-24-18 revealed Resident 156 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 156's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 2-07-2018 revealed the facility staff assessed the following about Resident 156: -Brief Interview of Mental Status (BIM'S) was a 15. According to the MDS Manuel, a score of 13 to 15 indicate intact cognition. -Required Limited assistance with bed mobility, transfers, eating, toilet use and personal hygiene. - No pain issues were identified for Resident 156. Record review of Resident 156's Comprehensive Care Plan (CCP) dated 1-27-2018 Resident 156 had a problem area of pain. The goal identified for Resident 156 was to be able to verbalize or demonstrate minimal pain or discomfort. Interventions to manage Resident 156's pain included administering pain medication and evaluating the effectiveness, assess for non verbal signs of pain such as guarding, moaning and grimacing. Assessing pain characteristics, asking the resident to be specific regarding the duration, location and the quality of the pain. Medicate and offer to medicate for pain prior to physical activities such as Activities of Daily Living (ADL's) or Therapy. Offer non-pharmaceutical means of relief, such as, repositioning, elevation of extremities on pillows, relaxation-quite music, and 1 to 1's. Record review of Nursing Assessment and Re-Admission sheet dated 1-15-2018 revealed Resident 156 had pain to a leg, foot, Shoulder, hip and back pain described as stabbing and shooting pain. The relieving factor was the administration of pain medication. Record review of NAAR dated 1-30-2018 revealed Resident 156 had leg and foot pain with the relieving factor was the administration of pain medication. Record review of Resident 156's Nurse's Notes (NN) dated 1-31-2018 with a time of 9:00 PM revealed Resident 156 refused to get out of bed, c/o (complained of) Pain). According to the NN dated 1-31-2018, pain medication was given. Record review of Resident 156's medical record revealed there was no evidence the facility staff had evaluated the effectiveness of the pain medication. Record review of Resident 156's NN dated 2-1-2018 with a time of 5:30 AM revealed Resident 156 was crying and expressing frustration c/o severe pain to bilat ( both) LE's ( lower extremities) with pain medication being administered. Record review of Resident 156's record that included the Medication Administration Record [REDACTED]. Record review of Resident 156's NN dated 2-2-2018 with the time identified as 8:00 AM revealed Resident 156 continues to cry loudly and to refuse cares. Record review of Resident 156's MAR for 2-2-2018 revealed at 9:50 AM pain medication and an anti-anxiety medication was administered to Resident 156. Further review of the MAR indicated [REDACTED]. Record review of Resident 156's NN dated 2-3-2018 with a time identified as 5:00 AM revealed Resident 156 was difficult to reposition in bed and change an adult brief related to Resident 156 yelling out in pain. Further review of Resident 156's NN dated 2-3-2018 at 5:00 AM revealed Resident 156 yelled out pain description, I hurt all over, its sharp pain. The NN dated 2-3-2018 at 5:00 AM revealed Resident 156 continued to cry and yell out with all cares with Resident 156 stating just let me die. Observation on 2-07-2018 at 8:45 AM revealed Resident 156 needed to use the bathroom. Registered Nurse (RN) C and Nursing Assistant (NA) D came into Resident 156's room and Resident 156 reported the need to use the bathroom. Resident 156 chose to use a bed pan instead of using the bathroom due to increased anxiety for the use of a mechanical lift. NA D with the assistants of another NA started to roll resident to the side. Resident 156 was observed to have facial grimacing reporting (gender) knee hurt and reported a pain level of an 8 to 9 on a scale of 0 to 10 with 10 being the worst pain. RN C asked Resident 156 if Resident 156 wanted pain medication with Resident 156 stating, yes. RN C obtained Resident 156's pain medication and administered to Resident 156. Observation with RN C on 2-07-2018 at 9:35 AM revealed NA D with another NA prepared to transfer Resident 156 using a mechanical lift. NA D placed the sling for the transfer under Resident 156 requiring Resident 156 to roll side to side. Resident 156 yelled out, oh that hurts my back. NA D explained the task of the transfer to Resident 156. NA A attached the sling to the mechanical lift and started to lift Resident 156 up. Resident 156 started to yell Oh my back, my back and started to cry. Resident 156 reported it feels like my back is broke. NA D started to raise Resident 156 up with Resident 156 yelling oh that hurts, stop. let me rest. Resident 156 stated put a sock in my mouth so I don't scream. On 2-07-2018 at 9:54 AM an interview was conducted with NA D. During the interview, NA D reported Resident 156 is always painful. NA D reported Resident 156 pain has been getting worse and this had been reported to the nurses. NA D reported Resident 156 is more painful when moved and that Resident 156's pain seems to be getting worse. On 2-07-2018 at 11:15 Am an interview was conducted with the Medical Records Manager (MRM). During the interview the MRM reported Resident 156 did not have a pain management flow sheet started for Resident 156. On 2-07-2018 at 1:25 PM an interview was conducted with RN C. During the interview when asked if Resident 156 had been pre-medicated prior to the ADL's being completed. RN C stated no, further reported Resident 156 should have been pre-medicated. When asked what Resident 156's acceptable pain level was, RN reported not knowing what was acceptable to Resident 156. On 2-08-2018 at 7:56 AM an interview was conducted with Resident 156 related to Resident 156's pain management. During the interview Resident 156 reported the goal for acceptable pain level was a 5 based on a scale of 0 to 10 with the 10 being the worst pain. Resident 156 reported (gender) pain level are between and 8 and 9 with movement. On 2-08-2018 at 10:45 AM an interview was conducted with Licensed Practical Nurse (LPN) [NAME] During the interview LPN G reported that all pain medication should be evaluated for the effectiveness. Record review of an undated Policy and Procedure for Pain Assessment and management revealed the following information. -Purpose: All Residents will be assessed for pain and identified by nursing staff. Residents with pain will receive individual interventions aimed at reducing chronic and/or acute discomfort utilizing current standards of practice for pain control. -Procedure: -2. develop an individualized care plan for pain management. -3. Pain Management Flow Sheet will be placed in each residents medication record for assessment and documentation of intermittent and breakthrough pain. -4. Pain assessment will be done using the 0 to 10 pain scale based on the residents cognitive status. -6. Interventions to treat residents pain will be implemented to manage pain effectively. -7. Evaluate effectiveness of PRN (as needed) [MEDICATION NAME] within an hour of time administered and document effectiveness on the back of the MAR indicated [REDACTED]. B. Resident 256 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interview on 2/7/18 at 2:21 PM, Resident 256 reported having pain at a level 10 (pain rating scale of 1-10) and reported having received a pain pill an hour ago. Resident 256 reported not getting relief from pain. A review of Resident 256's 2/2018 Medication Administration Record [REDACTED]. A review of Narcotic count record for Resident 256 revealed Resident 256 received [MEDICATION NAME] 5 mg 19 times between 2/1/18 and 2/7/18. A review of 2/2018 Resident 256 Medication Administration Record [REDACTED]. A review of the back side of the Medication Administration Record [REDACTED]. A review of Resident 256 PRN Pain Management Flow Sheet revealed documentation of [MEDICATION NAME] given 4 times as follows: 1 time on 2/4/18, twice on 2/5/18 and once on 2/7/18. The flow sheet identifies pain location, pain level, [MEDICATION NAME] given, and if [MEDICATION NAME] is effective. In an interview on 2/8/18 at 10:41 AM, Licensed Practical Nurse M reported pain flow sheet is to be completed when a resident asks for a pain medication. In an interview on 2/8/18 at 12:10 PM, Staff Development Registered Nurse reported no other PRN Pain Management Flow Sheet could be located for Resident 256. A review of undated policy titled Pain Assessment and Management revealed the following: -the Pain Management Flow sheet will be used for assessment and documentation of intermittent and breakthrough pain. -The effectiveness of PRN [MEDICATION NAME] will be evaluated within an hour of administration and documented on back of Medication Administration Record [REDACTED] | 2020-09-01 |
| 459 | HILLCREST NURSING HOME | 285080 | P O BOX 1087, 309 WEST 7TH STREET | MCCOOK | NE | 69001 | 2018-01-24 | 760 | G | 1 | 0 | 6LD811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.10D Based on record reviews and interviews, the facility failed to transcribe a medication order for a diuretic medication (medication to reduce swelling) for one sampled resident (Resident 4). The failure resulted in a 14 day delay in the medication being provided to the resident and resulted in the resident's continued leg swelling and development of blisters. Sample size was four current residents. Facility census was 77. Findings are: Record review of Resident 4's Face Sheet printed on 1/24/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 4's electronic medical record and chart revealed the following: - from the Departmental Notes an entry dated 12/15/17 at 4:37 p.m. revealed the resident was seen and received new orders from the physician. - A Message from Organization: (name of clinic). New Medication (a web-based communication tool with communication from the clinic to the facility) dated 12/15/17 and generated on 12/16/17 revealed the physician also started (Resident 4) on 20 mg (milligrams) of [MEDICATION NAME] PO (by mouth) daily. An Electronic Prescription via Sure Scripts form from the clinic to the pharmacy revealed an order dated 12/15/17 for Resident 4 was written for [MEDICATION NAME] 20 mg oral tab with instructions to administer 1 (one) Tablet by mouth once daily. - 12/23/17 at 3:34 p.m. from the Departmental Notes the resident was assessed with [REDACTED]. 2+ indicated indention of the skin 2-4 millimeters deep which does not rebound for 10-15 seconds when pushed inward) to BLLE (bilateral lower extremities) . - A Nursing Communication form sent to the physician on a follow up visit dated 12/29/17 revealed the resident was being seen in Follow-up and requested the physician Please look @ (at) red, raised open areas to L (left) lower leg . The physician provided a communication note from the visit which read: See web message from 12/15/17. Patient (Resident 4) should be on [MEDICATION NAME] (Generic name for [MEDICATION NAME]) 20 mg by mouth once daily. - Departmental Notes entry dated 12/29/17 at 5:30 p.m. recorded the resident had an appointment with the physician. Orders are as follows. See web message from 12.15.17. Patient (Resident 4) should be on [MEDICATION NAME] 20 mg by mouth once daily . - e-Medication Administration Record [REDACTED]. - Departmental Notes entry dated 1/18/18 at 12:12 p.m. revealed an entry by the Registered Dietitian which read: Current weight 215# (215 pounds). Admit weight was 195# in October. Dr reviewed weight of 214# with no dietary changes last month . [MEDICATION NAME] was added last month and increased this month, so we may see some weight fluctuations due to [MEDICAL CONDITION] changes . Record review of a facility Investigation Report dated 1/16/18, forwarded to the State Agency, revealed the facility investigated the delay in the order implementation for Resident 4's [MEDICATION NAME]. The investigation was initiated after Resident 4's spouse reported to the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator on 1/9/18 that Resident 4's [MEDICATION NAME] order was missed by the nursing staff when ordered on [DATE] and not started until 12/29/17. The spouse reported the resident's legs had some increased [MEDICAL CONDITION] with blisters to the lower extremities due to the resident not receiving [MEDICATION NAME]. The report acknowledged the error in getting the medication order transcribed and administering the medication to the resident. The Potential Causal factors revealed the physician sent the order over the Portal (the electronic computerized communication system between clinic and facility) and that the order had not been opened by the nurse on duty. The facility determined that once an order is opened on the portal per facility protocol, it is to be entered into the computer, if it is opened staff have no way to know it is a new order and has not been entered into the computer. The investigation Outcome revealed the order for [MEDICATION NAME] was missed on the Portal and the resident had not received (the resident's) [MEDICATION NAME] for 13 days. The report revealed It was noted by the Primary care Physician that there was increased swelling with small pinpoint blisters to lower extremities (for Resident 4) bilaterally. Primary Care Physician felt this increased swelling and blisters were caused by resident not receiving (the resident's) [MEDICATION NAME]. Interview with the ADON (Assistant Director of Nursing) and MDS Coordinator on 1/24/18 9:45 a.m. confirmed Resident 4 received a physician's orders [REDACTED]. Due to a problem with the computerized communication portal, the order was not transcribed and the medication was not started until after the physician alerted the facility to the mistake on 12/29/17. The ADON confirmed the facility investigated the issue and verified the omission of the original order resulted in the resident experiencing increased swelling and blisters. | 2020-09-01 |
| 610 | TIFFANY SQUARE | 285087 | 3119 WEST FAIDLEY AVENUE | GRAND ISLAND | NE | 68803 | 2018-03-07 | 686 | G | 0 | 1 | K8KC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review, and interview; the facility failed to have interventions in place to promote healing of a facility acquired Stage 2 (partial thickness loss of skin) pressure ulcer on the sacrum (fused bones found at the lower end of the spinal column) for 1 of 3 sampled residents (Resident # 61) and therefore the pressure ulcer worsened from a Stage 2 to a Stage 3 (full thickness loss of skin). The facility identified a census of 82 at the time of survey. Findings are: Record review of Resident 61's MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 2/09/18 revealed an admission date of [DATE]. Resident 61 had a BIMS (Brief Interview Mental Status) score of 7 which indicated Resident 61 had severe cognitive impairment. Resident 61 required extensive assistance of 2 staff with bed mobility and was dependent with two plus persons physical assist with transfers. Review of Resident 61's Pressure Ulcer Record dated 1/23/2018 revealed Resident 61 had a Stage 2 pressure ulcer on the sacrum with an onset date of 1/21/2018. Observation of Resident 61 on 3/1/2018 at lunch time (12:00 PM) revealed Resident 61 was sitting in their wheelchair. Observation of Resident 61 on 3/1/2018 at 1:30 PM revealed Resident 61 was sitting in their wheelchair. Observation of Resident 61 on 3/1/2018 at 3:00 PM revealed Resident 61 was sitting in their wheelchair. Observation of Resident 61 on 3/1/2018 at 3:10 PM revealed staff assisted Resident 61 to lay down in bed. The resident had not been out of the wheelchair since before 12PM. Observation on 3/06/18 at 1:14 PM revealed Resident 61 was sitting in a recliner with the sling from the lift still underneath the resident. Observation on 3/06/18 at 2:40 PM revealed Resident 61 was sitting in a wheelchair at an activity with the sling from the lift underneath the resident. Interview on 3/06/18 at 10:45 AM with NA-J (Nurse Aide) revealed that the resident was to be laid down and repositioned every 2 to 3 hours from side to side, to get resident off their bottom. Interview on 3/06/18 at 5:00 PM with LPN-A (Licensed Practical Nurse) revealed that the lift sling was not to be left underneath residents in the chair, unless care planned for that resident. Interview with OT-D (Occupational Therapist) on 3/6/2018 at 1:25 PM revealed that the mechanical lift slings were not be left under residents when they are sitting on a pressure reducing cushion in a chair because it defeated the purpose of the cushion. Review of Resident 61's Pressure Ulcer Record (V3) dated 1/23/18 revealed a Stage 2, 2.5 cm (centimeter) by 1.3 cm pressure ulcer on Resident 61's sacrum. The open area was a fluid filled blister but had erupted and was now open. Review of Resident 61's Pressure Ulcer Record (V3) dated 2/13/18 revealed the pressure ulcer worsened from Stage 2 to Stage 3. Review of Resident 61's Physician Visit/Communication form dated 2/20/18 revealed that Resident 61 had been evaluated at the would clinic for a Stage 3 pressure ulcer that measured 1.5 cm by 1.3 cm by 0.2 cm. Review of Resident 61's Pressure Ulcer Record (V3) dated 3/06/18 revealed a Stage 3 pressure ulcer on the sacrum that measured 2.0 cm by 1.7 cm which indicated the wound had gotten larger than last measurement. Observation of Resident 61 on 3/6/2018 at 10:15 AM revealed Resident 61 had a pressure ulcer present on their tailbone area. Interview with the ADON-G (Assistant Director of Nursing) on 3/6/2018 at 10:20 AM confirmed the pressure ulcer to Resident 61's tailbone area was facility acquired. Review of Resident 61's Care Plan dated 1/27/2018 revealed no documentation that Resident 61 was to be repositioned and whether or not the lift sling was to be left under the resident. | 2020-09-01 |
| 664 | HERITAGE OF BEL AIR | 285089 | 1203 NORTH 13TH STREET | NORFOLK | NE | 68702 | 2019-06-24 | 689 | G | 0 | 1 | 2H0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to implement interventions to prevent potential choking episodes for Resident 41. The sample size was 1 and the facility census was 84. Findings are: Review of a Progress Note dated 5/12/19 revealed at 12:50 PM Resident 41 began coughing during lunch. The resident had increased difficulty breathing and talking. The resident shook no when asked if the resident could talk. Back blows were performed with no improvement. The resident became unresponsive and cyanotic (bluish discoloration usually caused by low oxygen levels) with fixed pupils. The resident's chin was lifted, to obtain optimal airway, and the resident then coughed and was able to take breaths at that time. The resident's physician and Power of Attorney (POA) were notified per telephone. The resident's POA requested the resident's current diet remain unchanged. Review of a ST (Speech Therapy) Daily Treatment Note dated 5/14/19 revealed ST recommended a mechanical soft diet with extra sauces/gravies and no raw fruits or vegetables. Review of a Progress Note dated 5/14/19 at 10:30 PM, revealed Resident 41 was offered a ground meat sandwich. The resident coughed and had strider (high-pitched, wheezing sound caused by disrupted airflow) type respirations. The nurse attempted the [MEDICATION NAME] maneuver and performed back blows with no change. The resident began to have cyanosis to the lips, ears, and nail beds. The resident became unresponsive to tactile (sensory stimulation involving touch) and verbal stimulation. The resident was transferred out of the wheel chair, to the floor, rolled on side, and back blows were performed again. Oxygen was started and the resident started coughing. Review of a Progress Note dated 5/17/19 at 8:50 AM revealed Resident 41 had another choking/wheezing episode at the breakfast table. The wheezing lasted for a few seconds and then the resident stopped wheezing and took a drink of water. The resident did this a few times at the breakfast table, and then had more wheezing when seated in the recliner in the day area. The resident became cyanotic in the face. Oxygen was applied and a breathing treatment was completed. Review of a Progress Note dated 5/20/19 at 10:00 AM revealed Resident 41 choked on Cream of Wheat cereal. The Cream of Wheat cereal was stuck to the resident's throat. The resident was encouraged to drink more fluids and was able to drink the fluids. The staff were educated to add some milk to the Cream of Wheat cereal to help with swallowing. Review of Resident 41's current Care Plan revealed the Care Plan was updated on 5/20/19 to include the following interventions related to the resident's choking episodes: - Monitor for signs and symptoms of aspiration (sucking food into the airway), - All staff were informed of special dietary and safety needs, - Check the resident's mouth after meal for pocketed food and debris, - Follow the diet as prescribed with no raw fruits and vegetable, - Monitor for shortness of breath, choking, labored respiration, and lung congestion, and - Refer to speech therapist for swallowing screen/evaluation as needed. Review of a Progress Note dated 5/24/19 at 12:21 PM revealed Resident 41 was seated at the dining room table and had an extreme episode of wheezing/food stuck in the resident's throat. Back blows and [MEDICATION NAME] maneuver were performed with no change. Sips of water were given to clear the throat with no relief. The resident went unresponsive and turned blue/grey. The resident was transferred to bed and oxygen was started. Once the resident was laid down, color came back slowly and the resident coughed numerous times. Review of a ST Daily Treatment Note dated 5/27/19 revealed it was reported that Resident 41 had an extreme choking episode over the past weekend where the resident's airway was blocked for several minutes. The nurse stated that the meal provided during the incident did not have extra sauces/gravies. Resident 41's Therapist Progress and Updated Plan of Care dated 5/28/19 identified a list of foods to avoid to prevent potential choking while on the mechanical soft diet. Food items to avoid included rice, corn, cheese, bread, pie crusts, cookies, raw fruits, raw vegetables, potato chips, pineapple, sticky foods (such as chewy candies), lettuce, and dry cereal. Review of a ST Daily Treatment Note dated 5/30/19 revealed Resident 41 had oral residue post swallow of ground meats. On 6/20/19 at 12:20 PM Resident 41 was seated in the dining room for lunch. The resident was served a lettuce salad with dressing, which was placed in front of the resident ready for consumption. Interview with the Assistant Dietary Manager on 6/20/19 at 12:20 PM confirmed Resident 41 had dietary restrictions which included no raw fruits or vegetables. The Assistant Dietary Manager confirmed the resident should not have been served a lettuce salad. Resident 41 was observed on 6/24/19 from 9:20 AM to 9:37 AM. The resident was seated in the dining room eating breakfast. The resident was served hot cereal with milk, ground meat, and scrambled eggs with a variety of drinks. The resident ate independently. After eating, the resident was transferred from the dining room table to a recliner in the day area by Nursing Assistant (NA)-C and NA-L. The resident's mouth was not checked to ensure no food items were pocketed. Interviews with NA-B, NA-L, and Registered Nurse-M on 6/24/19 from 9:32 AM to 9:37 AM, confirmed Resident 41's mouth was not checked after breakfast on 6/24/19. Further interview confirmed the staff did not check Resident 41's mouth after meals. Review of Resident 41's Medical Record on 6/24/19 revealed no evidence to indicate oral inspections were completed after meals to check for pocketed food items. | 2020-09-01 |
| 794 | CENTENNIAL PARK RETIREMENT VILLAGE | 285094 | 510 CENTENNIAL CIRCLE | NORTH PLATTE | NE | 69101 | 2017-01-26 | 328 | G | 0 | 1 | EUUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6 Based on observations, record reviews and interviews; the facility failed to ensure that oxygen was in place and administered as ordered and that respiratory status was monitored for one sampled resident (Resident 39) who frequently removed oxygen resulting in low oxygen blood levels. The facility census was 50 with 17 current sampled residents and 2 closed records. Findings are: Review of the Resident Face Sheet revealed that Resident 39 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, edited 1/20/17, revealed that the resident was at risk for impaired gas exchange related to chronic [MEDICAL CONDITION]. Approaches included administer oxygen per nasal cannula, assess and record signs of impaired gas exchange (confusion, restlessness, irritability), resident refuses to wear oxygen frequently, monitor oxygen saturation as ordered and monitor and document respiratory status as needed with changes in respiratory status. Interview with a family representative on 1/24/17 at 12:30 PM revealed they often found the resident without oxygen. Further interview revealed that the resident was more confused, restless and agitated when the oxygen wasn't kept on which made it even more difficult to get the resident to keep the oxygen in place. Observations on 1/24/17 at 8:45 PM revealed the resident seated in the wheelchair in room with oxygen cannula (tubing placed in the nose to administer supplemental oxygen) on the floor. Further observations revealed NA (Nursing Assistant) - M attempted to place the oxygen on the resident and the resident refused. NA - M reported to LPN (Licensed Practical Nurse)- H, Charge Nurse, that the resident refused the oxygen and was agitated. LPN - H entered the room and encouraged the resident to use the oxygen and the resident complied. LPN - H checked the resident's oxygen saturation which was 79% (normal oxygen saturation is greater than 90%). LPN - H encouraged the resident to take deep breaths and after several minutes the oxygen saturation was 80%. At 9:15 PM, LPN - H reported that a respiratory treatment was administered and then the resident's oxygen saturation rate was 90%. Observations of the resident on 1/24/17 at 9:45 PM revealed that the resident's oxygen was off and the cannula was draped over the arm of the wheelchair. Interview on 1/24/17 at 10:00 PM with NA - M revealed that the resident continued to refuse to get ready for bed. Observations on 1/25/17 at 4:30 AM, 5:30 AM and 6:00 AM revealed the resident sleeping in bed with the oxygen cannula off. Interview with RN (Registered Nurse) - L on 1/25/17 at 6:05 AM revealed that RN-L was not aware that the resident's oxygen had been off this morning. RN - L checked the oxygen saturation which was reported to be 86%. Observations on 1/25/17 at 7:00 AM revealed the resident sleeping in bed with the oxygen cannula off. Observations on 1/25/17 at 8:20 AM revealed MA (Medication Aide) - [NAME] awakened the resident for morning cares. MA - [NAME] shut the oxygen concentrator off. Further observations revealed that the resident did not have oxygen on during the morning cares. MA - [NAME] applied the oxygen for the resident at 8:50 AM. Review of the Nurses Notes revealed no notes after 1/11/17 which stated that the resident was off Medicare A skilled nursing services. There was no documentation of the resident's refusal to use oxygen as ordered, restlessness and agitation or low oxygen saturation levels. Review of the Treatments, dated (MONTH) (YEAR), revealed an order, dated 12/12/16, for oxygen at 2 liters per minute per nasal cannula continuously. Review of the Routine Medications, dated (MONTH) (YEAR), revealed an order, dated 12/12/16 for respiratory treatments four times a day. Review of the Respiratory Assessment Flow Sheet, dated (MONTH) (YEAR), revealed an assessment completed daily after a respiratory treatment which showed oxygen saturation levels of 94% - 98%, and lungs clear. Interview with the DON (Director of Nursing) on 1/26/17 at 8:30 AM confirmed that the nurses should monitor and document the resident's respiratory status, in addition to the daily assessment, as the resident was at risk for low oxygen saturation levels, increased restlessness, agitation and discomfort when the oxygen was removed. | 2020-09-01 |
| 841 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 626 | G | 1 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.05 (5b) Based on record reviews and interviews, the facility failed to allow one sampled resident (Resident 89) to return to the facility following hospitalization to stabilize the resident's condition. The failure resulted in an extended hospital stay for the resident who no longer required hospital level of care. Facility census was 85. Sample size included 7 residents discharged from the facility to an acute care hospital setting. Findings are: Record review of an Admission Record for Resident 89 printed on 5/8/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of a Discharge- return anticipated MDS (Minimum Data Set, a federally mandated assessment and tracking tool) completed on 1/29/19 revealed Resident 89 had been discharged to an Acute hospital on [DATE] and the facility expected the resident to return when stabilized. Record review of Resident 89's electronic Progress Notes revealed on 1/29/19 the resident's physician was notified at 10:11 a.m. regarding the resident's aggression and anxiety and informed the the resident was either going to be put under an EPC (Emergency Protective Custody) or admitted to an available behavioral facility. At 1:39 p.m. the facility phoned the local police department, resident's physician, and resident's psychiatrist to inform them the resident was being sent EPC from the facility. At 1:53 p.m. the resident was escorted off the unit by the police department. At 1:56 p.m. an attempt was made to notify the resident's Sibling-[NAME] At 2:51 p.m. the facility received a call from the resident's psychiatrist who stated will let the psychiatrist know the resident was being EPC'd from the facility. An entry on 2/1/19 at 2:17 recorded by the facility SSD (Social Services Director) recorded an emergency contact, Sibling-B, was called and a message left that the resident was being admitted to a behavioral unit. There were no other progress notes regarding the resident after the admission to the behavioral health unit. Record review of Resident 89's closed record documents revealed: There was no discharge summary completed by the facility regarding Resident 89's discharge, nor was there any evidence the resident was notified in writing by the facility indicating the facility initiated discharge. Record review of a document dated 2/14/19 received by Certified Mail at the facility on 2/21/19 revealed a General Counsel attorney for the local hospital sent correspondence to the facility. The corresponding letter recorded Resident 89 was admitted to the hospital's Behavioral Health Unit at the request of the facility and law enforcement for short term care. The patient is now stabilized and ready for discharge back (to the facility). However when (the hospital) contacted (the facility) to make arrangements for discharge, we (the hospital) were advised by (the facility) that it would not accept the patient back from (the hospital) citing behavioral issues with the patient. The correspondence goes on stating: You (the facility) have advised on the telephone that you will not accept the patient back because of behavior issues. We hereby request copies of the medical records that document or substantiate these behavior issues . As you know, we (the hospital) are a short term Behavioral Health Unit. We are not a long-term behavioral health facility. We are not equipped to house nursing home residents on a long-term basis. Request is made for (the facility) to accept the patient back as a resident. Interviews with the hospital General Counsel attorney were conducted in person on 5/21/19 at 1:05 p.m. and by phone on 5/22/19 at 11:00 a.m. The General Counsel attorney verified that Resident 89 was admitted for acute care following an EPC request from the facility on 1/29/19. The resident's condition was stabilized and the facility informed the facility the resident was ready for re-admission. The facility denied the re-admission stating issues with the resident's behavior. The attorney stated the facility had not come to the hospital to evaluate the resident's stable condition at the time of the request. The denial of re-entry by the facility prompted the attorney's formal correspondence to the facility sent and verified as received on 2/21/19 by certified mail. The hospital never received any documentation as requested regarding the behavioral issues or medical records supporting the facility's decision not to re-admit the resident. Further interview by phone revealed the resident remained in the hospital's Behavioral Health acute care unit until 4/9/19 when the hospital found suitable placement for Resident 89 in a facility in Colorado. Record review of a facility policy entitled Transfer and Discharge from the Facility Policy, created in (MONTH) of (YEAR), included the following policy statements: - It is the policy of this facility that each resident has the right to remain in the facility and not transfer or discharge a resident. The policy identifies exceptions to this which included: . resident's needs cannot be met in the facility . - Should a resident's need (s) not be met by the services provided by the facility, the facility staff will reevaluate the resident's care plan to determine if changes to the care plan will help meet the resident's needs. If the facility cannot provide for the resident's needs, the resident may have to be transferred to another healthcare facility that can provide the services needed . - The resident and representative will receive timely notification, adequate preparation, orientation and information to make the transfer as orderly and safe as possible. The notice contain information about the transfer and information about resident's appeal rights . The resident will not be discharged during the appeal process. If the transfer is due to an emergency, the notice will be issued as soon as practicable . - The objective of the transfer/discharge policy is to ensure that the resident is informed of an impending discharge and their right to appeal the discharge . - Overview Of Regulatory Requirement Components for This Policy recorded Facility requirements The facility must permit each resident to remain in the facility and not transfer or discharge the resident unless-- (A) The transfer or discharge is necessary for the resident's welfare and the residents needs cannot be met in the facility . Record review of the facility's Facility Assessment Tool updated on 5/9/19 revealed the facility offered and was licensed for care in both an Advanced Alzheimer's unit of 22 beds and an Alzheimer's unit of 20 beds. The assessment identified Services and Care We offer Based on our Residents' Needs which included: Mental health and behavior- Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/[MEDICAL CONDITIONS], other psychiatric diagnoses, intellectual or developmental disabilities . Interview with the facility Administrator on 5/21/19 at 11:30 a.m. confirmed Resident 89 was admitted to the facility in (MONTH) of (YEAR) and resided in one of the locked Alzheimer's care units at the facility during the resident's stay. The Administrator verified the resident's behavioral episodes escalated and experienced nine episodes of aggression toward other residents in a short period of time. The facility attempted various interventions and involved both the resident's physician and psychiatrist in attempting to treat the resident. Due to failure in stabilizing the resident, the resident was EPC'd to an acute Behavioral Health facility on 1/29/19. The Administrator verified the facility determined it was not safe to allow the resident to return and the facility denied re-admission after the hospital had notified the facility the resident's condition stabilized and the resident was ready for discharge back to the facility. The Administrator verified the facility had no documentation supporting why they chose not to allow the resident to return. The resident was not given a notice of discharge or allowed an appeal to the decision. The resident's psychiatrist and medical practitioner had not been involved in the decision or provided any supportive documentation why the resident's needs could not be met by the facility. The Administrator verified that the facility does admit and care for both Alzheimer's residents and those with psychiatric [DIAGNOSES REDACTED]. The Administrator verified the decision to not re-admit the resident to the facility was based on the resident's condition at the time of transfer and not based on any evaluations of the resident at the time the hospital described the resident's condition was stable and appropriate for return to long-term care management. | 2020-09-01 |
| 847 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 684 | G | 1 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) abnormal bleeding was assessed and follow up was completed to ensure care was provided promptly for one current sampled resident (Resident 41) on blood thinning medication, 2) low blood sugar readings were assessed and follow up care provided to ensure needs were met for one current sampled resident (Resident 42, 3) [MEDICAL CONDITION] were assessed and follow up completed to ensure healing without complications for one current sampled resident (Resident 48) and 4) a PICC (Peripherally Inserted Central Venous Catheter) line was monitored every shift and a heart monitor present on re-admission was monitored as indicated for one current sampled resident (Resident 73). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 5/21/19, revealed that Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/3/19, revealed that the resident was at risk for bruising and bleeding related to the use of blood thinning medication. Interventions included that the staff were to inspect the resident's skin for bruising or unusual bleeding daily during care and report to the charge nurse and provider for further interventions. Further review revealed that the resident had both short term and long term cognitive deficits and had difficulty making self understood and understanding others. Review of the Progress Notes revealed the following including: - 2/25/19 at 4:30 AM This nurse noted a large bruise to the left side of the hip, bruise area was hardened, the resident grimaced when the area was touched, no reports of injury from the previous nurse, resident was unable to state the source of the injury due to cognitive impairment, will pass report to coming nurse to notify the primary care physician for evaluation; - 2/25/19 at 1:29 PM Nursing Late Entry Note: Was told in morning report that the resident had a bruise. Later in the day, during the skin assessment in the bath house, the bruise was assessed and appeared dark purple and spanned approximately 29 cm. (centimeters) across and 9 cm. wide. The resident was assessed by a Nurse Practitioner and orders were received to send the resident to the Emergency Department; - 2/25/19 at 9:23 PM Update from the hospital showed that the the resident's INR (International Normalized Ratio), a blood laboratory test for bleeding time, showed a critically high level at 6.16 ( a range of 2.0 - 3.0 generally considered a therapeutic range for people taking blood thinning medication such as [MEDICATION NAME]). Further review revealed that the resident was to be admitted to the Intensive Care Unit at least overnight. Interview with the DON (Director of Nursing) on 5/23/19 at 8:15 AM confirmed that the night shift nurse should have identified the resident's high risk for abnormal bleeding due to the use of blood thinning medication and completed a skin assessment including the size and characteristics of the bruising. Further interview confirmed that the nurse should have notified the provider right away to determine the need for further evaluation and treatment. The DON confirmed that the day shift nurse should also have identified the resident's high risk for abnormal bleeding, should have assessed and documented the bruise and followed up with the resident's provider for further evaluation and treatment to ensure that the resident's needs were met. B. Interview with Resident 42 on 5/20/19 at 9:40 AM revealed had a low blood sugar this morning and had to drink orange juice. Further interview revealed no follow up blood sugar was done. Review of the Care Plan, goal date 6/18/19, revealed that the resident had a [DIAGNOSES REDACTED]. Interventions included that the nursing staff would observe the resident for low blood sugar symptoms including flushed face, sweating, change in usual mental status, lethargy, irritability, fruity breath odor, nervousness, trembling and light headedness. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident's blood sugar was 64 on 5/16/19 at 6:59 AM and at 11:30 AM and the blood sugar on 5/1/19 at 7:30 AM was 61. Review of the Progress Notes, dated 5/20/19 and and 5/1/19 revealed no assessment of the resident, including symptoms of hypogylcemia (low blood sugar), treatment provided or a follow up assessment of symptoms or blood sugar obtained. Further review revealed that on 5/16/19 at 6:59 AM, the resident was given glucose for low sugar with no assessment of the resident's symptoms or follow up blood sugar. Interview with the DON on 5/23/19 at 9:20 AM confirmed that the blood sugar levels listed above were abnormally low for the resident. Further interview confirmed that the nurses were to assess and document the resident's symptoms of low blood sugar, interventions provided and the resident's response to the interventions, including a follow up blood sugar in about an hour, to ensure that the resident was stable and needs were met. C. Observations of Resident 48 on 5/20/19 at 3:50 PM revealed dried [MEDICAL CONDITION] and redness on face and arms and a bandage on the right outer neck area. Further observations at 1:30 PM revealed MA (Medication Aide) - C and MA - D provided skin care and applied [MEDICATION NAME] to excoriated areas on the coccyx and gluteal folds. Review of the Care Plan, goal date 7/2/19, revealed that the resident had altered skin integrity related to incontinent [MEDICAL CONDITION] and excoriation. Interventions included weekly skin inspection, thorough skin care and apply barrier cream after incontinent episodes. Review of the Weekly Skin Review, dated 5/16/19, revealed no assessment of the multiple [MEDICAL CONDITION], area covered with a bandage on the neck or the excoriation on the coccyx and gluteal folds. Interview with the DON on 5/23/19 at 10:10 AM confirmed that there was no documentation on weekly summaries or progress notes of the resident's current skin injuries including the [MEDICAL CONDITION] on the face and arms, area on the neck or excoriation. Further interview confirmed that these areas needed to be routinely assessed and documented to ensure healing without complications. D. Record review of Resident 73's MDS (Minimum Data Set, a federally mandated assessment tool utilized to develop resident care plans and tracking for admissions and discharges) records revealed the resident was initially admitted to the facility on [DATE]. The tracking MDS records indicated the resident was admitted to an acute care hospital on [DATE] and re-admitted to the facility on [DATE]. A Significant change in status MDS was completed on 4/29/19. The assessment revealed the was receiving IV (intravenous) therapy both during the hospital stay and during the reference period of the MDS (4/23/-4/29/19). Interview on 5/20/19 at 10:30 a.m. with MA (Medication Aide)-E revealed the unit where Resident 73 now resided was a unit designed for residents with minimal care needs. MA-E stated there was no charge nurse routinely staffed on the unit. Observation of Resident 73's PICC line dressing change on 5/20/19 at 2:40 p.m. revealed RN (Registered Nurse)-F and the facility DON assisting the resident during the dressing change. RN-F and the DON discovered the resident's surrounding area to the PICC line was bright red measuring 7 x 12 cm with some blistering areas alongside the insertion site. Both RN-F and the DON stated this was not present at the last changes. Also, during the observation, a heart monitor was observed in place. Interview with the DON following the observation 5/20/19 at 3:00 p.m. revealed Resident 73's PICC line was scheduled for weekly dressing changes and as needed. The DON also verified there was no licensed nurse assigned as a charge nurse on the 300 unit, but that licensed nurses from other halls come over and do the dressing changes when scheduled and LPN (Licensed Practical Nurse)-I (A restorative nurse) is on the unit some days. The DON was unaware of any orders or monitoring that should be done regarding the resident's heart monitor. Interview with LPN-I on 5/20/19 at 3:30 p.m. revealed LPN-I is not involved in the PICC line care and treatment for [REDACTED]. Interviews and observations of the night shift staff on 5/22/19 between 4:45 a.m. and 5:30 a.m. revealed MA-X was assigned to the unit where Resident 73 resided. MA-X described being the only staff member on the unit during from 6 p.m. to 6 a.m. and if needing a licensed nurse, the Alzheimer's unit charge nurse would come down to the unit. RN-T described working on the locked Alzheimer's units from 6 p.m. to 6 a.m. and confirmed there was no licensed charge nurse on the 300 unit where Resident 73 resided. RN-T described assisting with PICC line dressing changes for Resident 73 on the days scheduled for change, but does not make routine rounds or check the dressing on other days. Record review of Resident 73's current physician orders [REDACTED]. An order dated 4/22/19 for Change central Line dressing weekly and PRN (as needed) as needed for dislodgement or soiled. There were no instructions or orders related to the resident's heart monitor. Record review of Resident 73's Treatment Administration Record for (MONTH) 2019 revealed the facility was documenting weekly central line dressing changes every Monday. There was no documentation the line was changed on 5/13/19. There was no documentation on the resident's treatment records for (MONTH) 2019 that licensed nurses were monitoring the PICC line site other than on dressing change days. Record review of Resident 73's electronic progress notes revealed no documentation by licensed nurses that the PICC line site and heart monitor sites were being monitored except on days when the PICC line dressing was changed. Interviews with the DON and ADON (Assistant Director of Nursing) on 5/28/19 at 10:30 a.m. verified there was no supportive documentation that Resident 73's PICC line dressing was being monitored on every shift and there was no documentation or orders pertaining to the resident's heart monitor placed during the hospitalization in April. Source: University of Michigan Serious risks from common IV (intravenous) devices (MONTH) (YEAR). These (PICC lines) are not innocuous devices. The time has come to stop thinking of them as a device of convenience, and rather one with clear risks and benefits. Many studies and patient safety efforts have worked to reduce another clear risk associated with PICCs: infections often called CLABSIs, for central line associated bloodstream infections. But the risks of [MEDICAL CONDITION]'s ([MEDICAL CONDITION] clotting_ and the potentially lethal risk of a [MEDICAL CONDITION] embolism if the PICC clot breaks away, haven't gotten the kind of attention that a common device would warrant. | 2020-09-01 |
| 848 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 686 | G | 0 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12- D2 175 NAC 12-006.09D2b Based on observations, record reviews and interviews; the facility failed to provide care to prevent pressure ulcers and to promote healing, including repositioning at least every two hours, pressure relieving seat cushions, dressing changes as ordered, aseptic technique for dressing changes and follow up with ongoing resident non compliance with interventions for two current sampled residents (Residents 42 and 48). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 5/21/19, revealed that Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/18/19, revealed that the resident required assistance with activities of daily living including repositioning in bed, transfers and personal hygiene and cares. Further review revealed that the resident was at risk for pressure ulcers due to assistance required with bed mobility, diabetes, history of pressure ulcers and placed a pillow in the wheelchair. On 9/12/18, the resident had a pressure area to the coccyx and right buttock, on 1/17/19 the area to the coccyx was closed, on 2/22/19 the area was opened, and 5/17/19 the area was stable with 100% granulation tissue. Interventions included treatments as ordered, weekly skin assessments, pressure reducing wheelchair cushion and air mattress, the resident frequently sits on a pillow on top of the pressure reducing wheelchair cushion and staff will continue to educate the resident on the importance of not using a pillow on top of the pressure reducing device and to comply with treatment. Review of the Wound Evaluation Flow Sheet Multiple Weeks - V 4, dated 4/28/19, revealed the following including: - 2/22/19 Stage 4 pressure ulcer ( full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling) at the coccyx which measured 0.5 cm. (centimeters) wide, 1 cm. long and 0.5 cm. depth; - pressure ulcer acquired in the facility; - tunneling/undermining at 0.5 cm.; - moderate amount of drainage present; - peri wound with macerated (moist)/soft skin; - treatment order 3/28/19 honey fiber and foam dressing and skin prep peri- wound; - current preventative interventions are pressure redistribution mattress and wheelchair cushion; - current wound status/additional comments included maceration peri-wound (around the wound) is worse, resident is non-compliant with utilizing pressure reducing wheelchair cushion appropriately and puts a pillow on top of the cushion, education provided on the risks associated with non-compliance. Further review revealed the Wound Evaluation Week 3 on 5/17/19 including: - wound measured 0.7 cm. long, 1 cm. wide (larger) and 0.5 cm. depth; - no drainage; - 100% granulation tissue; - 4/18/19 treatment order of honey fiber and foam dressing, change daily; - education provided on putting pillow on top of the pressure reducing wheelchair cushion; - maceration around the wound is resolved at this time. Observations on 5/20/19 at 9:44 AM revealed the resident seated in the wheelchair with a pillow placed on the top of the wheelchair cushion and the Microair mattress set at 8 which is for 315 pounds. Further observations at 2:50 PM revealed the resident resting on the bed, air mattress set at 8 and a pillow placed at the resident's lower back. LPN (Licensed Practical Nurse) - L, Charge Nurse, applied disposable gloves, assisted the resident to turn onto side, removed the dressing at the coccyx area, noted brown and red colored drainage on the dressing, noted open area approximately 2 cm. and 1 cm. in depth and surrounding skin reddened and macerated. LPN - L, wearing the same disposable gloves, cleansed the ulcer with saline, wiped the area with gauze, applied skin prep to the surrounding skin, changed gloves with no hand washing, applied the honey fiber dressing to the inside of the wound, resident stated that hurts and the cover foam dressing was applied. Review of the MAR (Medication Administration Record) for (MONTH) 2019 revealed an order, dated 3/21/19, for LiquaCal two times a day for wound healing. Further review revealed no documentation that the medication was administered on 5/2/19 at 5:00 PM or on 5/8/19 at 9:00 AM and 5:00 PM. Review of the TAR (Treatment Administration Record) for (MONTH) 2019 revealed an order to cleanse the wounds to the coccyx, pat dry, apply honey fiber to the wound bed, cover with foam dressing, change daily until resolved, apply skin prep around the wound to macerated skin, for Stage 4 pressure area. Further review revealed that the resident refused the treatment on 5/2/19 and no documentation that it was done on 5/7/19 and 5/10/19. Interview with the DON (Director of Nursing) on 5/21/19 at 3:50 PM confirmed that the air mattress was not set at a therapeutic level for the resident. The DON set the air mattress at 5 based on the resident's weight of approximately 200 pounds. Interview with the DON on 5/23/19 at 9:20 AM confirmed that the resident continued to sit in the wheelchair with a pillow over the pressure reducing cushion which decreased the therapeutic benefits of the cushion. Further interview confirmed that the resident should not place a pillow over the air mattress as that also reduced the effectiveness of the pressure relieving mattress. The DON confirmed that wound care needed to be done as ordered and the protein supplement needed to be administered as ordered to promote healing of the pressure ulcer. Further interview confirmed that dressing changes, including the proper use of disposable gloves and hand washing, should be done to promote healing of the pressure ulcer. The DON confirmed that the disposable gloves were to be removed after the soiled dressing was removed and hand washing done before new gloves were donned to treat and apply the clean dressing to reduce the risk of cross contamination. B. Review of Resident 48's Care Plan, goal date 7/2/19, revealed that the resident required assistance of two staff for bed mobility and transfers, had impaired cognition due to confusion and [DIAGNOSES REDACTED]. Interventions included weekly skin inspection, pressure reducing wheelchair cushion and mattress, reposition side to side during the night, educate the resident on the importance of off loading pressure and repositioning side to side to reduce the risk for pressure and to improve current skin issues, respect the resident's right to refuse, encourage the resident to lay down and reposition to sides between meal times and treatments as ordered. Review of the Weekly Skin Review - V 3, dated 5/16/19, revealed that the resident had an open area at the left buttock which measured 0.5 cm. by 0.5 cm. and an open area (not measured) at the right gluteal fold. Observations on 5/20/19 at 9:15 AM, 10:00 AM, 11:00 AM, 12:15 PM and 1:30 PM revealed the resident seated in the wheelchair with a pillow over the wheelchair seat cushion and the canvas mechanical lift transfer sling. Further observations at 1:30 PM revealed MA (Medication Aide - C and MA - D transferred the resident to the bed with a full mechanical lift. MA - C and MA - D removed the resident's soiled disposable brief and provided skin care. Dressings were noted on the resident's right and left inner buttocks areas. The resident was positioned on back after cares were completed and remained positioned on back at 2:30 PM. Interview with MA - D on 5/20/19 at 1:45 PM revealed that the resident usually sat in the wheelchair all morning, usually got up around 5:00 AM, and would sometimes agree to lay down in bed for awhile in the afternoon. so that the disposable brief could be changed. Further interview revealed that the resident could not reposition self in the wheelchair. Observations on 5/21/19 at 7:00 AM, 11:45 AM and 1:20 PM revealed the resident seated in the wheelchair with a pillow and mechanical lift sling over the wheelchair cushion. Observations on 5/22/19 at 5:00 AM, 7:50 AM, 9:00 AM, 12:00 PM, 1:30 PM and 3:10 PM revealed the resident seated in the wheelchair with a pillow and mechanical lift sling over the wheelchair cushion. Further observations at 3:10 PM revealed MA - N and MA - S transferred the resident from the wheelchair to the bed with the full mechanical lift for skin care. MA - N and MA - S removed the soiled disposable brief, noted smeary bowel movement and urinary incontinence and provided skin care. The resident's anal, coccyx and scrotum were noted to be excoriated with some open areas. Interviews with MA - N and MA - S on 5/22/19 at 3:10 PM confirmed that the resident had been in the wheelchair all day until now and was not able to reposition self in the wheelchair due to bilateral [MEDICAL CONDITION]. Further interview revealed that the resident often refused to lay down during the day to check and change the disposable brief, wanted the pillow and the lift sling kept in the wheelchair and didn't want to be repositioned in the wheelchair. Observations on 5/22/19 at 3:15 PM revealed RN (Registered Nurse) - M, applied disposable gloves, removed the dressing at the left inner buttock area and with the same gloves, cleaned the open area (which measured approximately 4 cm. x 1.5 cm.) with saline, applied skin prep around the wound and a collogen dressing and a cover dressing. RN - M removed gloves and applied new gloves without hand washing in between, repositioned the resident to the other side, removed the dressing at the right inner buttock, noted brown colored drainage on the dressing, cleaned the open area with saline (area measured approximately 4cm. x 1.5 cm.), applied skin prep to the surrounding skin and applied a collogen and cover dressings. RN - M applied [MEDICATION NAME] to open and excoriated areas at the anal, coccyx area and scrotum and assisted MA - N to apply a disposable brief. RN - N removed the disposable gloves and gathered trash and supplies. Further observations revealed that the resident requested to get up into the wheelchair and MA - N and MA - S transferred the resident back into the wheelchair with a pillow and the mechanical lift sling on top of the wheelchair seat cushion. Review of the Treatment Administration Record, dated (MONTH) 2019, revealed an order dated 5/10/19 for Collagen and foam to left buttock three times a day until healed. Further review revealed no documentation that the treatment was done at 10:00 PM on 5/13/19, 6:00 AM on 5/14/19 and at 2:00 PM on 5/17/19. Further review revealed a treatment order, dated 5/18/19, for the right ischeal tuberosity daily until resolved. There was no documentation that the treatment was done on 5/19/19 at 8:00 PM as scheduled. Interview with the DON on 5/23/19 at 10:10 AM confirmed that the the pressure ulcers were facility acquired and interventions were not in place to promote healing, including repositioning at least every two hours and off loading at least every two hours while in the wheelchair. The DON confirmed that sitting in the wheelchair with a pillow and mechanical lift sling over the wheelchair pressure reducing cushion reduced the effectiveness of the seat cushion. Further interview confirmed that the treatments were to be done as ordered to promote healing as scheduled and skin assessments completed weekly to include all open areas to ensure healing without complications. The DON confirmed that disposable gloves were to be removed after soiled dressings were removed and hand washing done before clean gloves were donned to reduce the risk of cross contamination. Further interview revealed that the residents continued with non compliance with interventions to prevent and promote healing of pressure ulcers and further assessments needed to completed to determine the reasons and possible interventions to obtain compliance. Review of the facility policy Prevention and Management of Wounds, dated 5/21/19, revealed the Policy Statement An interdisciplinary approach to pressure ulcer treatment encourages nurses and therapists to work closely together to assess risk and intervene with preventative measures such as pressure relieving devices and proper positioning. The Wound Care Coordinator and/or licensed nurse shall be designated as being responsible for prevention and treatment of [REDACTED]. | 2020-09-01 |
| 850 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 689 | G | 0 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7a Based on observations, record reviews and interviews; the facility failed to ensure that 1) safety measures were in place to prevent one sampled resident (Resident 44) from falling during bathing. The failure resulted in the resident sustaining a fracture; 2) care plan interventions were in place to reduce the risk for recurrent falls for one current sampled resident (Resident 41); and 3) a loose grab bar was secured to the bed frame to reduce the risk for injuries for one current sampled resident (Resident 42). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Interview with Resident 44 on 5/22/19 at 1:45 p.m. revealed the resident describing having sustained a fall and fracture requiring surgery and hospitalization about a month after being admitted . The resident described the incident by stating the fall occurred in the tub room after the bath was completed. The resident stated being in a bath chair and that Usually the staff strapped the resident in the chair and had a second person present during transfers. On this occasion, the staff did not apply the strap or have a second person present. The resident described tumbling out of the chair and fracturing a leg resulting in the need for surgery after being diagnosed with [REDACTED]. Record review of Resident 44's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments revealed an Admission assessment was completed on 2/20/19. The assessment recorded the following items regarding the resident's condition: - The assessment recorded the resident was admitted from another nursing home on 2/14/19. - The assessment recorded a resident BIMS (Brief Interview for Mental Status) test score was 15 (cognitively intact memory). - The assessment recorded the resident's ability to transfer between surfaces (to and from bed, chair, wheelchair) required the assistance of Two (or more) and that the resident required Total dependence- full staff performance to complete transfer tasks. -The assessment recorded the resident required Two (or more) persons and Physical assist support for Bathing. - The assessment recorded the resident's weight at the time of the assessment was 355 pounds. - Under the fall history portion of the assessment the facility recorded the resident had a history of [REDACTED]. Record review of Resident 44's electronic Progress Notes revealed the following entry: - 3/6/19 at 5:50 p.m. the note recorded a Situation while the resident was transferring during bath and fell to floor. The note recorded the resident was being transferred during a bath and was in bath chair. Is a bariatric (obese) patient. The note recorded the resident was assessed and assisted to a comfortable position and that the resident complained of Left hip pain. The medical provider was called and an order received to transfer the resident to the emergency room for evaluation. Record review of a hospital History and Physical Reports form dated 3/6/19 revealed the resident's CC (chief complaint) at the time of admission was I fell getting out of the bathroom. The physical recorded the resident was sent from the facility today after falling getting out of the bathroom, landed on left side, and ER (emergency room found to have left displaced femur fracture. The physical assessment diagnosed : Left femur fracture. Record review of a facility undated New ownership investigation of Resident 44's fall on 3/6/19 revealed a nurse was called to the 100 wing tub room and observed resident on floor between tub and north wall. The resident was sitting up with head against the tub, left leg straight out and right leg was bent. The resident expressed pain to the left leg. An ambulance was called and the resident transferred to the emergency room . The BA (Bath Aide)-W was interviewed during the investigation and re-enacted the incident. The investigation recorded the resident bath was completed and BA-W took off the resident's strap to clean under the abdominal folds and then elevated the tub chair to get the resident's feet out of the tub and pulled the chair out of the whirlpool When getting the resident out of the tub chair to put the belt back on the resident leaned forward and fell out of the tub chair. The investigation report indicated the resident was interviewed and stated remembering the bath aide having to jerk the tub chair and I flew out of the chair. Interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 5/28/19 at 10:39 a.m. verified Resident 44 sustained a fall and fracture during the bathing process on 3/6/19. The DON and ADON verified there was only one staff member assisting the resident during the bath and the transfer out of the tub. The causal factor for the fall was verified as the removal of the seat belt strap by BA-W while assisting the resident out of the tub. The failure to apply the strap resulted in the resident falling forward and sustaining the injury. The DON and ADON stated that safety straps should not be removed during the bathing procedures. B. Review of Resident 41's Care Plan, goal date 6/3/19, revealed that the resident was at risk for falls due to history of falls and the resident was found on the floor by the bed on 4/16/19. Further review revealed interventions including staff will ensure that the resident's bed was left in the low position while the resident was in bed and the call light was within reach at all times when in the room. Observations on 5/22/19 at 5:00 AM revealed Resident 41 resting in bed with eyes closed. Further observations revealed that the bed was positioned approximately waist high and the call light was fastened to the connection on the wall and not within the resident's reach. Interview on 5/22/19 at 5:10 AM with LPN (Licensed Practical Nurse) - G, Charge Nurse, confirmed that the resident's bed was to be left in the low position and that the resident was to have the call light within reach to reduce the risk for falls. Interview with the DON (Director of Nursing) on 5/23/19 at 8:15 AM confirmed that the staff were to follow the care plan interventions to reduce the risk for falls. C. Review of Resident 42's Care Plan, goal date 6/18/19, revealed that the resident required staff assistance with bed mobility and that the resident utilized assist rails on the bed for repositioning. Observations on 5/20/19 at 9:10 AM revealed the assist rail on the open side of the bed was loose and presented a three to four inch gap between the assist rail and the airflow mattress. Interview with the DON on 5/21/19 at 3:50 PM confirmed that the assist rail needed to be tightened to the bed frame to reduce the risk for injuries. | 2020-09-01 |
| 861 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2019-05-28 | 867 | G | 0 | 1 | 3V0011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC ,[DATE].07 Based on observations, record reviews, and interviews, the facility Quality Assurance Program failed to identify, correct, and maintain regulatory required compliance resulting in multiple citations and repeat areas of non-compliance from prior surveys. Facility census was 89. Sample size included 24 current residents and three closed records. Findings are: Record review of the facility QAPI (Quality Assurance Program) plan developed on [DATE] revealed the purpose of the committee was to educate, support and encourage staff to increase their skills to provide quality care to all residents. To provide residents with a comfortable environment where they are involved in, and have a voice in, the daily activities of their home. The committee's plan is to review all data sources and other available data to identify, prioritize, and correct issues with performance. The QAPI committee will evaluate the effectiveness of actions taken for further recommendation. Observations, record reviews, and interviews during the survey processes from surveys conducted on [DATE] and the current survey from [DATE] through [DATE] revealed the following areas of repeated non-compliance: F578- ensuring facility staff had valid CPR (Cardiopulmonary Resuscitation) certifications. F583- providing privacy with resident personal cares. F622- documentation regarding discharges from the facility. F684- providing assessments and care for residents with skin abnormalities. F689- ensuring staff were performing safe transfer techniques preventing accidents with injury. F726- competency of staff. F732- posting staffing information daily. F757- ensuring medications were being monitored to rule out unnecessary medications. F880- infection control The current survey also identified patterns in five additional areas of non-compliance: F576- mail delivery on Saturdays. F584- environmental issues. F623- notice provision in writing for facility-initiated transfers and discharge. F625- written notice of bedhold policies when residents are transferred to the hospital. F725- provision of staffing to meet the needs of the residents. Failures at the following tasks resulted in negative outcomes: F626- facility denial of re-admission to Resident 89 following hospitalization . The failure resulted in a prolonged stay in an acute setting after the resident's condition was stabilized. F684- facility failed to assess and monitor Resident 41's bruising condition resulting in hospitalization for an adverse effect of medication. F686- facility failed to provide care and treatment to prevent the development and/or healing of pressure sores for Residents 42 and 48 F689- facility failed to ensure safety measures in place during bathing resulting in hospitalization and surgery for [REDACTED]. Interview with the Administrator on [DATE] at 10:39 a.m. discussed and confirmed the repeated areas of deficiency and current survey findings. | 2020-09-01 |
| 876 | MONUMENT REHABILITATION AND CARE CENTER | 285095 | 111 WEST 36TH STREET | SCOTTSBLUFF | NE | 69361 | 2018-07-10 | 689 | G | 0 | 1 | PRIL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7a Based on observations, record reviews, and interviews, the facility failed to: 1) safely transfer residents between surfaces for 2 sampled residents (Residents 5 and 89) resulting in fractures for Resident 5 and skin tearing for Resident 89; 2) ensure oxygen concentrators were turned off when unattended for one sampled resident (Resident 80) increasing the risk for room oxygenation which increases the risk for fire; and 3) transport wheelchair residents using footrests for four sampled residents (Residents 81, 88, 65, and 74) increasing the risk of injury for these residents. Sample size was 26 current residents. Facility census was 93. Findings are: [NAME] Record review of Resident 5's Admission Record printed on 7/4/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of a Physical Therapy Discharge Summary for Resident 5 signed by the therapist on 8/14/2017 revealed the PT provided resident and caregiver training and instruction and education to nursing staff on how to properly set-up the sit to stand lift and the pt (patient or Resident 5) in order to ensure safety was enhanced and pt knew how to perform transfer properly.: The summary identified outcomes at the time of discharge recorded Mobility for Chair or bed to chair transfer and Toilet Transfer required Substantial/Maximal Assistance from staff to perform the task. Record review of Resident 5's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment completed on 4/6/2018 revealed the resident required Extensive assistance (resident involved in activity, staff provide weight bearing support) with Transfer- how the resident moves between surfaces including to or from bed, chair, wheelchair, standing position. The MDS recorded two or more staff persons provided physical assistance for the task. Regarding Balance during transitions the MDS recorded the resident was Not steady, only able to stabilize with human assistance. The assessment recorded the resident's weight at 253 pounds. Record review of a Fall document dated 6/9/18 at 1:15 p.m. revealed an incident occurred involving Resident 5 on 6/9/18. The description of the incident read: Nurse called to room, noted resident laying on floor in between sit to stand lift and motorized wheelchair. Staff states resident was unresponsive prior to alerting this nurse. Resident noted to be responsive and answering questions appropriately, resident states doesn't know what happened, passed out and woke up on floor. The form listed a witnesses statement which described the resident was standing up in the sit to stand lift while they were holder (holding) the bucket from the bedside commode under (the resident) . Resident then became weak, let go of the lift, fell through the sling and fell to the floor . Record review of a fax communication to Resident 5's physician on 6/9/18 recorded Resident became weak and let go of sit to stand lift while in use, slipped through harness et (and) fell to floor. Did hit back of head on leg rest of wheelchair . Record review of an Occupational Therapy updated plan of treatment for [REDACTED]. Record review of a Fall document involving Resident 5, dated 6/27/18 at 8:40 p.m., revealed a description of the incident documented a nurse aide was assisting resident with lift transfer when resident became weak and lost grip and legs gave out. Resident noted by this nurse hanging with just left hand and wrist in the sit to stand lift sling. Resident described I think I passed out. The nurse assisted the Nurse Aide in lowering the resident to the floor and noted a skin tear on the left wrist along with the resident complaining of a sore wrist. The resident was assisted onto the bed and the on-call medical practitioner was notified with orders to notify primary care doctor if wrist pain continues. A witness statement from the Nurse Aide involved during the incident documented on the form on 6/28/18 I was getting (the resident) transferred from the bath chair to (the resident's) bed in the sit to stand and (the resident) went limp. I think (the resident) passed out. The notes section of the form recorded Resident uses sit to stand for transfers . New interventions: Staff to utilize 2 staff with lift transfers. Record review of Resident 5's Progress Notes on 6/28/18 revealed at 10:32 a.m. a call was placed to the resident's physician reporting the left wrist was swollen and painful due to the fall the previous night. At 11:50 a.m. the physician returned call and ordered x-rays for the resident. At 4:28 p.m. the physician reported the x-ray indicated the resident sustained [REDACTED]. On 6/29/18 the resident went to orthopedics and returned with orders to keep cast clean and dry to left wrist with the cast to remain at least 6 weeks. Correspondence to the State Agency on 7/10/18, verified by phone interview with Resident 5's POA (Power of Attorney) on 7/17/18 at 8:00 a.m. revealed the POA contacted Res 5 by phone on 6/10/18 after the facility reported an incident/fall on 6/9/18. The resident described passing out from hanging out in the sit to stand lift too long. The POA stated the facility contacted the POA again on 6/28/18 and told about the resident having another incident in the lift. The POA contacted the facility DON (Director of Nursing) who returned a call at 4:19 p.m. The DON stated the resident passed out in the sit to stand lift and the Nurse Aide could not keep the resident from falling. The POA asked the DON if two persons performed the lift as the resident was supposed to be a two person lift transfer. The DON responded, confirming only one staff member attempted the resident's transfer. The POA reported coming to the facility on [DATE] and speaking with the DON around 11:30 a.m. about the concerns of Resident 5 being transferred with only one person and reported the resident had said this wasn't the first time one person did the transfers alone (prior to 6/27/18). The DON assured the POA the resident would be a two-person assist. Observation of Resident 5 on 7/2/18 at 3:50 p.m. revealed the resident had a cast on the left arm below the elbow extending across the forearm and hand. Interview with Resident 5 on 7/2/18 at 3:51 p.m. revealed the resident experienced two recent falls while being transferred with a mechanical lift. Resident 5 stated on the first occasion, the resident passed out while being assisted on a sit to stand lift with two staff members helping. The second occasion resulted in the resident's arm being fractured. The resident described being transferred with the sit to stand lift but only one staff member was assisting with the lift transfer. The resident stated having passed out and does not recall much until being assessed by the nurse. The resident described continued pain from the fall and was x-rayed and diagnosed with [REDACTED]. The resident stated the staff were supposed to have two persons assisting with mechanical lifts, but at the time of the second fall, the staff member attempted the lift by self. The resident also stated that other occasions prior to 6/27/18 staff members were transferring the resident with only one staff member instead of two. Interview with the facility PT (Physical Therapist) on 7/5/18 at 2:18 p.m. revealed the PT was familiar with Resident 5 and the resident's therapy plans and treatment. The PT confirmed OT (Occupational Therapy) began seeing the resident on 6/22/18 for alignment and functional skills and reviewed the use of the sit to stand lift. The PT verified the staff were transferring the resident at the time of falls on 6/9/18 and 6/27/18 with the use of a sit to stand lift due to previous recommendations by therapy. The resident was now using a sling lift due to the fractured wrist and cast and difficulty for the resident to hang on. The PT stated staff should be utilizing two persons for transfers with sit to stand and sling lifts especially with this resident due to the resident's size and inability to bear weight without staff assistance. Interview with LPN (Licensed Practical Nurse)- K, the Restorative Nurse Coordinator, on 7/9/18 at 4:00 p.m. confirmed Res 5 had passed out in the sit to stand lift on 6/9/18 during a transfer while being assisted with two staff. LPN-K confirmed a second incident occurred on 6/27/18 while a single staff member, NA (Nurse Aide)-T, was transferring the resident from a bath chair using the sit to stand lift without another staff member. LPN-K agreed that due to a similar incident and the size of the resident, the staff should have been aware of the resident's potential to pass out in the lift and should have had additional staff assisting with the transfer on 6/27/18. Interview with NA-T on 7/9/18 at 5:27 p.m. confirmed NA-T was present during the 6/27/18 incident involving Resident 5. NA-T stated having assisted the resident with a bath and returned the resident to the room to transfer the resident in the wheelchair. NA-T stated looking for additional help to transfer the resident but could not find anyone. NA-T confirmed transferring Resident 5 by self in the sit to stand lift and the resident blacked out and slumped during the transfer. NA-T then screamed for help and the charge nurse responded. NA-T stated Resident 5's left hand got caught in the lift and the resident sustained [REDACTED]. Record review of NA-T's employee files revealed NA-T was hired at the facility on 2/28/18. Further review of the file revealed there was no evidence of training or competency testing for NA-T regarding the use of mechanical lifts during resident transfers. Interview with the Business Office Manager/Human Resources Director on 7/10/18 at 9:18 a.m. confirmed NA-T's employee file had not included any training or competency testing regarding the use of mechanical lifts during resident transfers. B. Record review of Resident 89's Admission Record revealed the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident 89's MDS assessments revealed an Admission assessment was completed on 6/20/2018. Review of the assessment revealed the resident's functional status for Transfer recorded the resident received Extensive Assistance from two or more staff members to complete transfer tasks from bed to chair. The assessment recorded the resident received Extensive Assistance from two or more staff members when transferring onto the toilet. The MDS assessment recorded Balance during transitions and walking was Not steady, only able to stabilize with human assistance for surface to surface transfer. Record review of Resident 89's care plan printed on 7/4/18 revealed a focus problem initiated on 6/20/18 which described the resident Requires assistance with ADL functions and recorded in the interventions Two person assist with transfers. Record review of a Fall document dated 6/28/18 at 10:21 a.m. for Resident 89 revealed an incident description involving the resident which recorded: Resident lowered to floor by cna (Nurse Aide) after knees buckled in restroom. The resident described knees just gave out while holding the transfer bar in restroom. The form recorded skin tear injuries to the right and left elbow. In the Witnesses section of the form, NA-X described being present and transferring resident from the wheelchair to the toilet with a gait belt and transfer bar, when resident's knees began to buckle. NA-X lowered the resident to the floor and called for help. Further review of attached Progress Notes revealed a late entry recorded on 6/28/18 at 10:36 which read Recommendation: Resident is to be 2 person transfer with all transfers and gait belt . Interview with Resident 89 on 7/2/18 at 2:42 p.m. revealed the resident had fallen recently. The resident described being assisted in the bathroom by a nurse aide and lost balance and fell resulting in an injury to the elbow. The resident stated there were supposed to be two staff assisting with transfers, but on this occasion, only one staff member assisted the resident. Interview with the DON and ADON (Assistant Director of Nursing) on 7/10/18 at 2:13 p.m. confirmed Resident 89's care plan identified the resident was to be transferred with two person assistance. The ADON confirmed the resident had an incident of being lowered to the floor on 6/28/18 while only one staff member was assisting the resident with a toilet transfer and that the resident sustained [REDACTED]. Record review of NA-X's employee file revealed the staff member was hired by the facility on 5/9/18. Record review of NA-X's education file revealed there was no documentation the employee was trained or competency tested in safe resident transfer techniques. Interview with the Business Office Manager/Human Resources Director on 7/10/18 at 9:18 a.m. confirmed NA-X's employee file had not included any training or competency testing regarding transfer techniques for safe resident transfers. C. Observations of Resident 80's room on 7/3/18 at 7:40 AM and at 11:40 AM revealed the oxygen concentrator on while the resident was out of the room for meals. Further observations on 7/9/18 at 3:20 PM revealed the oxygen concentrator on while the resident was out of the room. Interview with LPN - B, Unit Coordinator, on 7/10/18 at 7:30 AM confirmed that the oxygen concentrator should be turned off while the resident was out of the room to reduce the risk of fire and injuries. D. Observations on 7/5/18 at 7:40 AM revealed NA - P propelled Resident 81, seated in a wheelchair, though the hallway to the dining room without utilizing footrests. Observations on 7/5/18 at 11:10 AM revealed LPN - B propelled the resident, seated in a wheelchair, in the hallway without utilizing footrests. E. Observations on 7/5/18 at 7:40 AM revealed Resident 83 pushing Resident 88, seated in a wheelchair, in the dining room without utilizing footrests. F. Observations on 7/5/18 at 11:15 AM revealed a family member pushing Resident 65, seated in a wheelchair, in the hallway without utilizing footrests. [NAME] Observations on 7/5/18 at 11:30 AM revealed LPN - B transported Resident 74, seated in a wheelchair, in the hallway from the dining room to room without utilizing footrests. Interview with LPN - U, Assistant Director of Nursing, on 7/10/18 at 7:30 AM confirmed that resident were to be transported in wheelchairs and utilize footrests to support the residents' feet, reduce the risk of injuries and to promote comfort. H. Observation on 02/02/18 at 11:28 a.m. room [ROOM NUMBER]-A which belonged to Resident 11 had electrical cords plugged into the electrical sockets located next to the sink and cords were just dangling down. There was a box with a hair blow dryer, and electric razor, hair clippers and multiple electrical cords hanging out of the box located next to the sink. Observation on 07/09/18 at 2:50 p.m. revealed Resident 11 was sitting in the recliner in room [ROOM NUMBER]-A watching television. There were electrical cords that might have belonged to Resident 11's electric razor and or possibly a cell phone and they were plugged into the electric plug ins located next to the sink. One of the cords was dangling off to the side of the sink and the other cord was in the sink but were not attached to the electric razor or cell phone. Plug in by the sink did have a default reset located on it. Staff interview on 07/09/18 at 3:09 p.m. with LPN-G verified the resident had electrical cords that had been plugged into the electrical outlets along with a box full of electronics being stored on the sink counter top in Resident 11's room [ROOM NUMBER]-[NAME] LPN-G reported this was not safe having these electric cords plugged in and hanging in and round the sink. LPN-G reported she would move these items immediately. Observation on 07-09-18 at 6:40 pm room [ROOM NUMBER]-A where Resident 11 resides, all electrical cords and box of electronics that had been on counter top next to the sink had all been removed. Staff interview on 07/10/18 at 3:29 p.m. with the Administrator, Director of Nursing and Assistant Director of Nursing verified Resident 11 had electronics stored next to the sink and had electrical cords plugged in to the electrical outlets which were hanging in and along the sink. Administrator identified that electrical cords should not be left plugged into the electrical outlets next to sinks in resident rooms as this could increase the risk of injury to residents. | 2020-09-01 |