CMS-Nursing-Home-Full-Deficiencies

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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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
5067	MANORCARE HEALTH SERVICES	435004	400 8TH AVENUE NW	ABERDEEN	SD	57401	2011-02-02	279	D			9LHM11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to develop a comprehensive care plan for one of seven sampled residents with [MEDICAL CONDITION] medications (10). Findings include: 1. Review of resident 10's 6/4/10 admission physician's orders [REDACTED]. Further review of the current physician's orders [REDACTED]. Review of resident 10's 6/11/10 admission Minimum Data Set (MDS) revealed he had received an antidepressant every day the last seven days. Review of the [MEDICAL CONDITION] drug use Resident Assessment Protocol (RAP) dated 6/14/10 revealed the [MEDICAL CONDITION] drug use would be addressed on the care plan. Review of the current care plan revealed the [MEDICAL CONDITION] drug use had not been addressed on the care plan. Interview on 2/2/11 at 11:00 a.m. with director of nursing A and director care delivery C confirmed the [MEDICAL CONDITION] drug [MEDICATION NAME] had not been addressed on the care plan for resident 10. They confirmed the RAP decision had been to care plan the [MEDICAL CONDITION] drug use for resident 10. Interview on 2/2/11 at 11:20 a.m. with MDS coordinator D confirmed the [MEDICAL CONDITION] drug use for resident 10 had not been care planned. She stated it must have been missed when the care plan had been completed. She stated sometimes social services added that information regarding the [MEDICAL CONDITION] drug use or the MDS coordinator added it. Review of the provider's care plan policy dated 9/1/05 revealed "A comprehensive care plan is completed within seven (7) days of completion of the comprehensive assessment."	2014-04-01
5068	MANORCARE HEALTH SERVICES	435004	400 8TH AVENUE NW	ABERDEEN	SD	57401	2011-02-02	371	D			9LHM11	Based on observation, interview, and policy review, the provider failed to ensure all fluids were served in a sanitary manner for all residents who ate in two of two dining rooms. Findings include: 1. Observation on 1/31/11 between 5:45 p.m. and 6:15 p.m. revealed dietary aide G: Served glasses of juice, water, and milk to the residents in the main dining room. She frequently placed her hand over the top of the glass. Her fingers touched the rim of the glass where a resident's mouth would touch when the resident drank from the glass. She often touched a dining table as she leaned across to set a glass in front of the resident seated on the far side of a table. She repeated the above procedures numerous times while serving the residents. After she had finished serving the fluid filled glasses she went into the kitchen. She returned with several carafes on a cart. She served coffee and hot chocolate to the residents. She would pick up a coffee cup fill it with hot water and chocolate powder mix or coffee. When she placed a cup in front of a resident she touched the rim of the cup with her fingers. *She repeated the above procedures numerous times while serving the residents. 2. Observation on 1/31/11 at 5:20 p.m. revealed dietary aide J while wearing gloves served the residents in the station three dining room. She served the residents their glasses and cups of fluids by grasping the lip rim of the glassware. During that service the dietary aide touched the serving cart, rested her gloved hands on the tops of the tables where residents were sitting, and touched numerous other areas potentially contaminating her gloved hands. 3. Interview on 2/2/11 at 9:50 a.m. with registered dietitian B and food service director E confirmed the dietary aide should not have touched the rims of the glasses and cups. The employee health and safe food handling, safe food handling concepts, and tray set-up and place setting policies dated 4/7/06 were reviewed. They revealed no mention of the proper way to serve fluids without touching the rims of the cups or glasses. Interview on 2/2/11 at 10:35 a.m. with registered dietitian B revealed she did not find any policies or any training about the proper way to handle cups and glasses without touching the rims.	2014-04-01
5069	MANORCARE HEALTH SERVICES	435004	400 8TH AVENUE NW	ABERDEEN	SD	57401	2011-02-02	428	D			9LHM11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure the consultant pharmacist reported an irregularity of a missed [DIAGNOSES REDACTED]. Findings include: 1. Review of resident 10's 6/4/10 admission physician's orders [REDACTED]. Further review of the current physician's orders [REDACTED]. Review of the medical record revealed no evidence of the physician's documentation for a [DIAGNOSES REDACTED]. Review of the consultant pharmacist's monthly drug regimen review from June 2010 through January 2011 revealed no information regarding a [DIAGNOSES REDACTED]. There was no notification to the physician of the missed diagnosis. Interview on 2/2/11 at 10:40 a.m. with nurse supervisor RN F confirmed there was no documentation from a physician in resident 10's medical record for a [DIAGNOSES REDACTED]. She also confirmed in reviewing the pharmacist's monthly drug regimens for resident 10 there was no documentation the pharmacist had notified the physician of the missed diagnosis. Interview on 2/2/11 at 11:25 a.m. with director of nursing A confirmed there was no physician's documentation of a [DIAGNOSES REDACTED]. Review of the provider's policy for pharmacy drug review dated 9/1/05 revealed: "A review of the resident's drug regime is completed on a monthly basis by a licensed pharmacist." "Recommendations and irregularities are reported to the attending physician and the administrative director of nursing services." *"Follow-up to the recommendations is documented."	2014-04-01
5070	MANORCARE HEALTH SERVICES	435004	400 8TH AVENUE NW	ABERDEEN	SD	57401	2011-02-02	441	D			9LHM11	Based on observation, interview, and record review, the provider failed to ensure soiled linen was transported in a manner to prevent the spread of infection for two random observations. Findings include: 1. Observation on 2/1/11 at 9:15 a.m. revealed a staff person was pushing two uncovered wheeled tubs containing soiled linen out of the main dining room. She proceeded down the hallway to the soiled linen room. Observation on 2/2/11 at 9:14 a.m. revealed dietary aide H was pushing two uncovered wheeled tubs containing soiled clothing protectors and tablecloths from the main dining room down the hallway to the soiled linen room. The soiled linens in one of the carts was piled approximately a foot higher than the top of the tub during transport. Interview on 2/2/11 at 9:30 a.m. with laundry supervisor I revealed all soiled linens were to be transported in covered tubs. All tubs for transporting soiled linen had lids. Observation on 2/2/11 at 9:40 a.m. of the tubs in the soiled linen room revealed two empty tubs did not have lids. All of the remaining empty tubs were covered with lids. Interview on 2/2/11 at 9:42 a.m. with director of nursing (DON) A confirmed all tubs should have had covers. All soiled linens and clothing should have been covered for transport. Interview with DON A on 2/2/11 at 10:00 a.m. revealed she had found the lids to the uncovered tubs on the floor in the kitchen. Review of the policy for laundry services dated 6/2/06 revealed: "Soiled linen has been shown to be a source of large numbers of pathogenic organisms. The risk of actual disease transmission is negligible if handled, transported and laundered in a manner that minimizes exposures or contamination and avoids transfer of microorganisms. Techniques minimizing potential nosocomial and occupational risks with soiled linen handling include:... empty linen containers when three fourths full preventing overflow secure lids to linen containers prior to transport."	2014-04-01
5071	GOLDEN LIVINGCENTER - COVINGTON HEIGHTS	435031	3900 S CATHY AVE	SIOUX FALLS	SD	57106	2011-08-17	441	E			6HI811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure staff followed accepted professional practice standards for infection control for: Proper handwashing/hand hygiene techniques. Effective measures to prevent the spread of infections. Personal care items stored in a sanitary and [MEDICATION NAME] manner. Findings include: 1. Observation on 8/15/11 at 5:30 p.m. of medication (med) pass with licensed practical nurse (LPN) C revealed she: Entered resident 6's room. Did not wash her hands. Put gloves on both hands. Administered medications through a J-tube (jejostomy). Administered a nebulizer treatment using the same gloves and did the following: -Opened up the nebule that contained the nebulizer solution. -Placed the solution in the nebulizer. -Administered the nebulizer to resident 6 via the tracheostomy. She then went over to resident 6's roommate and: -Did not change her gloves or wash her hands. -Placed the oximetry probe on resident 6's roommate's finger. -Obtained the reading. -Removed gloves. Then exited the room and continued with the medication pass without washing or sanitizing her hands. 2. Random observation on 8/16/11 at 8:02 a.m. of certified nursing assistant (CNA) E revealed she knocked on resident 9's door; the resident was positive for clostridium difficile, she then: Put on a pair of gloves and a gown. -Entered the room. -Assisted the resident to the bathroom. -Removed the gown and gloves. -Washed her hands in the room. -Then exited the room. Interview on 8/16/11 at 2:20 p.m. clinical care coordinator B revealed: Personal care razors were sanitized with alcohol after each individual use. She agreed the razor had not been cleaned. She agreed the razor should not have been stored in the medication cart. Interview with staff education coordinator F on 8/16/11 at 3:30 p.m. revealed she agreed that staff had not followed the provider's policy and procedures regarding clostridium difficile (C-diff). Interview with the medical director on 8/17/11 at 1:30 p.m. revealed: Alcohol based rubs should not have been used with residents that were positive for[DIAGNOSES REDACTED]. Soap and water should be used for handwashing before and after caring for the resident with[DIAGNOSES REDACTED]. Review of the provider's October 2009 Handwashing/Hand Hygiene policy statement revealed: "All personal shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Employees must wash their hands for ten to fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: -Before and after performing performing any invasive procedure. -Before and after entering isolation precaution settings. -Before and after assisting a resident with personal care. -Before and after assisting a resident with toileting (hand washing with soap and water). -After contact with a resident with infectious diarrhea including but not limited to infections caused by norovirus, salmonella, shigella and clostridium difficile (hand washing with soap and water)." Review of the provider's October 2009 Clostridium Difficile policy statement revealed when caring for a resident with diarrhea or fecal incontinence, staff would maintain vigilant handwashing with soap and water, rather than alcohol-based hand rubs for mechanical removal of clostridium difficile spores from the hands. 3. Observation on 8/16/11 at 2:25 p.m. of the 400 wing (med) cart revealed a razor that was dirty with facial hair stored in the third drawer. Interview on 8/16/11 at 2:20 p.m. clinical care coordinator B revealed: Personal care razors were sanitized with alcohol after each individual use. She agreed the razor had not been cleaned. She agreed the razor should not have been stored in the medication cart. 4. Observation of the meal service on 8/15/11 during the supper meal starting after 5:00 p.m. and again during breakfast on 8/16/11 after 7:15 a.m. revealed: The dietary manager (DM) delivered a room tray to a resident in an isolation room. He did not follow the facility's isolation policy and procedures. -He did not put on an isolation gown and gloves to protect his clothing and hands. -He did not wash his hands before and after entering the isolation room. He returned to the steamtable filled with hot food and then to the kitchen's preparation areas without wahing his hands and wearing protective clothing when he delivered the meal. Interview on 8/16/11 at 7:30 a.m. with the DM after he had entered and exited the isolation room to deliver the room tray revealed: He was unaware the room was an isolation room. He had not paid attention to the sign on the door, and the isolation chest of drawers that stored the personal protective equipment (gowns and gloves) setting next to the doorway of the isolation room. He said he did not know the resident in that room was on isolation. When the surveyor stated another resident in a different room was also on isolation he stated he knew that resident was on isolation. Observation of the other isolation room revealed it had a sign on the door and an isolation chest of drawers filled with personal protective equipment next to the doorway of that isolation room. He was not aware he should not be going into any resident's room and then returning to the kitchen and preparation areas of raw and fresh food without protecting his clothing and his hands. 5. Observation on 8/17/11 at 9:10 a.m. of resident 3 revealed her catheter bag was laying flat on the floor. Interview at that time with registered nurse A revealed a catheter bag should not be lying on the floor. Review of resident 3's [DIAGNOSES REDACTED]. Review of resident 3's 8/15/11 care plan revealed a problem of "Urinary tract infection (UTI) potential due to a history of chronic UTI." Review of the provider's October 2009 Monitoring compliance with infection control checklist revealed a surveillance of a catheter included verifying that a catheter bag was off the floor.	2014-04-01
5072	GOLDEN LIVINGCENTER - COVINGTON HEIGHTS	435031	3900 S CATHY AVE	SIOUX FALLS	SD	57106	2011-08-17	371	E			6HI811	Based on observation, record review, and interview, the provider failed to ensure: Food thermometers were sanitized prior to use. The temperature of the food in the pan was checked prior to adding more food to the pan. The serving cart was properly stored during a fire drill. The dishmachine temperature log forms were accurately completed. Findings include: 1. Observation on 8/15/11 at 4:55 p.m. revealed cook H : Was preparing to check the temperature of the foods on the serving cart. Removed the shield on the stem thermometer. Poked the stem of the thermometer through the alcohol wipe package. Left the package on the stem of the thermometer and put the stem in the food item. Recorded the temperature on the menu. Removed the alcohol wipe package. Poked the stem of the thermometer through a second alcohol wipe package and checked the temperature of another food item with the package attached to the thermometer. Continued the process of poking the thermometer stem through the alcohol wipe package, checking the temperature, and removing the package for the remaining food items. Review of the provider's undated Food Thermometer Guidelines revealed: Wash, rinse, sanitize, and air-dry the thermometer before each use. A sanitizing mixture or alcohol wipe for food-contact surfaces could be used. After checking the temperature the thermometer should be washed, rinsed, sanitized, and air-dried. 2. Observation on 8/15/11 at 6:12 p.m. revealed cook I started to add fresh egg salad sandwiches to the pan in the serving cart. There were five sandwiches left in the pan. Temperature check of the five remaining sandwiches by the surveyor revealed the temperature was 60 degrees Fahrenheit. Cook H advised cook I to remove the five sandwiches from the pan. The dietary manager added ice to the pan under the sandwiches. Review of the provider's undated holding and serving policy revealed:Monitor temperatures of any item being held longer than midway through tray line service to ensure correct temperature was being maintained continuously. Hold potentially hazardous cold foods at a continuous temperature of 41 degrees Fahrenheit or below. 3. Observation on 8/16/11 at 11:10 a.m. revealed the fire alarm sounded. An unidentified staff person pushed the salad/dessert cart into a resident's room in the 600 wing. 4. Observation on 8/17/11 at 8:10 a.m. in the dishroom revealed: The provider was using a high temperature dishwasher that did not require a chemical sanitizer. The monthly dishmachine temperature log had a column under each meal labeled "test strip." At the bottom of the page there was a note "Record chlorine concentration for low temperature dishmachine." For the first 16 days of August the number 200 had been written under each test strip column for each day. Interview on 8/17/11 at 8:10 a.m. with the the dietary manager revealed: He would need to re-educate the cook to remove the alcohol wipe from the package and then wipe the thermometer. He would need to re-educate the cook to check the temperature of the food before adding to the pan. *He was not sure why the staff were recording 200 in the test strip column. He said he would visit with the staff to find out what they were testing. Interview on 8/17/11 at 1:40 p.m. with the dietary manager revealed the dishwasher had told him they had been recording the concentration of the cleaning product in the janitor's closet on the dishmachine form.	2014-04-01
5073	GOLDEN LIVINGCENTER - COVINGTON HEIGHTS	435031	3900 S CATHY AVE	SIOUX FALLS	SD	57106	2011-08-17	281	D			6HI811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Preceptor Based on observation, interview, and policy review, the provider failed to ensure: One of one medications and gastrostomy tube ([DEVICE]) flushes were administered according to accepted standards of clinical practice. One of forty-five physician's orders [REDACTED]. Findings include: 1. Observation on 8/16/11 at 7:35 a.m. with licensed practical nurse (LPN) G during the medication pass on the revealed: LPN G was administering eyes drops to resident 16. -Took both bottles of eye drops into resident 16's room. -Placed one bottle of eye drops on the resident's over bed table. -Administered one drop into each eye. She then obtained the second bottle of eye drops and: -Administered one drop into each eye. -She waited 20 seconds in-between administration of the scheduled eye drops. -She did not wait three to five minutes in between administering the eye drops. 2. Observation on 8/16/11 at 8:10 a.m. with registered nurse (RN) D during the medication pass revealed: She checked the medication administration record (MAR) for resident 23's order for flushing the [DEVICE]. She then: -Entered resident 23's room. -Washed her hands. -Put on a pair of gloves. -Drew up 30 cc (cubic centimeters) of water. -Inserted the 30 cc of water into resident 23's [DEVICE] with the syringe without first checking the placement of the [DEVICE]. Interview with RN D immediately after the above procedure revealed that placement was not checked on all gastric tubes. Placement was only checked if it is indicated on the physician's orders [REDACTED]. Review of the provider's October 2007 Medication Administration for Enteral Tubes policy revealed: Verify tube placement. Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds. 3. Observation on 8/16/11 at 8:15 a.m. during the medication pass with RN D revealed: Resident 23 had a 8/9/11 order on the MAR for [MEDICATION NAME] 500 milligrams (mg) one capsule by mouth every 12 hours for 10 days. The medication had been started on 8/9/11. RN D had administered the [MEDICATION NAME] 500 mg. capsule to resident 23. Review of resident 23's physician's orders [REDACTED]. Interview on 8/16/11 at 9:00 a.m. with RN D regarding the [MEDICATION NAME] order for resident 23 revealed: She was not able to find the order for the [MEDICATION NAME]. The medication had been brought to the facility by the resident from the oncology center on 8/8/11 after her treatment. The medication had been transcribed to the MAR and started on 8/9/11. Interview on 8/17/11 at 8:05 a.m. with clinical coordinator B regarding resident 23 revealed: She agreed there should have been an order for [REDACTED]. The nurse should have contacted the physician when she had obtained the bottle of [MEDICATION NAME] 500 mg on 8/8/11. The nurse should have obtained the physician's orders [REDACTED]. *She agreed the medication had been given 8 days without a physician's orders [REDACTED]. Review of the provider's September 2010 Non-Controlled Medication Orders policy revealed "Medications are administered only upon the receipt of a clear and complete, and signed order by a person lawfully authorized to prescribe."	2014-04-01
5074	GOLDEN LIVINGCENTER - COVINGTON HEIGHTS	435031	3900 S CATHY AVE	SIOUX FALLS	SD	57106	2011-08-17	368	E			6HI811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the provider failed to ensure meals were served in a timely manner for two of two meals observed. Findings include: 1. Review of the provider's Dining Services supper meal times revealed: Villa Dining Room (600 wing) was at 5:00 p.m. The Pheasant Room (500 wing) was at 5:20 p.m. Prairie Harvest (100/200 wings) was at 5:45 p.m. The Pheasant Room (300/400 wings) was at 6:15 p.m. Observation on 8/15/11 revealed the following: 4:55 p.m. Cook H was checking the temperatures of the hot food in the kitchen. 5:10 p.m. The serving cart arrived at the Villa Dining Room. Cook H had to wait for staff to bring him the residents' menus. 5:30 p.m. The serving cart arrived at the Pheasant Room. 6:12 p.m. The serving cart was taken to the kitchen to be replenished. 6:38 p.m. The serving cart was in the Prairie Harvest room. There were no resident menus brought to the serving cart. Staff commented they could not pick-up the menus until the beverage server had served the residents their beverages. The beverage server was observed returning from the kitchen. 6:45 p.m. The service in the Prairie Harvest room was delayed, because they had run out of soup bowls. 7:00 p.m. The serving cart was in the Pheasant Room. 7:18 p.m. The server had run out of soup bowls and side dishes. 7:20 p.m. The last tray was served. Interview on 8/15/11 at 7:20 p.m. with the dietary manager revealed: Meal service never ran that late. More dishes were on order. 2. Review of the provider's Dining Services dinner meal times revealed: Villa Dining Room was at 11:00 a.m. The Pheasant Room was at 11:20 a.m. Prairie Harvest was at 11:45 a.m. The Pheasant Room was at 12:15 p.m. Observation on 8/16/11 revealed the following: 11:07 a.m. The serving cart arrived at the Villa Dining Room. 11:10 a.m. The fire alarm was sounded, and the meal service was interrupted. 11:18 a.m. The first meal was served. A staff person had to return to the kitchen to get catsup and mustard for the hot dogs that were the alternate on the menu. 11:40 a.m. The serving cart arrived at the Pheasant Room. 12:10 p.m. The cart was returned to the kitchen to be refilled. 12:20 p.m. The cart arrived at the Prairie Harvest dining room. 12:50 p.m. The cart arrived at the Pheasant Room. 1:05 p.m. The last tray was served. Interview on 8/17/11 at 8:10 a.m. with the dietary manager revealed:Additional dishware had been ordered on [DATE] and 8/10/11. They had production sheets to assist the staff in knowing what foods and condiments would be needed. They would need to start printing and using the production sheets daily. The only staff person in the kitchen during meal service was the dishwasher. The dishwashers were not trained in food preparation, so staff serving the residents had to return to prepare any last minute food items requested by a resident. *They have done quality audits in the past on the timeliness of meal service. The book where the audits were kept was empty.	2014-04-01
5075	AVERA MARYHOUSE LONG TERM CARE	435034	717 EAST DAKOTA	PIERRE	SD	57501	2011-04-13	279	E			6FFB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Preceptor: Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans for 2 of 14 sampled residents (4 and 6): Were reviewed and revised. Had appropriate problems, goals, and approaches documented. Findings include: 1. Observation on 4/11/11 from 5:05 p.m. through 5:45 p.m. in resident 4's room revealed: Resident 4 had been sitting in a recliner in his/her room. -The supper tray had been placed on the bedside table. -The soup and sandwich had been uncovered. At 5:15 p.m. registered nurse (RN) F entered resident 4's room and approached him/her. Resident 4 had requested to go to the bathroom. RN F had assisted resident 4 to the bathroom. At 5:25 p.m. RN F had assisted resident 4 back to his/her chair. Resident 4's meal tray remained uncovered. RN F had asked resident 4 if he/she was going to eat the meal. Resident 4 refused to eat. RN F left the resident's room. Resident 4 remained in his/her chair with the uncovered meal tray placed on the bedside table. At 5:45 p.m. resident 4 remained in the chair with his/her eyes closed. Observation on 4/12/11 from 10:40 a.m. through 11:15 a.m. revealed: Resident 4 had been sitting at the dining room table with a meal that consisted of pancakes, scrambled eggs, cold cereal, juice, and tea. * He/she chewed on the one bite of pancake for several minutes. He/she had 4 natural teeth on the left lower jaw. He/she had then taken a few bites of scrambled eggs, two bites of pancake, one bite of cold cereal, and a few sips of tea. At 11:15 a.m. the staff had not offered any assistance to resident 4 during the meal. Resident 4 had been sleeping off and on at the dining room table. Observation on 4/12/11 from 7:32 a.m. through 7:50 a.m. revealed: At 7:32 a.m. resident 4 had been sitting in his/her recliner with a banana on a plate and a glass of juice on the bedside table. At 7:40 a.m. resident 4 had been assisted to the bathroom by RN F. At 7:45 a.m. he/she was assisted back to his/her recliner. -Resident 4 had eaten two bites of banana. -Resident 4 had not drank the juice. Interview on 4/12/11 at 7:40 a.m. with RN F revealed: Resident 4 could be difficult at times. Resident 4 had eaten when he/she wanted to eat. Interview on 4/12/11 at 9:30 a.m. with certified dietary manager (CDM) revealed: Resident 4 liked tea and toast. Resident 4 had been offered tomato soup at supper, because his/her daughter stated the resident liked that. Resident 4 stayed in his/her room for most meals. The dietitian had spoken with the resident's daughter. The resident's daughter had been bringing in food and eating with him/her at lunch time for a few weeks, with no improvement in appetite. Resident 4's weight had been 147 pounds on 4/6/11. Resident 4's weight had been 163.5 pounds on 10/13/10. CDM agreed resident 4 should have been placed on a supplement due to his/her weight loss and reduced appetite. Interview with RN F on 4/12/11 at 9:40 a.m. revealed: Resident 4 had a [DIAGNOSES REDACTED]. He/she had been prescribed [MEDICATION NAME] in January of 2011 for decreased appetite and reoccurring behaviors. Interview on 4/12/11 at 12:10 p.m. with resident 4, a son,and a daughter revealed he/she: Had lost a tremendous amount of weight since Christmas 2010. Had a decreased interest in activities. Had received dietary supplements from the provider but did not like them. The resident had not received assistance from staff during meal time. The food was usually cold when it was delivered to the resident's room. Stated the food was edible and laughed. The resident liked watermelon, muskmelon, and any kind of fruit. Resident 4 stated "It would be nice to have someone to sit with me during meals." Interview on 4/12/11 at 12:30 p.m. with certified nursing assistant (CNA) H revealed: She had never delivered a tray to resident 4. Sometimes the resident was just difficult and stubborn. Interview on 4/12/11 at 1:10 p.m. with the CDM revealed: She had not been aware of any nutritional at risk list of residents with weight loss. She had stated "Maybe the registered dietitian may do this." Interview on 4/12/11 at 1:15 p.m. with the registered dietitian (RD) revealed: There was not a nutritional at risk list for residents with weight loss. Resident 4 was too heavy, so they did not want him/her to gain weight. She had notified clinical coordinator E regarding the suggestion of an appetite stimulant and concerns of the antidepressant. The nurses faxed any dietary concerns from the dietitian to the attending physician. She could have offered Ensure to the resident but had not. There was no meeting regarding residents that were having weight loss. If there was weight loss it was discussed at the resident's care conferences. She felt 147 pounds was an ideal weight for resident 4. She stated, "Resident 4 was at a good weight, if we can keep him/her from losing anymore weight." She felt that the provider had done all they could do for resident 4. Interview on 4/12/11 at 2:30 p.m. with the DON regarding resident 4's weight loss revealed: She agreed the care plan should have been updated to reflect the weight loss and interventions. Staff should have been monitoring resident 4's intake. Staff should have been offering foods resident 4 liked. Interview on 4/12/11 at 2:30 p.m. with the DON and RN coordinator J revealed: The DON agreed: -The care plans needed to be individualized. -There was no documentation in resident 4's care plan regarding interventions for weight loss. -The care plans were not updated until discussed by the care plan team. Problems that arose for residents were discussed at care conferences. Care conference summaries identified problems for the resident but were not transcribed to the care plan with interventions specific to the individual's current problems. Nurse coordinator J revealed: -The resident had behavorial problems. -Had been refusing meals, refusing medications, hitting at the staff, and had refused cares after incontinent episodes. -The staff were afraid to approach the resident. - [MEDICATION NAME] had been discontinued due to the resident's sleepiness. -After [MEDICATION NAME] had been discontinued, the resident started having behavorial issues. -[MEDICATION NAME] had been started on 1/25/11. Record review on 4/11/11 at 5:40 p.m. revealed resident 4: Had been on a diabetic diet. Had an [MEDICATION NAME] level of 2.7 on 1/28/11. Normal [MEDICATION NAME] levels are 3.2 to 3.5. Record review of resident 4's quarterly nutritional summary dated 3/26/11 revealed: Was on a diabetic consistent carbohydrate diet. Was to receive eight ounces of Diabetic Shield (150 calories and 7 grams of protein) daily for skin. Average meal intake was 25%. Had very few teeth. Requirement of 1400-1700 calories per day, 72-83 grams of protein per day, and 1700-2000 milliliters of fluid per day. Record review on 4/12/11 at 9:05 a.m. of resident 4's weight variance report revealed: Had a 16 pound weight loss or 11% since December 2010. Record review of the resident's complete medical chart on revealed no follow up from the nursing staff regarding the dietitian's recommendation dated 3/10/11. That recommendation was regarding resident 4's decreased appetite since the antidepressant had been started, and that an appetite stimulant should have been helpful. Review of the provider's revised 3/8/11 policy for Comprehensive Care Plan revealed: "Comprehensive care plans will be revised as necessary to reflect change in the patient/resident and the care they are receiving. Revisions to the comprehensive care plan will take place on the paper copy in between MDS(Minimum Data Set) assessments. The comprehensive care plan in the computer will only be revised after each quarterly MDS assessment, or significant change MDS as applicable." 2. Observations on 4/11/11 and on 4/12/11 of resident 6 and the resident's room revealed: The room was very cluttered and disorganized. Box upon box of things were found stacked every place in her room. Old food was found on the night stand and in the refrigerator. The only area for the resident to move about in the room was a path from her bed to her bathroom. She spent the majority of the day sorting and resorting through multiple boxes of things. She seldom left her room. Review of resident 6's care plan last revised on 3/23/11 revealed no goals or interventions had been developed related to the care of the resident's room or the behaviors that had resulted in the resident's room appearance. Interview on 4/12/11 at 10:30 a.m. with the DON and the Minimum Data Set coordinator revealed: Resident 6 had a long history of hoarding both at home and at the facility. The provider had been trying to deal with her hoarding via several avenues, but no formal plan had ever been documented or developed. No formal care plan had been developed to monitor and help staff members intervene with residents' hoarding and resulting behaviors. They both agreed a formal plan of care should had been developed related to the resident 6's hoarding and resulting behaviors.	2014-04-01
5076	AVERA MARYHOUSE LONG TERM CARE	435034	717 EAST DAKOTA	PIERRE	SD	57501	2011-04-13	176	D			6FFB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure self-administration of medications was properly monitored for one of two sampled residents (6)who self-administered medications. Findings include: 1. Observation on 4/11/11 at 2:05 p.m. of resident 6's room revealed the night stand next to the door had several pills in a small cup on top of it. Interview on 4/11/11 at 2:06 p.m. with resident 6 revealed: The pills in the cup were her morning medications. She was unwilling to state why she had not yet taken the pills. She stated she thought she might take the pills sometime today. Interview on 4/11/11 at 2:10 p.m. with registered nurse M revealed: Resident 6's self-administered medications should have been taken by her shortly after being prepared by the nurse. She assumed the medication on the night stand were her morning medications but could not say for sure. She agreed the pills found should had been taken early in the morning as she prepared them for the resident around 8:00 a.m. Resident 6 had been found not to be taking her pills on other occasions. Review of resident 6's entire medical record revealed: The resident was approved by the care team to self-administer medications. Medications signed out for that morning were: -[MEDICATION NAME]. -Aspirin. -[MEDICATION NAME]. -[MEDICATION NAME]. -[MEDICATION NAME]. -[MEDICATION NAME]. -[MEDICATION NAME]. -[MEDICATION NAME]. -Multivitamin. -[MEDICATION NAME]. -Senna S. -[MEDICATION NAME]-XL. The nurse was to prepare the medications for the resident to self-administer. Review of the provider's 12/10/10 policy on self-administration of medications revealed: Nursing staff were to monitor the resident's self-administration of medication. Self-administration was to be reviewed upon changes in the resident's status. Interview on 4/12/11 at 10:30 a.m. with the director of nursing and the Minimum Data Set coordinator revealed: They agreed proper self-administration of medications had not occurred. The nurse should have checked back with the resident to ensure proper self-administration had occurred and should have documented any refusals to take medications. Medications given to the resident should have been taken within one hour of delivery to the resident. They agreed the resident had a long history of hoarding making it difficult to say if she had taken her medications or not.	2014-04-01
5077	AVERA MARYHOUSE LONG TERM CARE	435034	717 EAST DAKOTA	PIERRE	SD	57501	2011-04-13	323	E			6FFB11	Based on observation, interview, and policy review, the provider failed to ensure one of two first floor, in the west hallway exits to the exterior of the building were properly alarmed. Findings include: 1. Observation and testing on 4/11/11 at 4:30 p.m. of the first floor west hallway exit door closest to the nurses station revealed: The door had an alarm box in the right upper corner. That box had a key activated on and off switch. The alarm on the door had been turned off. Testing of the door revealed no alarm sounded when opened. Once through the door direct access to a river and a street were available. No wandering system was in place for that door. No staff monitored that door. Multiple residents passed through that hallway on a day-to-day basis. Observation and testing on 4/12/11 at 7:30 a.m. and at 4:45 p.m. of the first floor west hallway exit door closest to the nurses station revealed the status of the alarm was unchanged since the initial observation. Interview on 4/12/11 at 4:50 p.m. with registered nurse G revealed she: Agreed the door alarm had been turned off. Agreed the door was to be alarmed at all times. Was unsure why the alarm had been turned off. Interview and policy review on 4/13/11 at 9:50 a.m. with the director of nursing revealed: That door was to be alarmed at all times. The provider's safety policy revised on 10/12/10 called for that door to have been alarmed. She agreed having that door alarm turned off was a safety risk to the first floor residents.	2014-04-01
5078	AVERA MARYHOUSE LONG TERM CARE	435034	717 EAST DAKOTA	PIERRE	SD	57501	2011-04-13	309	D			6FFB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to assess, monitor, and intervene in the individualized care and service to maintain the highest practical physical well being for two of five sampled residents (8 and 14) who had no recorded bowel movement (BM) for four or more days. Findings include: 1. Review of resident 8's 4/5/11 resident progress notes revealed she had: Not had a BM since 3/30/11. Poor food intake as well. A flat abdomen. Not answered when asked if she felt she needed to have a BM. Poor fluid intake the previous night. No acute distress. Review of resident 8's April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] There had been no as needed medication (PRN) administered to the resident on 4/5/11. There were no PRN medications ordered for bowel elimination until 4/12/11 when an order was received for a [MEDICATION NAME] suppository to be given PRN for constipation. Review of resident 8's vital sign report revealed there were no documented BMs from: 3/30/11 to 4/5/11 (6 days). It was noted the BM on 4/5/11 was soft and formed. 3/16/11 to 3/21/11 (5 days). It was noted the BM on 3/21/11 was soft and formed. 2/13/11 to 2/18/11 (5 days). It was noted the BM on 2/18/11 was dry and hard. There was no documentation on the February 2011 and March 2011 MARs that a prn medication for bowels had been given. 2. Review of resident 14's vital sign report revealed there were no documented BMs from 3/31/11 to 4/3/11 (4 days). There was no documentation that PRN medication for constipation had been given. Review of resident 14's March 2011 MAR indicated [REDACTED] 10 milligrams [MEDICATION NAME] suppository. 30 milliliters Milk of Magnesia. Review of resident 14's 1/27/11 care plan revealed: Constipation was listed in the [DIAGNOSES REDACTED]. *There were no problems or goals related to constipation on the care plan. Interview on 4/12/11 at 4:58 p.m. with nurse coordinator J revealed the certified nursing assistants (CNA) would possibly note resident's BMs on their CNA sheet. Interview on 4/12/11 at 5:05 p.m. with CNA L revealed BMs were noted on the computer. Interview on 4/13/11 at 9:45 a.m. with the director of nursing revealed the laxative and BM record form was discarded after the information was entered into the computer. Interview on 4/13/11 at 11:10 a.m. with MDS coordinator N revealed the provider did not have a bowel protocol policy.	2014-04-01
5079	AVERA MARYHOUSE LONG TERM CARE	435034	717 EAST DAKOTA	PIERRE	SD	57501	2011-04-13	441	D			6FFB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure infection control policies were followed for one of one sampled resident (1) with a Multi-Drug Resistant Organism (MDRO). Findings include: 1. Review of resident 1's admission sheet revealed he: Was admitted on [DATE] from the hospital. Had a [DIAGNOSES REDACTED]. Review of resident 1's 3/28/11 Minimum Data Set revealed a MDRO was not coded as an active diagnosis. Interview with licensed practical nurse B on 4/11/11 at 5:00 p.m. revealed she was unsure if resident 1 had a MDRO of the nares. Observation on 4/11/11 at 3:00 p.m. of resident 1's room revealed a sign in bold print posted on the outside of the door that read: Contact precautions were to be followed and included: -A private room. -To wear gloves. -To wear a gown if the person entering aniticpated contact with the resident or environmental surfaces. -To limit the transport of the resident from the room. Review of 3/15/11 laboratory (lab) records revealed a MDRO screen was completed of his nares (nose) and on a wound. The results were positive. Review of resident 1's physician's progress notes from 3/22/11 through 4/12/11 revealed: The physician had seen him eight times. The MDRO had not been addressed in any of the progress notes. There was not any evidence of discussion of the treatment for [REDACTED]. Interview and review of the medical record on 4/12/11 at 8:30 a.m. with infection control nurse (ICN) A revealed: She was unaware resident 1 had been transferred to the transitional care unit (TCU). She was unaware of the current status of resident 1 and the treatment of [REDACTED]. She verified resident 1 had been there for three weeks. It was the provider's protocol throughout their entire health system to: -Inform her when there was a resident admitted with an infectious disease. -Follow the provider's protocol for the specific MDRO resident 1 had. -That protocol included a repeat nare screening for the MDRO, and if the results were positive to re-treat. She was unable to find documentation of any follow-up lab work being done in regards to the MDRO. She questionned if the follow-up lab work had been missed.The date it should have been done was the same date he had transferred to the TCU. She could not explain why further lab work was not evident. The provider did not have specific policies for specific MDROs. They followed the provider's infection control policy and the Isolation Precautions process Algorithm (flow chart). Review of the provider's January 2009 MDRO nasal screening tool preprinted order revealed the provider's procedure was to: Obtain a nasal swab for the MDRO screening if they met certain criteria that included a past history of a MDRO. The following orders would be done if the culture was positive: -To complete a prescribed treatment regime for seven days. -Complete a second screening on day eight, and repeat the treatment regime until the screening results had been negative. -That was to be signed by the physician. Interview with ICN A on 4/12/11 at 11:00 a.m. revealed: She had spoken with resident 1's physician and had been told because of resident 1's non-compliance, the physician had discontinued the treatment regime for the MDRO. Resident 1 had been on an antibiotic that would address the MDRO, but that had been discontinued. The physician had the ability to over-ride the provider's protocol. The provider did not have any documentation for that. Interview on 4/11/11 at 5:30 p.m. with care assistant O revealed when she entered resident 1's room she only put on gloves. She did not put a gown on. Random observation from 4/11/11 through 4/12/11 revealed when certified nursing assistants entered the room they put on gloves and gowns. Review of nurses progress notes since resident 1's admission on 3/22/11 revealed: There was no evidence of any discussion with the resident informing him of the decision to not further treat the MDRO. There was no discussion of the duration of resident 1's need to be in isolation, and how they would determine if that was no longer necessary if they never re-cultured. Interview on 4/12/11 at 4:00 p.m. with registered nurse coordinator (C) revealed: She reviewed resident 1's medical record and agreed there was no evidence of subsequent laboratory work being completed. She could not find that an Infection Event document had been completed when resident 1 was admitted . The document would have triggered a communication through their computer software to inform the ICN of the resident's admission. They had to be more dilligent when working within their own health care system to make sure all steps were followed. Things got missed such as the communication regarding the infection.	2014-04-01
5080	AVERA MARYHOUSE LONG TERM CARE	435034	717 EAST DAKOTA	PIERRE	SD	57501	2011-04-13	253	D			6FFB11	Based on observation and interview, the provider failed to: Schedule the cleaning of the isolation room to prevent potential cross-contamination. Maintain the following items in a sanitary manner: -The refrigerator at the first floor nurses station. -The windows of the activity room. -The floor of the supply room located in the back of the maintenance area. Findings include: 1. Observation on 4/12/11 at 1:30 p.m. in the transitional care unit (TCU) revealed: An environmental services staff person was cleaning rooms. Resident room 3521 had isolation precautions. Interview on 4/12/11 at 1:30 p.m. with environmental staff person O revealed: She was the person responsible for cleaning the rooms in the TCU. She was aware one room was an isolation room. She cleaned the room as part of the normal rotation and did not clean it last. She was not aware she should have cleaned the isolation room last. Interview on 4/12/11 at 1:40 p.m. with the infection control nurse revealed isolation rooms should have been cleaned last. Interview on 4/12/11 at 2:15 p.m. with the head of environmental services revealed isolation rooms should have been cleaned last. Review of the 5/2010 policy and procedure for cleaning isolation rooms did not mention isolation rooms were to be cleaned last. 2. Observation on 4/13/11 at 9:03 a.m. of the refrigerator at the first floor nurses station revealed: Spilled liquids in the bottom drawer of the refrigerator (Photo 3). Spilled liquids below the bottom drawer of the refrigerator (Photo 2). The vent panel located under the refrigerator door was covered with food debris (Photo 2). Interview on 4/13/11 at 9:03 a.m. with the head of environmental services revealed she thought the dietary department would be responsible for keeping the refrigerators clean. Interview on 4/13/11 at 9:05 a.m. with several unidentified staff people working in that area revealed the night shift were responsible for cleaning the refrigerator. No specific answers were given as to who on the night shift was responsible for cleaning the refrigerator. 3. Observation on 4/13/11 at 9:10 a.m. in the storage room in the back of the maintenance room revealed: The room was used to store clean supplies such as adult briefs, foam cups, plastic forks, and latex gloves. The floor of the room had several pieces of paper, cobwebs, and other debris on it (Photos 4 and 5). Interview on 4/13/11 at 8:50 a.m. with the head of maintenance revealed: He agreed the floor needed to be cleaned. It was environmental services responsibility to keep that area clean. Interview on 4/13/11 at 9:10 a.m. with the head of environmental services revealed: She agreed the floor needed to be cleaned. Maintenance had been cleaning that room previously. 4. Observation on 4/13/11 at 9:13 a.m. in the activity room revealed: The screens on the one window with screens were covered with dirt and cob webs (photo 6). The aluminum window frame was covered with a grey residue that came off when rubbed with a finger (photo 8). The caulk surrounding the window was separated from the frame and was covered by a brown residue (photo 8). The wall paper around the window was loose at the edges and was starting to peel. Interview on 4/13/11 at 9:13 a.m. with the head of environmental services revealed: She agreed the window needed to be cleaned. The windows were normally cleaned in the spring but had not been cleaned yet. She was short a cleaning person on her staff and was running behind schedule with cleaning. *She would need to have maintenance reseal the window with caulk and glue the wall paper down.	2014-04-01
5081	AVERA MARYHOUSE LONG TERM CARE	435034	717 EAST DAKOTA	PIERRE	SD	57501	2011-04-13	364	D			6FFB11	Surveyor: NELSEN, TRAVIS Based on interview and testing, the provider failed to prepare and serve palatable food to residents who dined in their rooms. Findings include: During group interview on 4/12/11 at 12:10 p.m. two random residents expressed concerns about the quality of food they received on the trays delivered to their rooms. One resident resided in the transitional care unit and the other on the first floor of the main building. Both residents stated the food was usually cold when delivered to their rooms. Surveyor: CHRISTENSEN, SUSAN Precepter: 2. Interview on 4/12/11 at 12:10 p.m. with resident 4's family revealed the food was usually cold when it was delivered to the resident's room. A temperature and palatability test tray on 4/13/11 at 10:30 a.m. by surveyor revealed: The temperature of the ham patty was 117 degrees Farenheit. Food should have been hot held at or above 135 degrees Farenheit until served. The ham was tasteless.	2014-04-01
5082	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2011-02-10	441	E			SQV011	Based on observation, interview, policy review, and record review, the provider failed to ensure: The chemicals and process used to sanitize all of the laundry was effective against drug resistant organisms. The chemical used to sanitize the whirlpool tub was applied effectively during the cleaning process. Two of four hopper spray hoses were stored correctly to prevent cross-contamination. Findings include: 1. Observation on 2/9/11 at 7:55 a.m. in the laundry revealed: Bacstat liquid softener by Ecolab was used in the laundry as a sanitizer. Bacstat was listed on a chart on the wall by the wash machines for use in the comingled loads. Interview on 2/9/11 at 7:59 a.m. with laundry aide C confirmed: He did not know which chemical was the sanitizer used in the laundry for the comingled clothing. He did not know what organisms the Bacstat was effective against. He further stated administrator A had all of that information. Interview on 2/9/11 at 4:15 p.m. with administrator A confirmed: She did not know what organisms the sanitizing chemical Bacstat liquid softener from Ecolab used on the comingled laundry was effective against. The water temperature used for the comingled laundry was 90-120 degrees Fahrenheit. The water temperature was not hot enough to sanitize the laundry. She was not able to receive a current information sheet from the chemical supplier that identified what Bacstat was effective against. Review of the provider laundry procedure dated 8/2006 revealed there was no information that directed which chemical was to be used for sanitizing the comingled laundry. 2. Interview on 2/9/11 at 2:40 p.m. with certified nursing assistant (CNA) H confirmed: She had applied the Mastercare disinfectant to the tub and tub chair surfaces for one to two minutes usually before she rinsed the tub/chair surfaces. She had never left it on for more than 5 minutes. Interview on 2/10/11 at 7:38 a.m. with CNA I confirmed he sprayed the Mastercare disinfectant on the tub surfaces and left it on for two to three minutes before he rinsed it off. Review of the label directions on the container of Mastercare disinfectant revealed a contact time of ten minutes was necessary for disinfection of bacteria and viruses listed on the label to include methicillin resistant staphylococcus aureus. Review of the provider whirlpool cleaning procedure revised on 4/2010 revealed ten minutes was to be used for thorough chemical action to occur. Interview on 2/10/11 at 8:15 a.m. with director of nursing (DON) B confirmed the CNAs had been trained during orientation to leave the disinfectant on the tub surface for ten minutes before the tub would be rinsed. 3. Random observation from 2/7/11 through 2/9/11 revealed: The south hopper hose nozzle was immersed in the water of the hopper bowl (picture 1) that could cause cross-contamination. The east and west hopper hose nozzles were placed on the edge of the hopper bowls in contact with the surfaces of the bowls that could cause cross-contamination. Interview on 2/9/11 at 7:59 a.m. with CNA I confirmed soiled linen, colostomy bags, soiled bedpans and urinals, and emesis basins were emptied and cleaned in the above hoppers. Interview and observation on 2/9/11 at 9:45 a.m. with plant operations manager J confirmed: The hoses were to be placed in the bracket provided. It was difficult to place the hose in the bracket provided. Interview and observation on 2/9/11 at 3:00 p.m. with DON B confirmed: She expected the hoses to be placed in the brackets provided to prevent cross-contamination. She was unable when she tried at that time to place the hose in the bracket provided.	2014-04-01
5083	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2011-02-10	520	F			SQV011	Based on interview, record review, and policy review, the provider failed to use the quality assurance process in an effective manner to resolve the extended response times for call lights for 5 of 12 sampled residents (4, 5, 9, 11, and 12) and 2 of 4 random residents (14 and 15)that had been identified. Findings include: 1. Interviews with random and sampled residents and families from 2/7/11 through 2/10/11 confirmed the staff response time to answer call lights was too long. Refer to F241. 2. Review of staff meeting minutes revealed: Certified nursing assistant (CNA) meeting minutes dated 3/17-18/10 addressed call lights were not answered for up to 20 to 47 minutes. The time of those call lights not being answered usually occurred during staff break times in the morning or from 7:00 p.m.-8:00 p.m. in the evening. CNA meeting minutes dated 7/8/10 addressed complaints from families in regards to answering of call lights. One family complained the call light had been on for 45 minutes, and the resident had needed to use the toilet. CNA meeting minutes dated 10/14/10 addressed call light complaints had been received again from families. The minutes further stated the call light had been on for over 20 minutes, and staffing that shift consisted of three nurses, a medication aide, and six CNAs. Interview on 2/9/11 at 4:45 p.m. with director of nursing (DON) B confirmed: She had been aware of the lengthy time it took for call lights to be answered. She had considered it to be an ongoing problem that had not been solved. She expected the call lights to be answered in 15 minutes or less. There was no policy that addressed the answering of call lights. She had not used the Quality Assurance process to address the lengthy call light response concerns presented by families and residents. Interview on 2/9/11 at 5:10 p.m. with administrator A confirmed: The DON had not submitted any written reports to the quality assurance committee that addressed the answering of call lights. The quality assurance committee no longer submitted written reports for the quality assurance meetings since 2005. Review of the quality assurance committee guidelines revised November 2000 revealed: Verbal reports were presented to the group at the monthly department head meetings. Areas of concern were discussed and suggestions were considered at those meetings. A summary of the present concerns were presented by the department heads and discussed. Interview on 2/10/11 at 8:00 a.m. with registered nurse L revealed she was not familiar with any QA activities unless she had been asked to track or trend a particular issue. She further revealed she had tracked call lights on her own and had followed-up with her own staff regarding call lights. Interview on 2/10/11 at 8:30 a.m. with social services designee K revealed she was a member of the QA committee. She also revealed she was unaware of any QA activities concerning call light response times. Interview on 2/10/11 at 8:45 a.m. with certified nurse assistant M revealed she was "not familiar" with QA activities. Interview on 2/10/11 at 9:00 a.m. with licensed practical nurse/Minimum Data Set coordinator O revealed she would not really know what QA was tracking. Interview with administrator A on 2/10/11 at 9:05 a.m. revealed: The QA committee did not have a true measuring tool to evaluate their QA activities. Once a change was implemented the change was discussed by conference call or email. The provider's QA evaluation process was not that formal. There had been no QA activities on the response time of call lights. The response time of call lights had been discussed at the nursing and CNA meetings. The provider dealt with call lights all the time.	2014-04-01
5084	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2011-02-10	241	E			SQV011	Based on interview and record review, the provider failed to create an environment that ensured dignity was maintained for 5 of 12 sampled residents (4, 5, 9, 11, and 12) and 2 of 4 random residents (14 and 15) evidenced by the extended staff response time to residents' call lights. Findings include: 1. Phone interview on 2/8/11 at 8:25 p.m. with resident 5's son confirmed: He was disappointed with the care his mother received. It had been difficult to find staff at times when they were visiting. He would wait a long time for the call light to be answered after it had been put on for his mother. Eventually he would have to go look for staff and would find them in another wing. Review of resident 5's electronic call light usage record for December 2010 and January 2011 revealed the following times that were over 15 minutes in duration: On 12/29/10 at 12:39:29 p.m. it took 34.4 minutes for her call light to be answered. On 1/8/11 at 9:38:32 a.m. it took 16.6 minutes for her call light to be answered. On 1/31/11 at 7:17:02 p.m. it took 21.1 minutes for her call light to be answered. 2. Interview on 2/10/11 at 10:30 a.m. with resident 11 revealed: It had taken as long as an hour and a half for the call light to be answered at times. She had turned the call light off herself at times, as she grew tired of waiting for staff to answer the call light. She felt there had not been enough staff available to answer call lights at those times. There had been no shift that had taken longer than another to answer her call light. The staff stated they had been in another wing at the times when she had waited a long time for a response. Review of resident 11's electronic call light usage record for December 1, 2010 through February 8, 2011 revealed the following times that were over 15 minutes in duration: Nine occurrences for the month of December 2010 that were over 15 minutes and up to 46.0 minutes in duration for the staff to have answered her call light. Thirteen occurrences for the month of January 2011 that were over 15 minutes and up to 29.9 minutes in duration for the staff to have answered her call light. Three occurrences for the month of February 2011 that were over 15 minutes and up to 51.0 minutes in duration for the staff to have answered her call light. 3. Interview on 2/9/11 at 1:00 p.m. with resident 14's son confirmed: He was disappointed with the care his mother received. Her clothes would be covered with food and water at times when he would visit her. She required repositioning when he would visit. It sometimes took over 30 minutes to have the call light answered in the evenings. Review of resident 14's electronic call light usage record for December 1, 2010 through February 9, 2011 revealed the following times that were over 15 minutes in duration: Four occurrences for the month of December 2010 that were over 15 minutes and up to 48.0 minutes in duration for the staff to have answered her call light. Two occurrences for the month of January 2011 that were over 15 minutes and up to 30.8 minutes in duration for the staff to have answered her call light. 4. Interview on 2/7/11 at 4:30 p.m with resident 4 and his daughter revealed there was a concern about the length of time it took for a response from the staff to resident 4's call lights. Resident 4's daughter stated it was an especially long response time for help to come for toileting. Resident 4 expressed his concern he would become wet or soiled when he had to wait so long. Resident 4's daughter further stated her father would often transfer himself to the toilet instead of waiting for help. Further interview with resident 4 on 2/8/11 at 9:00 a.m. revealed he was "pretty impatient." If he had not received help within twenty minutes after putting on his call light he was "out of here!" Review of resident 4's electronic call light record from 12/1/10 through 2/9/11 revealed the following wait times of 15 minutes or more for a response to the resident's room and/or bathroom call lights: December 2010 - 62 times ranging from 15.3 to 81 minutes. January 2011 - 42 times ranging from 15.2 to 71 minutes. February 2011 - 19 times ranging from 15.9 to 59 minutes. 5. Interview on 2/7/11 at 4:55 p.m. with resident 12 revealed it took an "eternity" for call lights to be answered by the staff, but it was not "all the time." Further interview with resident 12 on 2/9/11 at 7:55 a.m. revealed: Most of the time call lights were answered promptly but at times it "took awhile." He understood sometimes the staff were busy helping others. The staff could have at least come to the room to tell the resident how long the wait would have been. If the staff had done that his anxiety would have been lessened while he was waiting. The "place is 'homey', but they need to review the call lights." Review of resident 12's electronic call light record from 12/1/10 through 2/9/11 revealed the following wait times of 15 minutes or more for a response to the resident's room call lights: December 2010 - 39 times ranging from 15.1 to 77 minutes. January 2011 - 26 times ranging from 15.9 to 79 minutes. February 2011 - 7 times ranging from 17.5 to 47 minutes. 6. Interview with resident 9 on 2/9/11 at 8:30 a.m. revealed she had waited as long as 30 minutes for her call light to have been answered. 7. Interview with resident 15 on 2/9/11 at 4:00 p.m. revealed she had waited as long as 30 minutes for her call light to have been answered. Review of resident 15's electronic call light record of 2/7/11 revealed at 11:41:16 a.m. the response time to answer her call light had been 23.6 minutes. Surveyor 8. Interview on 2/9/11 at 4:45 p.m. with director of nursing B confirmed: She had been aware of the lengthy time it took for call lights to be answered. She considered it to be an ongoing problem that had not been solved. She expected the call lights to be answered in 15 minutes or less. There was no policy that addressed the answering of call lights.	2014-04-01
5085	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2011-02-10	371	E			SQV011	Based on observation, interview, and policy review, the provider failed to ensure food safety and sanitary practices were used for: Labeling and dating of thawed liquid supplements in the refrigerator. Handwashing and glove use between tasks during two of two meal service observations to prevent cross-contamination. Findings include: 1. Observation on 2/7/11 at 5:00 p.m. revealed: A plastic box containing 48 thawed Mighty Shake supplements in the small refrigerator in the kitchen. Five more thawed Mighty Shakes sat on the shelf next to the plastic box. Each Mighty Shake container stated the supplement was only good for fourteen days after thawing. None of those thawed Mighty Shake containers were marked with a thaw date. Interview at the above time with dietary chef E and dietary aide F revealed Mighty Shakes were removed from the freezer and placed in the refrigerator every day. They further revealed the supplements were usually used within one week of removal from the freezer. Observation from 2/8/11 at 4:40 p.m. through 2/9/11 at 8:30 a.m. revealed: The above plastic box continued to hold between twenty and forty-four thawed Mighty Shakes. There was still one of the five above thawed shakes on the shelf beside the box. It had been pushed all the way to the back of the refrigerator and out-of-sight. Interview with dietary manager (DM) D on 2/9/11 at 8:30 a.m. confirmed: The provider used alot of Mighty Shakes every day. The thawed Mighty Shake supplements were only good for fourteen days after being thawed. None of those Mighty Shake cartons or the plastic box of supplements had the thaw date written on them. The thawed Mighty Shakes should have been dated when they had been removed from the freezer to ensure they were used within the fourteen days. 2. Observation of the brunch service on 2/8/11 from 11:00 a.m. through 12:00 noon revealed dietary chef G washed his hands and put on clean gloves. With those gloved hands he touched the dietary cards and the individual menus filled out by each resident. Those menus and dietary cards were also touched by gloved and ungloved certified nurse assistants (CNA) during the meal service. The menus and cards were placed on the shelf above the steam table by the CNAs after the residents had made their menu choices. Further observation of the above brunch service revealed with those same gloved hands dietary chef G left the steam table. He then: Went to the large cooler in the kitchen and took out a package of pancakes. Removed two pancakes from the package, put them on a plate, and put them in the microwave. Removed the plate from the microwave, picked up the pancakes, and placed them on a resident's plate. Touched another resident's menu and dietary card and removed his gloves. Without washing his hands opened a can of soup, poured the soup in a bowl, and placed the bowl of soup in the microwave. Again without washing his hands put on a pair of clean gloves. Removed two slices of bread from the package, buttered them, and placed them in a frying pan. Went to the large cooler, removed two unwrapped slices of cheese and placed them between the two pieces of bread in the frying pan. Went back to the steam table and touched more dietary cards and residents' menus. Opened a drawer behind the steam table, removed a metal spatula by the serving surface, and turned the grilled cheese sandwich over in the pan. Removed the sandwich from the pan with the spatula and placed it on a resident's plate. Held the grilled sandwich with his left gloved hand and cut the sandwich in two. With those same gloved hands arranged the sandwich on the resident's plate. Touched more dietary cards and menus. Removed those gloves and without washing his hands removed two eggs from the cooler and whisked the eggs to make an omelet for another resident. 4. Observation of the supper service on 2/8/11 from 4:15 through 5:00 p.m. revealed dietary chef E was serving barbecued pork sandwiches. Before beginning the meal service she washed her hands and put on clean gloves. With those same gloved hands dietary chef E: Touched the residents' dietary cards and individual menus. Removed the buns from the plastic package and placed them on the residents' plates. Spooned barbecued pork onto the bottom buns and placed the top buns onto the meat. Held the sandwiches with her left gloved hand while slicing the buns in half with her right gloved hand. Left the steam table, went to the walk-in freezer in the back room of the kitchen, got a tray of pea salad and a tray of pears from that freezer, and set them on the steam table. Checked the temperatures of the dishes of pea salad and the dishes of pears with a thermometer. Put the pea salad back into the walk-in freezer and the pears into the cooler in the kitchen. Without changing those gloves or washing her hands went back to the steam table. Continued to touch dietary cards and residents' menus. Continued to remove the buns from the packages to make barbecued pork sandwiches and held them while she sliced them in two. Went back to the cooler in the kitchen and the freezer in the back room several more times for more pea salad and pears. Re-temped the pea salad. Continued to touch the dietary cards, menus, items from the refrigerator, and the buns as she made the barbecues. Interview with the dietary manager on 2/9/11 at 9:00 a.m. revealed she agreed: Gloves became contaminated when the dietary chefs touched dietary cards and menus handled by residents and others. Gloves became contaminated when the dietary chefs left the serving line and touched other areas and items throughout the kitchen with those same gloves. Contaminated gloves should not have been used to touch ready-to-eat foods. Review of the provider's undated dietary services use of plastic gloves policy revealed: Plastic gloves would have been worn to ensure bacteria was not transferred from the food handler's hands to the food product that was served. Hands should have been washed before plastic gloves were put on. Gloves were just like hands, they got soiled. Anytime a contaminated surface was touched the gloves had to be changed. 5. Random observation at 4:40 p.m. on 2/8/11 of the meal service in the assisted dining room revealed a staff member with gloved hands: Pulled a chair up to the table. Touched the back of the resident's chair. Cut the resident's sandwich with a knife and fork. Picked up the sandwich and assisted the resident to take a bite. Fed the resident bites of food with a fork. *Continued to pick up the sandwich and feed it to the resident.	2014-04-01
5086	GOLDEN LIVINGCENTER - ARLINGTON	435050	120 CARE CENTER ROAD POST OFFICE BOX 280	ARLINGTON	SD	57212	2011-01-05	281	D			ZPLO11	Based on observation, interview, and record review, the provider failed to ensure one of three nurses (C) followed professional standards when providing medications to the residents during 19 of 20 opportunities during medication pass and 6 random observtions following the medication pass observation . Findings include: 1. Random observation on 1/4/11 from 7:20 a.m. to 1:00 p.m. revealed nurse C for 19 of 20 observed medications set-up the medications, documented on the medication administration records (MAR), and then proceeded to give the medication to the residents. Interview on 1/5/11 at 7:35 a.m. with nurse C revealed the nurse nodded in agreement that: Documentation should have occurred after the residents had taken the medication. She had completed the documentation prior to giving the medications to the residents. Interview on 1/5/11 at 10:00 a.m. with director of nursing B revealed the nurses were to document the medications after they were taken by the resident. Review of the provider's policy and procedure for Medication Administration dated September revealed "The individual who administers the medication dose, records the administration on the resident's MAR (medication administration record) following the medication being given." Review of the South Dakota Board of Nursing statement dated 10/17/06 revealed "It is the position of the South Dakota Board of Nursing that the standard for safe administration of medication includes the practice of documenting medication following administration to the patient." Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, Mo., 2005, p. 847, revealed "After administering a medication, the nurse records it immediately on the appropriate record form. The nurse never charts a medication before administering it."	2014-04-01
5087	GOLDEN LIVINGCENTER - ARLINGTON	435050	120 CARE CENTER ROAD POST OFFICE BOX 280	ARLINGTON	SD	57212	2011-01-05	323	D			ZPLO11	Based on observation, interview, record review, and policy review, the provider failed to ensure gait belts were used consistently by staff to transfer residents for three of four transfers observed. Findings include: 1. Observation on 1/4/11 at 8:35 a.m. revealed certified nurse assistants (CNA) D and E: Transferred resident 2 from a wheelchair (w/c) onto the toilet by: -Placing their arms under the resident's shoulders. -Lifting the resident's total body weight as he/she did not stand. -Using the resident's slacks to help hold him/her up and pivoted onto the toilet. After the resident was finished on the toilet: -CNA D took the resident's hand and helped him/her stand. -Then as the CNAs redressed the resident he/she began to bend his/her knees and did not stand up. -The CNAs placed their arms under the resident's shoulders and lifted the resident back into the w/c. After the resident was back in the w/c the CNAs again placed their arms under the resident's shoulders to assist him/her to slide back in the w/c. Resident 2 was taken to the lounge and transferred into a recliner chair by using the same technique of placing their arms under the resident's shoulders and lifting him/her. A gait belt/transfer belt was not used to transfer the resident. 2. Observation on 1/4/11 at 4:10 p.m. two random CNAs transferred resident 2 from a recliner chair by the nursing station by placing their arms under his/her shoulders and lifting the resident into a Merri-walker. A gait belt was not used to transfer the resident. Interview on 1/5/11 at 7:45 a.m. with CNA E revealed she had forgotten to use the gait belt when transferring resident 2 the day before. 3. Observation on 1/4/11 at 9:40 a.m. revealed two random CNAs transferred a resident from her wheelchair to a recliner in the lounge by lifting her with her shoulders. One of the CNAs placed a gait belt around the resident, then both CNAs placed their arms under the residents arms and lifted the resident. The gait belt was grasped with the opposite hand by the CNA and used to guide the resident as she pivoted but was not offering any support during the lift of the resident. 4. Interviews and record reviews below pertain to the above findings 1, 2, and 3. Interview on 1/5/11 at 9:05 a.m. with physical therapy aide G revealed: She had given an in-service in the summer on how to use gait belts properly. She had reminded staff to use gait belts, if she happened to see them not using one to transfer a resident. She stated it was safer for the resident and the staff to use a gait belt when transferring a resident. She also stated it was a provider policy. Interview on 1/5/11 at 9:45 a.m. with director of nursing service B revealed: Staff were expected to use gait belts when transferring a resident. The CNAs were taught how to use a gait belt during nurse aide training. If she saw them not transferring a resident without a gait belt she would correct them. Review of the provider's procedure for transfer activities dated 2006 revealed: The purpose was to transfer the resident safely. A transfer belt/gait belt was to be used. Make sure w/c, etc was in place. Apply the transfer belt before attempting to transfer the resident. Hold the transfer belt from underneath. Support could provided by using a transfer belt. *Do not support the resident under the arms as that prevents the resident from his/her arms to help with the transfer.	2014-04-01
5088	GOLDEN LIVINGCENTER - ARLINGTON	435050	120 CARE CENTER ROAD POST OFFICE BOX 280	ARLINGTON	SD	57212	2011-01-05	282	D			ZPLO11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to ensure the care plan was followed for one of nine sampled residents (1). Findings include: 1. Observation on 1/3/11 at 4:40 p.m. revealed: Resident 1 was heard requesting ice chips, because her mouth was dry. The certified nurse assistant (CNA) was heard to respond she would check to see if she could have ice chips. Resident 1 was heard to respond she had previously been able to have ice chips. The CNA was heard to further respond she could not give her ice chips and that could only be done by the therapist. The CNA was heard to then offer the resident some water to swish in her mouth but not swallow and some thickened liquid to drink. The resident was heard to request the water to swish in her mouth. Review of resident 1's physician's orders [REDACTED]. Interview on 1/4/11 at 8:36 a.m. with CNA E revealed: She always worked on the same wing and knew the residents well. If there was a new admission or if she had a question she would go to the nurse for direction. The CNAs did not use the care plans for information regarding the residents. The CNAs did have an aide bath sheet. During an interview and CNA worksheet review on 1/4/11 at 8:57 a.m. two random CNAs had confirmed with another surveyor the CNAs did not use the care plans to determine the care needed for the residents. They did have a CNA worksheet the nurses completed each day to tell them who to get up, bathe, toilet, weights, oxygen, treatments provided by aides, and who had fell in the last 24 hours. Interview with administrator A on 1/4/11 at 3:50 p.m. revealed she did not know why resident 1 had not received ice chips when requested. As the ice chips were care planned that she could have them. She further wondered who the CNA had asked for directions regarding the ice chips. She asked if it was the dietary manager. Interview with certified dietary manager F on 1/4/11 at 6:30 p.m. revealed she was aware resident 1 was admitted with an order she could have ice chips. She further revealed no one had asked her for that information on the previous day. Interview and record review with director of nursing B on 1/4/11 at 4:55 p.m. revealed: The CNAs were to read the nursing communication book before they began their shift to get information regarding resident needs or changes in condition. She reviewed the provided information recorded in the communication book for resident 1. She confirmed there was no information in the communication book to inform the CNAs resident 1 could have ice chips. The CNAs had a worksheet that she provided a copy to this surveyor. The worksheet was to tell them about resident care. The worksheets were not part of the medical record and were not kept. She would not be able to determine if the information regarding the ice chips for resident 1 had ever been on the CNA worksheet. Interview on 1/5/11 at 7:45 a.m. with CNA E revealed: She knew the residents well. She knew which residents were able to express their wants and needs. She was not aware resident 1 could have ice chips. She would think she could not because when the ice melted it would not be a thickened consistency. -She had never received that information. -She had never seen it on her worksheet or in the communication book. She was not the CNA working with resident 1 when the resident had requested the ice chips on 1/3/11. If she had any questions she would ask the charge nurse for the information. She did not read the care plan to gather information regarding resident care. Interview on 1/5/11 at 11:00 a.m. with speech/language pathologist (SLP) H and CNA E and another staff person revealed the SLP was not aware resident 1 could have ice chips. She discovered that information was on the admission orders [REDACTED]. That information did not mention the availability of ice chips. She had not informed the CNA staff the resident could have ice chips.	2014-04-01
5089	GOLDEN LIVINGCENTER - BELLA VISTA	435060	302 ST CLOUD STREET	RAPID CITY	SD	57701	2011-02-16	281	F			S3VZ11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure physicians' orders and professional standards were followed for 9 of 13 sampled residents (1, 3, 5, 6, 7, 9, 10, 11, and 13). Findings include: 1. Review of resident 1's physician's re-admission order dated 2/14/11 revealed: -Mupirocin 22 grams (gm) topical ointment had been ordered for "2 days and then stop." The ointment had been ordered to be used on the chin as needed (PRN). That order was not found on the February 2011 medication administration record (MAR) or the treatment administration record (TAR). -[MEDICATION NAME] 325 milligram (mg) tab by mouth had been ordered for a dose of 650 mg every 4 hours PRN for pain or fever. On the February 2011 MAR that order read as Tylenol Arthritis Pain ([MEDICATION NAME]) by mouth for a dose of 650 mg every 6 hours PRN. -A topical skin cleanser (Fleet Bagenema with [MEDICATION NAME] soap) was noted on the February 2011 MAR to be used every three days PRN. That order was not found on the 2/14/11 admission orders [REDACTED]. -Entries on the February 2011 MAR for "[MEDICATION NAME] 10 mg as needed and Fleet Enema 7-19 gm as needed" had no frequency direction noted. Interview on 2/15/11 at 2:45 p.m. and on 2/16/11 at 8:30 a.m. with director of nursing (DON) B and professional services consultant (PSC) C revealed: -The order for Mupirocin had been missed when the admission nurse had entered the medications into the computer system for the MAR. The DON stated the night nurse was responsible for checking new orders for accuracy, but that nurse must have missed the Mupirocin order. A tube of the ointment had been received from the pharmacy but had not been used on the resident. -The order for [MEDICATION NAME] had not been entered correctly. The nurse had chosen the wrong medication from a list of Tylenol choices which then made the frequency incorrect. That error had not been corrected when reviewed by the night nurse. -They agreed any previous standing orders or protocols signed by the physician should have been reviewed when a resident was readmitted . That included the order for the topical skin cleanser. -They agreed the entries on the February 2011 MAR for [MEDICATION NAME] and Fleet Enema should have had the frequency direction noted. They agreed frequency was needed for medications to give direction for their unlicensed assistive personnel (UAP). It was not in the scope of practice for UAPs to assess and decide the frequency of as needed medications. Review of the policy for Medication Administration dated June 2005 revealed "Medications are administered in accordance with written orders of attending physicians, manufacturer's specifications, and professional standards of practice. All current medications and dosage schedules are listed on the patient's MAR or treatment record and administered according to facility policy." 2. Review of resident 9's February 2011 MAR revealed: -The morning medications refused by the resident on 2/9/11 and 2/10/11 had not been documented on the PRN Sheet. Those medications included [MEDICATION NAME] 20 mg, [MEDICATION NAME] 1-2 scoops, Senna 8.6 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] chloride 5 mg, [MEDICATION NAME] 25-100 mg, house supplement per protocol, and 2 cal supplement 60 cubic centimeters. -Entries on the MAR for "Gas-X 80 mg as needed, [MEDICATION NAME] as needed, and Oral Gel Anesthetic as needed" had no frequency direction noted. Interview on 2/15/11 at 2:45 p.m. and on 2/16/11 at 8:30 a.m. with DON B and PSC C revealed: -Their expectation was any medications refused by the resident should have been initialed and circled at the time of refusal and documented on the PRN Sheet with the reason for refusal noted. Review of the policy for Medication Administration - General Information dated 10/1/03 stated "If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR/TAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If several doses of a vital medication are withheld or refused, the physician and responsible party are notified and documentation of notification is made." 3. Review of resident 11's February 2011 MAR revealed the following as needed medications had no frequency direction: -[MEDICATION NAME] 325 mg. -[MEDICATION NAME] 10 mg, Fleet Enema 7-10 gm. -Artificial Tears 5-6 mg/ml. -Halls Cough Drops 5 mg [MEDICATION NAME]. -[MEDICATION NAME] Regular Strength 20 mg/ml. -Milk of Magnesia 30 cc. -Pepto-Bismol 262 mg/15 ml. Interview on 2/15/11 at 2:45 p.m. and on 2/16/11 at 8:30 a.m. with DON B and PSC C revealed they agreed frequency was needed for medications to give direction for their UAPs. It was not in a UAPs scope of practice to assess and decide the frequency of PRN medications. 4. Review of resident 5's MAR for 2/1/11 through 2/14/11 revealed: [MEDICATION NAME] 10 mg was to be given by mouth every day at 8:00 a.m. It was to be held if the blood pressure was less than 90 milligrams of mercury. No blood pressures were recorded on the MAR. Interview on 2/16/11 at 9:00 a.m. with unlicensed assistive personnel (UAP) F confirmed: Resident 5's blood pressure was checked every day. That was done any where from 6:00 a.m. until 2:00 p.m. It was not recorded on the MAR. Interview on 2/16/11 at 9:10 a.m. with UAP I confirmed: She had not checked resident 5's blood pressure before she had given the [MEDICATION NAME]. Interview on 2/16/11 at 9:55 a.m. with DON B confirmed she expected the blood pressure to be taken before the medication was given. 5. Review of resident 6's 2/1/11 through 2/14/11 MAR revealed [MEDICATION NAME] 0.5 mg was to be given by mouth every day at 8:00 a.m. Review of her physician's orders [REDACTED]. Interview on 2/16/11 at 10:05 a.m. with DON B confirmed: When chart clean-up was performed the correct time had been missed. The original order was difficult to read and should have been clarified. The medication had not been given as ordered by the physician. 6. Record review and interview revealed resident 10's [MEDICATION NAME] had not been administered following professional standards. Refer to F425, findings 1 and 2. 7. Review of resident 7's physician's orders [REDACTED]. an order for [REDACTED]. -There were no orders for the frequency of the PRN use. an order for [REDACTED]. -There were no specific orders for clarification of frequency for PRN use. Interview with DON B and PSC C on 2/15/11 at 12:05 p.m. revealed: They agreed the orders should have had frequency of PRN use included. DON B stated "The orders needed to be 'black and white' for specific clarification." 8. Review of resident 13's PRN sheet revealed: On 2/9/11 at 5:00 p.m. [MEDICATION NAME] 1 mg had been administered orally for increased agitation. -There was no follow-up result documented on the PRN documentation sheet. On 2/9/11 at 8:00 p.m. [MEDICATION NAME] 1 mg had been administered orally for agitation. -There was no follow-up result documented on the PRN documentation sheet. On 2/10/11 at 12:30 [MEDICATION NAME] 0.5 mg had been administered orally for increased agitation. -There was no follow-up result documented on the PRN documentation sheet. 9. Review of resident 3's February 2011 MAR revealed she was to have a [MEDICATION NAME] 5 percent topical patch applied daily for 12 hours and then removed. The MAR had no indication where that patch was to be applied. Interview on 2/15/11 at 12:00 p.m. with registered nurse G revealed resident 3 used the [MEDICATION NAME] on her left knee. She agreed the MAR did not have that information. Interview on 2/15/11 at 2:20 p.m. with DON B and PSC C revealed: They agreed the MAR had no information on where the [MEDICATION NAME] was to have been placed. They agreed UAPs were utilized for medication administration. They agreed UAPs could not assess where a topical medication was to be placed. 10. Review of the policy for Medication Administration dated June 2005 revealed "Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so." This applies to finding 3, 7, and 9. Review of the provider's medication administration general guidelines revised June 2005 revealed medications were to be administered as prescribed and in accordance with good nursing principles and practices. This applies to findings 4 and 5.	2014-04-01
5090	GOLDEN LIVINGCENTER - BELLA VISTA	435060	302 ST CLOUD STREET	RAPID CITY	SD	57701	2011-02-16	371	F			S3VZ11	Based on observation, testing, record review, and interview, the provider failed to maintain the kitchen in a clean and sanitary manner. Findings include: 1. Random observations in the kitchen from 2/14/11 through 2/15/11 revealed: The trash cans were soiled with splatters ranging in size from a small crumb to quarter size of debris and dried particles. Wire shelving units that held clean dishes were visibly dirty with a dried on yellow substance that was sticky to touch. The saran wrap dispenser was visibly dirty and sticky to touch. The sides and edges of the work table were visibly soiled with a red, sticky, grime build-up. The can opener was visibly soiled with a back and dark red substance (photo 3). The pads under the steamer legs contained a build-up of a tan, brown residue (photo 5). All of the the windows were spattered with an unknown substance. The red protector caps over the sprinkler heads were coated with a greasy, dusty build-up. The fire and smoke alarms were dirty with greasy, dusty build-up (photos 8 and 9). The convection oven was soiled with large amounts brown stains and burned particles inside and out. The floor was soiled with an unknown liquid substance and food particles scattered throughout the kitchen and dishwasher room (photos 7 and 11). The floor behind equipment and against the walls was dirty with dust, debris, and food particles ranging in size from a small crumb to a dinner roll (photos 4 and 12). The exterior dishwasher was soiled with a build-up of sticky grime and food particles (photo10). The table the mixer sat on was soiled with loose and dried on substances. The mixer was soiled at the blade insertion area with built-up sticky substances (photo 6). There was exposed plaster and cracks in the ceiling above clean storage shelves and food preparation and service areas (photos 1 and 2). Interview with director of dietary services D on 2/15/11 at 5:25 p.m. revealed: There was a daily and monthly cleaning list. She stated sometimes the scheduled cleaning was not always done. *She agreed the noted areas in the kitchen needed to be cleaned. Interview on 2/16/11 at 3:15 p.m. with administrator A during a kitchen tour with her revealed she agreed the unclean kitchen areas shown to her were in need of cleaning. The kitchen had not been kept clean and sanitary on a daily basis.	2014-04-01
5091	GOLDEN LIVINGCENTER - BELLA VISTA	435060	302 ST CLOUD STREET	RAPID CITY	SD	57701	2011-02-16	441	E			S3VZ11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure proper technique had been followed for four of four observed dressing changes for three of three residents (7, 8, and 9). Findings include: 1. Observation on 2/15/11 from 2:50 p.m. through 3:10 p.m. revealed registered nurse (RN) G performed a dressing change to both resident 9's feet. Director of nursing (DON) consultant M was also present during the observation. RN G washed her hands and then: Placed a clean towel on the bed. Removed the pressure relieving boot and sock from resident 9's right foot. Moved the garbage can closer to the bed. Used hand sanitizing gel. Took a pair of gloves from her pocket and put them on. Removed more gloves from her pocket and placed them on that clean towel. Placed the dressing change supplies on that clean towel. Removed a pen from her pocket and wrote the date on a [MEDICATION NAME] border dressing. Placed the pen back into her pocket. Removed a dressing from resident 9's right foot. Sprayed Saf-Cleanse onto clean gauze and cleansed the open area on resident 9's right foot. Removed a pair of scissors from her pocket. Without sanitizing the scissors she cut a piece of the [MEDICATION NAME] dressing with those scissors and placed the [MEDICATION NAME] on the clean towel. Placed the scissors on the clean towel. Removed her gloves and did not wash her hands or use hand sanitizing gel. Put on clean gloves she had previously removed from her pocket. Placed the piece of [MEDICATION NAME] dressing to the open area on resident 9's right foot. Removed the [MEDICATION NAME] border dressing from the package and touched the surface that would be in contact with the open wound. Removed her gloves and placed the sock and pressure relieving boot on resident 9's right foot. RN G then: Removed the pressure relieving boot and sock on resident 9's left foot. Removed her gloves. Washed her hands. Cut a length of gauze with the scissors she had previously used. She had not sanitized those scissors before she cut the gauze. Put on gloves. Used her gloved left hand to move the garbage can closer. Sprayed Saf-Cleanse onto clean gauze and cleansed the open area on resident 9's left foot. Opened a package that contained a [MEDICATION NAME] swab. Removed the [MEDICATION NAME] swab and cleansed the open area on resident 9's left foot. Placed the previously cut length of gauze on resident 9's left foot. Removed her gloves and placed the sock and pressure relieving boot on resident 9's left foot. Placed the scissors back in her pocket without sanitizing them. Took the garbage bag out of the garbage can and placed the barrier towel into another bag. Placed both bags on the floor in the bathroom while she washed her hands. Picked up those bags and a bag that contained the left over dressing supplies and left resident 9's room. Carried those bags to the soiled utility room and placed them in their respective containers. Left the soiled utility room and carried the bag of dressing supplies and placed it in the treatment cart drawer. No observation was made of RN G washing her hands or using hand sanitizing gel. Interview at 3:15 p.m. with RN G revealed: She had items in her pockets that included hand sanitizing gel, Sharpie marker, pen, and keys. She would have cleaned the scissors between residents. She agreed the gloves and scissors in her pocket would be contaminated. Interview with DON consultant M at that same time revealed gloves were located in all resident rooms. She agreed RN G would not have had to bring gloves from another area to complete the dressing change. Interview on 2/16/11 at 10:00 a.m. with professional services consultant C revealed there was no policy that included not carrying gloves in staff pockets. There was also no policy for the cleaning of scissors for dressing changes. Review of the providers revised July 2007 handwashing/hand hygiene policy revealed: If hands were not visibly soiled the use of an alcohol-based hand rub was indicated for use in the following situations: Before handling clean or soiled dressings. Before and after direct contact with residents. After handling used dressings and contaminated equipment. After contact with objects, such as medical equipment in the immediate area of the resident. *After removing gloves. Hand hygiene was always the final step after removing and disposing of gloves. The use of gloves had not replaced handwashing/hand hygiene. 2. Observation on 2/15/11 from 11:40 a.m. through 12:00 noon revealed RN G performed a dressing change to resident 8's right fifth digit (finger). DON B was present during the observation. RN G washed her hands and completed the dressing change as follows: Put on clean gloves. Laid out her supplies on a clean barrier. Removed scissors from her pocket and used them to cut a new dressing for resident 8's finger. Laid the scissors on the clean barrier. She had not sanitized the scissors. Removed the old dressing from resident 8's finger. Removed her gloves and put on clean gloves. She did not use hand sanitizer or wash her hands. Applied the [MEDICATION NAME] dressing and inserted a roll of Kerlix into the resident's hand. She removed her gloves. She had not used hand sanitizer or washed her hands. She gathered the supplies and placed them into a bag. She washed her hands. 3. Observation on 2/15/11 from 2:15 p.m. through 2:30 p.m. revealed RN G performed a dressing change to resident 7's left heel. Consultant M was present during the observation. RN G washed her hands and proceeded as follows: RN G donned gloves. Laid out a clean towel on the bed and set-up her supplies. Cut the old dressing with her scissors and removed the dirty dressing. Laid the same scissors back on the clean towel. Cleaned the wound with Saf-Clens and gauze. Removed her gloves and put on clean gloves. She had not washed her hands or used hand sanitizer. RN G cut a piece of packing strip for the wound with the same scissors she had used to remove the dirty dressings. She had not sanitized the scissors. She packed the wound. She applied dimethicone ointment as ordered to the skin around the heel. She wrapped the heel with a Kling wrap. RN G gathered the clean supplies that included the scissors and put the supplies into a bag. She had not sanitized the scissors. She bagged up the garbage. She washed her hands.	2014-04-01
5092	GOLDEN LIVINGCENTER - BELLA VISTA	435060	302 ST CLOUD STREET	RAPID CITY	SD	57701	2011-02-16	425	E			S3VZ11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure orders for medications for 2 of 13 sampled residents (7 and 10) were clarified to prevent actual or potential medication administration errors. Findings include: 1a. Review of resident 10's medication administration records (MAR) for November and December 2010 and January and February 2011 revealed: Trazadone (anti-depressant) was ordered by mouth, 50 milligrams (mg), one-half to one tablet at bedtime every day. The medication had been initialed by staff as given every day at bedtime. No entries had been made by staff if a one-half or one of a tablet had been given to the resident. Review of the resident's consultant pharmacist reviews from 4/7/10 through 2/3/11 revealed there were no entries that addressed the lack of documentation for the dosage of Trazadone given to resident 10. Review of the provider's medication administration guidelines revised in June 2005 revealed all current medications and dosage schedules were listed on the resident's MAR and administered according to facility policy. No policy was provided that directed unlicensed assistive personnel (UAP) how to determine the dosage to be given when it was not clear. b. Review of resident 10's MAR for November and December 2010 and January and February 2011 revealed: Trazadone was ordered by mouth, 50 milligrams (mg), one-half to one tablet at bedtime every day. UAP F initialed she had given the medication on 2/1/11 at 9:00 p.m. No entry was made as to how much was given to the resident on that date. Interview on 2/16/11 at 9:10 a.m. with UAP I confirmed if Trazadone had a range of one-half to one tablet on the MAR she would assess the resident for lethargy before determining how much to give the resident. If she was still unsure she would then contact the nurse for input. Interview on 2/16/11 at 10:40 a.m. with UAP F confirmed: She did not remember how much of the Trazadone she had given on 2/1/11 to resident 10. She had not consulted the nurse before she had given the medication to the resident. c. Review of the provider's undated medication aide responsibilities list stated the nurse was to have assessed residents before they delegated the task to the UAP. Interview on 2/16/11 at 10:15 a.m. with director of nursing (DON) B confirmed: None of the staff had documented the dosage of Trazadone given to resident 10. The dosage should have been documented by the staff when it was given. The UAPs should have had the nurse assess the resident for the dosage needed before they gave the Trazadone. Medication aides were not to assess a resident for needed medications. 2. Review of resident 7's physician's orders [REDACTED]. Review of consultant pharmacist's facsimile (fax) note to the physician on 1/6/11 indicated: -There was no noted communication from nursing whether or not to continue the order. -On that same fax the physician had ordered the omeprazole decreased to 20 milligrams by mouth daily. -That order had been received by the provider on 1/10/11 and had been noted by a registered nurse. Review of resident 7's February 2011 MAR revealed an entry for omeprazole 20 mg by mouth twice a day. Notations on that MAR indicated the resident had continued to receive the omeprazole twice a day. Interview with consultant C and DON B on 2/15/11 at 12:05 p.m. revealed: They agreed the physician had not been contacted as ordered on [DATE]. They agreed the dosage of the omeprazole had not been decreased as ordered by the physician in the fax received 1/10/11. That same fax contained the information noted by the consultant pharmacist. They agreed the resident continued to receive omeprazole 20 milligrams orally twice a day when it should have been changed to omeprazole 20 milligrams daily on 1/10/11 per the faxed order.	2014-04-01
5093	GOLDEN LIVINGCENTER - BELLA VISTA	435060	302 ST CLOUD STREET	RAPID CITY	SD	57701	2011-02-16	253	E			S3VZ11	Based on random observation, testing, and interview, the provider failed to maintain the following areas and/or items: - The toilet traps and/or the caulking around the bases of toilets in seven resident rooms 107, 108, 111, 212, 301, and 310. - The linoleum was heaved and/or cracked in four resident bathrooms 210, 212, 301, and 310. - The door frame to resident room 207. - The west bathing room tile floor in the shower area. - The bathroom door in resident room 204. Findings include: 1. Random observation on 2/14/11 from 3:00 p.m. to 6:15 p.m. and on 2/15/11 from 8:20 a.m. to 11:00 a.m. revealed the toilet traps had chipped and scratched porcelain in resident rooms 107, 108, 212, 301, and 310. Those chips ranged in size from golf balls to baseballs (photos 16, 17, and 18). The scratches were embedded in the porcelain and looked like a layers of pencil lead laid in the bottom of the toilet (photo 26). Interview with maintenance supervisor (MS) J and district maintenance supervisor (DMS) K at the time of the observations confirmed those findings. They stated they were not aware those toilet traps were chipped and scratched. Additional observation during the above dates and times revealed the caulk around the base of the toilets in resident rooms 111 and 310 was laid in layers that resembled ribbon frosting on a cake (photos 19 and 24). Those layers of caulk were bumpy to the touch and had several crevices and grooves that could fill with dirt and debris. Interview with MS J at the time of the observations confirmed those findings. He stated he had not laid that caulk but agreed it needed to be redone to be easily cleanable. 2. Random observation on 2/14/11 from 3:00 p.m. to 6:15 p.m. and on 2/15/11 from 8:20 a.m. to 11:00 a.m. revealed the linoleum was heaved, bulged, separated from the wall, and/or cracked in resident bathrooms 210, 212, 301, and 310 (photos 14, 20, 21, and 25). That heaved and bulged linoleum created an uneven walking surface that would not recede to the sublfloor when stepped on by this surveyor. The cracks and separated base coving from the wall created uncleanable surfaces. Interview with MS J and DMS K at the time of the observations confirmed those findings. MS J stated he was aware the linoleum needed to be replaced in some of the resident bathrooms. 3. Observation at 4:00 p.m. on 2/14/11 revealed a smear of unknown substance on the lower third of the door frame outside of room 207. Closer observation at that time revealed the unknown substance appeared to be droplets and smears of blood (photo 13). Interview with senior director of nursing services (SDNS) H at the time of the observation confirmed that finding. She stated she was not aware how the droplets and smears had gotten on the door frame but would have housekeeping clean that frame. Interview with housekeeping manager E at 4:10 p.m. on that same day revealed he agreed the substance on the door frame appeared to be blood. He stated he would use precautionary measures and a specific cleaning solution for blood to clean that area of the door frame. 4. Observation at 4:15 p.m. on 2/14/11 revealed a hole had been punched through the outside of the bathroom door in resident room 204. That hole was about half way up the door, the size of a nickel, had sharp edges to the touch, and splintered wood (photo 15). Interview with MS J on 2/15/11 at 9:00 a.m. confirmed the above observation and finding. MS J stated he was aware of the hole but had been busy with other work. 5. Observation at 4:30 p.m. on 2/14/11 revealed the tile around the shower floor in the west bathing room had areas of missing caulk (photos 22 and 23). That missing caulk allowed an open area under the tile that would allow dirt, debris, and water to penetrate the sub-floor under the shower. Interview with MS J on 2/15/11 at 9:15 a.m. confirmed the above observation and finding. 6. Continued interview with MS J at 9:20 a.m. on 2/15/11 revealed he had not had time to evaluate or do a preventative maintenance checklist on resident rooms and resident use areas.	2014-04-01
5094	TIESZEN MEMORIAL HOME	435069	312 EAST STATE ST	MARION	SD	57043	2011-01-31	281	D			XBEG11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on record reviews, nursing procedure review, and interview, the provider failed to follow established procedures and professional standards for documenting the death of one of one sampled resident (2). Findings include: 1. Review of the nurses notes for resident 2 revealed on [DATE] at 12:20 p.m.: "Called by CNA (certified nurse assistant) to resident room. Resident pale in color with no respirations and no heart rate per auscultation. No blood pressure. Pronounced deceased at 12:20 p.m. ____ son notified of father's death. ____ stated he will call ____ at the funeral home for body to be picked up. Dr. ____ at Avera McGreevy Clinic notified of resident ' s death. Review of the provider ' s [DATE] nursing procedure for death revealed: 1. Notify family. 2. Call Doctor. 3. Document when resp, heart beat, BP (blood pressure) ceased. 4. Call funeral home. 5. Have mortician sign for body. 6. Add to communication board. 7. Add to pharmacy sheet. 8. THIS WAS LINED THROUGH 9. Call DON (director of nurses) (any hour, leave note in administration box. 10. Chart all you did and what time the body left the building. 11. Call chaplain or minister if family wishes. 12. Pull Meds/MAR (medication administration record)/Care Off to the side NOCS (night shift) wait til a.m. Interview on [DATE] at 1:30 p.m. with DON revealed: "We don't pronounce dead. We never chart that way. It's probably the nurse that didn't know." Pursuant to SDCL [DATE].1 Determination of death - Any individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the [DIAGNOSES REDACTED], is dead. A determination of death shall be made in accordance with accepted medical standards. SDCL [DATE] and [DATE].1 - intent is to designate the signing of the Death certificate as a medical act by a physician, physician's assistant, or nurse practitioner. SDCL ,[DATE]A-22(11) Physician's assistant and SDCL ,[DATE]A-12 Nurse Practitioner act were amended to provide that such practitioners may perform the overlapping medical function. There is no South Dakota law specific to the act of pronouncement of death; current state laws only address who may sign the death certificate; for pronouncement of death to be effective it must be accompanied by a certificate, and since a nurse cannot sign a death certificate, a nurse cannot pronounce death. B. Based on record review, nursing procedure review, professional standards, and interview, the provider failed to follow established procedures and professional standards in the provision of bowel elimination care and acquired pressure ulcer documentation of one of one sampled resident (1). Findings include: 1. Review of Potter, Patricia A. and Perry, Anne Griffin, Fundamentals of Nursing, 6th edition, Mosby, St. Louis, MO, 2005, revealed: ?Page (P) 261: -Nurses were responsible for making accurate and appropriate clinical decisions. -The nurse would take immediate action when a client ' s clinical condition deteriorated, and who decided if a client was experiencing complications that warranted notification of the physician. ?P. 279: -"The nurse follows the nursing process to organize and deliver nursing care. Use of the process allows the nurse to integrate elements of critical thinking to make judgments and take actions based on reason. The nursing process is used to identify, diagnose, and treat response to health and illness. The process includes five steps: assessment, nursing diagnosis, planning, implementation, and evaluation. 2. Provision of bowel elimination care for resident 1 who had no recorded bowel movement (BM) for 13 days. Refer to F309 finding A. 3. Provision of pressure ulcer care for resident 1 who acquired a pressure ulcer, accurate discovery and continued course of care documentation. Refer to F314.	2014-04-01
5095	TIESZEN MEMORIAL HOME	435069	312 EAST STATE ST	MARION	SD	57043	2011-01-31	309	G			XBEG11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on record review, nursing procedure review, professional standards, and interview, the provider failed to assess, monitor, and intervene in the individualized care and service to maintain the highest practical physical and psychosocial well being for one of one sampled resident (1) who had no recorded bowel movement (BM) for 13 days. Findings include: ?Review of resident 1's Medicare Assessment Form dated 12/15/10 through 1/19/11 revealed: ?Symbol key for use with documentation that included: -Check mark=assessment matched standard parameter. -H=deviation, chart findings (on this form or focus notes). -Arrow to left=deviation continues, no change since preceding H assessment. -P=pre-existing condition, describe. ?Standard parameters identified for "Gastrointestinal" that pertained to bowel elimination were: -Abdomen soft. -Nontender and nondistended. -Continent of bowels. -Passing [MEDICATION NAME]. -Bowel sounds present times 4 quadrants. -No N (nausea)/V (vomiting), diarrhea, constipation. -No tarry or bloody stools. -Stools brown, semi-soft, formed, describe if abnormal. -Supp (suppository)/enemas: type/color returned. ?12/15/10 at 9:15 p.m. There was a check mark and a note BS (bowel sounds positive X 4. There was also an asterisk with a note that read "res (resident) states BM was "last week." ?12/16/10 at 10:00 a.m. There was a check mark and an asterisk with a note that read "C/o (complains of) constipation Dr. ____ to see res. today will get order for bowels." ?12/16/10 at 8:20 p.m. There was a check mark and an asterisk with a note that read no BM. Those forms dated 12/17/10 at 9:25 a.m. through 1/19/11 at 1:30 p.m. had check marks indicating the assessment matched the standard parameters. There were no other notes on these dates related to bowel elimination. Review of resident 1's BM report roster dated 1/10/11 through 1/24/11 revealed no record of the resident having had a BM after 1/10/11 at 9:27 p.m. until 1/24/11 at 4:09 a.m. Review of resident 1's nurses' notes dated 12/15/10 through 1/24/11 revealed the following entries related to bowel elimination: ?12/16/10 at 2:30 p.m. Senakot 1-4 tabs (tablets) PO (orally) daily PRN (as needed, per request to nurse). Adjust per results. ?12//28/10 at 5:15 p.m. . . . frequently incontinent of bladder and continent of bowel. ?12/31/10 at 11:00 a.m. Weekly summary . . .Continent of bowels . . . . ?1/4/10 (incorrect year) at 2:20 p.m. . . . frequently incontinent of bowel/bladder. Wears pads at all Xs . . . . ?1/6/11 at 1:45 p.m. MDS (Minimum Data Set) 30 days Medicare assess . . . frequently incontinent of bowel/bladder . . . . ?1/21/11 at 5:30 p.m. Received the following order per T.O. (telephone order): [MEDICATION NAME] 17 gm (gram) daily. (May decrease dose if has loose stools). ?1/22/11 at 9:15 a.m. Orders from Dr. visit on 1/20/11 to increase Senna to 6 tabs PO daily, [MEDICATION NAME] 17 gm PO daily, [MEDICATION NAME] supp every 12 hours PRN. ?1/23/11 at 11:40 a.m. Dr. ____ faxed per pharmacy request to clarify Senna order. ?1/24/11 at 2:50 a.m. CNA (certified nurse assistant) reported res had a extra large loose BM and also appeared warm to touch and more lethargic than usual. T-103.3, P-124, R-24, B/P-88/44, SPO2-91% RA. LSC bilat. (bilateral). Also soft, NT with BS+ no pedal [MEDICAL CONDITION]. Tylenol given for increased temp. Fluids given. Review of resident 1's care plan revealed problem/need "Alteration in Bowel Elimination - Constipation" was 1/21/11; goal - resident will have BM every 2-3 days through 3/31/11. Approaches were [MEDICATION NAME] 17 gm daily, Senna 6 tablets daily, and [MEDICATION NAME] rectal suppository every 12 hours as needed. Review of the provider's prepared Patient Transfer Form to hospital dated 1/24/11 reflected resident had received Senna tablets and [MEDICATION NAME] for bowels with the last BM on 1/10/11. Review of 6/4/98 nursing procedure for Unusual complaints and symptoms revealed staff were to check vital signs and do assessment, chart in nurses notes, notify doctor if necessary, notify family if necessary, and put the chart on the UPPER RACK so each shift followed up. Interview on 1/31/11 at 12:00 noon with certified nurse assistant (CNA) A revealed CNAs used palm hand held or wall mounted electronic documentation devices. They were able and must record bowel elimination or BMs. The system prompted the individual to document the above. The CNA demonstrated by accessing a resident file and proceeded to the screen that read Bowel movement (BM) this shift? The CNA stated he/she was not able to print the report, but the nurses were able to access and print. The CNA believed the night nurse accessed the report and provided the information to the day nurse, so they would address. The CNA also indicated the nurse usually "does something," if there was no record of a BM after 3 days. CNA A preferred to carry the palm so "I can record things as they happen, but have to do it for sure before the end of my shift." CNA A also stated "Some of the older ones wait until the end of the shift." Interview on 1/31/11 at 12:20 p.m. with registered nurse (RN) B revealed he/she had worked on 1/20/11. Resident 1's physician discussed treatment options with him/her and his/her spouse and spoke to the resident's daughter per phone. RN 2 did not recall any discussion related to bowel elimination. Discussion was related to making decisions about hospice treatment or other interventions as RN 2 indicated resident 1 was not improving. Interview on 1/31/11 at 12:30 p.m. with RN C revealed nurses used the Medicare Assessment Form with no additional instructions other than what was on the form indicating the use of the symbol key. Interview on 1/31/11 at 12:40 p.m. with CNA D confirmed CNAs use the palm hand held or wall mounted electronic documentation devices to document bowel and bladder elimination plus "lots of other ADLs (activities of daily living)." CNA D reported the nurses were the ones who looked at how often the residents had BMs. If a resident did not have a BM after 2-3 days, the nurse usually gave a laxative or a suppository. Interview on 1/31/11 at 12:50 p.m. with RN E revealed there was no policy or procedure for the use of the Medicare Assessment form. RN E stated "It s pretty self explanatory." RN E reported a resident was given a laxative or a suppository when there was no BM after 3 days. RN E confirmed the CNAs documented BMs using the palm devices. He/she confirmed the night nurse pulled the BM reports and prepared a check list for the day nurse. The night nurse might give a suppository in the early a.m., but the night nurse provided the check list to the "cart" nurse every morning. Interview on 1/31/11 at 1:30 p.m. with the director of nurses (DON) confirmed there is no written policy or procedure for use of the Medicare Assessment Form, stating , "It is self explanatory, directions are on it." DON confirmed the CNA staff must document on bowel elimination each shift. The system prompted them and they could not leave without finishing that. DON continued confirming the night nurse checked the residents' BM reports, prepared a BM check list, and provided that list to the day nurse. When asked why there might have been no response or intervention after 2-3 days for resident who did not have a BM the DON stated, "The day nurse probably didn't share that information." The DON did not offer or provide anyone else or any other documentation when asked if there was anyone else or any other documentation he/she would like to have the surveyor review regarding resident 1. B. Based on record review, nursing procedure review, professional standards, and interview, the provider failed to prevent the development of a pressure ulcer for one of one sampled resident (1). Findings include: Provision of pressure ulcer care for resident 1 who acquired a pressure ulcer, accurate documentation of discovery and continued course of care documentation. Refer to F314.	2014-04-01
5096	TIESZEN MEMORIAL HOME	435069	312 EAST STATE ST	MARION	SD	57043	2011-01-31	314	G			XBEG11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, nursing procedures review, professional standards and interview the provider failed to prevent the development of an additional pressure ulcer and failed to provide accurate documentation of the discovery and course of care for one of one resident (1) with an acquired pressure ulcer. Findings include: Review of resident 1's skin assessment form completed by a nurse on 12/15/10 revealed a stage I (persistent area of skin redness without a break in the skin) pressure ulcer to the coccyx and scattered bruising on both forearms. Review of resident 1's Norton Plus Pressure Ulcer form completed by a nurse on 12/22/10 revealed a score of 6. A score of 6 out of 20 indicated a higher level of risk for pressure ulcer development. The Norton Scale is a total rating scale that measures functional capabilities and other health care issues of the person that contribute to his/her risk in developing pressure ulcers. Review of resident 1's nurse notes from 12/15/10 through 1/24/11 pertaining to the skin revealed: ?12/15/10 Admit - Treatments for "discolored area on buttocks" and left (L) abd. (abdominal) fold. ?12/28/10 at 5:15 p.m. Norton pressure scale done quarterly. Stage I area to coccyx area reddened, no open areas, no dressing, no swelling noted. ?12/31/10 at 11:00 a.m. R (right) buttock scabbed area no redness or drainage noted; 1 cm diameter. ?1/4/10 (incorrect year) at 2:20 p.m. Norton pressure scale done quarterly, score 6. Currently has a stage I to coccyx being treated with [MEDICATION NAME] BID (twice daily) until healed. Has pressure relieving mattress, repositioned per turn sheet, supplements given. ?1/5/11 at 2:30 a.m. Resident has 4 cm diameter blister to heel of L foot. Dark-red in color and fluid filled. No drainage presently. ?1/6/11 at 11:50 a.m. .... (2) Protective boot/device L foot heel wound (3) clean daily-reapply dressing. ?1/6/11 at 1:45 p.m. Has unstageable (not able to determine severity) pressure area to L heel. ?1/6/11 at 3:00 p.m. Dr. ____ here to remove dead skin layer from left heel. Outer layer of dead skin removed, dressing applied, heel protector also applied. ?1/14/11 at 6:00 p.m. Weekly summary - Open wound on left heel, half-dollar sized black area, no drainage, scant red ring surrounding black area. Review of resident 1's Medicare Assessment Form from 12/15/10 through 1/24/11 revealed: ?Symbol key for use with documentation that included: -Check mark=assessment matched standard parameter. -H=deviation, chart findings (on this form or focus notes). -Arrow to left=deviation continues, no change since preceding H assessment. -P=Pre-existing condition, describe. ?Standard parameters identified for "Integumentary" that pertained to skin were: -Skin color within normal limits (WNL). -Skin warm/dry. -Turgor WNL for patient's age. -Moist mucous membranes. -Skin intact, no redness, rash, bleeding, bruising, scaling or breakdown. -No mouth sores. -No itchiness. -Bony prominences and heels W/O (without) pressure areas or breakdown. ?12/15/10 at 9:15 p.m. Asterisk not identified on symbol key, then bruising scattered to bilateral arms, stage I redness to coccyx. ?12/16/10 at 10:00 a.m. and 8:20 p.m. (arrow to right). ?12/14/10 9:25 (check mark), scattered bruising bilateral arms, see TAR (treatment administration record) for details on coccyx. ?12/17/10 at 2:30 a.m. (check mark). ?12/18/10 at 10:30 a.m. through 12/21/10 at 9:50 a.m. (check mark) then scattered bruises bil. (bilateral) arms. ?12/22/10 at 1:00 p.m. (check mark) scattered bruises to forearms bil. *Stage 1 nickel-size open area to buttocks. No drainage noted. ?12/23/10 at 9:25 a.m. (check mark) scattered bruises to bil. forearms. Stage I nickel size area on Rt buttocks, DuoDerm covering. ?12/24/10 at 9:00 a.m. (check mark) scattered bruises to bil. forearms. Stage I on Rt buttocks-see TAR (treatment administration record). ?12/28/10 at 10:00 a.m. through 1/4/11 (check mark) See TAR for Rt buttocks documentation. ?1/5/11 at 1:00 p.m. (difficult to tell if an asterisk or a check mark that was crossed through) Pressure ulcer L heel measures 5 cm (centimeter) long X 4 cm wide purplish color with thin covering of skin - was a LARGE Fluid Filled Blister like Area. Dr. ____ to see tomorrow 1-6-11. ?1/6/11 at 10:30 (check mark) L heel purple area. ?1/7/11 at 9:35 (check mark) See TAR for L heel documentation. ?1/8/11 at 9:10 (check mark) See TAR for L heel documentation. L heel with 1 ? inch round blackened area with edges pink. No redness, drainage, or foul odor noted. Heel protector on L. ?1/9/11 and 1/10/11 (check mark) See TAR for L heel documentation. ?1/11/11 at 11:00 a.m. (check mark) See TAR for Lt heel & buttocks documentation. ?1/12/11 at 9:20 a.m. (check mark) L heel half dollar size black area - dry. No [MEDICAL CONDITION] or drainage. Surrounding edges red. Refer to TAR for tx (treatment). ?1/13/11 at 8:40 (check mark) L heel ulcer. Refer to TAR for details. ?1/14/11 at 1:20 p.m. (check mark) L heel ulcer half-dollar sized black area. No drainage, scant amount of redness surrounding black area. ?1/15/11 at 6:45 a.m. (check mark) L heel ulcer (See TAR). ?1/16/11 at 6:45 a.m. (arrow to right). ?1/17/11 at 10:20 a.m. (check mark) L heel ulcer See TAR. ?1/18/11 at 1:00 p.m. (check mark) L heel ulcer See TAR for detail. ?1/19/11 at 1:30 p.m. (No symbol) L heel ulcer left open to air with protective boot. Half dollar sized black, no drainage, dry. Review of resident 1's care plan activity of daily living (ADL) sheet and care plan with admitted [DATE] revealed: ?Resident required an assist of one person for position change in bed and turn sheet. ?Problem/need identified 12/15/10 was "Potential for skin breakdown." ?Goal was to maintain intact skin integrity over the next 90 days ?Approaches included: ?Monitor skin daily with dressing and 2 X week with bathing. ?Trim nails weekly. ?Heel boots on bilat. while in bed. ?Increase vitamin C and protein as diet allowed. ?Provide measures to decrease pressure/irritation to skin, fleece pad, heel/elbow protectors, wheel chair cushions. ?Change incontinent pad as soon as possible after voiding or bowel movement. ?Apply preventive or barrier lotion after incontinence. ?Keep bed linen clean, dry and free from wrinkles. ?Offer supplements as ordered. ?Have one or two people move resident to avoid skin friction rubs. ?Use draw sheet or lifting device to move resident. ?Reposition resident per turn sheet. ?Pressure relieving mattress to bed. ?Cleans perineal area with Promise cream and water after each incontinence. Keep resident as clean and dry as possible. ?Additional handwritten approaches added on 1/6/11 were protective boot/device to left foot and clean daily, reapply dressing left heel. ?Added on 1/7/11 was air pressure relieving mattress. Review of provider prepared Patient Transfer Form dated 1/24/11 for resident 1 documented he/she had a L heel open area blackened, (symbol for no) drainage. Interview on 1/31/11 between noon and 12:45 p.m. with two separate unidentified CNAs and CNA D revealed they did not "input identified skin problems such as skin tears or what may be pressure ulcers on the palm or wall mounted electronic documentation devices. They go right to the nurse to report." Interview on 1/31/11 at 12:30 p.m. with RN C revealed the nurses used the Medicare Assessment Form with no additional instructions other than what was on the form, indicating the use of the symbol key. Interview on 1/31/11 at 12:50 p.m. with RN E revealed the CNA staff came directly to the nurse to report any identified skin concerns or problems. Also there was no policy or procedure for the use of the Medicare Assessment Form. "It's pretty self explanatory." Interview on 1/31/11 at 1:30 p.m. with the director of nurses (DON) confirmed there was no policy or procedure for the use of the Medicare Assessment Form. "It's self explanatory, directions on it." When asked if there was anyone else or any other documentation she would like to have the surveyor review to ascertain that the surveyor had found all data related to the course of stay of resident 1 from 12/15/10 through 1/24/11, there was none offered or provided. Review of the provider's nursing procedures dated 6/4/98 "Open areas" revealed: ?When found: 1. Document in nurses notes. 2. Add to are plan. 3. Put on dressing list on MAR. 4. Notify dietary department. 5. Obtain DuoDerm order if needed. 6. Add to communication board. 7. Charge out dressing ?Facts to be charted on when open areas existed: 1. Size and stage. 2. Location of open areas. 3. Drainage. 4. Color. 5. Odor. 6. What you did to it. 7. Swelling. (Off to side) definitions of stages on next page: ?Stages -Stage 1: A persistent area of skin redness (without a break in the skin) that did not disappear when pressure was relieved. -Stage 2: A partial thickness loss of skin layer that presented clinically as an abrasion, blister, or shallow crater. -Stage 3: A full thickness of skin was lost, exposing the subcutaneous tissue as a deep crater with or without undermining adjacent tissue. -Stage 4: A full thickness of skin and subcutaneous tissue was lost, exposing muscle and/or bone. Review of a document dated 11/07 titled " Open areas-skin tears " revealed: When found: -Document in nurses notes. ?Size of wound. ?How deep the wound is (stage). ?Drainage present. ?Location of open area. ?Color of wound and surrounding tissue. ?Treatment to be done. ?Add the open area to the resident's care plan. ?Place their name and the problem on the dressing list or have it added to the computer. ?Notify the kitchen that an open area is present. ?If DuoDerm is needed, obtain a physician's orders [REDACTED]. ?Charge out any dressing used. ?Write a note on the communication board to notify nursing staff of any change in the resident's care. ?The open area should be charted on a minimum of twice weekly. When healed: ?Chart what the healed area looked like. ?Take the problem off the care plan. ?Take the treatment of [REDACTED]. ?Notify the kitchen that area is healed ?Notify the nursing staff of the open area being healed. Review of resident 1's electronic Treatment Administration Record received after the 1/31/11 exit interview revealed there was no documentation to reflect the origination of the acquired left foot heel ulcer noted on 1/5/11 at 2:30 a.m. Review of the provider's word document titled "Skin Issues" from 1/3/11 through 1/24/11 received after the 1/31/11 exit interview revealed resident 1 was included on 1/3/11. Documentation reflected the previously noted stage I area to right outer buttock. Documentation from 1/11/11 reflected the presence of a left heel ulcer. That area measured 3.5 cm X 2.75 cm with a dark purplish/black intact scabbed area measuring 2.5 cm X 2.5 cm in diameter adjacent to healthy tissue at the wounds medial edge. Stage II area surrounding the scabbed portions measured approximately 0.75 cm in width and extended to the wound edges on the proximal, lateral, and distal sides of the wound. That area was filling in with granulation tissue without redness or swelling. There was a small amount of dried blood noted to the old dressing. Heel lift boot was in place to the left lower extremity. Nowhere in that documentation was there an explanation on how the pressure ulcer originated, or that the physician had removed an outer layer of dead skin.	2014-04-01
5097	BETHESDA HOME OF ABERDEEN	435073	1224 S HIGH ST	ABERDEEN	SD	57401	2011-05-04	253	E			RHFO11	Based on random observation and interview, the provider failed to maintain the following areas and/or items: Schedule the cleaning and maintenance for two of three whirlpool tub rooms E wing and A wing to prevent potential cross-contamination. Schedule the maintenance of tables in the dining room: -Six of eight plastic tables. -Four of twenty-four wooden tables. -Wooden doors in the main dining room and various ones throughout the facility. Registers in resident rooms and hallways on eight of eight wings. Wooden hand rails in eight of eight wings. One cracked padded toilet seat in resident room (406). One broken flush handle on a toilet in a resident room (404). Loose cupboard doors in the G wing kitchenette and the activity room. A gallon of drinking water located under the sink along side a small black plunger in the G wing kitchenette. A sling lift on G wing. Findings include: 1. Random observation of the E wing tub room on 5/2/11 from 3:00 p.m. to 4:30 p.m. revealed: Areas on the tub lift where paint had chipped away exposing rust and an uncleanable surface (photo 1). An area where a protective piece of plastic on the tub lift had broken off exposing a sharp uncleanable surface (photo 1). Deep scratches inside the tub near the back and bottom had removed the surface coating making it unable to be cleaned (photo 2). A large amount of white and dark brown debris covered the outer edges of the trim around the tub (photo 3). Four of four casters on a shower chair had rusted and created a non cleanable surface (photo 5). Random observation of the A wing tub room on 5/2/11 revealed: A round hole on the inside of the tub created a noncleanable surface (photo 4). A large amount of dark brown and green debris on the outside trim of the tub (photo 7). Interview with certified nurses assistant (CNA) J on 5/3/11 at 8:15 a.m. revealed housekeeping was responsible for cleaning the outside of the tubs. Interview on 5/4/11 at 9:40 a.m. with the housekeeping/laundry supervisor revealed: The bath aides were responsible for cleaning the outside of the tubs. There was not a policy for the cleaning of the outside of the tubs. Interview on 5/4/11 at 9:00 a.m. with the maintenance supervisor confirmed the above findings and revealed: He relied on a maintenance repair request from the facility staff. A maintenance repair request had not been submitted for the areas listed. He did not have the tub rooms on his preventative maintenance checklist. Interview on 5/3/11 at 10:45 a.m. with the director of nursing revealed: The bath aides had been responsible for the cleaning of the inside of the tubs. The housekeeping department had been responsible for cleaning of the outside of the tubs. There was a policy for cleaning the inside of the tubs but not the outside. She agreed the current practice for tub maintenance and cleaning impacted the entire facility. 2. Observation on 5/4/11 at 11:30 a.m. in the dining room revealed: Six of eight plastic tables had multiple chipped and cracked areas creating uncleanable and hazardous surfaces (photo 22). Four of twenty-four wooden tables had exposed and gouged areas of raw wood creating uncleanable and hazardous surfaces (photo 23). The wooden entry double-doors to the dining room had gouged sharp areas of raw wood creating uncleanable and hazardous surfaces. Interview on 5/4/11 at 11:45 a.m.with the maintenance supervisor revealed: He had been unaware of the condition of the plastic and wooden tables in the dining room. He had not had the dining room tables on his preventative maintenance checklist. He had not been aware of the condition of the double-doors to the dining room. 3. Random observation in eight of eight wings and numerous resident rooms revealed: Raw exposed boards adhered to the registers by Velcro tape creating uncleanable surfaces. Areas of chipped and scratched paint on the registers exposing areas of rust creating uncleanable surfaces (photo 18). Interview with the maintenance supervisor on 5/4/11 at 8:45 a.m. confirmed the findings and revealed: He was unaware the raw wood and the Velcro tape on the registers were uncleanable surfaces. He did not have the registers on his preventative maintenance checklist. He had painted the registers with room changes or as needed. 4. Random observation from 5/2/11 through 5/4/11 of eight of eight wings revealed handrails with gouged sharp areas of raw wood creating uncleanable and hazardous surfaces (photo 24). Interview with the maintenance supervisor on 5/4/11 at 8:45 a.m. confirmed the findings and revealed: He had been aware of the condition of the hand rails. He did not have the hand rails on his preventative maintenance checklist. He had a difficult time keeping up with maintenance of the hand rails. He had repaired hand rails as needed. 5. One observation on 5/2/11 of the bathroom in a resident room 406 revealed a soft padded toilet seat that had a crack making it an uncleanable surface (photo 10). Interview on 5/4/11 at 8:45 a.m. with the maintenance supervisor confirmed the above findings and stated he was unaware of the condition of the toilet seat. 6. One observation on 5/2/11 of the bathroom in a resident room 404 revealed a broken flush handle on the toilet. Interview on 5/4/11 at 8:45 a.m. with the maintenance supervisor at 8:45 a.m. confirmed the above findings and revealed he had been unaware of the condition of the flush handle on the toilet. 7. Random observation on 5/2/11 of the G wing kitchenette and of the activity room revealed loose cupboard doors (photos 12 and 17). Interview on 5/4/11 at 8:45 a.m. with the maintenance supervisor confirmed the above findings and revealed: He had been unaware of the condition of the cupboard doors. He had not had the G wing kitchenette or the activity room on his preventative maintenance checklist. 8. Random observation on 5/2/11 of the G wing kitchenette revealed a gallon of drinking water located under the sink beside a black plunger (photo 13). 9. Random observation on 5/2/11 of the G wing revealed a resident sling lift with the following : A crack down the entire upper plastic housing making it an uncleanable surface with sharp edges creating a hazard (photo 19). An ace wrap around the front of the sling creating an uncleanable surface (photo 19). Multiple areas where the paint had chipped making it an uncleanable surface. Interview on 5/4/11 at 9:00 a.m. with the administrator confirmed the above findings and revealed: He had not been aware of the condition of the plastic and wooden tables in the dining room. Had not been aware of the condition of the tubs on the A and E wings. He was aware of the multiple wooden doorways in need of repair throughout the facility. He had been aware the hand rails and the registers were in need of repair. He agreed the above practices affected the entire facility.	2014-04-01
5098	BETHESDA HOME OF ABERDEEN	435073	1224 S HIGH ST	ABERDEEN	SD	57401	2011-05-04	441	E			RHFO11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on random observation, testing, and interview, the provider failed to ensure: An effective process was used to identify and clean contaminated surfaces in resident rooms. The chemicals and process used to sanitize all of the laundry was effective against drug resistant organisms. Medical equipment was cleaned and stored properly after use. Food and drink were not stored in resident care areas. Findings include: 1 a. Observation at 8:55 a.m. on 5/4/11 revealed a housekeeper and cart in the D wing. Interview with the housekeeper at the time of the observation revealed she used a quaternary disinfectant in the mop bucket. Testing of the solution in the mop bucket at that time revealed the proper amount of disinfectant was in the mop bucket. b. Observation at 2:55 p.m. on 5/4/11 revealed the housekeeping supervisor had filled a mop bucket with the quaternary disinfectant into a mop bucket from the G wing housekeeping closet. Testing of the solution revealed 100 parts per million (ppm). c. Observation at 3:10 p.m. on 5/4/11 revealed the housekeeping supervisor had filled a mop bucket with the quaternary disinfectant into a mop bucket from the D wing housekeeping closet. Testing of the solution revealed 200 ppm. Interview on 5/4/11at 9:40 a.m. with the laundry supervisor at 9:40 a.m. revealed: She was unaware of the strength of the chemicals that had been dispensed into the mop buckets. She did not have the tools available to test the ppm strength of the chemical used for the mop buckets. She agreed there was an inconsistency with the amount of chemicals that had been dispensed from the auto dispensers in the house keeping closets. 2. Interview 5/4/11 at 9:40 a.m. with the laundry supervisor revealed: There had been previous cases of Clostridium Difficile in the facility. She was unaware of the strength of the chemicals that had been dispensed into the laundry machines that were used for all of the laundry. She was unaware what chemical would kill Clostridium Difficile. The chemical salesman did not log or track the strength of the chemicals in the machines. She did not have the tools available to test the ppm strength of the chemical used for the laundry contaminated by Clostridium Difficile. 3. Random observation on 5/3/11 of residents' bathrooms on the D and E wings on 5/3/11 revealed: An uncovered bedpan sitting on the rail behind the toilet in rooms [ROOM NUMBERS] (photo 11). An uncovered urine collection device (hat) sitting on the rail behind the toilet in room [ROOM NUMBER]. An uncovered graduated container sitting on the back of a toilet in room [ROOM NUMBER]. Interview on 5/3/11 with certified nurse assistant (CNA) E at 7:40 a.m. revealed: She had obtained water from the resident sink and a small amount of soap from the dispenser in resident 6's bathroom and combined them in the graduated cylinder. She had swished the fluid and dumped it in the resident's toilet. She had placed the graduated cylinder onto the back of the toilet. She was unaware of a facility policy for cleaning bed pans, urinals, hats, or graduated cylinders. She had always used soap and water to clean bed pans, urinals, hats, and graduated cylinders. She had never covered bed pans, urinals, hats, and graduated cylinders after cleaning and for storage. Soiled bed pans, urinals, hats, and graduated cylinders went to the soiled utility room to be cleaned. 4. Random observation from 5/2/11 through 5/4/11 of the E wing tub room revealed: A plastic container with candy, gum, and a bottle [MEDICATION NAME] reliever were sitting on top of a plastic stand along side patient care supplies and cleaning supplies (photo14). A foam coffee cup inside the plastic stand in the tub room sitting along side patient care supplies and cleaning supplies. (photo 15). An open container with granola bars and candy sitting inside the plastic stand along side resident care items and cleaning supplies (photo 16). Interview on 5/3/11 at 8:15 a.m. with CNA J revealed: Food and drink should not have been in the tub room. She had been covering for a CNA who had been out on extended leave. The food and drink had not belonged to her. The bath aide she had been covering for had used the food items to bribe combative residents during their baths. 5. Interview on 5/3/11 at 10:45 a.m. with the director of nursing (DON) revealed: There was no policy for cleaning soiled bed pans, urinals, hats, and graduated cylinders. The above items should have been covered and taken to the soiled utility room and cleaned. The above items should not have been cleaned in the resident bathroom. The sinks in the residents bathrooms should not have been used for cleaning soiled bed pans, urinals, hats, and graduated cylinders. Hand soap was not to have been used as the cleaning solution. Food and drink should not have been in resident care areas. She agreed the infection control practices impacted the entire facility. Review of the facility exposure manual, page five revealed: Food and drink should not have been kept where potentially infectious materials were present. Eating and drinking were prohibited in resident care areas. Interview with employee C on 5/3/11 at 3:00 p.m. confirmed CDC (centers for Disease Control) infection control protocols found in the infection control manuals would be followed until new policies and procedures were completed and implemented. 6.Observation on 05/02/11 at 4:00 p.m. revealed a nebulizer machine in the drawer of resident 4's bedside table. It was visibly soiled with a dried brown substance and unidentifiable particles (photo 9). That same nebulizer machine remained uncleaned throughout the entire survey. The resident received six documented nebulizer treatments during that time frame. Interview on 5/4/11 at 11:25 a.m. with licensed nurse A revealed: She was unaware the nebulizer machine was soiled. She agreed the nebulizer machine needed to be cleaned. She removed the nebulizer machine from the resident's room. Interview on 5/4/11 at 1:45 p.m. with the director of nurses revealed: She was aware the nebulizer in resident 4's room was soiled, because licensed nurse A had told her. She agreed the nebulizer had been in need of cleaning.	2014-04-01
5099	BETHESDA HOME OF ABERDEEN	435073	1224 S HIGH ST	ABERDEEN	SD	57401	2011-05-04	334	D			RHFO11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the provider failed to offer seasonal flu immunizations to three of three sampled residents (1, 18, and 19). Findings include: 1. Review of the Bethesda immunization permission form revealed residents 1, 18, and 19 refused the influenza immunization at admission and had not been offered the yearly flu immunization since their admission. At the time of admission new residents are required to sign the Bethesda immunization permission form designating either consent to or refuse of annual flu immunizations. This form states "Bethesda Home will utilize this one-time consent to immunize yearly for influenza ... " Review of the resident influenza immunization record for 2010-2011 revealed an " R " had been placed along side the name of resident 1, 18, and 19 who had refused flu immunizations at admission. Lines were drawn through the documentation row indicating the resident had not been offered the immunization. The provider had mailed influenza immunization information letters dated October 5, 2010 to all resident families, including the families of resident 1, 18, and 19. The letter stated "This is for your information only, no response is required as we have the permission and physician orders [REDACTED]. Interview with nurse B on 5/3/11 at 10:30 a.m. revealed the admission influenza consent or refusal was followed. Interview with nurse B also revealed residents had not been asked each year if they wanted the influenza vaccine. Interview with nurse C on 5/4/11 at 9:32 a.m. confirmed the same.	2014-04-01
5100	BETHESDA HOME OF ABERDEEN	435073	1224 S HIGH ST	ABERDEEN	SD	57401	2011-05-04	241	E			RHFO11	Based on random observation, interview, and policy review, the provider failed to ensure dignity was considered for five randomly observed residents during feeding assistance at four meals in the dining room. Findings include: 1. Observation on 5/3/11 during the supper meal in the dining room revealed a certified nursing assistant (CNA) L: -Used a spoon to assist a resident to eat her supper. -Used the edge of the spoon to scrape spilled food from the resident's lips and chin. -Used a spoon to pick up a quarter sized area of pureed food from the resident's bib and had placed it back onto the resident's plate. 2. Observation on 5/4/11 during the breakfast meal in the dining room revealed dietary aide H: -Used a spoon to assist a resident to eat her breakfast. -Used the edge of the spoon to scrape spilled food from the resident's lips and chin. 3. Random observation during the noon meal on 5/4/11 revealed a CNA assisting the resident. The spoonful of food the CNA had attempted to feed the resident was too large a portion. The excess food remained on the resident's face until the CNA used the spoon to clean off the resident's mouth. The excess food that had been cleaned off the mouth area was put back into the dish to be served again. 4. Random observation on 5/4/11 at 7:45 a.m. in the dining room revealed dietary staff R while feeding two different residents at the same time: Wiped the mouth area of two residents with a paper napkin and went from one resident to the other without sanitizing her hands between residents. Picked food off one of the resident's clothing protector and put it back into the serving bowl to be served again. Used the spoon to scrape excess food off the resident's mouth and put that same spoon back into the serving bowl. 5. Review of the provider's 8/30/10 policy for dignity and dining revealed: "Do not use utensils to clean off resident's mouth/face i.e. like feeding a child-use napkin (not clothing protector) even if you must use several napkins during the meal." Ensure proper infection control is being utilized in the dining room. Interview on 5/4/11 at 2:00 p.m. with staff trainer registered nurse C confirmed: The policy should have been followed. The mouth should not have been cleaned off with a spoon. Staff should have sanitized their hands between residents when feeding them and wiping their mouths.	2014-04-01
5101	BETHESDA HOME OF ABERDEEN	435073	1224 S HIGH ST	ABERDEEN	SD	57401	2011-05-04	371	E			RHFO11	Based on observation, interview, and policy review, the provider failed to store, prepare, distribute and serve food under sanitary conditions for two observed meals as follows: Meal preparation and serving from the tray line in the kitchen. Distribution of meals in the dining area. Feeding residents using proper hand cleaning techniques. Findings include: 1. Observation on 5/3/11 at 11:30 a.m. of the tray line for the noon meal revealed: Dietary staff N touched her nose, pushed her glasses up on her nose, touched her hair, and did not sanitize hands before she filled more meal trays. She left the tray line to go to the cupboard and stove, and put on pot holder mitts. She returned to the tray line without cleaning her hands. She went to the stove to get a new pan of lasagna, returned to the tray line, and used the spatula to lift up the used pan from the steam table. She then used that same soiled spatula to continue putting lasagna onto the residents' serving plates. Her hands were not cleaned after the pot holder mitts were removed. She removed a piece of garlic bread from one plate and put it back into the large stock of bread. She again touched her glasses, nose, and other parts of her personal clothing, did not sanitize her hands, and continued to fill the residnets' plates. She continued the same processes throughout the entire time she prepared the noon meal plates. 2. Observation at the same time revealed dietary staff O: Touched the inside of the soup bowls with her thumb when filling them. Coughed into her hand and elbow area when holding a plate of food. Left the tray line to get a paper towel to wipe spilled soup off her hand, used the same paper towel to wipe spilled soup off the side of a soup bowl, and placed it on the serving tray. At no time during the above process did she use hand sanitizer or wash her hands. 3. Observation at the same time revealed dietary staff P: Touched the telephone, handed it to another staff person, and then returned to putting food on the noon trays without cleaning his hands. Went to the cooler, made a grilled sandwich at the stove, touched all those areas, and then came back to put dessert dishes on the noon meal trays without sanitizing his hands. 4. Observation at the same time revealed dietary staff Q: Had long acrylic, brightly painted fingernails. Touched used soiled dishes and then touched clean dishes without washing or sanitizing her hands. Went to the cooler to get a large tray of individual dessert dishes, touched the refrigerator door handles, and did not sanitize her hands before returning to the tray line. Touched dessert dishes by grasping the dish by the upper lip, touched the inside of the dish, and placed it on the serving trays many repeated times. Touched her face and hair with her hands then returned to putting dessert dishes on the serving trays without sanitizing her hands. 5. Observation on 5/4/11 at 11:35 a.m. revealed dietary staff N and O repeated the same processes documented above and did not use acceptable hand cleaning techniques or use hand sanitizing solution at any time. Interview at that time with dietary staff N and O confirmed they should have cleaned their hands when they left the tray line or touched clothing and body parts. Interview on 5/4/11 at 11:55 a.m. with dietary manager M confirmed the facility policy should have been followed at all times when working with food in the kitchen and dining areas. 6. On 5/4/11 at 11:40 a.m. dietary aide D was observed pouring water and juice for several residents. Dietary aide D was observed adjusting her uniform slacks, followed by leaning on the dining table to take a residents lunch order, and then continued pouring and distributing water and juice to residents. Employee D failed to sanitize hands between any of the tasks. At 12:05 p.m. employee D applied sanitizing gel to her hands. Random observation on 05/3/11 of the supper meal on revealed CNA L helped two residents at the same table with their meals. While not wearing gloves the CNA: Assisted the first resident. She wiped food off that resident's mouth with his clothing protector. Wiped her nose. Wiped her hands on her uniform pants. Touched a second resident's chair. Assisted the second resident with her fluids, touched the rims of the glasses, and held the glasses for her to drink. Wiped the second resident's mouth with her clothing protector. The CNA did not wash or sanitize her hands during the above time period. Random observation on 05/4/11 of the breakfast meal revealed dietary aide H helped two residents at the same table with their meals. While not wearing gloves the dietary aide: Touched her face. Assisted the first resident. She wiped food off that resident's mouth with her clothing protector. wiped up a spill. Assisted the second resident with her fluids, touched the rims of the glasses, and held the glasses for her to drink. Wiped the second resident's mouth with her clothing protector. The CNA did not wash or sanitize her hands during the above time period. Random observation on 05/4/11 of the noon meal revealed CNA I helped a resident with her meal. While not wearing gloves the CNA: Touched a second resident's chair. Held a small child. Held another resident's hand. Assisted the resident with her fluids, touched the rims of the glasses, and held the glasses for her to drink. The CNA did not wash or sanitize her hands during the above time period. Review of the 2010 policy for food safety revealed: The food service manager would ensure good sanitary food handling practices were followed. Sanitary conditions were maintained in the storage, preparation, and serving areas. Personnel should follow sanitary practices and good personal hygiene at all times. Acrylic or painted nails must be covered when handling or serving food. Avoid touching mouth or face while preparing food.	2014-04-01
5102	THE NEIGHBORHOODS AT BROOKVIEW	435083	2421 YORKSHIRE DR	BROOKINGS	SD	57006	2011-01-05	323	E			UQHU11	Based on observation and interview, the provider failed to ensure: Resident walkers were appropriately utilized for randomly observed residents (17 and three unidentified). A door leading to a hazardous area was secured and had an appropriate locking device. Findings Include: 1. Random observations on 1/3/11 and 1/4/11 of the east and south hallways revealed: Three unidentified residents were observed on 1/3/11 during the supper hour being pushed backwards down the east hallway in their wheeled walkers to the dining room. The residents were seated in the center of the walker facing backwards. Staff members were pushing them using the handles of the walkers. Resident 17 on 1/4/11 at 2:00 p.m. was being pushed backwards down the south hallway in the resident's wheeled walker. The resident was seated in the center of the walker facing backwards and a staff member was pushing the resident using the handles of the walker. The resident was transported from the south hallway nurses station to the dining room where she attended an activity. Interview on 1/4/11 at 2:10 p.m. with case manager (CM) E revealed: Several residents down the east hallway were transported within the facility via their wheeled walkers in the above described manner. Residents were transported in that manner after they became too tired to walk with the aid of the walker. Interview on 1/4/11 at 2:15 p.m. with CM B revealed she had one resident in the south hallway who was transported in the above described manner, and that was resident 17. Interview on 1/4/11 at 2:20 p.m. with physical therapist G revealed: Residents should not be transported via wheeled walkers with the center seat. She was not aware facility staff were utilizing the walkers in that fashion. She agreed residents should never be transported backwards as it might make the resident disoriented and dizzy. Use of the wheeled walkers with a center seat as a means of resident transport was against the manufacturer's suggested use. Interview on 1/4/11 at 2:45 p.m. with CM B revealed: She had been in contact with director of nursing A and found no resident transportation policy existed. No specific policy or procedure existed for the use of the wheeled walkers with a center seat. 2. Random observations and testing on 1/3/11 and on 1/4/11 of the doorway leading to the boiler and maintenance room revealed: The door had a bolt type lock in the upper right hand corner of the door. The door was noted to be unsecured on several occasions. The only way to secure the door was be means of the bolt lock. Once the bolt lock was secured, it left whoever was behind the door trapped. That was demonstrated when this surveyor was accidentally locked behind that door during the morning of 1/4/11. Residents were observed in the hallway where the unsecured door was located. Interview on 1/4/11 at 9:30 a.m. with maintenance person C and CM B revealed: Both agreed the door should have been locked at all times. Both agreed the bolt type lock could accidentally trap a person behind it. Both agreed the bolt lock on the door was a potential hazard for residents as well as staff. *Maintenance person C suggested the lock should be changed to a master keyed door lock that would secure the door and still leave residents or staff shut in the area a means of getting out.	2014-04-01
5103	THE NEIGHBORHOODS AT BROOKVIEW	435083	2421 YORKSHIRE DR	BROOKINGS	SD	57006	2011-01-05	441	D			UQHU11	Based on observation, interview, and policy review, the provider failed to ensure appropriate glove use and hand hygiene for two of two observed residents (9 and 10) receiving personal care. Findings include: 1. Observation on 1/4/11 at 11:20 a.m. of personal care given resident 10 by certified nurse aide (CNA) D revealed: On several occasions the CNA was seen touching, the resident and multiple surfaces in the resident's room with her gloved hands that had been exposed to body fluids. The CNA did not wash her hands immediately after the removal of her gloves that had been exposed to body fluids. The CNA used her bare hands to push into a garbage can personal care items that had been exposed to body fluids. Her hands were not washed until several minutes after exposure. Prior to washing her hands she again touched the resident and multiple surfaces in the resident's room. 2. Observation on 1/4/11 at 1:00 p.m. of the personal care given resident 9 by CNA D revealed: On several occasions the CNA was seen touching the resident and multiple surfaces in the resident's room with her gloved hands that had been exposed to body fluids. The CNA did not wash her hands immediately after removal of gloves that had been exposed to body fluids. The CNA tied a garbage bag closed with her gloved hands that had been exposed to body fluids. That same garbage bag was later transported bare handed from the resident's room to the dirty utility room. After leaving the dirty utility room the CNA went to another resident's room to assist with the care of another resident without performing any hand hygiene. 3. Interview and policy review on 1/5/11 at 10:30 p.m. with case manager B revealed: She agreed proper glove use and hand hygiene was not properly adhered to based on this surveyor's observations. According to the provider's policy on handwashing dated 7/22/04: -Handwashing was the most important means of preventing nosocomial infection. -Hands must be washed before and after resident contact, after contact with body fluids, and after removal of gloves.	2014-04-01
5104	THE NEIGHBORHOODS AT BROOKVIEW	435083	2421 YORKSHIRE DR	BROOKINGS	SD	57006	2011-01-05	164	B			UQHU11	Based on observation, interview, and record review, the provider failed to ensure resident identifiable information contained on the electronic medication record was not visible to the residents or public by two of four nurses (E and F) observed administering medications. Findings include: 1. Random observations on 1/3/11 between 3:45 p.m. and 5:05 p.m. revealed licensed practical nurse (LPN) F was administering medications on the north hallway. The LPN would go to different residents' rooms to administer medications. While she was away from the medication cart resident identifiable information included on the electronic medication record screen was visible to passing residents or members of the public. 2. Observation of the medication pass on 1/3/11 from 5:45 p.m. to 5:55 p.m. revealed registered nurse (RN) E was administering medications on the east hallway. On two occasions the RN went into residents' rooms to administer medications. While she was away from the medication cart resident identifiable information included on the electronic medication record screen was visible to passing residents or members of the public. 3. Random observations on 1/4/11 between 5:45 p.m. and 6:00 p.m. revealed LPN F was administering medications with the medication cart located in the main lobby. The LPN would go into the dining room to administer medication to residents. While she was away from the medication cart resident identifiable information included on the electronic medication record screen was visible to passing residents or members of the public. 4. Review of the provider's policy for confidentiality, security, and integrity within information systems effective 8/1/97 revealed: The policy had been developed to maintain confidentiality, security, and integrity of data/information contained within computer systems. All data information maintained on any computer system was governed by the confidential information section of the provider's personnel policies manual. *The confidentiality portion of the policy did not include any information about protecting resident identifiable information that appeared on computer screens. Interview on 1/5/11 at 11:00 a.m. with director of nursing A revealed she was not aware of the provider having a specific policy that addressed maintaining the confidentiality of resident identifiable information on the electronic medication record screens.	2014-04-01
5105	RIVERVIEW MANOR	435086	611 EAST 2ND AVE	FLANDREAU	SD	57028	2011-01-05	279	E			UUM911	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the provider failed to develop comprehensive collaborative care plans for three of three sampled residents (4, 10, and 11) receiving hospice services. Findings include: 1a. Review of resident 4's Minimum Data Set ((MDS) dated [DATE] revealed: It was an admission assessment. He/she was on hospice. Review of resident 4's care plan dated 12/30/10 revealed: He/she was terminally ill. Hospice services were identified as an approach. The care plan did not address: -How often hospice services were provided. -What services were to be provided by hospice. -How the provider and the hospice were going to coordinate and divide up the provision of services and care for the resident. Review of resident 4's entire medical record revealed: There were two separate binders that included documents regarding resident 4's care. -One of those binders included the provider care. -The second binder contained documentation made by the hospice provider. Interview on 1/4/10 at 11:15 a.m. with licensed practical nurse E revealed she was unaware the second binder for resident 4 contained only hospice documentation. Review of the hospice's contract with the provider dated 7/20/04 revealed "The hospice and the home will develop a mutually acceptable overall plan of care for the resident." b. Review of resident 11's nurses notes from 12/16/10 through 1/4/11 revealed the resident had repeated bouts of [MEDICAL CONDITION], redness, and shiny, taut skin on his/her right shin. At times he/she complained of pain in his/her shin. It was documented hospice was notified several times about that. There was no reference to the physician being notified. Review of resident 11's care plan dated 12/7/10 revealed: The resident had a potential for pain related to arthritis and a neck fracture. Hospice services were provided for debilitation. A problem related to maintaining his/her weight with a hospice care approach. There were no specific approaches to address what hospice was going to provide regarding the pain or weight. A problem related to occasional [MEDICAL CONDITION] of legs and feet. The approaches were check and lotion skin in the morning and evening and report any redness, irritation, or open areas. There was no approach regarding hospice care of the [MEDICAL CONDITION] in the legs. Interview on 1/5/11 at 10:30 a.m. with registered nurse (RN) A and hospice licensed practical nurse (LPN) C revealed: LPN C revealed she had contacted the hospice RN regarding the redness and [MEDICAL CONDITION] of resident 11's shins and was told the family had opted to not medically treat it. As part of their hospice plan they would not notify the physician, but keep the resident comfortable. LPN C and RN A agreed the care plan did not address the treatment preferences and limitations in place for resident 11 as part of his/her advanced directives. They agreed the care plan did not specify what services hospice provided to resident 11 and how the provider and hospice coordinated those services. They agreed a new nurse would not be able to access this information by looking at the provider's care plan. c. Review of the provider's February 2008 hospice policy did not address the collaboration of care between the provider and hospice as part of an individualized care plan for a resident receiving hospice services. Review of the providers July 1981 Resident Care Plan policy revealed: The care plan should "Insure individualized rather than routine care. It serves as a guide in carrying out resident care. The plan involves all facets of the residents' care during their stay, step by step, beginning with small achievable goals or activities. The interdisciplinary team, i.e. director of nursing, (DON), food service supervisor, restorative care coordinator, activity director, and social services designee shall indicate specific steps the staff will perform in order to implement the care plan." 2. Review of the quarterly MDS dated [DATE] and the annual MDS dated [DATE] for resident 10 revealed the resident was coded for Hospice. Review of the medical record revealed resident 10 had been on Hospice since 2/16/10. Review of the care plan for resident 10 dated 11/10/10 revealed: Problem #15 was terminal illness, end stage [MEDICAL CONDITION], Hospice services. -Approach (1): "Assist to reposition every 2 hours with oral care and back rub, pain medication as ordered." -Approach (2): "Hospice services and follow through (F/T) on recommendations." -Approach (3): "Promote comfort through repositioning and medications, promote choices and privacy, listen and allow venting of feelings, be supportive, keep family and doctor informed." Problem #17 was Hospice intervention requested. -Approach (1): "Family's choice contacted for hospice consult." -Approach (2): "Per family request notebook left in room for hospice to document visits." -Approach (3): "RVM (provider) staff aware of hospice support." -Approach (4): "Hospice kept informed of any changes." Interview with social service director F on 1/5/11 at 9:25 a.m. revealed: There were two separate binders that included documents for resident 10's care. One binder was the faciliy's medical record for resident 10 that included the care plan. The second binder was for the documentations and care plans by the hospice provider. Interview with hospice licensed practical nurse C on 1/5/11 at 10:35 a.m. revealed: The nurse came 1 to 2 times per week. The hospice aide usually came 5 times per week. She confirmed there was a separate plan of care by the hospice team, but their services were not identified into one facility plan of care for the resident. She stated the hospice nurse and aide left documentation on each visit as to what they had provided. She pointed out the most recent hospice team plan of care dated 12/14/10 that was in the separate hospice binder.	2014-04-01
5106	GOOD SAMARITAN SOCIETY CORSICA	435089	455 NORTH DAKOTA	CORSICA	SD	57328	2011-01-25	225	D			3RX511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the provider failed to properly investigate and report one of one alleged instance of certified nursing assistant misconduct with one of one sampled resident (1). Findings include: 1. Review of the investigative report submitted to the South Dakota Department of Health by the provider on 1/10/11 revealed: Inappropriate conduct with resident 1 was alleged to have occurred on 12/23/10. Investigation into the alleged misconduct did not occur until 12/29/10. No documentation was found in the report indicating the alleged misconduct had been reported to any State of South Dakota agency prior to that time. Review of resident 1's entire medical record revealed: No documentation was present related to the 12/23/10 incident. Resident 1's cognitive status was documented as impaired. Interview on 1/25/11 at 9:25 a.m. with resident 1 revealed she was cognitively unable to answer questions regarding the 12/23/10 incident. Interview on 1/25/11 at 9:35 a.m. with certified nursing assistant (CNA) 4 revealed: She believed she had seen CNA 5 kiss resident 1 on the lips on 12/23/10 at around 1:00 a.m. CNA 5's back was turned to her at the time she stated she had witnessed that occurrence. She had reported what she had thought she had seen to registered nurse (RN) 3 shortly after the incident had occurred that night. No incident report was filed, and she had not formally documented the incident in the resident's record. She had not had any personal or professional problems with CNA 5 prior to that incident. She continued to work with CNA 5 throughout the rest of that night. She had worked with CNA 5 multiple other times since the incident she had reported on 12/23/10. She had not witnessed any inappropriate behavior with residents after the above incident. Interview on 1/25/11 at 10:45 a.m. with office manager 6 revealed: She had sat in on the interview of CNA 5 with director of nursing (DON) 2 on 12/29/10. DON 2 was in charge of the interview, and she was mainly there as a witness. CNA 5 adamantly denied inappropriate behavior with resident 1. CNA 5 admitted resident 1 was kissed on the forehead not the lips. Interview and policy review on 1/25/11 at 11:20 a.m. with social services designee 7 revealed: She was the social services designee at the time of the above incident. She now was in charge of the quality assurance for the provider and no longer acted as the social services designee. She was the employee who had reported the allegation of CNA 4 to administrator 1 on 12/29/10. She had received the allegation that CNA 5 had inappropriate resident contact with resident 1 from an anonymous third party on 12/29/10. She went to administrator 1 on 12/29/10 after hearing the alleged concern. CNA 4 and RN 3 had never contacted her related to the 12/23/10 incident. She had never filled out an incident report or documented any information in the resident's chart once she had received the anonymous third party allegation. She was not involved in the investigation of the allegation once she reported it to administrator 1. She agreed the provider's abuse and neglect policy revised October 2009 called for: -Staff were to fill out an resident/visitor incident report at the time of the report of abuse or neglect was received. -Staff suspected of abuse or neglect would be removed from direct care of residents. -Staff suspected of abuse or neglect would be placed on suspension pending results of an internal investigation. -The appropriate state agency would be reported to as soon as possible. -Appropriate investigation into the matter describing the who, what, when, where, and how of the allegation would be conducted, documented, and reported to all appropriate agencies. Social services would make that investigative report to the state survey agency within five business days. -The reported incident would be placed into the provider's incident record log. She agreed the provider and its staff had not followed its abuse and neglect policy revised October 2009 in any of the above areas. She stated that 12/23/10 incident "fell though the cracks." Interview on 1/25/11 at 12:05 p.m. with DON 2 regarding the 12/23/10 incident involving CNA 5 revealed she agreed: The provider's abuse and neglect policies and procedures had not been followed. Appropriate investigation and reporting had not occurred. No nursing assessment of resident 1 had occurred after the incident was reported. She did not believe CNA 5 had abused resident 1. Interview on 1/25/11 at 12:35 p.m. with administrator 1 regarding the 12/23/10 incident involving CNA 5 and resident 1 revealed: The provider's abuse and neglect policies and procedures had not been followed. Appropriate investigation and reporting had not occurred. She did not believe CNA 5 had abused resident 1. Interview on 1/25/11 at 1:20 p.m. with CNA 5 regarding the 12/23/10 incident revealed: CNA 5 admits kissing resident 1 on the forehead not the lips. "I would not ever kiss a resident on the lips. That is sick." CNA 5 was confronted by RN 3 that night, but RN 3 stated she had witnessed him kiss resident 1 on the lips. CNA 5 had not been asked to fill out a statement or incident report related to the above incident. CNA 5 was not removed from duty that night. CNA 5 was never removed from duty. Administration had not talked to him about that incident until 12/29/10. Stated CNA 4 could not have seen CNA 5 as the curtain to the resident's bed area had been pulled, and she stated she had seen CNA 5 from the doorway. CNA 4 had a history of [REDACTED]. CNA 5 stated he informed DON 2 of that when CNA 4 started working at the facility. DON 2 did not believe CNA 5 had abused resident 1. Interview on 1/25/11 at 2:00 p.m. with RN 3 regarding the 12/23/10 incident revealed: She had been a nurse since July 2010, and this was her first job as a nurse. She had worked for the provider as a CNA for several years prior to becoming a nurse. She did not believe CNA 5 had abused resident 1. She did tell CNA 5 she had seen him kiss resident 1. However it was reported to her by CNA 4. She stated she was trying to protect CNA 4's identity when she stated that. She had not filled out an incident report or documented anything in resident 1's medical record related to that evening. She had not contacted the administrator on duty that night. She had not removed CNA 5 from duty. She did not have CNA 4 fill out an incident report or submit a witness statement. She was not aware at the time of the incident that she should have removed CNA 5 from duty, contacted the administrator on call, had CNA 4 fill out an incident report and witness statement, and documented her actions.	2014-04-01
5107	LAKE ANDES HEALTH CARE CENTER	435097	740 EAST LAKE ST POST OFFICE BOX 130	LAKE ANDES	SD	57356	2011-01-05	494	E			9E3F11	Based on record review and interview, the provider failed to ensure: Three of four nurse aides (E, F, and G) working in the facility became certified before four months had elapsed from their dates of hire. The provider maintained their nurse aide program requirements as specified by the State of South Dakota. Findings include: 1. Review of nurse aide E's certified nursing assistant pathway form revealed 8/24/10 was the date the nurse aide had begun the initial 40 hours textbook and skills training. Four months from that date was 12/24/10. Review of nurse aide E's certified nurse aide competency evaluation results dated 12/22/10 revealed a score of 57% on the knowledge portion of the test. A score of 75% or more was required to pass the test to become certified as a nursing assistant. The schedule for December 2010 and January 2011 revealed nurse aide E worked a seven hour shift on 1/1/11 after failing the nurse aide certification testing and had been employed more than four months. 2. Review of nurse aide F's certified nursing assistant pathway form revealed 8/24/10 was the date the nurse aide had begun the initial 40 hours textbook and skills training. Four months from that date was 12/24/10. Review of nurse aide F's certified nurse aide competency evaluation results dated 12/22/10 revealed a score of 59% on the knowledge portion of the test. A score of 75% or more was required to pass the test to become certified as a nursing assistant. The schedule for December 2010 and January 2011 revealed nurse aide F continued to work the following shifts after failing the nurse aide certification testing and had been employed more than four months: A 12 hour shift on 12/24/10. A 12 hour shift on 12/27/10. A 12 hour shift on 12/30/10. A 12 hour shift on 1/1/11. A 12 hour shift on 1/2/11. 3. Review of nurse aide G's certified nursing assistant pathway form revealed 8/24/10 was the date the nurse aide had begun the initial 40 hours textbook and skills training. Four months from that date was 12/24/10. Review of nurse aide G's certified nurse aide competency evaluation results dated 12/22/10 revealed a score of 64% on the knowledge portion of the test. A score of 75% or more was required to pass the test to become certified as a nursing assistant. The schedule for December, 2010 and January, 2011 revealed nurse aide G continued to work the following shifts after failing the nurse aide certification testing and was employed more than four months: A 4 hour shift on 1/4/11. Interview on 1/5/11 at 11:50 a.m. with nurse aide trainer D confirmed: * She believed a nurse aide could continue to work longer than four months without passing the complete nurse aide certification course if they passed the manual skills portion of the test . *She had not known they had to pass both the manual skills portion and the knowledge portion of the test to be able to continue working past the four month time frame. Interview with director of nursing B on 1/5/11 at 11:50 a.m. confirmed nurse aides E, F, and G worked the above hours after they had failed the nurse aide testing on 12/22/10. They had been employed for more than four months. They had continued to be scheduled to work as nurse aides for the provider on the schedule for January 2011. 4. Review of the provider's pass/fail bi-annual report from the the South Dakota Health Care Association revealed the written portion of the nurse aide training test had a pass rate of 74% (14 out of 19). That report covered the testing period from 1/5/09 to 1/5/11. Interview on 1/5/11 at 3:30 p.m. with licensed practical nurse D revealed: -She had been the primary instructor for the nurse aide training program for about five years. -She was unaware of and had never received a pass/fail rate report. -She had other nurse aides fail the written examination in the past two years. -Three out of four nurse aides of the last nurse aide training group had failed the written examination. -That had been the most in one examination group that had failed.	2014-04-01
5108	LAKE ANDES HEALTH CARE CENTER	435097	740 EAST LAKE ST POST OFFICE BOX 130	LAKE ANDES	SD	57356	2011-01-05	202	D			9E3F11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure proper documentation was done for one of one closed resident records (10) who was transferred to another facility. Findings include: 1. Review of resident 10's record revealed: -Resident 10 had an admission date of [DATE]. -A progress note dated [DATE] written by the physician noted "A lot of behavior problems." -A [DATE] nursing note stated the resident was out of the facility and had been transported with administrator A and dietary manager K to a behavior facility in Sioux Falls. -No documentation was noted in the nursing notes describing resident 10's status after [DATE]. -No physician's order to transfer or transport the resident had been received from the physician. -No documentation was noted from the physician regarding the reason for the transfer. -No recap of stay/discharge summary of the resident's stay was noted in the record. Interview on [DATE] at 9:50 a.m. and at 11:30 a.m. with director of nursing B revealed: -There were no other notes or documentation found from the physician regarding the transfer. -The nursing notes had not contained any further information of the resident's status after [DATE]. -The recap of stay/discharge summary was not done. -She had known the resident was now deceased but had not known the date of death .	2014-04-01
5109	LAKE ANDES HEALTH CARE CENTER	435097	740 EAST LAKE ST POST OFFICE BOX 130	LAKE ANDES	SD	57356	2011-01-05	283	D			9E3F11	Based on record review and interview, the provider failed to ensure a discharge summary was done for one of one closed resident record (10). Findings include: 1. Review of resident 10's record revealed no discharge summary or recap of stay had been completed. Refer to F202 finding 1.	2014-04-01
5110	LAKE ANDES HEALTH CARE CENTER	435097	740 EAST LAKE ST POST OFFICE BOX 130	LAKE ANDES	SD	57356	2011-01-05	499	D			9E3F11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel file review and interview, the provider failed to ensure one of one certified nurse aide (CNA) (H) had a current nurse aide certification. Findings include: 1. Review of CNA H's employee file revealed a copy of her nurse aide certification. That certification had an expiration date of [DATE]. Interview on [DATE] at 3:30 p.m. with office manager I and administrator A revealed CNA H was currently on maternity leave and had last worked at the facility as a CNA on [DATE]. Interview on [DATE] at 3:40 p.m. with director of nursing (DON) B and registered nurse consultant C confirmed CNA H's certification had expired on [DATE]. DON B further stated she had notified CNA H about the expiration date of her certification. CNA H had planned to come to the facility that day to complete the necessary paperwork for renewal of her certification.	2014-04-01
5111	BOWDLE NURSING HOME	435107	8001 W 5TH STREET POST OFFICE BOX 556	BOWDLE	SD	57428	2011-03-09	441	E			FOR111	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure one of one resident's (1) clean dressing change was completed in a sanitary and [MEDICATION NAME] manner. Findings include: 1. Observation on 3/8/11 from 8:30 a.m. until 8:38 a.m. of registered nurse (RN) D applying a clean dressing on resident 1's right sacral wound after a bath revealed RN D with ungloved hands: Opened two different dressing packages and laid them on the resident's bed. Left the room to get a pair of scissors. Returned to the room with a pair of blue-handled, all-purpose scissors. Without washing her hands or using an alcohol-based hand rub used those scissors to cut the hydrogel dressing to size and applied it directly to the wound. Applied the second dressing over the hydrogel dressing and the wound. Washed her hands. Left the room and returned those blue-handled scissors to the pencil box at the nurse's station. Further observation revealed that pencil box contained another pair of all-purpose scissors and numerous pens and pencils. Interview at that time with RN D revealed: She had washed her hands after first entering resident 1's room. She had not washed her hands or used an alcohol-based hand rub after returning to the resident's room with the scissors, because she had not "touched anything." Interview with the director of nursing at 8:40 a.m. confirmed RN D had used those blue-handled scissors from the pencil box to cut resident 1's hydrogel dressing, and had returned them to that box on the desk. She further revealed she had ordered bandage scissors for each resident but had not received them yet. Interview with RN D on 3/8/11 at 1:50 p.m. confirmed she had not cleaned those scissors prior to using them to cut resident 1's hydrogel dressing. She had cleaned them before putting them back in the pencil box. Review of the provider's handwashing/hand hygiene policy revised March 16, 2010 revealed staff should have used an alcohol-based hand rub before handling clean or soiled dressings, gauze pads, etc. Review of the provider's dry/clean dressings policy revised June 2005 revealed staff should have: Assembled the equipment and supplies needed including scissors. Wiped nozzles, foil packets, bottle tops, etc. with alcohol pads as necessary. Established a clean field. *Put on clean gloves after hands had been washed and dryed thoroughly.	2014-04-01
5112	BOWDLE NURSING HOME	435107	8001 W 5TH STREET POST OFFICE BOX 556	BOWDLE	SD	57428	2011-03-09	281	E			FOR111	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to ensure 2 of 3 nurses (E and F) followed professional standards when providing medications to residents (1&11) during 2 of 41 opportunities observed during medication passes. Findings include: 1. Observation on 3-8-11 at 4:15 p.m. during a medication pass revealed nurse F crushed and administered potassium chloride 20 meq (milliequivalent) CR (controlled release) to resident 11. Review of the medication container label stated the medication was potassium chloride 20 meq CR. A DO NOT CRUSH label was on that medication cassette. Review of resident 11's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Todd P. Semla et al., Geriatric Dosage Handbook, 15th Ed., Lexi-Comp, Hudson, Ohio, 2010, pages 1411 and 2024, revealed controlled release potassium tablets were not to be crushed or altered. Review of resident 11's Current Meds order form signed and dated by the physician extender on 2-16-11 revealed there was no order to crush medications. Interview on 3-9-11 at 1:45 p.m. with facility employee C revealed extended release medications were not to be crushed. 2. Observations on 3-7-11 at 5:05 p.m. of nurse E and on 3-8-11 at 10:55 a.m. of nurse F revealed resident 1 was administered two sprays in each nostril of Nasal Spray 0.65% (Normal Saline). Review of resident 1's March 2011 MAR indicated [REDACTED]. May have at bedside. Review of the Current Meds order form revealed: Normal Saline Nasal Spray 1 spray each nostril qid (four times a day) prn, do use it Bid (twice a day). Review of the pharmacy label on the bottle of Nasal Spray revealed 2 sprays were to be administered in each nostril. Interview on 3-9-11 in the morning with nurse G confirmed the order should have been clarified with the physician as to whether one or two sprays was the correct dose.	2014-04-01
5113	ST WILLIAMS HOME FOR THE AGED	435122	100 SOUTH 9TH STREET	MILBANK	SD	57252	2011-01-12	164	E			FYSY11	Based on observation, interview, and policy review, the provider failed to ensure resident medical information was kept confidential for eight random observations of two of two medication carts. Findings include: 1. Random observations from 5:00 p.m. on 1/10/11 through 6:10 p.m. on 1/11/10 revealed: Eight times the medication administration records (MAR) were left open on the top of the medication carts. That revealed resident medical information to anyone passing by. The medication carts were stationed in various areas of the hallways, and especially the hallway between the front door and the nursing station. That hallway was busy with residents, visitors, and staff going back and forth. Interview on 1/12/11 at 10:40 a.m. with nurse A revealed: Leaving the MARs open was a breach of confidentiality. All staff were required to read and sign a copy of the confidentiality policy. Review of the provider's confidentiality policy dated January 2005 revealed "Information known or contained in the resident's medical record will be treated as confidential."	2014-04-01
5114	ST WILLIAMS HOME FOR THE AGED	435122	100 SOUTH 9TH STREET	MILBANK	SD	57252	2011-01-12	176	D			FYSY11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to determine if self-administration of medications was safe for three of four sampled residents (3, 10, and 13). Findings include: 1. Observation and interview on 1/11/11 at 4:30 p.m. with resident 13 revealed he/she kept Aspercreme, [MEDICATION NAME], and artifical tears in his/her room. Review of the resident's physician's orders [REDACTED]. Review of resident 13's medical record revealed there was not an assessment completed by an interdisciplinary team to determine if keeping and using those medications in his/her room was a safe practice. 2. Observation on 1/11/11 at 8:05 a.m. revealed nurse Q: Set up the oral medications in applesauce and drew up insulin for resident 10. Assisted the resident into a private area. Handed him/her the cup with the medications and applesauce in it. Gave the insulin to the resident. Helped the resident to the dining room door and returned to the medication cart. The resident propelled his/her wheelchair up to a table and took his/her medications by himself/herself without supervision by nurse Q. Interview on 1/12/11 at 10:40 a.m. with nurse A revealed: A self-administration assessment needed to be done at the time the order was written. The nurse who signed off on the physician's orders [REDACTED]. Interview with resident 10 on 1/12/11 at 10:05 a.m. revealed sometimes the nurses did not watch her take her medications. She usually took her medication right away when the nurse handed them to her. But she was eating something that morning when the nurse brought her medicine. She did not believe any of her tablemates would try to take her medications by mistake. She would tell the nurse if they did. Interview and chart review with nurse Q on 1/12/11 at 10:50 a.m. revealed: There was no orders for resident 10 to allow self-administration of medications or to allow the resident to have medications left with her to take without nurse supervision. There was an assessment for resident 10 to continue her nebulizer treatment without supervision. That assessment did not extend to any oral medication. There was no assessment that it was a safe practice for resident 10 to have medications left with her. 3. Observation on 1/12/11 at 8:40 a.m. when entering resident 3's room revealed she was sitting in her wheelchair without her glasses. Resident 3 had completed her breakfast meal, and her breakfast tray was still sitting on the bedside table. Certified nurse aide (CNA) T entered resident 3's room at 8:45 a.m. to remove her breakfast tray. The CNA stated "You need to take this." Resident 3 asked what it was. CNA T replied "I shouldn't be doing this" as she handed her the medication cup containing several pills. Resident 3 stated there was a lot of "little ones" in here, and the CNA agreed. The CNA stayed with the resident as she consumed her medication. She then left the room with the resident's breakfast tray. Review of the significant change Minimum Data Set 3.0 dated 10/19/10 for resident 3 revealed she: Could not recall what day of the week it was when the assessment was conducted. Could not recall two of the three words given to her to remember. Had problems at times with focusing attention. Had times of disorganized thinking Had trouble at times concentrating. Review of resident 3's care plan dated 1/7/11 revealed no information it was safe for the resident to safely take her medications without supervision of a nurse. Interview and chart review with nurse Q on 1/12/11 at 10:50 a.m. revealed there were no orders for resident 3 to allow self-administration of medications or to allow the resident to have medications left with her to take without nurse supervision. She further revealed there was no assessment that it was a safe practice for resident 3 to have medications left with her. 4. Review of the provider's self-administration of medications policy dated 1/11/11 revealed "Assessment for Self-Administration of Medications Form should be completed by the RN/LPM (registered nurse/licensed practical nurse) and evaluated by the interdisciplinary team prior to beginning self-administration of medications."	2014-04-01
5115	ST WILLIAMS HOME FOR THE AGED	435122	100 SOUTH 9TH STREET	MILBANK	SD	57252	2011-01-12	371	E			FYSY11	Based on observation, interview, and policy review, the provider failed to ensure four of four observed meals were distributed and served under sanitary conditions in the dining areas. Findings include: 1. Observation at 5:45 p.m. on 1/10/11 during the evening meal in the dining room revealed: Certified nurse assistant (CNA) J held the cover to the pink insulated individual serving tray against the front portion of her uniform and alongside her leg area while waiting in the serving line. Dietary aide (DA) F delivered meals to residents using a red plastic tray, placed the tray on the table near many different residents, and reused that same tray many times during the meal distribution. DA F and housekeeping staff (HS) H both touched the prewrapped silverware packets and placed them on the soiled red trays. The trays were soiled with wet liquid and food particles from the previous delivered meal. HS H wiped his/her hand across the face area then continued to touch silverware packets, held the red tray next to the side of his/her legs when returned from the resident to the tray line. No handwashing was ever completed throughout the entire meal distribution. Cold order cook G removed the plastic lids to beverage glasses throughout the entire meal distribution and touched the top area of the glasses. His/her gloved hands however had touched the coffee machine, carts, and steam table all with the same pair of gloves on. G also removed individual ice cream portions from the wrappers and wore the same gloves as mentioned above. Cook I touched the refrigerator doors, ice cream boxes, steam table, and serving plates without any handwashing. 2. Observation during the noon meal in the dining room at 11:35 a.m. on 1/11/11 revealed: DA K wiped his face and nose area numerous times during the meal distribution, continued to deliver food on the red tray to residents, touched silverware packets, drinking glasses, and plates without washing his hands. M took covers off the beverage glasses, touched the tops of the glasses and cups, went to the coffee machine, touched the beverage cart and steam table, and did not wash her hands throughout the continued process. DA N distributed meals on the red trays, set the tray on two different tables next to residents, carried the empty tray back to the tray line holding it next to her leg while walking, and used the same tray over again without cleaning it. DA K completed the same process as above plus pushed his glasses up twice and touched his face several times. He continued to touch the prewrapped silverware packets and place them on the soiled red tray over and over again. 3. Observation during the evening meal in the dining room at 5:35 p.m. on 1/11/11 revealed: All of the unsanitary practices listed in finding 1 and 2 continued to be observed during that meal distribution process also. DA F delivered many random resident meals on the soiled red trays. At 5:55 p.m. a resident who had just blown his nose and wiped it with a handkerchief handed the DA his water glass to get it refilled. The soiled glass was placed on the red tray with another resident's food and taken back to the tray line. DA F handed the soiled glass to G who touched the soiled glass and refilled it with water. The soiled glass was then placed on another red tray that contained a resident's meal and left it set there. DA F returned to the tray line, picked up the soiled water glass, placed it on the red tray with another plate of food, and returned it to the resident. At no time did any of the dietary staff wash their hands after they touched the soiled water glass. 4. Random observations of CNAs serving the evening meal in the assisted dining room on 1/10/11 and 1/11/11 revealed the CNAs grasped the rim of the residents' drinking glasses when setting them on the tables for their meal. The CNAs touched the rim of the drinking glass with their bare hands contaminating the rim of the drinking glass. 5. Observation on 1/11/11 at 5:35 p.m. revealed a randomly observed CNA while serving meals to residents in the assisted dining room revealed during and after serving the resident she placed the serving tray on the table next to the resident. Then she placed the tray on a card table that had not been cleaned after residents were using it for a card game. And then she placed the tray on a notebook on top of the piano. Finally she returned it to the stack of serving trays in the main dining room contaminating the top surface of the serving tray on which it was placed. 6. Observation on 1/12/11 at 7:40 a.m. CNA Y and dietary aide V revealed both staff served residents in the assisted dining room their glasses of liquids by grasping the rims of the glasses. That procedure contaminated the surface of the glass where the resident would place their lips to take a drink. 7. Review of the provider's policy and procedure for sanitation/infection control for dietary department dated 2004 revealed hands should be washed: After touching any part of the body. After working with any dirty equipment. Between working with different foods. After handling soiled dishes. 8. Interview on 1/12/11 at 8:20 a.m. with certified dietary manager O confirmed: Policy and procedure for sanitation/infection control should have been followed. Serving trays should be cleaned or changed when soiled. Soiled beverage glasses should not be reused and placed on trays with residents' food.	2014-04-01
5116	ST WILLIAMS HOME FOR THE AGED	435122	100 SOUTH 9TH STREET	MILBANK	SD	57252	2011-01-12	441	D			FYSY11	Based on observation, interview, and policy review, the provider failed to ensure soiled linens were transported in a manner to prevent the possible spread of infection for one or four random observations. Findings include: 1. Observation on 1/10/11 at 6:25 p.m. revealed certified nurse assistant (CNA) J: Helped resident 2 change clothes and get into bed. After she had helped him/her get comfortable she picked up his/her dirty clothes and towels. *Bundled them against her uniform and carried them in the hall to the soiled linen hamper. Interview on 1/12/10 at 10:30 a.m. with infection control nurse E revealed the staff were taught to put soiled laundry into a plastic bag to carry it in the halls. Review of American Health Care Association, How to be a Nurse Assistant, 4th Ed., Salem, MA., 2008, pp. 142, revealed "Always carry linen by holding it away from your uniform, even if it is not visibly soiled." 2. Observation on 1/11/11 at 7:30 a.m. revealed a randomly observed CNA carried unbagged soiled linens from a resident's room across the hall to the soiled linen room. 3. Observation on 1/11/11 at 9:45 a.m. revealed CNA U removed a soiled incontinent pad from a resident's bed and carried it from the resident's room down the hallway to the soiled linen room without bagging the soiled linen. Interview with staff Z on 1/12/11 at 8:35 a.m. revealed CNA U was not a new CNA and had worked there for a few years. 4. Observation on 1/12/11 at 8:15 a.m. revealed CNA U carried a huge amount of soiled bed linens from a resident's room down the hallway to the soiled linen room without bagging the soiled linen. Interview with staff person Z on 1/12/11 at 8:35 a.m. revealed CNA U was not a new CNA and had worked there for a few years. 5. Interview with staff person X on 1/12/11 at 7:50 a.m. revealed the staff were to bag soiled linen and clothing before removing it from resident rooms. Soiled linen bags were provided for the staff to use on each wing. 6. Review of the provider's resident laundry policy dated 10/19/04 revealed "Soiled clothing is placed in a laundry bag, separate from soiled linen and pads."	2014-04-01
5117	ST WILLIAMS HOME FOR THE AGED	435122	100 SOUTH 9TH STREET	MILBANK	SD	57252	2011-01-12	425	D			FYSY11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure the appropriate disposition of medications for one of two closed records (14) reviewed. Findings include: 1. Review of resident 14's closed record revealed there was no documentation for the disposition of the following medications: [REDACTED] Senna with DSS. Darifenacen. Donepezel. Terazosin Hcl (hydrochloride). Esomeprazole. Aspirin EC (enteric coated). Interview with nurse E on 1/12/11 at 11:20 a.m. revealed: She and director of nursing A had searched for additional information without success. The Senna and the aspirin were from stock bottles and could not be checked as to what was done with the pills left. *The darifenacen, donepezel, Terazosin Hcl, and the esomeprazole were on punch cards and should have been returned to the pharmacy. There was no documentation available as to what was done with those medications.	2014-04-01
5118	ST WILLIAMS HOME FOR THE AGED	435122	100 SOUTH 9TH STREET	MILBANK	SD	57252	2011-01-12	281	D			FYSY11	Based on observation, interview, and policy review, the provider failed to ensure one of three licensed nurses (P) administered medications according to professional standards. Findings include: 1. Observation on 1/10/11 at 5:55 p.m. revealed nurse P: Set medications into three different medication cups. Stacked the cups with the medications in them. Carried the cups into the dining room. Gave one cup to a resident by the windows. Crossed the dining room and gave another cup to a second resident. Went to the north end of the dining room and gave a third resident the last cup. *She watched in the dining room a few minutes, then returned to the medication cart she was using. Interview on 1/12/11 at 10:40 a.m. with nurse A revealed the nurses were not to set-up more than one resident's med at a time. Review of the provider's administration of medication policy dated 3/1/06 revealed "Only one resident's medication is to be prepared at a time."	2014-04-01
5119	STRAND-KJORSVIG COMMUNITY REST HOME	435125	801 S MAIN POST OFFICE BOX 195	ROSLYN	SD	57261	2010-12-15	281	D			77SW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure: Appropriate dressing change procedures and standards were followed by nursing staff for one of two observed dressing changes (3). Appropriate procedures and infection control practices were followed during personal care for one of three sampled residents (11). Findings include: 1. Observation on 12/14/10 at 9:45 a.m. revealed resident 3 had a dressing change to her left outer ankle. Licensed practical nurse (LPN) F washed her hands prior to starting the procedure. She continued with the procedure as follows: Laid all the dressing supplies on the resident's bed on top of the bedspread. Applied gloves and removed the soiled dressing. With the same gloves on she cleaned the left outer ankle wound. With the same gloves on she applied a new dressing to the left outer ankle wound. Removed the gloves, disposed of the supplies, and washed her hands. Interview on 12/15/10 at 10:30 a.m. with director of nursing D and infection control nurse E revealed: The policy/procedure for a nonsterile dressing change was not followed correctly. The dressing supplies should have been placed on a paper towel and not directly on the resident's bedspread. New gloves and handwashing should have been completed before cleansing the wound. New gloves and handwashing should have been completed before applying the new dressing. Review of the undated nonsterile dressing policy/procedure revealed: "Prepare a clean dry work area at bedside by placing a paper towel/chux on top of the treatment cart and assembling necessary supplies." "Don clean gloves, remove soiled dressing, and discard in bag. Remove gloves and place in bag." "Wash hands thoroughly." "Don another pair of gloves of clean gloves and cleanse wound with normal saline. Discard materials and gloves in bag." "Wash hands thoroughly, don another pair of clean gloves, and apply clean dressings as prescribed." 2. Observation on 12/15/10 at 9:22 a.m. during care for resident 11 revealed certified nurse aide (CNA) H: Completed appropriate handwashing and gloving prior to providing care for the resident Sat on the clean incontinent pad (Chux) on the resident's bed while providing care thus potentially contaminating the Chux. While wearing gloves pulled down the resident's slacks and briefs. Removed the soiled pad from the brief. Placed the soiled pad on the clean Chux on the bed thus potentially contaminating the clean Chux. Provided perineal care contaminating her gloves. Using the soiled gloved hands placed a new pad in the resident's brief. Pulled the resident's brief and slacks up while wearing the contaminated gloves. [MEDICATION NAME] the resident's slacks while wearing the contaminated gloves. Removed the soiled pad from the now contaminated Chux and placed the soiled pad and wipes in the garbage can. Assisted the resident with the lift to a better position on the now contaminated Chux on the bed while still wearing the contaminated gloves. Repositioned the resident by manually lifting with two-persons on the bed while wearing the contaminated gloves. The contaminated gloves were then removed and placed in the garbage. Interview with CNA H at that time confirmed: She had not removed her gloves nor washed/or sanitized her hands during the procedure. She had not replaced the contaminated Chux on the bed before assisting the resident to bed. She was aware she should have removed the gloves following the perineal care and before continuing with the resident's care. Interview with director of nursing (DON) D on 12/15/10 at 12:15 p.m. revealed CNA H had informed her of the care provided to resident 11. The CNA stated she knew better. Both CNAs assisting resident 11 were "seasoned" CNAs. The care provided resident 11 was not what DON D or the infection control nurse would have expected to see provided to the residents. Review of the undated provider policy for handwashing did not address when gloves should be used and changed. The policy did state "Handwashing indications: In the absence of a true emergency, personnel should ALWAYS wash their hands:...After contact with the resident/patient blood and body fluids....After handling any contaminated items....After removing gloves." 3. Observation on 12/15/10 at 9:22 a.m. during the above procedure (finding 2) revealed resident 11 was standing with her slacks and brief lowered. The strap to the lift belt was dangling and continually touching the resident's lower abdomen and pubic area before and after the areas were cleansed. CNA G removed the lift belt and draped the belt over the lift. The lift was returned to the storage area without sending the soiled lift belt to the laundry. Interview with CNAs G and H at that time revealed the lift was dedicated to resident 11. They were not aware the strap had touched the resident during care. Interview with DON D on 12/15/10 at 10:20 p.m. revealed the lift was for any resident on that hallway that needed it. The only resident using the lift at that time was resident 11. The lift was to be cleaned between residents when used with multiple residents.	2014-04-01
5120	STRAND-KJORSVIG COMMUNITY REST HOME	435125	801 S MAIN POST OFFICE BOX 195	ROSLYN	SD	57261	2010-12-15	368	C			77SW11	Based on interview and policy review, the provider failed to offer each resident a substantial snack at bedtime. Findings include: 1. Interview during the group meeting with eight residents on 12/14/10 at 10:15 p.m. revealed: The staff did not offer them a snack at bedtime. They knew they could get something to eat after supper, but they had to ask for it. Interview on 12/15/10 at 10:50 a.m. with the director of nursing D revealed: The certified nurse aides were to pass bedtime snacks to the residents. She did not know the residents had to ask for them. She could not find a policy for the passing of bedtime snacks in the nursing policy manual. She stated she would ask dietary if they had one. Review of the dietary department's policy for meal service, snacks, and substitutions revised 10/15/10 revealed: "The dietary department will ensure that between meals and/or bedtime snacks are available for the request of the residents." "Bedtime snacks will be provided by the dietary department." "A cart will be assembled by dietary and delivered to the nursing department before leaving in the evening." "The cart will be taken to the resident's rooms by nursing."	2014-04-01
5121	STRAND-KJORSVIG COMMUNITY REST HOME	435125	801 S MAIN POST OFFICE BOX 195	ROSLYN	SD	57261	2010-12-15	441	D			77SW11	Based on observation, interview, and policy review, the provider failed to ensure: One of two sampled residents (3) dressing changes were performed in a clean and sanitary manner. One of three observations of handwashing and glove usage with resident's personal care (11) was performed in a clean and sanitary manner. Laundry staff handled processing and transporting of soiled linen in a safe and sanitary manner. Findings include: 1. Observation and interviews on 12/14/10 and on 12/15/10 regarding the dressing changes for resident 3 revealed infection control standards were not followed. Refer to F281, finding 1. 2. Observation and interviews on 12/15/10 at 9:22 a.m. during resident 11's personal care revealed infection control standards were not followed. Refer to 281, finding 2 3. Observation and interviews on 12/15/10 at 9:22 a.m. during resident 11's personal care revealed infection control standards were not followed. Refer to 281, finding 3. 4. Observation on the afternoon of 12/14/10 revealed the laundry staff person J was transporting soiled linen in the hallway while wearing a protective gown and gloves. Observation on 12/15/10 at 9:00 a.m. revealed laundry supervisor I was transporting the soiled linen cart in the hallway to the laundry while wearing a protective gown and gloves. Interview with laundry supervisor I on 12/15/10 at 9:40 a.m. revealed the laundry staff had two gowns to wear when transporting soiled linen carts in the hallways and sorting soiled linens. The gowns were not dedicated, so only one gown was worn for sorting soiled laundry and the other was to be used only when transporting soiled linen carts in the hallways. At times during the day the gowns could have been used to sort laundry contaminating the gowns, before wearing them through the hallways to transport the soiled linen carts. Interview with the interim administrator A on 12/15/10 at 9:50 a.m. revealed: She was not aware the soiled linen carts could be transported through the hallways without wearing protective clothing and gloves. She was not aware protective clothing and gloving was not necessarey as long at the soiled clothing was bagged and in a covered container. She had not considered the gowns could have been contaminated and possibly causing the spread of micro-organisms as the staff traveled the hallways with the soiled linen carts.	2014-04-01
5122	STRAND-KJORSVIG COMMUNITY REST HOME	435125	801 S MAIN POST OFFICE BOX 195	ROSLYN	SD	57261	2010-12-15	161	C			77SW11	Based on record review and interview, the provider failed to ensure the surety bond protected resident personal funds for loss other than that occurred by employee dishonesty for all residents of the facility. Findings include: 1. Review of the information on the surety bond indicated residents' funds were protected from "employee or employees when the dishonest act of the employees shall have been committed." The bond did not protect the residents' funds from losses occurring as a result of acts or errors of negligence, incompetence, or dishonesty. The bond did not specify that the obligee may collect due to any failure by the facility, whether by commission, bankruptcy, or omission, to hold, safeguard, manage, and account for the residents' funds as required. Interview with administrator B on 12/14/10 at 1:00 p.m. revealed he was not sure if the bond offered protection of residents' funds from anything more than employee dishonesty. Interview with administrator B and administrator-in-training C on 12/14/10 at 2:47 p.m. revealed the requirements of the surety bond were being faxed to the insurance company for review. Interview with administrator-in-training C on 12/15/10 at 12:30 p.m. revealed the insurance company had forwarded the information regarding the additional coverage the bond needed to provide to the surety bond company for review and adjustment to the bond to meet the requirements.	2014-04-01
5123	VIOLET TSCHETTER MEMORIAL HOME	435126	50 SEVENTH ST SE POST OFFICE BOX 946	HURON	SD	57350	2011-06-15	334	D			BBUQ11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to document for 2 of 14 sampled residents (8 and 11) if a pneumococcal or influenza vaccination had been: Received prior to entering the facility. Offered and declined while the resident was in the facility. Administered within the facility after admission. Findings include: 1. Review of resident 11's medical record for pneumococcal and influenza vaccinations revealed: She was admitted on [DATE]. The form used to record immunization status was documented to indicate there was no record of the resident receiving a pneumococcal vaccination. The resident's last influenza vaccination was documented as 10/2/08. A consent form dated 12/7/10 related to immunizations was signed by resident 11 but not completed. The permission section to administer the pneumococcal vaccination one time and the influenza vaccination annually were not documented either "Yes" or "No." The area to document the date of a previous pneumococcal vaccination was not completed. A FAX communication to resident 11's physician signed by the physician on 12/8/10 indicated there was no record of a pneumococcal vaccination and the last influenza vaccination was 10/2/08. There was no documentation in the rest of resident 11's health care record of her ever receiving a pneumococcal vaccination or an influenza vaccination after 10/2/08. The provider was given the opportunity to find documentation to support resident 11 having received a pneumococcal vaccination at any time or an influenza vaccination after 10/2/08. The provider could not supply any documentation for the above. Interview on 6/15/11 at 9:25 a.m. with resident 11 revealed: She was not aware of having received a pneumococcal or influenza vaccination from the provider. Her physician would have known if she had received them before. She would have consented to receiving the pneumococcal and influenza vaccinations from the provider. 2. Review of resident 8's medical record revealed: She had been admitted on [DATE]. The area for pneumococcal vaccination on the form used to record immunization status was blank. There was no documentation in the rest of resident 8's health care record of her ever receiving a pneumococcal vaccination. The provider was given the opportunity to find documentation to support resident 8 having received a pneumococcal vaccination at any time. The provider could not supply any documentation for the above. Review of a physician's protocol revised June 2008 and used as a policy for administration of vaccinations revealed: Pneumococcal vaccinations were to be administered. Influenza vaccinations were to be administered annually. *Staff were to have checked with the clinic for immunization records before administering immunizations. Interview on 6/15/11 at 3:00 p.m. with the director of nursing revealed the above protocol was the only policy the provider had for administering immunizations.	2014-04-01
5124	VIOLET TSCHETTER MEMORIAL HOME	435126	50 SEVENTH ST SE POST OFFICE BOX 946	HURON	SD	57350	2011-06-15	279	D			BBUQ11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the provider failed to ensure care plans were comprehensive and individualized for 2 of 16 sampled residents (2 and 3). Findings include: 1. Review of resident 3's entire medical record revealed: Documentation in the nurse's note on 5/20/11 stated a Foley catheter (tube to drain urine) had been inserted. The signed and dated 6/8/11, June 2011 physician orders [REDACTED]. An order dated 5/20/11 to record the urinary output from the Foley catheter. A care plan that had a problem, goal, and approach for urinary incontinence. -The typed next review date of the care plan was 5/12/11. -The hand written next review date of the care plan was 8/25/11. That same care plan did not contain a focus care planned area for the catheter. Interview on 6/15/11 at 10:30 a.m. with the director of nurses (DON) revealed: She agreed a focus problem area for the Foley catheter should have been added to the care plan. *She was unsure if there was a policy for care plans. 2. Review of resident 2's medical record revealed the provider failed to develop a comprehensive care plan that addressed his room change and transition to the new room location. Refer to F247.	2014-04-01
5125	VIOLET TSCHETTER MEMORIAL HOME	435126	50 SEVENTH ST SE POST OFFICE BOX 946	HURON	SD	57350	2011-06-15	281	D			BBUQ11	Based on record review and interview the provider failed to ensure physician's orders were obtained before implementing a nursing procedure for 1 of 16 sampled residents (3). Findings include: 1. Review of resident 3's entire medical record revealed: An untimed notation on 5/6/11 by a registered nurse (RN) in the progress notes. That notation stated a residual catheterization had been done and returned 300 cubic centimeters (cc) of urine. -There was no physician's order for that catheterization. At 4:30 p.m. on 5/19/11 a notation in the progress notes by an RN stated the resident had been catheterized, and 575 ccs of urine was obtained. There was no physician's order for that catheterization. Interview on 6/14/11 at 1:45 p.m. with RN C revealed: She stated there was no order in resident 3's chart for those catheterizations. She stated there was no comminication in the resident's chart to the physician regarding those catheterizations. Interview on 6/15/11 at 10:30 a.m. with the director of nurses revealed: She stated there were no orders for the catheterizations on 5/6/11 and 5/19/11. She agreed there should have been a physician's order obtained prior to those catheterizations. She was unable to locate a policy for physician's orders.	2014-04-01
5126	VIOLET TSCHETTER MEMORIAL HOME	435126	50 SEVENTH ST SE POST OFFICE BOX 946	HURON	SD	57350	2011-06-15	371	D			BBUQ11	Based on observation and interview, the provider failed to ensure proper sanitary procedures were followed while serving the meal for two of two observed meal services. The staff failed to: Store ready-to-serve food containers in a manner that avoided cross-contamination. Change gloves and wash hands to prevent cross-contamination. Findings include: 1. Observation on 6/14/11 from 11:25 a.m. through 12:30 p.m. revealed cook D: Had stored small covered food pans inside large covered food pans on the steam stable. -The large pans contained french fries and chicken nuggets that touched the outside of the small pans. -The smaller pans contained ground and pureed ready-to-serve food. Removed the small pans from the large pans and sat them on the front serving counter and served the food from them. Put those same small pans back into the larger pans. Those smaller pans touched the food in the large pans and cross-contaminated the food. 2. Observation on 6/14/11 at 5:25 p.m. revealed the certified dietary manager (CDM) while serving the evening meal and wearing gloves: Left the serving area. Opened the refrigerator door and removed cheese. Opened the cupboard and removed bread. Opened the bread bag and took out bread slices. Made a sandwich. Closed the bread bag. Returned to the serving area and without removing her gloves or sanitizing her hands continued serving the evening meal. Interview on 6/15/11 at 9:10 a.m. with the CDM revealed: She agreed the storage of the small pans inside the larger pans that contained food was cross-contamination. *She agreed she should have washed her hands and/or changed her gloves before returning to the serving line to have avoided cross-contamination.	2014-04-01
5127	VIOLET TSCHETTER MEMORIAL HOME	435126	50 SEVENTH ST SE POST OFFICE BOX 946	HURON	SD	57350	2011-06-15	441	D			BBUQ11	Based on observation, interview, and policy/procedure review, the provider failed to ensure proper infection control practices were followed for: Handwashing and glove use during one of one observed resident's (4) treatments and care by a nurse. Use of gloves during three of three observed resident's (4, 15, and 16) care provided by a certified nursing assistant. Findings include: 1. Observation on 6/14/11 at 3:10 p.m. of nurse A while she provided care to resident 4 revealed she entered the resident's room and without washing her hands or putting on gloves: Removed the soiled dressing from the feeding tube ostomy site and threw it away. Placed a clean dressing on the site. Assembled the nebulizer inhalation chamber and placed the nebulizer solution in the chamber. Placed the nebulizer mask with the chamber attached to the resident's face for inhalation and started that treatment. Then accessed the port to the feeding tube with a syringe and drew back on the plunger of the syringe to check for residual fluids in the stomach. Then using a stethoscope listened as she injected air into the feeding tube to check for proper placement of the tube. Used the syringe to flush the tube with water. Then gave a bolus feeding by way of the feeding tube and flushed with water again. Clamped off the feeding tube and closed the port access. Then removed the nebulizer mask and chamber from the resident's face. Took the feeding tube syringe and the nebulizer equipment to the resident's bathroom room sink and rinsed them with water. Placed them on a clean towel to dry. Left the resident's room. Knocked on other resident doors and opened the doors with her hands to check for staff until they were located. Used hand sanitizer after she had located the staff and had returned to the medication cart. Review of the 2006 clean dressing change policy revealed: Gloves should have been worn during the dressing change. The gloves should have been changed after the soiled dressing was removed and before the clean dressing was applied. Review of the January 2008 enteral feeding tube policy revealed: Hands should have been washed before the feeding was started. Gloves should have been worn during the feeding. 2. Observation on 6/14/11 at 3:20 p.m. during resident toileting care for resident 4 revealed certified nursing assistant (CNA) B with the same gloves on: Wiped the resident's bottom. Pulled the resident's pants and slacks up. Opened the bathroom door. Held onto the gait belt while he assisted the resident to the easy chair. Touched the resident's right arm, back, and left arm. Pulled his own slacks up. Picked the walker up, folded it, and placed it against the wall. Removed his gloves and washed his hands. Review of the April 2009 handwashing technique policy revealed there had been no direction as to when hands should have been washed. The provider had no glove use policy in place. Interview on 6/15/11 at 2:00 p.m. with the interim director of nursing confirmed: Nurse A should have washed her hands when she entered the room and before she had left the room. Nurse A should have washed her hands between tasks. She should have worn gloves during those tasks. CNA B should have removed his gloves and washed his hands after he had completed the toileting care. 3. Observation on 6/15/11 at 7:45 a.m. of CNA D revealed she entered resident 15's room and without washing her hands: Donned gloves. Zipped up the resident's jacket. Put a gait belt on the resident. Flushed the toilet. Removed her gloves. Without sanitizing her hands proceeded to clean the resident's eyeglasses. Bagged the soiled towel. Combed the resident's hair. Pushed resident 15 to the elevator area. Disposed of the soiled laundry. Used hand sanitizer at the nurses desk. 4. Observation on 6/15/11 at 7:50 a.m. of CNA D revealed she entered resident 16's room to assist the resident with personal care. She: Washed her hands and donned gloves. Set out garbage bags on the bed, folded a blanket, adjusted items on the table, cranked up the bed, and set out clothes for the resident. Removed her gloves. Without sanitizing her hands put on new gloves. Gave the resident a cloth to wash her face. Cleaned the resident's eyeglasses, put dirty socks in the bag on the bed, adjusted the lift sling, applied lotion to the residents feet, and put clean socks on the resident. Removed her gloves and put on clean gloves without sanitizing her hands. Turned on the resident's call light to signal for assistance in transferring the resident. Turned off the call light when assistance had arrived. Raised the resident in the sling and washed her bottom. Removed her gloves. Used the lift and sat the resident into her wheelchair. Without washing or sanitizing her hands put on clean gloves. Gathered the soiled clothes and garbage, lowered the bed, and brushed the resident's hair. Removed her gloves. Did not wash her hands. Applied hand sanitizer to her hands. Interview on 6/15/11 at 10:30 a.m. with the DON revealed: She expected the CNAs to sanitize their hands when they had changed their gloves. *She expected the CNAs to wash their hands before leaving a resident's room when they had provided personal care.	2014-04-01
5128	VIOLET TSCHETTER MEMORIAL HOME	435126	50 SEVENTH ST SE POST OFFICE BOX 946	HURON	SD	57350	2011-06-15	278	D			BBUQ11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure assessment information for 2 of 14 sampled residents (8 and 11) was accurate for: Immunizations. Diagnosis. Findings include: 1. Review of resident 11's Minimum Data Set (MDS) 3.0 assessments revealed: 12/14/10, 3/8/11, and 5/31/11 - The section for influenza vaccine received in the facility was documented as "No." The documentation for the reason why the influenza vaccine was not received stated "Offered and declined." 12/21/10 - The section for influenza vaccine received in the facility was documented as "Yes." The date of administration was documented as "11/22/10." 12/14/10, 12/21/10, 3/8/11, and 5/31/11 - The section for pneumococcal vaccination was documented as being up to date. 12/14/10, 3/8/11, and 5/31/11 - The [DIAGNOSES REDACTED]." 12/21/10 - The [DIAGNOSES REDACTED]." Review of resident 11's medical record revealed there was no documentation the resident: Had received an influenza vaccination while in the facility or from another provider after 10/2/08. Had been offered by the provider the opportunity to receive or decline an influenza vaccination. Had ever received a pneumococcal vaccination. *Had ever had [MEDICAL CONDITION]. Interview on 6/15/11 at 4:25 p.m. with registered nurse A and the social worker designee revealed they were not aware of resident 11 having [MEDICAL CONDITION]. Refer to F334, finding 1. 2. Review of resident 8's 12/14/10, 3/8/11, and 5/31/1 MDS 3.0 assessments revealed the section for pneumococcal vaccination was documented as being up to date. Review of resident 8's medical record revealed there was no documentation the resident had received a pneumonia vaccination while in the facility or from another provider. Refer to F334, finding 2.	2014-04-01
5129	VIOLET TSCHETTER MEMORIAL HOME	435126	50 SEVENTH ST SE POST OFFICE BOX 946	HURON	SD	57350	2011-06-15	247	D			BBUQ11	Based on record review, policy review, and interview, the provider failed to furnish advance notice to 1 of 14 sampled residents (2) before moving him to another room. Findings include: 1. Review of resident 2's nursing progress notes from 12/26/10 through 4/18/11 revealed: He had been in one room on 1/15/11. On 2/6/11 he was in a different room. He continued to be in the new room at the time of the survey. No entries were made in the nursing progress notes that explained the room change. Review of the social services progress notes from 10/25/10 through 3/17/11 revealed no explanation for the room change. Review of resident 2's Minimum Data Set assessments for 12/7/10 and 2/22/11 revealed no behaviors had been exhibited by the resident during that time frame. Review of the care plan in place from 12/10/10 through 3/2/11 revealed no explanation or approaches that addressed the room change for resident 2. Review of the provider's undated resident's rights pamphlet provided in the admission packet to residents revealed: A subheading "Accomodation of Needs". Under that subheading it stated the resident would receive notice before a room or roommate would be changed. A subheading "Social Services". Under that subheading it stated the provider would "provide social services to attain or maintain your highest level of well-being". Interview on 6/15/11 at 9:10 a.m. with the interim director of nursing confirmed: The room change occurred before she was employed by the provider. The room change occurred before the present social services designee was employed by the provider. She would have expected documentation that addressed the room change for resident 2. She would have expected documentation by the social services department that addressed the room change. It should have been an interdisciplinary team decision. The care plan should have addressed the room change. The care plan should have included approaches to help with adjustment for the resident after the room change . Interview on 6/15/11 at 11:15 a.m. with resident 2's charge nurse A confirmed: She had no direct knowledge as to why resident 2 had been moved to another location. *She believed the move for resident 2 was related to complaints from other residents. 2. Interview with resident 2 on 6/14/11at 1:45 p.m. and 6/15/11 at 10:27 a.m. revealed he was moved from his 3rd floor room without choice or notice to a room on 2nd floor.	2014-04-01
5130	VIOLET TSCHETTER MEMORIAL HOME	435126	50 SEVENTH ST SE POST OFFICE BOX 946	HURON	SD	57350	2011-06-15	250	D			BBUQ11	Based on record review, policy review, and interview, the provider failed to maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 14 sampled residents reviewed (2). Findings include: 1. The provider's social service's designee failed to provide an assessment or interventions when resident 2 was moved. Refer to F247.	2014-04-01
5131	VIOLET TSCHETTER MEMORIAL HOME	435126	50 SEVENTH ST SE POST OFFICE BOX 946	HURON	SD	57350	2011-06-15	431	D			BBUQ11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider did not ensure controlled substance medications were accounted for and destroyed for one of two residents (14) sampled for closed record review. Findings include: 1. Review of the closed record for resident 14 revealed she died on [DATE]. The medication administration records (MAR) revealed: Fentanyl patch 12 microgram (mcg) was started on [DATE]. Three patches were documented as administered. Acetaminophen 500 milligram (mg)/hydrocodone 5 mg was started on [DATE]. Eight tablets were documented as administered. Fentanyl patch 25 mcg was started on [DATE]. Two patches were documented as administered. Morphine sulfate solution 20 mg/1 milliliter (ml) was started on [DATE]. Nineteen 0.5 ml doses were documented as administered for a total of 9.5 ml. Interview on [DATE] at 2:09 p.m. with consultant pharmacist J revealed: The pharmacy had delivered controlled substance medications for resident 14 to the provider: - Five fentanyl 12 mcg patches on [DATE]. - Thirty tablets of acetaminophen 500 mg/hydrocodone 5 mg on [DATE]. - Five fentanyl 25 mcg patches on [DATE]. - One bottle (30 ml) of morphine sulfate solution 20 mg/1 ml on [DATE]. That bottle was sent to replace a 30 ml bottle that was removed by the provider from the emergency supply. The consultant pharmacist who served the facility had been to the facility on [DATE]. It was not known if the consultant pharmacist and a nurse had destroyed any controlled substances at that time. If controlled substances had been destroyed, the only copy of the destruction record was maintained by the provider. Surveyor calculation revealed the quantities of controlled substances should have been remaining following the death of resident 14: Two fentanyl 12 mcg patches. Twenty-two tablets of acetaminophen 500 mg/hydrocodone 5 mg. Three fentanyl 25 mcg patches. Partial 30 ml bottle of morphine sulfate solution 20 mg/1 ml containing 20.5 ml. Interview on [DATE] at 3:00 p.m. with the director of nursing (DON) revealed she and the administrator could not find the above quantities of controlled substances. The DON stated she and the administrator could not find any documentation showing the above controlled substances had been destroyed by a nurse from the facility and a pharmacist.	2014-04-01
5132	DOW RUMMEL VILLAGE	435127	1321 W DOW RUMMEL ST	SIOUX FALLS	SD	57104	2011-01-20	221	D			8H2U11	Surveyor Preceptor Based on observation, interview, record review, and policy review, the provider failed to do ongoing assessment and care planning for restraint use for one of two sampled residents (9) with restraints. Findings include: 1. Review of resident 9's entire medical record on 1/19/11 at 4:00 p.m. revealed: The physician's original order dated 10/20/09 stated the resident may use Geriatric (geri) chair with lap tray (restraint). Care plan approaches dated 10/20/10 revealed: -"Restraint protocol will be followed as long as she uses the geri-chair." -"Lap tray will be removed during meals." Random observation on 1/19/11 from 11:45 a.m. to 12:30 p.m. of resident 9 revealed: At 11:45 a.m. she was placed at the dining room table in a geri-chair with a lap tray. At 12 noon she was still sitting at the table in the geri-chair with the lap tray on drinking a glass of water. At 12:05 p.m. she was banging a glass with ice on the side of the geri-chair lap tray. At 12:15 p.m. she was sitting at the table in the geri-chair with the lap tray and had not received her meal. The other four residents at the table had received their food. At 12:30 p.m. a staff member placed a meal on the table in front of resident 9 who continued to sit in the geri-chair with lap tray. Interview on 1/19/11 at 4:30 p.m. with director of nursing (DON) A and director of assisted living H revealed: -Both agreed an initial assessment had not been done for resident 9's restraint. -Restraints were reviewed monthly at the quality of life meetings. Review of the provider's policy for Physical Restraints dated 8/1/97 revealed: Nursing staff and the care team would complete the Physical Restraint Elimination Assessment quarterly at care plan conferences. The resident's care plan would be updated to include the reason for the restraint, the required monitoring, and a measurable goal related to the rationale for its use. Interview with DON A on 1/20/11 at 8:15 a.m. revealed: She agreed the provider's policy for physical restraints had not been followed. She expected the provider's policy for physical restraints to be followed. The provider's policies were outdated and needed revision. She agreed the geri-chair lap tray had not been removed at meal time. Her expectations were for the staff to follow the care plan. Interview with licensed nurse B on 1/20/11 at 7:20 a.m. and at 9:00 a.m. revealed: She was not sure what the provider's policy for physical restraints was about. She agreed assessments had not been done for resident 9's restraint usage.	2014-04-01
5133	DOW RUMMEL VILLAGE	435127	1321 W DOW RUMMEL ST	SIOUX FALLS	SD	57104	2011-01-20	281	D			8H2U11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, policy review, and interview, the provider failed to ensure professional standards were upheld as evidenced by: One of twelve sampled residents (5) failed to receive medications as ordered by her physician at admission, and one of one resident (7) with a physician order [REDACTED]. One of twelve sampled residents (18) medication administration records (MAR) had discrepancies from one month to the next month that were not clarified. One of two sampled residents (14) who were administered insulin was given an expired medication. Three of four observed residents (14, 16, and 17) insulin administrations were done without using universal precautions. Findings include: 1. Interview with resident 5 on [DATE] at 4:30 p.m. revealed she: Had been a resident for only a couple of weeks. She had lived in an assisted living facility prior to going to the hospital for pneumonia. Had arthritis and had always had a lot of pain because of that. Was kind of upset, because she had just found out she was not receiving any medication for pain. Knew she was having some more pain recently but thought it was because she was getting therapy. Received her medications from the nurses in a small cup. Knew she was getting more medications now then she had before so did not realize she was not getting anything for pain. Review of resident 5's [DATE] MAR indicated [REDACTED]. Review of resident 5's physician's orders [REDACTED]. an order for [REDACTED]. Further review revealed a discharge treatment form dated [DATE] from the hospital with an order for [REDACTED]. Interview with registered nurse (RN) C revealed the above orders were the admission orders [REDACTED]. They should have went by the discharge treatment form dated [DATE] for the specific physician's orders [REDACTED]. Review of resident 5's nurses notes dated [DATE] revealed "One (1) page of MARs from assisted living (AL) not faxed to pharmacy when transferred to Allen Wing. Has not been receiving [MEDICATION NAME], TUMS, [MEDICATION NAME], and multivitamin (MVI). MAR faxed to (pharmacy) to fill these medications(meds)." Signed by RN B. Interview with RN B on [DATE] at 4:00 p.m. revealed: She had become aware resident 5 was not receiving pain medications when she did a pain assessment on her for the Minimum Data Set on [DATE]. Resident 5 had told her she received a medication for pain. In review of resident 5's MAR indicated [REDACTED]. She discovered there were several medications resident 5 was not receiving. She discovered one page of medications for resident 5 was missing and had not been received from the pharmacy. Interview with director of nurses (DON) A on [DATE] at 5:20 p.m. revealed: Resident 5 had not received the pain medications and several other supplements from the time of admission. When resident 5 was admitted the nurses faxed the MARs from the assisted living to the pharmacy. Somehow the page of the MAR indicated [REDACTED]. No one could explain how that had happened including the pharmacist. The nurses should have caught the omission when they reconciled the medications with the MAR indicated [REDACTED]. Interview with DON A on [DATE] at 11:45 a.m. revealed: They did not have a policy on following physician orders. She could not find the professional standard they followed for following physician orders. She was in contact with their pharmacy provider to find a professional standard. The professional standard provided was electronically mailed to the DON by the pharmacist. It stated "The physician is in charge of directing the clients care and the nurses are to carry out the physician's orders [REDACTED]. 2. Review of the most current physician's orders [REDACTED]. Review of the treatment record for resident 7 revealed an undated sheet of paper stating the resident was to be weighed daily and charted. Review of the weight log for resident 7 on [DATE] at 1:45 p.m. revealed the last recorded weight was 125.5 pounds (lb) on [DATE]. Interview on [DATE] at 1:45 p.m. with RN C, RN E, and certified nursing assistant (CNA) I revealed: The scale in the whirlpool room used for daily weights was not working properly. Resident 7 weighed 126 lb on Saturday ([DATE]). The whirlpool room scale had not been working since Sunday ([DATE]). Maintenance was working on the scale but did not have it fixed yet. The wheel chair scale they used to use was no longer available. There was a scale in the memory care unit, but resident 7 would not be able to stand on the scale to be weighed. Observation in the whirlpool room on [DATE] at 9:15 a.m. revealed the scale was being worked on. Interview with CNA I on [DATE] at 9:30 a.m. revealed: The scale had been repaired and the resident had been weighed. The resident's weight was 118 lb. Review of the weight log for resident 7 on [DATE] at 11:00 a.m. revealed: A weight of 125 lb had been recorded on [DATE]. A weight of 126 lb had been recorded on [DATE]. A weight of 118.5 lb had been recorded on [DATE]. Interview with DON A on [DATE] at 11:00 a.m. revealed: She was aware resident 7 was to be weighed daily. She was not aware that resident 7 had not been weighed daily since [DATE] when the scale had broke. There were other scales available in the facility. She would have expect the staff to use one of the other scales to complete the daily weights. Surveyor Preceptor 3. Review of resident 18's complete medical record revealed: A physician's orders [REDACTED]. A physican's order dated [DATE] to administer "cough syrup one half hour before each feeding four times a day (QID)." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." Interview with the director of nursing (DON) A on [DATE] at 8:15 a.m. revealed: She agreed the above was a documentation error. The current order for the [MEDICATION NAME] was dated [DATE]. Review of the provider's policy for Medication Administration General Guidelines revised [DATE] revealed: All current medications, dosages, and administration schedules would be listed on the resident's MAR. To ensure accuracy in the administration of medications staff administering the medications were responsible for checking to see if the medication and dosage schedule on the resident's administration record matched the label on the medication package. If the medication package was marked with "Directions changed refer to med sheet" sticker indicating a recent change in directions for use or any reason to question the medication directions. The nurse would verify the physician's orders [REDACTED]. 4. Observation and interview on [DATE] at 5:30 p.m. revealed: Licensed nurse (LN) C took a vial of [MEDICATION NAME]for resident 14 from the medication cart. -LN C administered nine units of [MEDICATION NAME] 100 unit/milliliter per physician's orders [REDACTED]. -The open date of the [MEDICATION NAME] was [DATE]. -LN C looked at the date on the [MEDICATION NAME] after administering the insulin and put the insulin into the medication room for destruction. -LN C agreed the [MEDICATION NAME] was opened on [DATE] and had expired. Review of the provider's policy for Medication Storage and Expiration Guidelines effective [DATE] revealed: [MEDICATION NAME]vials were to be discarded when the product expiration date was reached. [MEDICATION NAME]vials should have been discarded 28 days after being opened. Interview on [DATE] at 8:15 a.m. with DON A revealed: She agreed with the provider's policy for Medication Storage and Expiration Guidelines to discard opened insulin vials. Her expectations were for the nurses to discard and not use the expired insulin vials. 5. Observation, interview, and policy review revealed on [DATE]with LN C revealed: At 5:30 p.m. she administered insulin to resident 14 without wearing gloves. At 5:35 p.m. she administered insulin to resident 17 without wearing gloves. *At 5:42 p.m. she administered insulin to resident 16 without wearing gloves. Review of the provider's policy for Bloodborne and Airborne Exposure Control Plan dated [DATE] revealed "Personal protective equipment is specialized clothing of equipment used by healthcare workers to protect themselves from direct exposure to blood or other potentially infectious materials. Dow Rummel provides for employees use of appropriate personal protective equipment such as, but not limited to, gloves, gowns, fluid-resistant aprons, face shield or masks, eye protection, resuscitation, bags, pocket masks or other ventilation." Interview with DON A on [DATE] at 8:15 a.m. revealed her expectations were for the nurses to wear gloves when administering insulin.	2014-04-01
5134	DOW RUMMEL VILLAGE	435127	1321 W DOW RUMMEL ST	SIOUX FALLS	SD	57104	2011-01-20	282	D			8H2U11	Surveyor Preceptor Based on observation, interview, and record review, the provider failed to ensure care plans were followed for the use of a restraint for one of two sampled residents (9). Findings include: 1. Review of resident 9's care plan dated 10/20/10 revealed: "Restraint protocol will be followed as long as she uses the geri chair." "Lap tray will be removed during meals." Refer to F221, finding 1.	2014-04-01
5135	DOW RUMMEL VILLAGE	435127	1321 W DOW RUMMEL ST	SIOUX FALLS	SD	57104	2011-01-20	431	E			8H2U11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor Preceptor Based on observation, interview, and policy review, the provider failed to maintain safe and secure storage of medications in one of one medication room and one of two medication carts. Findings include: 1. Random observation on 1/18/11 from 4:45 p.m. through 6:10 p.m. revealed: The medication room door was open at 4:45 p.m. -Licensed nurse (LN) C was sitting at the nurses desk with her back to the medication room. -Multiple prescriptions were on the counter in the medication room. -At 4:50 p.m. LN C went into the open medication room, then returned to the nurses desk positioning herself with her back to the open medication room door. -At 4:53 p.m. certified nursing assistant (CNA) D went into the medication room through the open door, obtained a walkie talkie, and left through the open medication door. -At 4:55 p.m. LN C got up from the nurses station and closed the medication room door. At 5:15 p.m. LN E unlocked the medication room door, opened the door, and then sat down at the nurses station. At 5:18 p.m. LN C and LN E were sitting at the nurses station with their backs to the open medication room door. At 5:20 p.m. LN C went in and out of the open medication room, then returned to the nurses desk positioning herself with her back to the open medication room door. At 6:10 p.m. LN E was sitting at the nurses station with her back to the open medication room door. 2. Random observation on 1/18/11 from 5:15 p.m. through 6:00 p.m. revealed: At 5:15 p.m. LN C left the medication cart unlocked and went and sat down by the nurses station. -Resident 15 with a [DIAGNOSES REDACTED]. At 5:30 p.m. LN C walked away from the unlocked medication cart. At 5:40 p.m. LN C left the medication cart unlocked and unattended as she went into the medication room. At 5:47 p.m. in the dining room LN C was administering medications to the residents. -Residents were entering and exiting the dining room. -On multiple observations LN C walked away from and out of view of the unlocked medication cart as she administered medications to residents in the dining room. Review of the provider's policy for Medication Storage and Handling dated 11/1/04 revealed: "All drugs or medications must be stored in a well-illuminated locked storage area." "Medication rooms, carts and medication supplies are locked or are attended by persons with authorized access." Review of the provider's policy for Medication Administration General Guidelines revised January 2010 revealed: "Do not leave medications unattended. The nurse or med aide is responsible for the safekeeping of drugs." "The cart must be clearly visible to the personnel administering medications." "The medication cart will remained locked when not in direct sight of the personnel administering medications. Medications must be inaccessible to residents and others passing by." Interview with director of nursing A on 1/20/11 at 8:15 a.m. revealed: She agreed the facility was not following the policies for medication storage and handling, and medication general guidelines. Her expectations were for the personnel administering medications to follow the policies. The nurses should havw kept medications off the medication room cupboard when the door was open. She prefered the medication room door be closed. *She expected the medication cart to be locked when not in the view of the personnel administering medications.	2014-04-01
5136	DOW RUMMEL VILLAGE	435127	1321 W DOW RUMMEL ST	SIOUX FALLS	SD	57104	2011-01-20	441	D			8H2U11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, the provider failed to implement an infection control procedure that notified housekeeping of the type of infectious organism in isolation rooms. Findings include: 1. Interview with director of housekeeping and laundry J on 1/20/11 at 8:00 a.m. revealed: Housekeeping staff were not notified of the type of infectious organism in isolation rooms. She was aware certain organisms such as Clostridium difficile (C. diff) would require specific disinfectants to be controlled. She was aware the current disinfectant the facility used would not be effective against [DIAGNOSES REDACTED]. If [DIAGNOSES REDACTED] was in the facility the housekeeping staff would continue to use the current disinfectant until they were notified. Interview with infection control registered nurse (RN) B on 1/20/11 at 10:00 a.m. revealed: She would expect the charge nurse to notify housekeeping of the infectious organism before they cleaned the room. She was not aware housekeeping was not notified of the infectious organism. She agreed housekeeping should be notified of the infectious organism, so they could use the proper cleaning procedures. Interview with RN C, a charge nurse, on 1/20/11 at 10:12 a.m. revealed: She would not inform the housekeeping staff of the type of infectious organism in the isolation room. *She would inform the housekeeping staff of the proper contact precautions they should follow when cleaning the room.	2014-04-01
5137	GOOD SAMARITAN SOCIETY SELBY	435123	4861 LINCOLN AVENUE	SELBY	SD	57472	2010-12-22	281	E			Y8ZR11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to ensure appropriate infection control and medication administration procedures were followed by two of two nurses (C and D) during 16 of 32 random observations of medication administration in the dining room. Findings include: 1. Observation on 12/20/10 from 5:15 p.m. until 6:05 p.m. during medication administration revealed nurse C: Poured pills into the palm of her hand from two separate pill bottles and then put the pills into the medication cup. Punched a pill from the prepackaged punch card into the medication cup. Using her fingers she removed the pill, broke it in half, and returned the two halves of the pill to the medication cup. Placed a medication cup on the top of the medication cart and poured a liquid medication in the cup. She then proceeded to raise the medication cup to eye level. The medication cup contained an excessive amount of medication. She then proceeded to pour the excess medication back into the bottle. Poured pills into the palm of her bare hand from two separate pill bottles and then placed the pills in the medication cup. Poured pills from a pill bottle into the palm of her hand, used her fingers to remove pills from the mouth of another pill bottle, and again poured pills from another pill bottle into the palm of her hand and placed all the pills in the medication cup. Poured medication into a resident's orange juice and left the juice with the resident at the table to consume. Left medications at the table with numerous residents during the evening meal. Returned to the medication cart to document the medications as taken without observing those residents taking their medications. Further observation during that time revealed nurse C opened the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She looked at the MAR, and then proceeded to retrieve the medications from the cart and set-up the medications. At no time during the above medication administration did the nurse compare the medication record with the labels on the punch cards or the medication bottles. Observation and interview on 12/20/10 at 6:00 p.m. with resident 11 revealed the liquid in the medication cup was actually a medication. The resident stated she took the medication after she was all done eating since it tasted so terrible. The nurse left the medication with the resident at the table during the meals for the resident to take as she wished. 2. Observation on 12/21/10 at 8:20 a.m. revealed nurse D: Poured pills into the palm of her hand and then placed the pills in the medication cup. Sat the medication cup on the cart and poured the liquid medicine in the medication cup. Poured a powder in a paper cup and left the paper cup with the resident at the table. The resident mixed the powder with her water and took her medication one pill at a time without being observed by the nurse. Observation on 12/21/10 from 12:25 p.m. to 12:50 p.m. of nurse D revealed she: Used her bare fingers to puch a pill from the bottle lid into the medication cup. Opened the MAR, set-up the medications, administered the medications, and documented the administration without comparing the MAR indicated [REDACTED]. Punched the pills into a medication cup, placed the pills from the medication cup onto a resident's spoon, and used her bare hand to reposition the pills on the spoon to prevent them from spilling. 3. Interview with director of nursing B and administrator A on 12/21/10 at 4:30 p.m. revealed no residents in the facility had physicians' orders that would allow medications to be taken unobserved by the nurse. 4. Interview on 12/21/10 at 10:10 a.m. with resident 13 revealed: There were several times he did not get the right number of medications. He was to get nine pills in the morning. He always looked at them and often one or more were missing. He wondered what happened to the residents that could not tell the nurses the pills were wrong. 5. Interview on 12/21/10 at 11:45 a.m. with resident 12 revealed: Approximately three months ago she was given the wrong medications. It occurred while she was wrapping silverware and could not touch anything but the silverware. A nurse came up to her and gave her medications, since she could not touch the med cup the nurse poured them into her mouth. She stated she spit out the medications immediately, because there were too many pills. She was to only get two Tylenol. The nurse took the wrong med and brought her back the Tylenol. She stated she "Worried about the residents who do not know what medications they take." 6. Observation on 12/20/10 at 4:15 p.m. revealed nurse C crushed [MEDICATION NAME] ER (extended release) 90 milligrams (mg) for resident 6. Review of the medication container label stated the medication was [MEDICATION NAME] MN ([MEDICATION NAME]) ER 60 mg and to give one and a half tablets. Review of resident 6's physician's orders [REDACTED]. Review of the provider's procedure for crushing medications revised January 2009 revealed: "Some medications such as sustained release medications and other ar not to be crushed or chewed. Consult with a drug handbook or the pharmacist to verify that the resident's specific medications can be crushed." Review of Todd P. Semla et al., Geriatric Dosage Handbook, 15th Ed., Lexi-Comp, Hudson, Ohio, 2010, p. 924, revealed extended release tablets were not to be chewed or crushed. Interview on 12/21/10 at 5:40 p.m. with director of nursing B revealed extended release medications were not to be crushed. 7. Observation on 12/22/10 at 8:25 a.m. revealed nurse C gave resident 2 one cinnamon 500 mg capsule. Interview on 12/22/10 at 8:55 a.m. with nurse C revealed: She had given resident 2 one of the cinnamon 500 mg capsules. She looked at the MAR indicated [REDACTED]. She stated she must have "just" missed it. Interview on 12/21/10 at 5:40 p.m. with director of nursing B revealed the [MEDICATION NAME] should not have been crushed. 8. Observation on 12/21/10 at 12:53 p.m., at 12:55 p.m., at 12:58 p.m., and at 1:00 p.m. revealed nurse D: Removed a med from a punch card. Signed the MAR. Then gave a resident the med. She did not compare the medication container with the MAR. 9. Observation on 12/21/10 at 12:56 p.m. revealed nurse D poured a liquid medication into a plastic medication cup by: Setting the cup on the top of the medication cart. Poured the liquid medication into the cup. She did not lift the cup to eye level nor did she bend over until she was at eye level with the medication cup to ensure she was giving the correct amount. 10. Observation on 12/20/10 at 4:15 p.m. and at 4:35 p.m. revealed nurse C administered eye drops to resident 6 and resident 14. She did not wear gloves or use a gauze pad either time. Review of the provider's eye medication procedure revised January 2009 revealed the nurse was to use a glove or a gauze pad to retract the lower eye lid and have the resident look up. 11. Observation on 12/20/10 at 4:45 p.m. revealed nurse C did not wear gloves when she gave insulin to resident 15. Review of the provider's insulin administration procedure revised January 2009 revealed the nurse was to wash his/her hands and put on gloves before giving the insulin. 12. Observation on 12/21/10 at 9:30 a.m. revealed nurse D did not wear gloves when she gave insulin to resident 2. 13. The following nursing standards refer to the findings 1, 2, 3, 4, 5, 7, 8, and 9 above. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed. , St. Louis, Mo., 2005, p. 852, revealed: To prepare tablets or capsules from a floor stock bottle pour required number into bottle cap and transfer medication into medication cup. Do not touch medication with fingers. Extra tablets or capsules may be returned to the bottle. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, Mo., 2005, p. 841, revealed: When administering medications the nurse should compare the label of the medication container with the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Before removing the medication container from the drawer or shelf. -When removing the the medication from the container. -Before returning the container to storage. With unit dose prepackaged medications the nurse checks the label with the MAR indicated [REDACTED]. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, Mo., 2005, p. 842, revealed: "Standards are actions that ensure safe nursing practice. To ensure safe medication administration the nurse should be aware of a nursing standard called the six rights of medication administration." The six rights of medication administration are: -The right medication. -The right dose. -The right resident. -The right route. -The right time. -The right documentation. Review of the provider's policy for oral medication administration dated October 1997 revealed: "If a medication is liquid, pour correct amount directly into a graduated medication cup or measuring device provided with the liquid. Discard excess or over pour in an appropriate manner. Do not pour medication back into the original container." Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, Mo., 2005, p. 853, revealed: Hold medication cup at eye level and fill to desired level on scale. Scale should be even with fluid level at its surface. Discard any excess liquid into sink to prevent contamination of the bottle's contents.	2014-03-01
5138	AURORA-BRULE NURSING HOME	43A107	408 SOUTH JOHNSTON STREET	WHITE LAKE	SD	57383	2010-12-01	441	E			QEWS11	Based on observation, interview, and record review, the provider failed to ensure medical equipment was cleaned after use for five of five blood-sugar testings for. Findings include: 1. Observation on 11/29/10 between 5:00 p.m. and 5:50 p.m. revealed licensed nurse C: Took the treatment cart into resident 6's room. Took a glucometer out of a plastic box on the treatment cart. Prepared the glucometer to test the resident's blood-sugar test. Placed the glucometer on the resident's furniture and proceeded to do the blood-sugar. Completed the blood-sugar test, removed the test strip, and replaced the glucometer into the plastic box on the treatment cart without cleaning it. Went directly to resident 14's room, followed the same procedure, and again replaced the glucometer into the plastic box without cleaning it.. Went directly to resident 15's room, followed the same procedure, and again replaced the glucometer into the plastic box without cleaning it. 2. Observation and interview on 11/30/10 between 11:45 a.m. and 11:50 a.m. revealed licensed nurse B: Took the treatment cart into the director of nurses' (DON) office. Resident 6 entered the office and sat in a chair. Nurse B took the glucometer out of the plastic box on the treatment cart. Prepared the glucometer and tested the resident's blood-sugar. Replaced the glucometer back into the plastic box on the treatment cart. After resident 6 left the DON's office, the nurse had resident 15 come in and sit in the chair. Nurse B followed the same procedure and replaced the glucometer back into the plastic box. When asked if she ever cleaned the glucometer after use the nurse left the DON's office without replying and returned with a container of the appropriate type of wipes. She placed the container of wipes on the treatment cart and cleaned the glucometer. 3. Interview on 12/1/10 at 8:45 a.m. with the DON revealed: The glucometer was to be cleaned after each resident. The wipes used to clean the glucometer were supposed to be kept on the treatment cart, but someone kept moving them. *The did not have a written policy related to cleaning the glucometer after each use. Review of the glucometer's manufacturer's manual revealed they suggested cleaning the glucometer between residents.	2014-03-01
5139	AURORA-BRULE NURSING HOME	43A107	408 SOUTH JOHNSTON STREET	WHITE LAKE	SD	57383	2010-12-01	281	D			QEWS11	Based on record review, interview, and policy review, the provider failed to follow physician's orders for one of one sampled resident (6) that went on a therapeutic leave. Findings include: 1. Review of resident 6's physician's orders dated 10/29/10 revealed the following orders: Oxygen 5 liters per nasal cannula through C-Pap (Continous Positive Airway Pressure) at night. Resident may self-administer. Oxygen per nasal cannula to keep oxygen saturation at 90 percent or greater. Therapeutic passes with medications. Review of resident 6's nurses notes revealed: "11/25/10 - 1100 out of facility (OOF) with family -stable. 11/26/10 - 1800 Returned (Rtn) to facility without incident." The nurses notes were signed by nurse A. Interview on 11/29/10 at 5:00p with resident 6 revealed when she had gone on therapeutic leaveon 11/25/10 they had not sent her oxygen with her. She had done okay, but it was a little hard without the oxygen. She was not sure why she did not have the oxygen, but thought it was because she only had a big oxygen concentrator. They had sent the C-pap machine. Review of the provider's 3/1/10 Therapeutic home passes with medications (meds)/treatment policy revealed: "A nebulizer, oxygen concentrator, and or C-pap machines need arrangements made, possibly home health, unless they own their own machines. Meds are to be counted and charted in nurses notes, when resident leaves and upon their return, include the treatment (rx) number (#) in the charting." Interview with nurse A on 12/1/10 at 7:45 a.m. revealed she really could not say for sure if resident 6 had oxygen with her when she left on therapeutic leave. Someone else was getting her ready while nurse got her medications set up to go. Interview on 1/29/10 at 5:00 p.m. with the director of nurses E revealed: The nurses should have documented all the medications that had been sent with resident 6. They had not followed their policy. Resident 6 should have had the oxygen sent along with her medications when she left the facility.	2014-03-01
5140	UNITED RETIREMENT CENTER	435079	405 FIRST AVE	BROOKINGS	SD	57006	2010-10-20	281	F			ZKVE11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure neurological assessments were completed per policy following a fall for four of four sampled residents (3, 4, 5, and 7) with known head injuries. Findings include: 1. Review of resident 7's nurse's progress notes report revealed she fell at 1:30 a.m. on [DATE]. She was found on the floor with her head under the bed. Assessment of her injuries revealed she had a bruise to her forehead. Her medical record revealed there was no documentation of a neurological assessment (neuro checks) having been completed following that fall. Resident 7 expired on [DATE] in the facility. 2. Review of resident 3's record for falls that would have required neurological assessments according to their facility policy revealed: An incident report dated [DATE] documented a fall at 10:10 a.m. in the resident's room that resulted in bleeding from the top of her scalp and her left elbow. She complained of pain on the top of her head. The scalp abrasion was cleansed, and ice was applied. Neurological checks per protocol were started. The Neurological Assessment Flow Sheet for that fall noted assessments were done on [DATE] at 11:05 a.m., 11:30 a.m., 12:35 p.m., and 7:00 p.m. On [DATE] assessments were done at 4:00 a.m. and 6:30 p.m. No further documentation was noted on that form. An incident report dated [DATE] documented a fall at 10:50 p.m. in the resident's bathroom. The resident stated she had hit her head. The Neurological Assessment Flow Sheet for that fall noted assessments were done on [DATE] at 8:50 p.m. and at 11:00 p.m. No further documentation was noted on that form. An incident report dated [DATE] documented a fall at 4:10 p.m. in the resident's room. She was found on the floor beside her bed on her knees with her head downward. The Neurological Assessment Flow Sheet for that fall noted assessments were done on [DATE] at 4:10 p.m., 10:30 p.m., and 11:30 p.m. On [DATE] an assessment was done at 12:30 a.m. No further documentation was noted on that form. 3. Review of resident 4's record for falls that would have required neurological assessments according to their facility policy revealed: An incident report dated [DATE] documented a fall at 8:20 a.m. in the resident's bathroom. The resident stated he had gotten up from the toilet and reached for his wheelchair that was not locked. He had fallen forward and had hit his head on the wall. The Neurological Assessment Flow Sheet for that fall noted assessments were done on [DATE] at 8:20 a.m., 8:45 a.m., 9:00 a.m., 9:30 a.m., 10:30 a.m., and 11:30 a.m. At 1:00 p.m. it was noted all vitals were in a normal range, and neuro checks were discontinued. An incident report dated [DATE] documented a fall at 6:15 p.m. in the resident's bathroom. The resident was found lying on the floor on his back. He stated he had hit his head. The Neurological Assessment Flow Sheet for that fall noted assessments were done on [DATE] at 6:15 p.m., 7:20 p.m., 8:10 p.m., and 9:30 p.m. On [DATE] assessments were done at 1:10 a.m., 5:20 a.m. and 7:00 a.m. It was documented that vital signs were stable and the neuro checks were discontinued. That was not dated, timed, or signed. An incident report dated [DATE] documented a fall at 11:00 p.m. in the resident's room. He was found on the floor, and he stated he had bumped the back of his head. The Neurological Assessment Flow Sheet for that fall noted assessments were done on [DATE] at 10:00 p.m. and 10:15 p.m. On [DATE] assessments were done at 2:00 a.m. and 6:00 a.m. No further documentation was noted on that form. 4. Review of resident 5's record for falls that would have required neurological assessments according to their facility policy revealed: An incident report dated [DATE] documented a fall at 3:30 p.m. in the facility's lobby. The resident stated she had bumped her head on the entry door frame. No Neurological Assessment Flow Sheet for that fall was found. 5. Interview on [DATE] from 4:10 p.m. to 5:10 p.m. with the DON revealed: Neurological assessments needed to be completed per policy for residents that had hit their head during a fall. When neurological assessments were discontinued early it needed to be after the second 60 minute assessment. Documentation of the discontinuation of neurological assessments needed to be noted on the Neurological Assessment Flow Sheet. She agreed the neurological assessments in findings 2, 3, and 4 were not complete and had not followed facility policy. Review of the provider's [DATE] reporting and investigating accidents policy revealed neuro checks were to have been completed on all residents with known or suspected head injury. Those neuro checks were to have been completed: Every 15 minutes times (x) 4 Every 30 minutes x 4 Every 60 minutes x 4 Every four hours x 4 Nurses would have been permitted to vary the neuro checks time frames slightly due to other residents' needs and schedules. Those neuro checks could have been discontinued at the nurse's discretion after two 60 minute checks were completed and the resident appeared stable. Interview with the director of nursing (DON) at 8:20 a.m. on [DATE] revealed it was her expectation and the provider's standard of practice to have neuro checks completed per their policy. She confirmed no neuro checks had been done following resident 7's head injury. The above policy and interview applies to all findings.	2014-02-01
5141	UNITED RETIREMENT CENTER	435079	405 FIRST AVE	BROOKINGS	SD	57006	2010-10-20	279	E			ZKVE11	Based on record review, policy review, and interview, the provider failed to ensure care plans were updated and/or revised based on accurate assessments and in a timely manner for five of nine sampled residents (1, 2, 3, 4, and 5) with falls. Findings include: 1. Record review for resident 1 revealed: A care plan dated 10/5/10 noted the resident was a "high risk faller" and "may use the restroom unattended." A Fall Risk Assessment Form noted a score of ten or more indicated the resident was at high-risk for falls. The Fall Risk Assessment Form dated 7/8/10 noted the resident as a high-risk for falls with a score of 14. The Fall Risk Assessment Form dated 9/30/10 noted the resident as a high-risk for falls with a score of 14. Item B. History of Falls (past 3 months) on that form noted a score of zero for no falls during that period of time. Incident reports in the record noted a total of four falls during that time period occurring on 6/29/10, 7/26/10, 8/7/10, and 9/11/10. On the back of that form a hand written note by licensed practical nurse (LPN) 1 stated "Care team feel that he is not @ (at) high risk b/c (because) he ambulates @ times." Interview on 10/20/10 at 4:30 p.m. with the director of nursing (DON) revealed: She agreed the 9/30/10 fall risk assessment had not accurately documented the resident's falls for the past three months. The Care Plan Team consisted of the social worker, LPN 1, physical therapist aide, activities director, case manager, and the DON. She did not know why the resident was not at high risk for falls as per the comment on the back of the fall risk form. The DON did not remember that Care Plan Team meeting. She stated the signs in the residents' bathrooms "Must not use restroom unattended" were implemented sometime in May or June 2010. All residents that were at high risk for falls would have that sign in their bathroom. Interview on 10/21/10 at 8:45 a.m. with the quality assurance (QA) coordinator revealed the QA committee notes documented the "Must not use restroom unattended" bathroom signs were implemented on 6/21/10. Resident 1's name was not on the list for that sign. Interview on 10/21/10 at 9:05 a.m. with case manager 2 revealed: She did not remember the fall risk assessment on 9/30/10, and the care plan team's decision for resident 1 to not be at high risk for falls. She agreed resident 1 was at high risk for falls. 2. Record review for resident 2 revealed: A fall incident report dated 10/9/10 had no care plan update noted. The resident was sent to the emergency room because of hip pain complaints. A care plan dated 9/27/10 had no problem/needs/goals/approaches noted for that fall. 3. Record review for resident 3 revealed: A care plan dated 8/25/10 had an approach that stated "Staff will check on me more frequently regarding my need to use the BR (bathroom)." That care plan's toileting schedule stated "Every one hour after breakfast and lunch unless the resident was sleeping, with rounds at night, and prior to bedtime." Interview on 10/20/10 at 4:30 p.m. with the DON revealed she expected the care plan to have more specific times for checking on the resident than stating ". . .more frequently." 4. Record review for resident 4 revealed: A fall incident report dated 9/23/10 had no care plan update noted. The resident fell and stated he had hit his head. The incident report noted the fall might have been due to a possible urgency with urination. The care plan dated 9/17/10 had no problem/needs/goals/approaches noted for that fall. 5. Record review for resident 5 revealed: A care plan dated 9/9/10 stated an approach of "Staff will check on me more often and offer services more frequently because I forget to call for help despite staff reminding me." That care plan's toileting schedule stated before and after meals and twice at night. Interview on 10/20/10 at 4:30 p.m. with the DON revealed she expected the care plan to have more specific times for checking on the resident than stating ". . .more frequently." Interview on 10/21/10 from 8:30 a.m. to 9:00 a.m. with the DON revealed: She expected after a fall the care plan would be updated before that nurse's shift was over and before that nurse went home. It was the case managers' responsibility to periodically update and review the residents' care plans, but it was also everyone's job to make sure the care plans were updated. It was not any one person's responsibility to monitor the accuracy of the residents' care plans. Review of the provider's policy for Reporting and Investigating Accidents revised March 2003 revealed "A short term care plan will be initiated to include new approaches as appropriate." Review of the provider's policy for Falls updated March 2010 revealed: "The care plan will be updated immediately after each fall, identifying the fall, goals and interventions to provide care as well as to reduce the potential for further falls. Information obtained from conversation with the resident and appropriate witnesses to the fall may be used in developing approaches to prevent future falls." "The resident's plan of care will be reviewed and updated as appropriate to reflect potential for falls and approaches to reduce falls. The plan of care will be reviewed with the resident/family/responsible party."	2014-02-01
5142	UNITED RETIREMENT CENTER	435079	405 FIRST AVE	BROOKINGS	SD	57006	2010-10-20	282	D			ZKVE11	Based on observation, interview, record review, and policy review, the provider failed to ensure care plans were followed, and trained and competent staff provided services to one of nine sampled residents (8). Findings include: 1. Review of resident 8's 4/12/10 care plan revealed an entry that stated: "High risk faller." "Do not leave unattended in the bathroom." Review of resident 8's 6/14/10 fall follow-up report revealed: She did not want to wait for staff to help her off the toilet when she was in the bathroom. She had started to walk back to her chair from the bathroom when certified nursing assistant (CNA) 7 had opened the door and tried to catch her before she fell . She stated she knew the staff were "way too busy" to help her. That fall had resulted in a skin tear to resident 8's right forearm. She also complained of back pain following that fall. Review of information provided to the Department of Health surveyors prior to entering the facility revealed CNA 7 had reported she and the housekeeping/laundry supervisor had been assisting resident 8 to the bathroom. That report stated CNA 7 left the housekeeping/laundry supervisor alone with resident 8. The housekeeping/laundry supervisor had gotten resident 8 "settled" and had left her alone. Per that report it was noted the DON reminded both of those staff members resident 8 was "not to have been left alone in the bathroom as indicated in her care plan." Interview at 7:30 a.m. on 10/20/10 with the housekeeping/laundry supervisor revealed she had not been trained to assist with resident care. She stated if needed she would help residents get a drink of water, put on a sweater, or push them in their wheelchair to their destination. She stated she had not been trained to transfer residents or assist them to the bathroom. She stated she did not remember helping a resident to the bathroom. Interview at 8:20 a.m. on 10/21/10 with the director of nursing (DON) revealed it was her expectation all staff should assist residents as needed. She confirmed the housekeeping/laundry supervisor had not been trained in assisting or transferring residents to the bathroom. She confirmed she was aware the housekeeping/laundry supervisor had helped resident 8 to the bathroom on 6/14/10. She stated she knew the housekeeping/laundry supervisor was just trying to be helpful at that time. She stated she had reminded both CNA 7 and the housekeeping/laundry supervisor after the fall not to leave resident 8 unattended when in the bathroom. She did not confirm any disciplinary action had been taken to ensure the housekeeping/laundry supervisor did not provide services to residents beyond her scope of responsibilities. Review of the provider's March 2010 all staff resident assistant policy revealed: Residents not safe with independent mobility would not be left alone in the bathroom. Resident's independent or monitored use of the restroom was clearly documented in the care plan. Staff would be educated on that policy upon hire and annually. That was mandatory training. *Failure to follow that policy would have been considered an "extremely serious" violation and would warrant immediate dismissal. Review of the training attendance sheet associated with the distribution of the above policy revealed both CNA 7 and the housekeeping/laundry supervisor had attended that training.	2014-02-01
5143	UNITED RETIREMENT CENTER	435079	405 FIRST AVE	BROOKINGS	SD	57006	2010-10-20	226	D			ZKVE11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to have a policy in place that ensured an appropriate investigation was implemented following an unwitnessed fall and subsequent death for one of one expired residents (7). Findings include: 1. Review of resident 7's closed record revealed she had been admitted on [DATE] and had expired at the facility on [DATE]. Her record revealed she had fallen at 1:30 a.m. on [DATE]. That fall was unwitnessed and had resulted in a bruise to the resident's forehead. The incident report was not completed until 1:37 a.m. on [DATE]. The resident died at approximately 10:00 a.m. on [DATE]. Notification of that death was made to the Department of Health via facsimile (fax) on [DATE] at 3:26 p.m. Report of that death included a copy of the follow-up report and written statements by staff who responded to resident 7's fall on [DATE]. Report of that death also included date discrepancies that indicated the fall occurred on [DATE] and the death on [DATE]. Review of the above follow-up report revealed: Resident 7 was found on the floor. The summary of the interview with the resident indicated the nurse was unable to understand most words. The nurse heard her say "poison," "can't trust," and "pulled." The resident denied having a [MEDICAL CONDITION]. Her vital signs were taken with a blood pressure of ,[DATE], temperature 98.7 degrees, respirations 24 breaths per minute, and pulse 104 beats per minute. Her change in physical function was reported as "Hospice." Her change in cognition/behavior was reported as "Hospice, incoherent most of the time." The type of injury was reported as a bruise to the forehead. The location of the incident was indicated as "Found beside bed at 55 degree angle. Soaker pulled at angle, blankets also at angle. Bed up approximately 6 inches from low position." Review of the faxed report also revealed copies of statements received from staff who responded to resident 7's [DATE] fall. Those statements included: a. Licensed practical nurse (LPN) 4 stated in her written report: Resident 7 was in the middle of the bed when she had done a visual check between midnight and 12:15 a.m. LPN 4 was in another room when certified nursing assistant (CNA) 5 yelled down the hallway to her, came into that room where LPN 4 was, and stated "We got a code red." The resident was found on the floor with her head under the bed. Her blankets and soaker pad were "skewed." Her bed was noted to be raised 4 to 6 inches from the low position. She asked resident 7 if she was hurt, but the resident was "unable to answer coherently or consistently." CNA 6 entered the room to assist so LPN 4 sent CNA 5 for "vitals equipment." CNA 5 "Returned after some time with the electric blood pressure cuff which did not work." LPN 4 sent CNA 5 to find a manual blood pressure cuff and stethoscope, but the CNA was unable to locate those. LPN 4 left CNA 6 in charge of the resident and returned with a manual cuff and stethoscope. b. CNA 5 stated in her written report: She went to assist another resident at approximately 1:00 a.m. At that time she heard a noise and went to resident 7's room. She found resident 7 on the floor with her "Head under the support beam." The head of the bed and the siderail were down, and "The bed itself was raised to my hips." She "rushed down the hallway" and told LPN 4 about the resident. She told CNA 6 they needed help with that resident. CNA 5 left and got a working blood pressure cuff. c. CNA 6 stated in her written report: She was in resident 7's room between 10:30 p.m. and 11:00 p.m. the night of [DATE]. When she left the room the resident had two pillows under her feet. She had one pillow under her head with the head of the bed slightly elevated. The side rail was put up, and the bed was lowered. At 1:00 a.m. she was notified by CNA 5 the above resident was on the floor. CNA 5 told her resident 7 was asking for help in her room. Resident 7 was found on the floor with her head "half under the bed." Resident 7's bed was "elevated and flat" at that time. While LPN 4 and CNA 5 were gone looking for a blood pressure cuff she (CNA 6) "sat and talked with" resident 7 and asked her questions. The above report did not indicate resident 7's response to those questions. Review of resident 7's [DATE] quarterly Minimum Data Set (MDS) revealed: She had a short term memory problem. She had clear speech with distinct, intelligible words, and was usually understood. She had multiple behaviors and was verbally abusive. She was totally dependent on staff for transfer, bed mobility, locomotion, dressing, eating, toilet use, and personal hygiene. She required two or more persons to physically assist her with bed mobility and transfer. She had limitation in her range of motion on both sides of her neck, hands, legs, and feet. She had partial loss of voluntary movement in all of her extremities. She had no falls recorded in the previous 180 days. Review of resident 7's [DIAGNOSES REDACTED]. A neuro-[MEDICAL CONDITION] disorder. A [MEDICAL CONDITION] disorder. An anxiety disorder. allergies [REDACTED]. Review of the provider's revised [DATE] reporting and investigating accidents policy revealed: A follow-up report must have been completed on the shift the accident/incident occurred. The follow-up report must have been submitted to the director of nursing (DON) who would forward it on to the administrator or designee. The policy did not include information about further investigation. Interview with the DON at 8:20 a.m. on [DATE] revealed: When reviewing a follow-up report she looked at what happened, and did not look at discrepancies in dates or times. She had not considered the differences in dates and times in the multiple reports/interviews to be of any concern. She had not interviewed the staff members who assisted resident 7 on [DATE]. She had reviewed their written statements. She had not reviewed the call light records to see if resident 7 had tried calling for assistance. She had not conducted any further investigation into the circumstances surrounding resident 7's fall and subsequent death. She had not considered the resident's first fall in 180 days to be unusual. She had not thought the discrepancies in the report of the height of the bed needed further investigation. She had not considered the resident's words "pulled," "can't trust," and "poison" to need further investigation. She had thought resident 7 might have pulled herself out of bed. She knew her staff and residents well enough to know no further investigation was needed for the possibility of abuse or neglect.	2014-02-01
5144	UNITED RETIREMENT CENTER	435079	405 FIRST AVE	BROOKINGS	SD	57006	2010-10-20	514	F			ZKVE11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure complete and accurate documentation was maintained following falls for eight of nine sampled residents (1, 2, 3, 4, 5, 6, 7, and 8). Findings include: 1. Review of resident 7's closed medical record revealed a fall follow-up report had been completed on [DATE] at 1:37 a.m. for a fall that had occurred at 1:30 a.m. on [DATE]. That resident expired at 10:00 a.m. on [DATE] in the facility. Review of the above follow-up report revealed: Resident 7 had been found on the floor. The summary of the interview with the resident indicated the nurse was unable to understand most words. The nurse heard her say "poison," "can't trust," and "pulled." The resident denied having a [MEDICAL CONDITION]. Her vital signs were taken with a blood pressure of ,[DATE], temperature 98.7 degrees, respirations 24 breaths per minute, and pulse 104 beats per minute. Her change in physical function was reported as "Hospice." Her change in cognition/behavior was reported as "Hospice, incoherent most of the time." The type of injury was reported as a bruise to the forehead. The location of the incident was indicated as "Found beside bed at 55 degree angle. Soaker pulled at angle, blankets also at angle. Bed up approximately 6 inches from low position." Review of resident 7's nurse's notes revealed an entry on [DATE] at 1:42 p.m. regarding a change in a physician's orders [REDACTED]. "Resident's treatment was done to her toes at which time the resident was attempting to speak with staff and had a smile on her face." "Speech was mumbled was able to understand resident when asked how she was and resident said fine." "Color was good, bruise noted to left side of forehead." "No agitation or anxiety noted." The above entry had no indication of the time that care had been provided. Review of that same nurses' note revealed the following entry: "Called into resident's room at 1000 (10 a.m.)." "Resident was found to be white and cool to touch. No respirations or heart rate noted." No additional documentation was found in those nurses' notes regarding any care provided to resident 7 between the time of her fall at 1:30 a.m. on [DATE] and the time of her death at 10:00 a.m. on [DATE]. No neurological checks were documented as having been completed at any time after that fall. (refer to F281). Interview with the director of nursing at 8:20 a.m. on [DATE] revealed it was her expectation a follow up report on a fall should have been completed before the end of the shift on which the fall occurred. She stated she was not sure if the times on the documentation were accurate and could not confirm the follow-up report was completed more than 24 hours after resident 7's fall. 2. Review of resident 6's [DATE] fall follow-up report revealed she had fallen on [DATE] at 8:30 a.m. She had a red area to her right clavicle area and had stated her back hurt. That fall was unwitnessed, and the resident was unable to say what had happened. Review of resident 6's nurses' notes revealed the next entry after the above fall was on [DATE] at 12:54 a.m. That entry stated: "Resident cooperative with staff." "No new s/s (signs/symptoms) of injury noted." "No c/o (complaints of) pain." "Will continue to monitor." No documentation was found between those above two entries to monitor resident 6's injury. No post fall summary was found five days after the fall. 3. Review of resident 8's [DATE] fall follow-up report revealed a fall at 8:30 a.m. that had resulted in a skin tear to her right forearm. She also complained of back pain following that fall. Neuro checks were completed on resident 8 with documentation of normal vital signs through 2:30 p.m. on [DATE]. Review of resident 8's nurses' notes revealed the next entry after the fall report occurred at 4:59 p.m. on [DATE]. That entry referred to a change in physician's orders [REDACTED]. The next entry on the same day at 10:26 p.m. indicated resident 8 was complaining of back pain. That pain was reported to the oncoming nurse to monitor. There were no further entries in resident 8's nurses notes regarding that back pain or the condition of the skin tear. 4. Record review for resident 1 revealed no five day post-fall documentation was noted for falls that had occured on [DATE], [DATE], [DATE], and [DATE]. 5. Record review for resident 2 revealed no five day post-fall documentation was noted for falls that had occured on [DATE] or [DATE] (the incident report date was not noted) and [DATE]. 6. Record review for resident 3 revealed no five day post-fall documentation was noted for falls that had occured on [DATE], [DATE] (2 falls), [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 7. Record review for resident 4 revealed no five day post-fall documentation was noted for falls that had occured on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 8. Record review for resident 5 revealed no five day post-fall documentation was noted for a fall that had occured on [DATE]. 9. Interview with the DON at 8:20 a.m. on [DATE] revealed she felt nurse's time was better spent providing care than documenting according to the above standards when there was no obvious injury to a resident. She stated they were in the process of revising their policy to reflect that change. She confirmed documentation should have been completed per the policy when injury had occurred. That interview applies to all findings above. 10. Interview with the administrator at 3:20 p.m. on [DATE] revealed they had no individual policies related to documentation standards. She stated all documentation policies were related to specific needs. She confirmed there were documentation standards expected following a resident's fall. 11. Review of the policy for reporting and investigating accidents revised [DATE] stated: The date and time the accident/incident took place must be included on the Incident Report. "If a resident has struck his/her head, or it is suspected the resident has struck his/her head, neuro checks are initiated for 24 hours and documentation on the resident's condition will be carried out for the next 72 hours (or longer, at nurses discretion)." "Using the neurological assessment form the following neurological assessment time frame is utilized: 1. Every 15 minutes x (times) 4. 2. Every 30 minutes x 4. 3. Every 60 minutes x 4. 4. Every four hours x 4." "Nurses will be permitted to vary the neurological assessment time frames slightly due to other resident needs and schedules." "Neuro checks may be discontinued at the nurses discretion after two 60 minute checks have been completed and resident appears stable. The 72 hour follow-up documentation will continue even if the neurological checks are discontinued." Review of the policy for falls updated [DATE] revealed "Follow up assessment of the fall will be done daily x (times) 5 days or longer if indicated by the status of the condition. On day five, a post fall summary will be completed by a nurse to determine further intervention and/or adjustment to the plan of care." The above policy and interview applies to all findings.	2014-02-01
5145	UNITED RETIREMENT CENTER	435079	405 FIRST AVE	BROOKINGS	SD	57006	2010-10-20	492	D			ZKVE11	Based on observation, interview, policy review, and administrative rule review, the provider failed to follow professional standards and South Dakota Board of Nursing Administrative rule for one of one housekeeper (3) who was performing certified nurse aid (CNA) duties without proper South Dakota state certification. Findings include: 1. Interview on 10/19/10 at 2:15 p.m. with housekeeper 3 revealed: She had been hired as a housekeeper about one year ago. She had been a CNA in another state, and her certification was still current in that state. She had used those CNA skills when working here as a housekeeper. She had helped out the other CNAs if they needed her. Observation of and interview with housekeeper 3 on 10/20/10 at 2:15 p.m. revealed: While she cleaned a resident's room the resident needed help into the bathroom. The housekeeper had helped the resident into the bathroom and out of the bathroom when the resident was done. The housekeeper stated she had always told another CNA when she had toileted a resident, so the correct documentation was done on the bathroom door toileting form. For this current incident she stated she would just write it down herself, so she would not have to take time to find another CNA to do it. Interview on 10/20/10 at 4:15 p.m. with the director of nursing (DON) revealed: The provider had no written policy outlining guidelines of patient care for staff who were CNAs but were hired as housekeepers. She agreed the housekeeper could use her CNA skills for resident care such as transfers, toileting, and ambulating. All CNAs needed to have education hours each year to keep their certification current. Interview on 10/21/10 at 10:00 a.m. with the human resources person revealed: Housekeeper 3 had been hired on 6/6/10. Housekeeper 3 had been a CNA in another state, and a copy of that state's registry was on file. Forms needed to be filled out to transfer her certification to South Dakota. That transfer step had not been done. Any education for housekeeper 3 would be on file with the housekeeping supervisor. *A list of that education for 2010 was received for housekeeper 3. However the list was not specific if the education was for general housekeeping staff or for continued CNA yearly certification.	2014-02-01
5146	FIRESTEEL HEALTHCARE CENTER	435109	1120 EAST 7TH AVENUE	MITCHELL	SD	57301	2010-10-06	514	D			2DK211	Based on record review, policy review, and interview, the provider failed to ensure complete and accurate documentation was maintained for one of one resident (5) following an emergency choking event. Findings include: 1. Review of documentation contained in a 9/20/10 incident report regarding an emergency choking event with resident 5 revealed three registered nurses (RN) (1, 2, and 3) were involved in providing some aspect of care at that time. a. Review of resident 5's 9/18/10 nurses' notes revealed minimal documentation by RN 1 regarding nursing care provided in response to an emergency choking event. Review of those same nurses's notes backdated 9/18/10 but completed on 9/20/10 as a late entry revealed additional comments clarifying the nursing care provided during the above event. Review of those notes revealed timelines of events were generalized and were not specific as to time of occurrence. Interview with RN 1 at 1:57 p.m. on 10/6/10 revealed she had documented at the end of her shift regarding care she had provided to resident 5 during the choking event. She confirmed that documentation was lacking in specifics and accurate timelines. She stated she realized additional documentation was needed for clarification. She stated additional documentation was added on 9/20/10. b. Review of those same nurses' notes revealed no documentation was found by RNs 2 and 3 regarding care provided to resident 5. Interview with RN 2 at 2:45 p.m. on 10/6/10 revealed she was not directly involved with providing care for resident 5 during the above incident. However she did make observations of his status of the care provided. She confirmed she did call the paramedics and was present when they arrived. She stated she did not document her observations in resident 5's nurses' notes. c. Interview with RN 3 at 3:19 p.m. on 10/6/10 revealed he was the house supervisor on 9/18/10. He stated he responded to the call for help and assisted with providing nursing care to resident 5. He confirmed documentation of his actions during that event could not be found in resident 5's medical record. d. Interview with the director of nursing (DON) and administrator at 1:24 p.m. and again at 2:11 p.m. on 10/6/10 revealed they were both notified of the above incident on 9/18/10. They stated an incident report was completed with statements obtained from all caregivers involved. They confirmed the documentation was lacking in timelines and specifics related to resident 5's care. Both stated it was their expectation more complete and accurate documentation be maintained on any emergency events. The DON confirmed the addendum to RN 1's documentation on 9/19/10 should have contained the date and time of the entry. She also confirmed documentation by RN 2 and RN 3 was not found in resident 5's medical record related to that emergency event. Review of the provider's revised April 2008 charting and documentation policy revealed: All observations and services performed must be documented in the resident's clinical record. All incidents, accidents, or changes in the resident's condition must be recorded. Documentation of procedures and treatments should include care-specific details and should include at a minimum: a. The date and time the procedure was provided. b. The name and title of the individual(s) who provided care. c. The assessment date and/or any unusual findings obtained during the procedure/treatment. d. How the resident tolerated the procedure/treatment. Accurate medical records should be maintained in the facility. If it is necessary to change or add information in the residents's medical record, it should be completed by means of an addendum and signed and dated by the person making such change or addition. Late entries in the medical record should be dated at the time of the entry and noted as a "late entry." Review of the provider's 9/26/06 staff RN job description revealed the duties included ensuring accurate documentation of all medical records and reporting forms.	2014-02-01
5147	PRAIRIE VIEW CARE CENTER	435118	401 SOUTH FIRST AVENUE POST OFFICE BOX 68	WOONSOCKET	SD	57385	2011-01-13	431	D			193D11	Based on observation, interview, and policy review, the provider failed to maintain safe and secure storage of medications during two of four randomly observed medication administrations. Findings include: 1. Observation on 01/12/11 from 9:30 a.m. through 9:45 a.m. revealed: An unlocked medication cart in the 100 wing hallway. Registered nurse (RN) C was in a resident's room. RN C came out of the resident's room, returned to the medication cart, and replaced a container of eye drops in the cart without attempting to unlock the cart. The same unlocked medication cart was moved further down that hallway. RN C was in a different resident's room. There were residents and staff moving throughout the 100 wing hallway when the cart was unlocked. 2. Observation on 1/12/11 from 11:15 a.m. to 12:00 noon in the dining room revealed: The medication cart was unlocked. RN C had her back to the unlocked medication cart multiple times while she passed medications. There were residents, visitors, and staff in the dining room while that cart was left unlocked. 3. Review of the provider's medication administration policy from Omnicare of South Dakota revealed: The medication cart would remain locked when not in direct sight of the person administering medication. Medications must have been inaccessible to residents and others passing by. Interview on 1/12/11 at 4:20 p.m. with the director of nurses A revealed: She expected the nurses to lock the medication cart when they were in a resident room. She considered "direct sight" to be where the nurse could visually see, an eye's view. Interview with RN C on 1/12/11 at 4:45 p.m. revealed: She had usually locked the medication cart when she was not in attendance. *She had considered the drawers on the cart to have a first lock in place that residents could not open, because she had to slide a hinge to open them.	2014-02-01
5148	PRAIRIE VIEW CARE CENTER	435118	401 SOUTH FIRST AVENUE POST OFFICE BOX 68	WOONSOCKET	SD	57385	2011-01-13	520	C			193D11	Based on interview and policy review, the provider failed to ensure the medical director was present at the quarterly Quality Assurance (QA) committee meetings for the past year. Findings include: 1. Interview with QA coordinator/licensed practical nurse B on 01/12/11 at 2:30 p.m. revealed: The physician designated by the provider as a quarterly member of the QA committee was the medical director. The medical director had only participated in one QA meeting in 2010 on 4/19/10. QA meetings had been held monthly in 2010 with other committee members. She was aware there was to be a physician present at the QA meetings at least quarterly. She agreed the physician had only been present for one QA meeting in 2010. Interview with director of nurses A on 01/12/11 at 2:40 p.m. revealed: She was aware there was to be a physician present at the QA meetings at least quarterly. She agreed the physician had only been present for one QA meeting in 2010. Review of the provider's undated Clinical Guideline: QA & A Committee revealed the medical director would be in the committee membership. Review of the provider's Medical Director Agreement dated 05/01/04 revealed: The duration of the agreement was ongoing. The medical director would participate in quality assurance as requested. An undated, handwritten, and initialed notation had been made on the agreement that added QA committee participation.	2014-02-01
5149	PRAIRIE VIEW CARE CENTER	435118	401 SOUTH FIRST AVENUE POST OFFICE BOX 68	WOONSOCKET	SD	57385	2011-01-13	371	E			193D11	Based on observation, interview, and policy review, the provider failed to ensure proper sanitary procedures were followed during the serving process for two of two observed meals and for scoops used in food preparation. The staff failed to: Place the scoops in the food in a manner to prevent cross-contamination during the serving process. Place scoops in food storage bins to prevent cross-contamination. Prevent cross-contamination by not cleaning work surfaces between preparation of different foods. Prevent cross-contamination of the thermometer used to check the temperatures of the food as it was prepared. Wash hands and change gloves appropriately between tasks to prevent cross-contamination. Handle ready-to-eat foods in a safe and sanitary manner. Have hair restrained effectively. Findings include: 1. Observation during the supper meal on 1/11/11 from 4:05 p.m. until 6:00 p.m. revealed dietary staff E during the supper meal preparation: Served taco casserole and stewed tomatoes on to a plate for a staff member. Placed the two soiled serving utensils on a paper towel, and the food soaked through to the counter top. Used the soiled serving spoon to remove enough taco casserole to prepare the pureed servings. Placed the serving spoon on the soiled paper towel on the counter again. Placed the serving spoon in the taco casserole on the steam table, and then used it to serve the casserole to the residents. The soiled ladle for the stewed tomatoes was moved to the lid of the container that held the stewed tomatoes. That lid had been touched by the hot pads and the staff hands during meal preparation. The hot pads had been touched by gloved and ungloved hands and had been placed on multiple counter tops in the kitchen during the meal preparation. The ladle was then placed in the stewed tomatoes and remained there while the meal was served. 2. Observation on 1/11/11 at 4:25 p.m. revealed a scoop was lying in the flour bin with the handle in the flour. 3. Observation on 1/11/11 at 2:15 p.m. revealed dietary staff E: Placed two heads of lettuce in the vegetable preparation sink on top of the opened lettuce bag. A colander of cooked ground beef was placed on the drainboard above the sink with the lettuce. The sink contained hardened grease and pieces of ground beef. The lettuce and bag were sitting on top of the grease and pieces of meat. Interview with dietary staff E on 1/11/11 at 2:15 p.m. confirmed the lettuce was placed on top of the particles of meat and grease from the ground beef in the sink. 4. a. Observation on 1/11/11 at 4:05 p.m. and at 4:20 p.m. revealed dietary staff E washed the food thermometer with hand soap. She then rinsed it in the hand sink in the kitchen. The soap container did not state it was food-contact safe. b. Observation on 1/12/11 at 10:50 a.m. revealed dietary staff G: Checked the temperature of the green beans. Then checked the temperature of the chicken without cleaning the thermometer in-between the two foods. Swabbed the thermometer, laid it on the sink drainboard, and then moved it to the counter. Checked the temperature of the beef stew without first swabbing the thermometer. Swabbed the thermometer and laid it on the counter. Checked the temperature of the carrot salad without first swabbing the thermometer. The thermometer had no protective case. Review of the undated provider policy and procedure for thermometers revealed: The thermometer should be washed, rinsed, and sanitized using a food-contact safe product. That was to have been done after each use and between foods to prevent cross-contamination. It was to be stored in its case when it was not being used. 5. Observation on 1/12/11 at 11:15 a.m. revealed dietary staff G: Touched her face and head with her gloved hands. Walked into the dining room and came back into the kitchen. Touched her uniform. Opened the refrigerator door with her gloved hands. Opened the cupboard and removed bowls. Placed the bowls on the counter. Spooned pudding into the bowls from individual pudding packs. Took the pudding out to the dining room on a cart and placed the dishes onto the tables. Came back to the kitchen and removed her gloves. Rubbed her hands on her slacks. Used the phone to say a prayer on the overhead speakers. Put clean gloves on without washing her hands. Removed the salad from the refrigerator and placed it on the serving line. Checked the temperature of the salad. Rubbed her nose and face with her gloved hands. Opened cupboard doors. Changed her gloves without washing her hands. Continued serving the meal. Review of the provider's undated policy for glove use in the dietary revealed gloves should: Be changed before beginning a new task. Never be used in place of handwashing. Be changed before handling ready-to-eat food. Be put on or changed after washing hands first. 6. Observation on 1/11/11 at 5:20 p.m. revealed dietary staff F picked a slice of bread up with her bare hand and placed it on a plate served to a resident. 7. a. Observation on 1/11/11 at 4:00 p.m. revealed dietary manager D placed her hair net on her hair. However she had not covered her bangs with the hair net while she served the evening meal. b. Observation on 1/12/11 at 11:15 a.m. revealed dietary staff G's hair net had not restrained all of her hair. Some of the hair on both sides of her face was hanging out of the hair net. 8. Interview with dietary manager D on 1/12/11 at 4:00 p.m. and 5:05 p.m. confirmed: The food utensils should have remained in the food once serving began. The scoop handle should not have touched the flour in the flour bin as that caused cross-contamination. Sinks and surfaces should have been cleaned before preparing the next food item to prevent cross-contamination. The lettuce should not have come in contact with the ground beef. Thermometers should have been rinsed with water and debris removed with a paper towel, then swabbed with an alcohol swab. She did not know if the hand soap had been rated as food-contact safe. Gloves should have been changed between tasks or any time they became contaminated. Hands should have been washed every time gloves were changed. Ready-to-eat foods should not have been touched with bare hands. Dietary staff F should have worn a glove before she picked up the bread. Her hair net had not covered her bangs. *Dietary staff G's hair net had not restrained all of her hair.	2014-02-01
5150	WINNER REGIONAL HEALTHCARE CENTER	435056	805 E 8TH ST	WINNER	SD	57580	2011-12-14	280	E			IY0E11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure: The care plan for 1 of 1 sampled resident (3) was completed to show essential information for the care of the resident. Care plans for 5 of 13 sampled residents (2, 8, 10, 12, and 13) were followed for residents receiving restorative care. Findings include: 1. Review of resident 3's record revealed he was admitted on [DATE]. Review of a 7/28/11 hospital discharge summary revealed he had a pacemaker placed in 2009. Review of resident 3's cumulative [DIAGNOSES REDACTED]. Review of resident 3's current falls care plan revealed the pacemaker locater box had been checked. There had been no recorded goals or approaches documented for the pacemaker on the falls care plan. Review of resident 3's comprehensive care plan dated 11/15/11 revealed there:Was no focus area for a pacemaker. Were no goals or interventions about the care he should have been provided in relation to the pacemaker Interview on 12/14/11 at 9:30 a.m. with registered nurse (RN) K regarding resident 3 revealed: She stated his condition had been "grave" at the time of his admission. She agreed the pacemaker should have been included in his care plan. 2. Review of residents 2, 10, and 12's care plans revealed they had not been followed as written for restorative therapy. Refer to F281, findings 1.a, b, and c. 3. Review of resident 8's 8/31/11 care plan revealed she was to have received restorative care two to four times a week. Review of resident 8's November 2011 restorative care daily documentation revealed: She had received only three treatments. Her treatment had not been completed five times due to her sleeping or she had attended an activity. Review of resident 8's December 2011 restorative care daily documentation from 12/1/11 through 12/12/11 revealed she had received four treatments. 4. Review of resident 13's 5/27/11 care plan revealed she was to have received restorative care four to six times a week. Review of resident 13's November 2011 restorative care daily documentation revealed: She had received only one treatment. Her treatment had not been completed four times due to a doctor appointment, being at the hospital, not feeling well, and refusing treatment. Review of resident 13's December 2011 restorative care daily documentation from 12/1/11 through 12/12/11 revealed: She had received no treatments. She had refused three times.	2014-01-01
5151	WINNER REGIONAL HEALTHCARE CENTER	435056	805 E 8TH ST	WINNER	SD	57580	2011-12-14	281	E			IY0E12	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure policy and professional standards were followed when medications were administered by gastrostomy tube ([DEVICE] (a tube placed directly into the stomach)) for one of one resident (20) observed for [DEVICE] medication administration. Findings include: 1. Observation on 1/18/12 at 2:25 p.m. of licensed practical nurse (LPN) M administering medications by [DEVICE] to resident 20 at the nurse's station revealed the LPN: Removed [MEDICATION NAME] solution from the medication room refrigerator and measured 20 milliliters (ml) into a medication cup. Then opened a dantrolene 100 milligram (mg) capsule and sprinkled the contents on the surface of the [MEDICATION NAME] solution. Then crushed a [MEDICATION NAME] 2 mg tablet and sprinkled the contents on the surface of the [MEDICATION NAME] solution. Did not make any attempt to dissolve the dantrolene and [MEDICATION NAME] into the [MEDICATION NAME] solution or to warm the [MEDICATION NAME] solution. LPN M then went to resident 20's room to administer the above medications. After obtaining approximately 300 ml of water from the resident's faucet she: Listened with the stethoscope against the abdominal wall as she inserted approximately 30 ml of air into the [DEVICE]. Then without flushing the [DEVICE] with water, she administered the above combined medications directly into the syringe attached to the [DEVICE]. At the time of administration the dantrolene and [MEDICATION NAME] were both in powder form and floating on the surface of the [MEDICATION NAME] solution. She added approximately 40 ml of water to the medications that were in the syringe. The medications and water did not appear to flow freely through the [DEVICE]. She then used the syringe plunger to push the contents into the [DEVICE]. She added 40 to 60 ml of water to the syringe six different times, each time using the syringe plunger to push the contents into the [DEVICE]. Interview at the above time with LPN M revealed often the medications flowed freely through the syringe and [DEVICE] when she administered them. She stated the resident was also receiving a nebulizer treatment at the same time the medications were being administered through the [DEVICE]. The treatment could have caused the resident to stiffen and prevent the medications and water from flowing freely. Interview on 1/19/12 at 2:50 p.m. with LPN M confirmed she had not flushed resident 20's [DEVICE] with water before starting to administer the medications. Review of the provider's 5/1/08 (reviewed January 2012) policy for medication by enteral tube ([DEVICE]) revealed: Medications must have been in or made into a liquid form before they were administered through the [DEVICE]. Warm water might have helped to dissolve some medications better than cool water. Administering medications together might have produced an interaction that could have clogged the [DEVICE]. Medications were not to have been mixed together. The [DEVICE] was to have been flushed with water before and after each medication administered. At least 10 ml of warm water was to have been used for each flush. Medications should have been allowed to flow freely through the [DEVICE] by gravity or through gentle plunge with the syringe. Review of the American Society for [MEDICATION NAME] & Enteral Nutrition ( A.S.P.E.N.) enteral nutrition practice recommendations published online [DATE] revealed the following medication administration guidelines: Avoid mixing together medications intended for administration through an enteral feeding tube given the risks for physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses (ie, do not mix medications together, but do dilute them appropriately prior to administration). Each medication should be administered separately through an appropriate access. Grind simple compressed tablets to a fine powder and mix with sterile water. Open hard gelatin capsules and mix powder with sterile water. Prior to administering medication stop the feeding and flush the tube with at least 15 ml water. Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe at least 30 ml in size. Flush the tube again with at least 15 ml of water taking into account the patient's volume status. Repeat with the next medication (if appropriate). Flush the tube one final time with at least 15 ml of water.	2014-01-01
5152	WINNER REGIONAL HEALTHCARE CENTER	435056	805 E 8TH ST	WINNER	SD	57580	2011-12-14	224	G			IY0E11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure one of one unlicensed assistive personnel (UAP) (B) in the special care unit provided care without mistreating one of one resident (18). Findings include: 1. Observation on 12/14/11 at 10:30 a.m. during care for resident 18 provided by UAP B revealed: The UAP put gloves on her hands after she had washed them for less than 15 seconds. She entered resident 18's room. She told the resident she had eye drops to administer. She opened the eye drop bottle and approached the resident. The resident began calling out repetitively she was "going to die-don't-no", and she had shut her eyes tightly. The UAP attempted to open the resident's right eye with her hands as the resident resisted by pushing away with her hands and saying no. The resident's eye had remained closed, and the UAP applied an eye drop that landed on the resident's closed eyelids. The UAP then pulled the resident's left lower eyelid down with her fingers, so the eyelashes touched the resident's skin under her eye. The resident continued to resist as before. The UAP then tried to put an eye drop in the resident's eye and jabbed the resident in the eye with the end of the eye drop applicator as the resident thrashed about trying to resist the eye drops. The resident cried out "ouch" when that happened. The UAP stated to the resident "Oh, you're okay." The eye drop rolled down the resident's cheek. The UAP then put down the eye drops and picked up a tube of [MEDICATION NAME] ointment. With the same gloves applied that ointment to the resident's left heel. She then put down the ointment, picked up a jar of [MEDICATION NAME] cream, used her gloved hand and removed cream, and applied it to the resident's left heel. She then put that jar down and used a wet wipe to cleanse under the resident's breasts. She picked up another jar of [MEDICATION NAME] cream, dipped her gloved fingers into that cream, and applied it under the resident's breasts. The UAP changed her gloves without washing her hands. She then dressed the resident's lower body while the resident was in bed. She assisted the resident to a sitting position and placed a gait belt around the resident's waist. She then transferred the resident to the wheelchair using the gait belt. As she transferred the resident the resident's left leg was pushed against the edge of the wheelchair where the foot pedal would have attached to the wheelchair. The pedal had not been attached at that time. The resident stood in a crouched position with her body bent at the knees and the waist. The UAP pushed the resident's bottom towards the chair with her body, as she turned the resident towards the chair. During the transfer the resident had cried out "Stop pushing me-you're pushing me-that hurts-you're hurting my leg." The UAP had told the resident she was okay, and she had not hurt her. She had not checked the resident's leg after that transfer. The UAP then wheeled the resident into the bathroom and transferred her to the toilet using the gait belt. The resident had not stood well, and the UAP pushed the resident's bottom over again during that transfer. The UAP then removed the resident's soiled gown and placed it on the floor. She then placed the resident's soiled incontinence products in the trash can. She dressed the resident's upper body. She had the resident stand holding onto the grab bar, as she cleansed the resident's bottom with wet wipes. The UAP pulled the resident's slacks up and transferred her into the wheelchair. She combed the resident's hair and put her glasses on her. She removed her gloves and without washing her hands pushed the resident in her wheelchair out to the dining area. She returned to the resident's room and gathered up the trash, soiled clothing, and medications she had used during the resident's care. She placed the soiled laundry and trash in the soiled utility room. She then entered the medication room and placed the medications in the medication cart. After that she washed her hands for less than 15 seconds. Interview on 12/14/11 at 12:50 p.m. with registered nurse (RN) consultant L confirmed: The UAP should not have forced the resident to have the eye drops applied. The UAP should have notified the nurse if she was unable to apply the eye drops as ordered for the resident. If giving resident 18's eye drops continued to be a struggle with the resident the physician should have been notified. The UAP should have asked for assistance during the transfer, as it had been unsafe and had put the resident at increased risk for bruises. Interview and observation on 12/14/11 at 1:20 p.m. with (RN) consultant L confirmed: Upon examination of resident 18's left lower leg two old yellow-green bruises were present. They were at the height of the edges of resident 18's leg where it had been pushed against on the wheelchair during the transfer that morning. The bruises could have happened during transfers into the wheelchair. Review of the provider's revised 2/17/06 Resident's Rights policy revealed: "It is the policy of this facility to promote and protect the rights of residents residing in our facility." The provider would ensure residents had always been treated with respect, kindness, and dignity. It had included the ABCs of resident rights. Under Choice in the ABCs it had stated the resident had the right to refuse treatment.	2014-01-01
5153	WINNER REGIONAL HEALTHCARE CENTER	435056	805 E 8TH ST	WINNER	SD	57580	2011-12-14	371	F			IY0E11	Based on observation, interview, and policy review, the provider failed to ensure proper sanitary procedures were followed while serving two of two observed meal services. The staff failed to: Clean the food testing thermometer after each use to prevent cross-contamination. Wash hands between glove changes to prevent cross-contamination. Findings include: 1. Observation on 12/13/11 at 11:30 a.m. of cook F revealed she sanitized the probe on the food testing thermometer with an alcohol swab and proceeded as follows: tested the temperature of the meatballs. -Reused the same alcohol swab to wipe the thermometer probe. Took the temperature of the scalloped potatoes. -Used a clean alcohol swab to sanitize the thermometer probe. Took the temperature of the mashed potatoes. -Reused the same alcohol swab to sanitize the thermometer probe. Took the temperature of the super mashed potatoes. -Reused the same dirty alcohol swab to sanitize the thermometer probe. 2. Observation on 12/13/11 from 11:45 a.m. through 12:30 a.m. of cook G revealed she changed her gloves two times during the meal service. She did not wash her hands after she took off her soiled gloves and before she had put on clean gloves. 3. Observation on 12/13/11 at 12:10 a.m. revealed dietary assistant J changed gloves. She did not wash her hands before she put on clean gloves. 4. Observation on 12/13/11 at 4:45 p.m. of cook H revealed she sanitized the probe on the food testing thermometer with an alcohol swab and proceeded as follows: tested the temperature of the hamburger patty. -Reused the same alcohol swab to sanitize the thermometer probe. tested the temperature of the French fries. -Reused the same alcohol swab to sanitize the thermometer probe. tested the temperature of the vegetables. -Reused that same dirty alcohol swab to sanitize the thermometer probe. tested the temperature of the pureed meat. -Reused that same dirty alcohol swab to sanitize the thermometer probe. tested the temperature of the pureed vegetable. -Again reused that same dirty alcohol swab to sanitize the thermometer probe. 5. Observation on 12/13/11 from 5:00 p.m. through 5:45 p.m. revealed cook I changed her gloves five times. She did not wash her hands before she put on clean gloves. She had used hand sanitizer before she had put on clean gloves three of the five times she had changed her gloves. 6. Interview on 12/14/11 at 10:45 a.m. with the certified dietary manager and the registered dietician revealed they agreed: The food testing thermometer probe should have been sanitized with a clean alcohol swab each time it had been wiped off. Handwashing should have been completed when gloves had been changed by dietary staff members G, I, and J. 7. Review of the provider's February 2009 Hand Hygiene policy revealed: Handwashing with soap and water was to have been completed by personnel in jobs who had no contact with the residents. *Waterless antiseptic agents were to have been used by staff who worked with clean and dirty resident supplies and resident equipment in resident care areas.	2014-01-01
5154	WINNER REGIONAL HEALTHCARE CENTER	435056	805 E 8TH ST	WINNER	SD	57580	2011-12-14	441	E			IY0E11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and policy review, the provider failed to ensure proper handwashing and glove use was used during randomly observed: Resident care for 2 of 2 resident (2 and 18) . Medication administrations for 1 of 11 residents (2). Findings include: 1. Observation on 12/13/11 at 10:45 a.m. revealed restorative nurse aide (NA) E: Wore gloves while she cleaned resident 2's bottom after a bowel movement as he was assisted off the toilet. Pulled his slacks up. Grabbed the walker with her hands and placed it in front of him. Touched his coat. Assisted him into the easy chair. Removed her gloves. Without washing her hands placed a blanket on him. Placed his call light within reach. Opened the room door. Pushed a laundry cart to the soiled utility room. At that time washed her hands at the nurse's desk. 2. Observation of care for resident 18 revealed improper handwashing and glove use during that care. Refer to F224, finding 1. 3. Random observation on 12/14/11 at 9:45 a.m. during medication pass revealed licensed practical nurse (LPN) C; Entered resident 2's room and put gloves on without first washing her hands. Applied ointment to the resident's toe with her gloved hand. Removed the gloves before she left the room. Did not wash her hands when she left the room. Opened the room door. Walked to the medication cart located at the nurse's desk and removed multiple packages of medications from her pockets and placed them in the medication cart. Then she had washed her hands. Review of the provider's revised May 2007 handwashing/hand hygiene policy revealed: When gloves were removed hands were to have been washed. Gloves were to be removed and hands washed before moving from a soiled area to a clean area. Handwashing was to have been done before and after care had been given to the resident. Handwashing was to have been done between cares on different body sites on the same resident. *Hands were to be washed for 15 seconds to clean all of the surfaces. B. Based on random observation, testing, and interview, the provider failed to ensure the following: - Three plumbing fixtures were not pitted and corroded (public restroom, woiled uitility, and the oxygen storage room). - Three back rests and/or arm rests for toilets in resident room [ROOM NUMBER], 211, and 214 were not hazardous and/or were easily cleanable. - Three toilets (resident room [ROOM NUMBER], 136, and 138) had caulking that was not stained, encased with dirt, and was easily cleanable. - The wooden shelf in the three hundred wing bathing room was durable and cleanable. - Food and drink was not stored nor used by the bath aides in the three hundred wing bathing room. Findings include: 1. Observation from 9:00 a.m. to 11:30 a.m. and again from 1:30 to 1:45 p.m. on 12/14/11 revealed the following: a. The sink fixtures in the public restrooms by the dining area, soiled utility by the nurses station, and in the oxygen storage room had pits and chips in the chrome plating. Those chips and pits were the size of cherry and sunflower seeds and were scattered around the faucet and handles. Those chips and pits had eroded and exposed the metal below the chrome plating. Interview with the director of plant operations (DPO) at the time of the observations confirmed those findings. He stated he was not aware of the conditions of those sinks. b. The back rests for the toilets in resident rooms [ROOM NUMBER] were built to ensure durability, cleanability, and were not hazardous. Those back rests were homemade from [MEDICATION NAME] chloride (PVC) plumbing pipe. They were attached with wire strapping and/or secured with string to the handrail behind the toilet. The PVC pipe had jagged ends that were sharp to the touch. The homemade cushions were vinyl covered with exposed seams and screws. Other back rests were made from the backs of old vinyl chairs (photos 1, 2, 3, and 4). The arm rests on the toilet riser shared by residents in room [ROOM NUMBER] a and b were covered with fake sheepskin (photo 1). Interview with the DPO at the time of the observations confirmed those findings. He stated he was not aware there were homemade backrests. He stated they might have been made by a former maintenance man. The DPO revealed he was very aware those homemade backrests were not durable, cleanable, and created a potential for a hazard with the sharp edges. He also stated staff were aware fake sheep skin could not be used on any communal resident use items as it created a high infection control issue. c. The caulking around the base of the toilets in residents rooms [ROOM NUMBER] had layers and layers of caulk that had built-up to one half to one inch with a rough surface. That caulk was stained and encased with dirt and debris. Some caulk had pulled away from the toilet base (photos 5 and 6). d. The four tiered wooden bookcase in the 300 wing bathing room was missing the vinyl edging and had pitted and corroded wooden shelves (photo 7). Interview with the DPO at the time of the observation confirmed that finding. He stated he was not aware of the condition of the wooden shelf, or it would have been replaced. The DPO removed the shelf at that time. e. Two of the four shelves of the wooden bookcase in the 300 wing bathing room had the following opened items: a bottle of pop; and packages of candy, cookies, and bars. Interview with the DPO at the time of the observation confirmed that finding. The DPO relayed to the surveyor it was not a good practice, and it was poor infection control practices to have food and drink in a bathing and grooming area. The DPO removed those items at that time.	2014-01-01
5155	GOOD SAMARITAN SOCIETY DE SMET	435074	411 CALUMET AVENUE NW	DE SMET	SD	57231	2010-10-14	279	D			0Q5G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the provider failed to ensure the plan of care for 2 of 12 sampled residents (2 and 9) contained sufficient information to meet the residents' needs. Findings include: 1. Random observations from 10/13/10 to 10/14/10 revealed resident 2 was in his wheelchair with a fastened seatbelt. Record review for resident 2 revealed: -There was no documentation in the interdisciplinary progress notes to suggest a seatbelt was indicated. -The last physical restraint assessment in the chart was dated 2/11/09. -There was no physician's order to resume the seatbelt. -A physician's order dated 3/4/10 to discontinue the seatbelt. Review of resident 2's care plan dated 7/21/10 revealed no goals or interventions related to the use of the seatbelt. Interview on 10/14/10 at 8:50 a.m. with the director of nursing (DON) revealed: -The resident had changed wheelchairs multiple times due to comfort and positioning issues. -The wheelchair the resident was in during the survey was the original wheelchair resident 2 had started with. -She had not documented the wheelchair changes that had been made or the resident's ability to remove the seatbelt. -A physician's order to resume the seatbelt should have been obtained. -No goals or interventions had been made on the care plan for the resident's use of the seatbelt. -It would have been her expectation for goals and interventions to be listed on the care plan for resident 2's seatbelt use. Review of the provider's physical restraints procedure revised February 2005 revealed the following should have been completed: -The physician should have been contacted. -A physician's order for the seat belt should have been obtained. -An informed consent for permission to use the seat belt should have been obtained. -The resident's care plan should have included the reason for the restraint, required monitoring, and a measurable goal related to the rationale for its use. -There should have been documentation in the interdisciplinary progress notes. 2. Review of resident 9's care record revealed on 9/29/10 he had stated "I'm going to kill myself." Review of resident 9's care plan dated 9/29/10 revealed no mention of his threat to kill himself. Interview on 10/14/10 at 10:15 a.m. with the Minimum Data Set coordinator revealed resident 9's care plan had been incomplete. It should have included the resident's [MEDICAL CONDITION]. Review of the provider's care plan policy revised January 2009 revealed care plans should have been: -Reviewed at least quarterly. -Reviewed, evaluated, and updated when a significant change in the resident's condition occurred. -Modified to reflect the care currently required/provided for the resident.	2014-01-01
101	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	684	D	1	0	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, and policy review, the provider failed to ensure necessary care and services was provided for two of twelve sampled residents (52 and 56) as evidenced by: Not giving a timely opportunity to use a toilet or commode and not having a repositioning schedule in place to prevent decline for resident 52. Not investigating a skin tear of unknown origin and not providing an ordered as needed treatment to a swollen surgical site for resident 56. Findings include:1. Observation on 5/22/19 at 1:14 p.m. of resident 52 in her room revealed:She was alone in her room sitting in her wheel chair (w/c) with her back to the door. There was an over bed table in front of her with her lunch on it.There was a large wet area on the floor behind her w/c that was yellow colored.There was a bubble cup on the floor.She had gray sweat pants on.Those sweat pants were wet between her legs where she was sitting.The left front hip crease area of her sweat pants were also wet.Observation and interview on 5/22/19 at 1:18 p.m. of resident 52 in her room revealed:Certified nurse aide (CNA) M walked into the room.She noticed the wet area on the floor and to the resident's sweat pants.She stated she had offered to lay her down at approximately 10:00 a.m. so she could change her brief.-The resident had refused.She used her Walkie Talkie to ask for assistance to the room.She left and returned with a mop and bucket.She mopped up the wet area on the floor behind her w/c.She picked the bubble cup up from the floor and put it on her overbed table.She went into the bathroom and without washing her hands she put on gloves.Observation and Interview on 5/22/19 at 1:34 p.m. of resident 52 in her room revealed:CNAs H and I entered the room.CNA I stated that he and another CNA had changed the resident's brief at 11:50 a.m.-She had had a bowel movement (BM).-When asked, CNA I stated that he had documented that brief change.CNA H states:-They check on her every two hours.-They do not have the correct Hoyer sling to take her to the toilet or put her on a commode.-She is a Hoyer lift so there is no way to toilet her.Both CNAs I and M agree with CNA H's above statements.At 1:38 p.m. CNA M removes her gloves.-Did not perform hand hygiene.-Left the room.Observation on 5/22/19 at 1:39 p.m. of resident 52 reveals:CNAs H and I have used the Hoyer lift to lay her on her bed.They performed a brief change.They changed her linens.They put her into dry clothes.They put her into a clean and dry w/c.-Her over-the-bed table with her lunch and bubble cups was placed in front of her.Both CNAs leave the room.Observation on 5/22/19 at 2:13 p.m. of resident 52 reveals:She is sitting in her w/c with her back to the door.Her over-the bed table with her lunch tray and three bubble cups were on that table.One bubble cup was empty.Observation on 5/22/19 of resident 52 in her room revealed:At 2:22 p.m., 3:32 p.m., and 3:55 p.m. she was alone in her room.-She was in her w/c.-The television was on.-Her over-the-bed table and lunch tray were in front of her.-She was asleep.Observation on 5/22/19 at 4:20 p.m. of resident 52 in her room revealed:She was in the same position as above.Her lunch tray had been removed.Her over-the-bed table was in front of her.Observation on 5/22/19 at 4:48 p.m., 5:02 p.m., 5:46 p.m., 6:22 p.m., and 6:30 p.m., of resident 52 in her room revealed:She was in the same position as above.Between 2:13 p.m. and 6:30 p.m., there had been no observation of anyone:Entering or leaving her room.Changing her brief.Repositioning her.Interview on 5/23/19 at 8:39 a.m. with the director of nursing concerning resident 52 revealed:We implement a turn and repositioning every two hours:-While in bed.-While in a w/c.She is a heavy wetter.They should be checking her brief at least every hour.They should be repositioning her at least every two hours.She is a Hoyer lift.They should be offering her a bedpan or toileting her.-I am unaware the staff is just allowing her to urinate and have BM's in her brief.She does not have the mental capacity to make a decisionI am not sure she would be able to hold herself up on a commode.Interview on 5/23/19 at 9:00 a.m. with the administrator concerning resident 52 revealed:She agreed the resident is not to be left alone in her room in her w/c.There was no documentation to prove that she had been toileted or repositioned every two hours.Interview on 5/23/19 at 12:40 p.m. with the administrator revealed:Everyone should be toileted or be asked if they need a bedpan.Resident's should be toileted every two hours and as needed.They should not be told or allowed to:-Urinate in their brief.-Have a BM in their brief.-And then be changed in place of toileting, unless they have refused toileting or a bedpan.There is no specific toileting schedule for a resident that wears briefs and is a Hoyer lift. Record review of the CNAs 5/22/19 continence and BM task documentation revealed:At 3:40 a.m. she was incontinent and had no BM.At 1:49 p.m. and 1:50 p.m. she was incontinent and had a medium BM.There was no documentation that at 10:00 a.m. the resident refused a brief change as CNA M stated at 1:18 p.m. above.There was no documentation that at 11:50 a.m. a brief change had been done as CNA I had stated at 1:34 p.m. above. 2. Observation and interview on 5/21/19 at 1:40 p.m. of LPN J while she completed wound care for the resident revealed: LPN J stated:-Resident 56's (surgical area) looks quite swollen today. --She did not provide ice for the surgical site even though there had been an order dated 5/2/19 that stated (MONTH) ice swollen area on (surgical site) for no more that 20 minutes per hour as needed for wound care. -She had been unsure of what happened to the resident's left forearm where there had been a two inch [MEDICATION NAME] gentle dressing in place. --The first treatment for [REDACTED]. --A skilled progress note on 5/7/19 stated Resident has a skin tear to right forearm, dressing CDI, (clean, dry, intact) to be changed every 3 days or PRN. --She could not identify any additional nursing progress notes or reports related to the skin tear on the resident's left arm. Interview on 5/23/19 at 10:45 a.m. with the DON regarding resident 56's swollen surgical site and skin tear on her right forearm confirmed: The ordered treatment of [REDACTED]. The skin tear on her right forearm should have been documented in the progress notes and investigated on 5/6/19 by the identifying nurse . Review of the provider's Qtr 3, (YEAR) Abuse and Neglect Clinical Protocol revealed: Assessment and Recognition; The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment. Review of the providers Director of Nursing job description revealed: The Director of Nursing provides leadership, organization, planning, direction and administration of services toward the delivery of optimum resident care that is consistent with the established standards of nursing practice and the goals for a skilled nursing facility as part of the organization as a while. Also, provides information and assistance to Administration regarding nursing related issues; ensures the delivery services and programs continues to respond to the needs of the residents while contributing to the financial stability of the facility. *Plans, organizes, directs and supervises the delivery of nursing care activities provided to the residents; directly or through delegation; in accordance with organizational goals, federal and state requirements, and other professional standards, to ensure quality and continuity or nursing/medical services.	2020-09-01
103	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	689	D	1	0	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, record review, and policy review, the facility failed to ensure one of one sampled residents (60) who was totally dependant was transferred safely. Findings include: Review of resident 60's 4/25/19 Minimum Data Set (MDS) assessment revealed: She was admitted on [DATE]. Her Brief Interview for Mental Status (BIMS) score was zero indicating her cognition was severely impaired. She required the extensive assistance of two staff for: -Bed mobility. -Dressing. -Toilet use. She was totally dependent on two or more staff for transfers. Interview of 5/21/19 at 8:51 a.m. with resident 60's representative revealed: She felt the lift used to transfer her mother caused pain. There were two men who worked in the evening who would help get her mother to bed. -She could not remember their names. She had asked them to pick her mother up and move her from the chair to the bed and vice versa. She had witnessed them moving her in this manner, without the lift and believed that it was easier on her mother. Interview on 5/22/19 at 3:19 p.m. with certified nursing assistant (CNA) H regarding resident 60 revealed she: Required a full lift transfer. Denied seeing signs or symptoms of pain for the resident during transfer. Denied seeing anyone transfer her without a lift, stating it would be unsafe. Interview on 5/22/19 3:22 p.m. wit CNA I regarding resident 60 revealed he had: Met resident 60's representative. Never seen or heard of anyone transferring her without a lift. Would not transfer the resident without a lift because it would jeopardize his job. Interview of 5/22/19 at 2:41p.m. with the administrator and the director of nursing (DON) regarding resident 60 revealed: They would not be surprised if the family asked for the resident to be transferred without the lift. They would be surprised if the staff would transfer her without the lift. They had not heard of this happening. They did not transfer people without the total lift if they had been assessed to need the lift. Review of provider's Qtr3, (YEAR) Safe Lifting and Movement of Residents policy revealed: The provider will use appropriate techniques and devices to lift and move residents to protect their safety and well-being. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.	2020-09-01
136	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-01-31	689	E	1	0	NOYG11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, and policy review, the provider failed to ensure: Timely preventative maintenance to include checking lift clips for one of three total mechanical lifts (2) to prevent a fall for one of one sampled resident (1). Staff education and training for all direct care staff including four of four interviewed certified nurse assistants (CNA) (A, B, C, and D) about proper usage, sling selection, and appropriate maintenance of total mechanical lifts when used with sampled residents 1, 4, and 5. Findings include: 1. Review of resident 1's 1/18/18 South Dakota Department of Health (SD DOH) event report revealed: Certified nursing assistants (CNA) D and F had been transferring the resident into her wheelchair with the total mechanical lift. The sling hooked on the right front hook slide off Hoyer hook when sling was pulled back to sit resident straight into her w/c (wheelchair). The resident fell forward and hit the right side of her head on the floor. The lock on the right hook did not go into lock position causing the right sling hook to slide off Hoyer. The equipment malfunction was written up for the maintenance department, and the Hoyer lift had been removed from the floor. The report had been completed by licensed practical nurse [NAME] Observation on 1/30/18 at 3:50 p.m. in the 100 hallway revealed on Hoyer lift 4 one of four clips was broken. Interview on 1/31/18 at 9:00 a.m. with CNA D regarding resident 1's fall out of the lift revealed: She had been employed at the facility for approximately sixteen years. They had been using the total mechanical lift labeled 2. All four clips had been broken on the lift prior to transferring resident 1 on 1/18/18. The clips had been broken for awhile, but she was not sure how long they had been broken. She had not reported the broken clips to maintenance. She had not had training on proper use and maintenance of the lifts since she had been employed. The resident had fallen forward and hit her head. Review of the mechanical lift preventative maintenance record for lift 2 revealed: The following items had been on the list to check: -Emergency lowering. -Chassis function. -[MEDICATION NAME] and connections - adjust. -[MEDICATION NAME]. -Boom/arm pivot pins and bushings. -Scale display. -Front chasers. -Hand control. -Leg bolts. -Foot pedal. -Leg spreader pivot bar. -Mast/base bolts. -All casters clean. -Batteries. -Charger. -Lube pivot points on lift. -Check all external hardware and tighten if necessary. The above items had been checked on 12/13/17. Clips had not been monitored on the preventative maintenance record for lift 2. The lift was checked on 1/19/18, but clips had not been addressed on the record. Interview on 1/31/18 at 1:45 p.m. with the administrator, director of nursing, and quality assurance and performance improvement (QAPI) coordinator regarding the above incident revealed: The maintenance director was to do monthly preventative maintenance on the lifts. The administrator thought the clips had been broken after CNAs D and F began transferring resident 1. The QAPI coordinator had conducted interviews with CNAs D and F and was aware the clips had been broken prior to them using the lift for resident 1. Review of the provider's undated Mechanical Lift policy revealed maintenance was to service the lifts every six months or sooner if problems occurred. They were to keep a log of those services and maintain the records for five years. Review of the provider's undated Preventative Maintenance policy revealed: Preventative maintenance checklist to be completed by maintenance department with daily, monthly, quarterly, and annual tasks. Maintenance to keep checklist and initial and date those items when completed. The list includes but not limited to elevator policy, daycare door, and annual reports of smoke barrier condition and repair if needed. 2a. Observation and interview on 1/31/18 from 8:40 a.m. through 8:50 a.m. with CNAs A and B revealed: CNA A had been employed at the facility for three years. CNA B had been employed at the facility for one-and-a-half years. At 8:40 a.m. they went into resident 4's room to transfer her from her wheelchair to her bed. -They were using the total mechanical lift labeled 1. -They had a sling with four straps, but the lift had six hooks. -The lift was difficult to maneuver as the wheels had not moved easily. b. At 8:50 a.m. they went into resident 1's room to transfer her from her wheelchair to her bed. -They used the same lift but had a sling with six straps instead of just the four. The resident had a bruise under her right eye that was yellow and black. -CNA B stated that was from her fall out of the lift on 1/18/18. -When she fell she hit her head on the floor. -She thought the bruise was looking better. Neither CNA A or B had any training on the lifts since they started. c. Observation and interview on 1/31/18 at 8:55 a.m. with CNAs C and D regarding resident 5 revealed: CNA C had been employed at the facility for seven years. CNA D had been employed at the facility for sixteen years. They entered her room with the total mechanical lift labeled 2. They were transferring her from her wheelchair to her bed. The lift had four hooks. They were using a sling with six straps. They doubled up the straps in the front/leg hooks using the middle and bottom straps. -The head strap they hooked on the purple loop on the back/head hook. -The middle strap they hooked on the black loop on the front/leg hook. -The leg or lower strap they hooked the blue loop onto the front/leg hook. The lift had been hard to maneuver, and when asked about it CNA D stated You really have to put your back in it to get them to move. Only one resident that used the total mechanical lift had her own sling. CNA C and D were not sure if it mattered if they used the sling with 6 straps versus the sling with 4 straps. Neither CNA C or D had any training on the lifts since they had started at the facility. d. Review of the annual staff training records and agendas revealed they had not provided any training on proper use, sling selection, or maintenance of the lifts to any staff. There had not been any education after resident 1 had fallen out of the lift on 1/18/18 due to broken clips. Interview on 1/31/18 at 10:30 a.m. with the administrator revealed they had not provided any training on the mechanical lifts other then what the staff got when they started. They had not conducted any training after resident 1's fall on 1/18/18. Interview on 1/31/18 at 10:40 a.m. with the director of nursing and restorative aide [NAME] revealed: They had multiple, different sized slings that were used for multiple residents. Restorative aide [NAME] had been in charge of ordering new slings. She relied on the CNAs to inform her if new slings were needed and what size slings they needed. -They would guess the sling size based on the size of the resident. The CNAs had not been educated on correct sling sizes. They used different type slings with the mechanical lifts. They were unaware if the manufacturer's recommendations stated to use: -Four strap slings with six hook mechanical lifts. -Six strap slings with four hook mechanical lifts. Therapy had not been involved in determining appropriate sling sizes for the residents, and it had been left up to the CNAs to choose the size of sling.	2020-09-01
137	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-01-31	867	E	1	0	NOYG11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, record review, and policy review, the provider failed to identify concerns with multiple falls and to implement an effective performance improvement plan (PIP) and quality assurance program. Findings include: 1. Review of the provider's event summary report from 11/1/17 through 1/30/18 revealed there had been thirty-two falls involving sixteen residents. Interview on 1/31/18 at 12:25 p.m. with the quality assurance program nurse revealed: She had been in the role for about two years. She had received some training from the state quality assurance coordinator at the beginning. She was also the infection control nurse, the grievance official, and worked on the floor two days a week. -Today she had been scheduled to work in the office and not on the floor. Relevant to falls, she had taken over completing post fall huddle reports because CNAs and other staff were not completing them. -They had not looked at the data collected to determine staffing issues or environmental issues. -Interventions were implemented after the fall had occurred. -The falls PIP had been going on since (MONTH) (YEAR). Other PIP projects she was currently working on included: -Pressure ulcers - no date of initiation. -[MEDICATION NAME] screening - no date of initiation. -Food temperature recording was initiated in (MONTH) (YEAR). --She was unsure why the dietary manager was not involved with this PIP. -Perineal and catheter care was initiated in (MONTH) (YEAR). -Self-administration of medications was initiated in (MONTH) (YEAR). She had been in charge of all the above PIPs. Interview on 1/31/18 at 1:00 p.m. with the director of nursing revealed they had not had other department heads involved in the quality assurance PIP process. Review of the provider's undated Quality Assurance Performance Improvement policy revealed goals were to incorporate quality process assessment, evaluation, and improvement planning for all systems sustaining of improvement in quality within the organization.	2020-09-01
149	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-11-28	585	E	1	0	QFLH11	> Based on interview and policy review, the provider failed to have a facility based system in place to document grievances brought to their attention by staff, residents, or family members. Findings include: 1. Interview on 11/28/17 at 11:00 a.m. with an anonymous family member revealed she had been yelled at by a staff member a few weeks back. While she could not recall the name of the staff member who had yelled at her, she identified another staff member who had witnessed the event. Interview on 11/28/17 at 11:15 a.m. with an anonymous staff member revealed: Earlier in the month she had overhead certified nursing assistant (CNA) C getting loud with the above family member and resident. She had been walking down the hall towards the residents' rooms when the voices started to get loud. She had walked into the room and heard CNA C yelling at the family member. She had reported the incident to the charge nurse. She was unable to remember who the charge nurse was that night. Interview on 11/28/17 at 1:30 p.m. with the social services designee and the director of nursing (DON) regarding their grievance process revealed they: Had no way of tracking grievances. Were unable to provide what grievances had been received since 9/18/17, and how those grievances were resolved. Stated grievances were handled on an individual basis but could not provide what grievances they had looked into and resolved. Interview on 11/28/17 at 1:45 p.m. with the administrator revealed: They currently had a grievance form that staff should have been filling out but were not. They were changing the process but had no timeline for when that would be implemented. The DON had received a note under her door on 11/27/17 regarding CNA C and her behavior being inappropriate towards family and residents. -The note had not been signed. They were waiting to talk to CNA C on 11/29/17, as that was the next shift she was scheduled to work. They had not started an investigation into the matter. They had not documented that as a grievance. Review of the provider's current undated grievance procedure revealed: A grievance is a complaint in which a resident (or family member) feels he/she has not been treated fairly, or that a mistake has been made in the resident's care or in the administration of a rule, plan, or policy. The policy had not addressed the grievance form or documentation of the grievance.	2020-09-01
150	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-11-28	610	E	1	0	QFLH11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to thoroughly investigate falls for two of two sampled residents (1 and 4). Findings include: 1. Review of resident 1's 10/6/17 South Dakota Department of Health (SD DOH) event reporting form revealed: The fall had occurred at 4:30 a.m. The resident's wife had received a call at home from the resident asking her to contact the nurses in the facility, as he needed help. Staff received the call from the wife, and they found him sitting on the floor. Resident first stated he was sitting on his wheeled walker and fell asleep and woke up to falling onto the floor. Then later stated that he was trying to move his wheelchair to the hallway and fell . His left eye was swollen. His wife had taken him to the hospital where he was admitted for weakness, [MEDICAL CONDITION], and fall with periorbital hematoma. They will encourage resident to utilize his wheelchair (if still appropriate) and walker and not to walk on his own. Will keep call light in reach and make sure his cell phone is on his person, so if not within call light reach able to make contact with staff or wife. The administrator's name had been on the final investigation conclusionary summary. There had been no documentation regarding the following investigation areas: -Interviews conducted with the wife or staff members who had been working. -Where the call light had been located. -The last time he had been checked on. -What level of assistance he required. -If the care plan had been followed. -What the environment looked like upon entering the room. -If he had been assisted to bed and who last worked with him. -If there had been any medication changes. 2. Review of resident 4's 11/19/17 South Dakota Department of Health (SD DOH) event reporting form revealed: The fall had occurred at 11:30 a.m. Resident prone on floor beside tipped recliner. He had complained of pain to his left eye brow where an abrasion had been noted. Extensive assist of 2 to stand and transfer to bed. Resident moved closer to the nursing station and is reminded to use call light for assistance of which his dementia keeps him from remembering this. The administrator's name had been on the final investigation conclusionary summary. There had been no documentation regarding the following investigation areas: -Interviews conducted with the staff members who had been working. -Where the call light had been located. -The last time he had been checked on. -If the care plan had been followed. -Why the recliner would have tipped over. -If there had been any medication changes. 3. Interview on 11/28/17 at 4:00 p.m. with the administrator and the director of nursing revealed there had been no further documentation regarding the above incidents and the investigations. Review of the provider's undated How to Conduct an Investigation policy revealed: The investigation should have included: -Who. -What. -When. -Where. -How. Documentation is needed to reflect that the standard of care was met. *Any event that is not consistent with the routine care of the resident is worthy of investigation.	2020-09-01
151	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-11-28	658	D	1	0	QFLH11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, record review, interview, and policy review, the provider failed to ensure professional standards of practice were followed for one of one sampled resident (1) for: Receipt, transcription, clarification, implementation, re-evaluation, and follow-up to physician's orders. Appropriate nurse documentation of medication when not readily available in the facility versus refused by the resident. Findings include: 1. Review of resident 1's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Disorder of the kidney. -Muscle weakness. -Unspecified dementia. -[DIAGNOSES REDACTED]. -Essential hypertension. He had fallen on 10/6/17 at 4:30 a.m. Review of resident 1's 10/6/17 nursing progress note revealed: At 4:30 a.m. Received call from resident's wife asking for him to be checked on. -Resident called wife from personal cell phone and told her he needed help. -Resident checked on and found sitting on the floor. -Resident first stated that he was sitting on his wheeled walker and fell asleep but woke up as he was falling on the floor. -Then later stated that he was trying to move his wheelchair to the hallway and fell . -Noticed left eye was swollen. -No other injuries noted. -Vitals, range of motion, and neuro (signs) checked. -Doctor and spouse notified of event. --There had been no documentation regarding the recommendation from the physician regarding the resident hitting his head. At 9:39 a.m. Residents wife here with resident this AM. States that she called (physician's name) regarding fall this AM and plans to take resident to the (hospital name) ER (emergency room ) and to see (physician's name). At 10:05 a.m. Resident to (hospital name) ER via private vehicle accompanied by wife. Meds (medication) sent with. At 11:47 a.m. (Physician's name) updated that resident was taken to (hospital name) ER to see (another physician's name) with wife this AM following fall. At 5:10 p.m. Call received from (nurse's name) from (hospital name) states that resident was admitted for weakness, [MEDICAL CONDITION], and fall with periorbital hematoma. Review of resident 1's 10/6/17 event report revealed: He had an injury to his left eyebrow. The injuries noted were bump, redness, and swelling. They had not faxed the physician but had documented they had been notified at 5:04 a.m. There had been no documentation regarding what communication or recommendations the physician made regarding the injury to his head. Interview on 11/28/17 at 10:30 a.m. with resident 1 and his spouse revealed: He had [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. She had received a call on 10/6/17 at 4:10 a.m. from her husband asking her to contact the nursing staff as he needed help. She had called the facility, and then drove to the facility about forty-five minutes later. When she arrived and saw the injury to his eye she had been worried about his vision. She had notified her husband's physician at the Veterans hospital of his fall. She was told he should go to the hospital. She drove him herself to the hospital. He had been admitted into the hospital and had been there for one week. They wanted him to use the condom catheter at night, so he could sleep. Initially the nurses had used a product they had in the building that was too small and very old. She had requested they use the condom catheters provided by the Veterans hospital instead of the others, as she did not want her husband to be in pain. He stated it helped him be more alert throughout the day if he got sleep at night. 2. Review of resident 1's nurses' progress notes revealed on 10/12/17 he had returned from the hospital with a condom catheter in place. Review of resident 1's 10/12/17 hospital discharge paperwork revealed there was no order for a condom catheter. Review of resident 1's nurses notes revealed: On 10/12/17 at 3:00 p.m. he had been readmitted with a condom catheter. On 10/13/17 the condom catheter had come off and tore. -Staff had spoken to the wife and resident about not replacing the condom catheter to encourage resident with toileting and continence. There had been no documentation regarding clarification with the physician regarding the use of the condom catheter. Interview on 11/28/17 at 3:10 p.m. with the Minimum Data Set coordinator revealed there was no documentation of a physician's order for the condom catheter or clarification that resident 1 should have one. 3. Review of resident 1's physician's orders revealed on 11/1/17 the physician had ordered a condom catheter to be put on every night and taken off in the morning for nocturnal incontinence. They were to trial the condom catheter for two weeks. Then they were to reassess the purpose that was to decrease skin breakdown related to nocturnal incontinence. Review of resident 1's treatment administration records from 11/1/17 through 11/28/17 revealed: On 11/1/17, 11/2/17, and 11/3/17 NA (not available). From 11/4/17 through 11/8/17 staff had initialed as putting on the catheter. On 11/9/17 an R (refused) had been marked. From 11/10/17 through 11/13/17 NA had been marked. From 11/14/17 through 11/16/17 it was eligible and circled. From 11/17/17 through 11/19/17 NA had been marked. 11/20/17 had been initialed. 11/21/17 brief was written. 11/22/17 a dash had been marked. From 11/23/17 through 11/26/17 NA had been marked. 11/27/17 had been left blank. Interview on 11/28/17 at 1:30 p.m. with licensed practical nurse A and registered nurse (RN) B revealed: They were unsure of where the first condom catheters had come from. They now had the condom catheters from the VA but had not been using them. The NA on the treatment administration record meant not available. RN B stated the wife had requested he not wear them. -She agreed it was because the condom catheters used initially were not the right size and were old. There had been no communication with the physician regarding discontinuing the condom catheter. Review of resident 1's medical record revealed there was no documentation the physician had been notified about discontinuing the condom catheter. 4. Review of resident 1's physician's orders revealed on 11/1/17 the physician had ordered myrbetriq extended release tablets 25 milligrams everyday for urinary incontinence/overactive bladder. Review of resident 1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Observation and interview on 11/28/17 at 3:30 p.m. with licensed practical nurse A revealed: The R with a circle around it on the MAR meant the resident had refused the medication. The medication myrbetriq had not been in the medication cart. She had stated it was going to be discontinued and had been put into the cupboard. The cupboard had been searched, and the medication had not been there. She then stated it had been returned to the pharmacy. They had been marking refused on the Medication Administration Record [REDACTED]. There had been no physician's order to discontinue the medication. Review of resident 1's medication disposition sheets revealed: On 11/9/17 they had sent back eight myrbetriq tablets due to being overstocked. On 11/24/17 they had sent back twenty-six myrbetriq tablets due to the medication being discontinued. Review of resident 1's medical record revealed there had been no physician's documentation of an order to discontinue the medication. 5. Interview on 11/28/17 at 4:00 p.m. with the administrator and the DON revealed staff should have: Documented the physician's recommendations in the resident's medical record after the fall. Contacted the physician for clarification of use regarding the condom catheter after returning from the hospital, and prior to discontinuing the condom catheter and myrbetriq medication. Not have been marking refused on the MARs. They should have received an order for [REDACTED].>They were not sure why the staff had sent the medication back to the pharmacy. Policies for following physician's orders, clarification of physician's orders, and documentation had been requested of the administrator and DON but one had not been provided by the end of the survey. [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis., (YEAR), p. 367, revealed: Telephone orders (TOs) occur when a health care provider gives therapeutic orders over the phone to a registered nurse. Verbal orders (VOs) occur when a health care provider gives therapeutic orders to a registered nurse while they are standing in proximity to one another. TOs and VOs usually occur at night or during emergencies, they should be used only when absolutely necessary and not for the sake of convenience. The nurse receiving a TO or VO enters the complete order into the computer using the computerized provider order entry software or writes it out on a physician's order sheet for entry in the computer as soon as possible. [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis., (YEAR), p. 628, revealed: Nurses and other health care providers use accurate documentation to communicate with one another. Many medication errors result from inaccurate documentation. Therefore always document medications accurately at the time of administration and verify any inaccurate documentation before giving medications.	2020-09-01
160	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	600	H	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to: Provide necessary care in services resulting in neglect and resident-to-resident altercations for two of two sampled closed resident record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit (MCU). Implement a resident-specific care plan that included evaluations and revisions of interventions to prevent abuse and neglect for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. Provide supervision and monitoring of the delivery and implementation of care for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. Ensure effective communication between nursing and direct care staff and health care providers regarding physical and verbal abuse for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. Contact the primary physician at the time of an acute change in condition that required the plan of care to be revised to meet the residents' needs in a timely manner for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. Ensure staff responded professionally to medical and psychiatric emergencies for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. Ensure thorough orientation upon hiring for one of one licensed nurse (B) and one of one certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) (D). Findings include: 1. Review of a South Dakota Department of Health (SD DOH) initial Required Healthcare Event Reporting form completed by the director of nursing (DON) regarding resident 1 that had been sent to the SD DOH on 2/23/18 revealed: The type of event being reported was Suspicion/allegation of abuse/neglect on 2/22/18 at 5:40 p.m. The allegation type was Physical harm/injury. Under the heading Suspicion/Allegation of Abuse/Neglect: Resident to resident /Patient to patient. Both Names and Cognition. (Resident 1) (Resident 2) Both residents have dementia and live in our memory care unit (MCU). * A brief explanation of the event indicated: (CNA/UAP E) was in the medication room when she heard a loud bang. She immediately went to investigate to find (resident 1) laying on the floor bleeding from her nose and mouth. (Resident 2) was standing beside (resident 1) mocking her when (CNA/UAP E) found them. Large bump to the back of (resident 1's) head when assessed by nurse. Resident was sent to ER. Social worker notified at the time of the fall but unaware of the circumstances. Management staff are made aware of the situation after reading notes this morning. The law enforcement had been notified on 2/22/18 at 6:00 p.m. due to Assault of resident. The Department of Social Services had not been notified. Review of the SD DOH final Required Healthcare Event Reporting form for resident 1 sent to the SD DOH on 2/23/18 revealed the conclusionary statement: The initial SD DOH facility event report statement was included. On 2/23/18 at 8:30 a.m.: Staff development nurse called (the medical director/Resident 2's primary physician) regarding incident and requested a return call ASAP. 8:45 a.m. DON, infection control nurse (LPN J), staff development nurse (LPN A) spoke with CNA/UAP [NAME] about the events that occurred the previous day. CNA/UAP [NAME] had reported: She had been in the medication room when the event occurred. CNA/UAP H had been in the common room with all nine residents present. CNA/UAP [NAME] heard a loud thud and came out to investigate the noise. She found: -Resident 1 on the floor in the hallway between the door of her room and the common area, bleeding from her nose. She was lying on her back and attempting to roll to her side to get up. -Resident 2 was standing over resident 1, Mocking her for crying and verbally berating her. -As CNA/UAP [NAME] was assisting her to sit up, she began bleeding from her mouth. -CNA/UAP [NAME] laid her on her back on the floor to redirect resident 2 away from resident 1, and contacted the nurse by phone. -Once CNA/UAP [NAME] had notified the nurse CNA/UAP H: --Exited the bathroom. --Attempted to redirect resident 2 away from the area as he continued to mock resident 1. -At that time LPN B entered the MCU. -She attempted to obtain resident 1's vital signs but was unsuccessful. -She contacted 911 for transport. -Family was notified, and PCP (primary care physician) was faxed about the incident. -Resident 1 was transported by ambulance to the emergency room at 6:17 p.m. -CNA/UAP [NAME] reported she had not been gone from the common room for more than two minutes when the event had occurred. The above report went on to document: On 2/23/18 at 10:30 a.m. the infection control nurse had attempted to contact the medical director/resident 2's physician's personal cell phone. At 11:30 a.m. the infection control nurse had contacted the medical director/resident 2's physician's office and spoke to the receptionist. Message left with the receptionist regarding the severity of the situation and the urgency of needing to speak with the physician. At 11:40 a.m. the infection control nurse had received a phone call from another doctor, and they discussed resident 2's background and behavioral history. -She received a verbal order to send resident 2 to the emergency room for an evaluation. At 11:45 a.m. the staff development nurse contacted resident 2's wife and notified her he was being transported to the emergency room . At 12:15 p.m. he was transported to the emergency room . Documentation at the end of the conclusionary summary stated: In conclusion abuse/neglect has not been substantiated at this time due to lack of proof of any wrong doing. -The police department was investigating the incident. Documentation below the conclusionary summary stated: -Was abuse/neglect allegation substantiated? was marked N/[NAME] There was no proof/witness to substantiate. Police are investigating at this time. -Action taken by the facility: Resident that possibly caused harm was removed from the facility and transferred (to a) facility that can meet his behavioral needs. Interview on 3/7/18 at 8:10 a.m. with CNA/UAP [NAME] regarding the above event on 2/22/18 revealed she confirmed the above conclusionary report and added: She had worked as a restorative aide until 3:30 p.m. that day. She had worked on the MCU from 3:30 p.m. until 6:30 p.m. with CNA/UAP H. Supper was finished between 5:15-5:30 p.m. CNA/UAP H had wheeled the MCU supper cart to the kitchen and returned to the MCU. CNA/UAP [NAME] then went to the medication room next to the common area to finish setting up the supper medication. Residents 1 and 2: -Had been placed at separate tables. -We always sat them at different tables. -Resident 1 had frequent repetitions of the word [NAME], [NAME], [NAME] that would cause resident 2 to become upset with her. -CNA/UAP H was in the bathroom when the event occurred. -She came out of the bathroom at the time LPN B entered the MCU. -LPN B was unable to get vital signs, but resident 1 was resisting. -After resident 1 had been transported to the ER resident 2 had stated, They called the cops at me. -Resident 2 had remained on the MCU. -CNA/UAP [NAME] had left the MCU at approximately 6:35 p.m. -CNA/UAP H remained on the MCU to care for the residents alone. -Resident 2 was still on the MCU when CNA/UAP [NAME] returned to work the following day. Resident 2's behaviors: -Were OK when he had been admitted to the MCU. -Became worse and worse over the last couple months. -Had received medication changes due to his worsened behaviors, but the behaviors had not changed. -Because of his worsened behavior CNA/UAP [NAME] had not been comfortable working on the MCU alone. -When asked if she had discussed her discomfort with his behavior, she stated Not really. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding the above event on 2/22/18 revealed she: Worked as day shift charge nurse on the Warren and MCU units. Went to the MCU at 1:00 p.m. to administer a medication. Returned again at around 5:40 p.m. after she received the phone call from CNA/UAP E. Confirmed the events on the SD DOH event report conclusionary summary statement. Had not known resident 2 had behavior issues until that day. Entered the unit to find resident 2 standing over resident 1 mocking her. Instructed CNA/UAP H to get CNA I. Lifted resident 1 by the pants from the floor to her wheelchair with CNA/UAP I's assistance and wheeled her to her room. Used a flashlight to find the cause of the bleeding in her mouth. Was unable to obtain vital signs. Did not attempt to obtain neurological checks. Left the CNAs on the MCU while she went back to the Warren unit to call the ambulance. Did not know how to call out for 911, so called the other nurse in the building for instructions. Informed the emergency medical system (EMS) person of resident 1 possibly being pushed or hit and answered yes when the EMS person had asked if the other person remained in the building. Had not known how to fill out paperwork for a transport, so the oncoming LPN C assisted her. Stated: -There was no written instruction on how to handle emergency situations. -She had not received orientation regarding emergency situations. -LPN C was her only contact to assist her to handle the situation. Stated the licensed social worker (LSW) was still in the building, and he told LPN C to tell LPN B to: -Fax the physician about the fall. -Get a fax order from resident 2's physician to get resident 1 moved. LPN B stated the LSW: -Wanted to wait for the fax order follow-up for resident 2. -Did not enter the MCU during the event or after resident 1 had been transported to the ER. LPN B: -Called resident 1's power of attorney to notify him of the injury and transport to the ER. -Faxed resident 1's primary physician regarding the event. -Did not notify the director of nursing or the administrator of the event. -Did not notify resident 2's family about the event. -Did not immediately phone resident 1 or 2's physicians about their significant change in status. When asked if LPN B had observed any other aggressive incidents by resident 2 she stated: She had been called back to the MCU on the evening of 2/21/18 by CNA D to check resident 1's chest. CNA D had told her resident 1 had been Punched in the chest. -LPN B stated she: -Did not think it had occurred at that time. -Had not asked who punched resident 1 or when it had occurred. -Thought it happened earlier and the aide wanted her to follow up on it. -Had looked at her chest and placed a note in her chart. -Had not completed an event report. -Had not reported it to other nursing staff. Interview on 3/7/18 at 10:15 a.m. with CNA/UAP H regarding the 2/22/18 event revealed: She came to work at 10:30 a.m. CNA/UAP [NAME] came to work in the MCU at 3:30 p.m. After the supper meal was done CNA/UAP [NAME] went to the medication room to get medications ready. The residents were fine, so she went into the bathroom. When she came out of the bathroom she saw resident 1 on the floor. She confirmed the events according the SD DOH conclusionary report and added that after resident 1 was transported to the ER: -Resident 2 was agitated and mentioned he was going to jail. -He had threatened to harm other residents and her. -She confirmed she was scared by his threats. -She immediately told the nurse (LPN C) about his threats to harm others. -Sometimes he would become verbally aggressive, but she had never seen him harm anyone before. -Later that evening he went to his room and stayed there. -CNA/UAP H left the MCU at around 9:00 p.m. Interview on 3/7/18 at 10:12 a.m. with CNA F regarding the event on 2/22/18 revealed she: Came to work on MCU at 6:00 p.m. and worked there until 6:30 a.m. the following morning. Thought resident 2 was already in bed when she reported to the MCU. Stated he slept all night getting up one time to the bathroom. Was not afraid of him. Checked all residents every two hours, and thought the nurse had told her to check on resident 2 every hour. Did not recall having worked with CNA/UAP H that evening. Did not remember resident 2 raising a fist at her. Had never seen resident 2 hit or push other residents. Did observe resident 2 become verbally aggressive with residents. Used the pocket care plan to guide her care of the residents. Interview on 3/7/18 at 11:11 a.m. with the LSW regarding the 2/22/18 resident-to-resident altercation revealed he: Had clocked out and was walking through the facility at 6:00 p.m. when LPN C informed him I think (resident 2) may have pushed someone down, and they need to go to the hospital. Instructed LPN C to let the administrator or the director of nursing know. Denied he had recommended to LPN C to fax resident 2's primary care physician (PCP) regarding a behavioral health referral. Stated It was more hearsay than reportable so I left. Stated, I thought it was being handled. Had heard of other occasions that resident 2 had pushed others, but he did not get involved. Was not involved with reviewing event reports. Did not assess resident 2's behavioral problems and said, I did not actively think about how (resident 2) would act after the situation. Further interview at the above time with the LSW revealed: The interdisciplinary team gathered daily at 9:00 a.m. for a stand-up meeting to review any resident's concerns. -They reviewed falls. -Resident behaviors were not reviewed routinely. The CNAs documented resident's behaviors. He: -Imported resident behavior reports to review for the seven-day look back at the time of each residents' Minimum Data Set assessment. -Did not review the days that were not in their seven-day look back. -Was more involved with missing money or elopements. -Was not involved with resident-to-resident behavior. -Was not aware the CNAs attempted to keep residents 1 and 2 separated in order to prevent resident 2 from becoming aggressive toward resident 1. Interview on 3/7/18 at 2:20 p.m. with infection control/staff development LPN J regarding altercations between residents 1 and 2 revealed: She had been aware of resident 2's episodes of verbal aggression but had not been aware of physical aggression. She was aware of the 12/14/17 event but did not remember the altercation had been intentional.She vaguely remembered the 1/24/18 event when resident 1 had been pushed. She had recalled reviewing the 1/24/18 event at a stand-up meeting, but had not put it together to report the event to the SD DOH. The LSW would not have been involved with that type of event. The LSW would talk to a resident if their behavior was inappropriate such as touching but not for physically aggressive behaviors. Interview on 3/7/18 at 4:35 p.m. with LPN C regarding the 2/22/18 resident-to-resident altercation revealed she: Worked the 6:00 p.m. to 6:30 a.m. shift. Was scheduled as the charge nurse on Warren and memory care units that date. Was aware of resident 2's aggressive behaviors. Was informed by LPN B of the fall event in the memory care unit. Reported to LSW on 2/22/18 at approximately 6:30 p.m. that she heard two different stories: resident 2 hit resident 1 or they suspected he hit her. Was instructed by the LSW to fax resident 2's doctor to get an order to send him to behavioral health. Was not instructed by the LSW to call the administrator and/or the director of nursing. Stated the LSW left the facility and did not assess the situation to ensure the safety of other residents. Acknowledged on 2/22/18 at approximately 8:00 p.m.: -CNA/UAP H had reported to her resident 2 raised his fist at her and tried to hit her. -She had instructed CNA/UAP H to ignore resident 2 and leave him alone. -She told her she would go back to memory care to check on him. There was no communication to the PCP regarding resident 2's behaviors. She had not documented in the interdisciplinary progress notes (IPN) regarding having monitored resident 2's behaviors. When asked if there was protocol for notifying the DON or administrator about incidents LPN C stated: I think we are supposed to notify the DON or administration if a resident was hospitalized . She probably should have followed up with LPN B regarding what resident reporting she had done before she left. She had not known what LPN B completed for notification before she left the building. I didn't really think of calling. Interventions for resident 2's aggressive behavior was to redirect/steer other residents away from him and hope he did not follow. Review of resident 1's medical record revealed:She had been admitted on [DATE]. She resided on the memory care unit. A 12/12/17 physician's progress note indicated: -[DIAGNOSES REDACTED]. -No longer even to do social chatter. -[MEDICATION NAME] had been helpful for anxiety and agitation. -She was quickly declining cognitively. -She walked with a shuffled gait, head held down. A 12/27/17 order to change [MEDICATION NAME] from three times daily to as-needed. A 1/31/18 fax to the primary physician to discontinue the as-needed [MEDICATION NAME], because she had not used the prescription in the last fourteen days. That order was approved. A 2/13/18 physician's progress note revealed:-She was seen at the Veteran's Administration (VA) Hospital. -The VA physician had changed her [MEDICATION NAME] from a scheduled dose to as-needed. -The same physician had also added [MEDICATION NAME] (to treat depression and anxiety). -Really no improvement. -Still attempts 'exit-seeking'. -Gait now more shuffle than walking. -Echolalia (word repetition)-unable to formulate words otherwise. A quarterly memory care unit assessment form completed 5/19/17, 8/18/17, 11/17/17, and 2/14/18 had indicated on each assessment she: -Required a calm and structured environment to maintain comfort and dignity. -Exhibited pacing and agitation. -Was known to wander. Review of the 2/22/18 at 10:53 a.m. care conference note completed by the LSW in the IPN revealed:A care conference was held on that day. The clinical coordinator/Minimum Data Set (MDS) nurse, dietary manager, LSW were present. The resident's power of attorney was present by phone. Resident 1 was on a list to have received one-to-one activity once every week. She had lost thirteen pounds in the past six months. The physician saw her 2/13/18, and States she is tolerating her medication well. She was needing more assistance with her activities of daily living. She could not formulate words and continued to have echolalia. No concerns noted during care conference. Review of the IPN for resident 1 revealed: A 2/22/18 at 6:20 p.m. note by LPN B revealed at 5:40 p.m.: -The memory unit called me no one witnessed it and (resident 1) was on the floor bleeding on her left side, she was crying out, she could move all of her limbs freely, she was bleeding from her mouth and nose had has a huge knot on the back of her head. -She coughed up a huge clot. -The staff were unable to obtain her vital signs, because She was too worked up. -She may have fallen or she was punched by or pushed by another resident. At 6:17 p.m. she left by ambulance to the emergency room . LPN B had notified the power of attorney of the event. LPN C who was coming on duty had talked to the LSW about the event. LPN B indicated she was Sending a fax to her Dr (doctor) about the incident, and the other Dr about his behavior. The other resident was mocking her the whole time she was on the floor. Laughing at her too. A 2/23/17 at 3:59 p.m. note by the DON indicated she had contacted the hospital for an update on resident 1. She was instructed the resident had a fracture to her skull and a subdural hemorrhage. A 3/2/18 at 2:18 a.m. late entry by LPN C: Late entry for 02/23/18. Resident sent to the ER after falling and hitting her head. Hospital said has 2 bleeds in her head. There were no further entries in the IPN notes. Review of the provider's 2/22/18 at 5:30 p.m. fall report by LPN B for resident 1 revealed:The fall was not witnessed. Memory care called her. She entered memory care and found the resident on her left side. She was bleeding from her nose and mouth. There was a Huge lump the size of a golf ball on back of her occipital bone. Patient (resident) could move all 4 of her limbs freely, we then got her off the floor and sat her in a wheelchair where we tried to get vitals, but she was so shook up. Patient was then take via ambulance to (hospital name) ER. Patient did cough up a large clot and spit it out. The primary physician had been faxed at 6:00 p.m. The power of attorney had been notified at 6:00 p.m. Under the heading Was first aid administered, LPN B had written Yes/ambulance. The physician signature of notification had not been signed. A Post Fall Investigation form attached to the fall report revealed:-Resident 1 had been walking away from the supper table, To do her normal wandering at the time of the fall. -No assistive devices were in use at the time of the fall. -Resident may have hit, pushed, punched her to make her fall. -Staff members present at the time of her fall were CNA/UAP E, CNA/UAP H, and LPN B. -Is fall suspicious for abuse, mistreatment, or neglect (failure to follow care plan) of resident? had been marked Yes. -Police came here also on 2/22/18 at 6:00 p.m. -Under the heading Nursing assessment regarding the cause of the fall and interventions added to care plan to prevent further fall, including education given to resident/staff. LPN B had documented Yes - 2/22/18. -There was no documentation of any investigation of the event or interventions. -The form had been signed by LPN B, the director of nursing (DON), The Minimum Data Set (MDS) coordinator, and the administrator. Review of resident 1's 9/1/17 through 11/15/17 Behavior Detailed Entry Reports revealed: The 9/1/17 through 9/30/17, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-six of thirty days. On the above days the wandering behavior had: -Placed her at significant risk for twenty-six of thirty days. -Significantly intruded on the privacy or activities of others for twenty-five of twenty-six days. The 9/1/17 though 9/30/17, 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behaviors. The 10/1/17 through 10/31/17 (YEAR), 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-three of thirty-one days. On the above days the wandering behavior had: -Placed her at significant risk for twenty-one of thirty-one days. -Significantly intruded on the privacy or activities of others for twenty-three of thirty-one days. The 10/1/17 through 10/31/17, 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. The 11/1/17 through 11/15/17, 6:00 a.m. through 6:30 p.m. entries revealed: -She had wandered in hallways or other residents' rooms for nine of fifteen days. On the above days the wandering behavior had: -Placed her at significant risk for eight of fifteen days. -Significantly intruded on the privacy or activities of others for seven of fifteen days. On 11/13/17 at 1:30 p.m. she was Physically abusive. Hit others. -There was no further documentation in the medical record regarding who she had hit or what had prompted the behavior. The 11/1/17 through 11/15/17, 6:00 p.m. through 6:30 a.m. entries revealed on 11/7/17 at 3:45 a.m. she had screamed at staff. -There was no further documentation in the medical record regarding what had prompted the behavior. Review of resident 1's 11/15/17 quarterly Minimum Data Set (MDS) assessment for resident 1 revealed: She had exhibited physically aggressive behavior symptoms toward others one-to-three days per week. She had not exhibited behavioral symptoms directed toward others such as pacing, rummaging, hitting or scratching, or disruptive sounds in the seven day look-back period. She had overall presence of behavioral symptoms. The above symptoms put her and others at risk for physical illness or injury. She wandered one-to-three days per week. -It significantly intruded on the privacy or activity of other residents. -It also placed the resident at significant risk of getting to a potentially dangerous place. Her behavior had worsened compared with the prior MDS assessment on 8/16/2017. Review of resident 1's 11/16/17 through 2/14/18 Behavior Detailed Entry Reports revealed: The 11/16/17 through 11/30/17, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for seven of fifteen days. On the above days the wandering behavior had: -Placed her at significant risk for seven of fifteen days. -Significantly intruded on the privacy or activities of others for seven of fifteen days. The (MONTH) 15 through (MONTH) 30,2017, 6:00 p.m. through 6:30 a.m. entries revealed she did not display any behavior. The 12/1/17 through 12/31/17, from 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-one of thirty-one days. On the above days the wandering behavior had: -Placed her at significant risk for seventeen of thirty-one days. -Significantly intruded on the privacy or activities of others for eighteen of thirty-one days. The (MONTH) (YEAR) 6:00 p.m. through 6:30 a.m. entries revealed: -On 12/10/17 at 8:00 p.m. she had refused assistance with dressing. -On 12/11/17 at 10:00 p.m. she was Physically abusive. Hit staff. -There was no further documentation of behavior. Review of the 1/1/18 through 1/31/18, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for ten of thirty-one days. On the above days the wandering behavior had: -Placed her at significant risk for four of thirty-one days. -Significantly intruded on the privacy or activities of others for five of thirty-one days. The 1/1/18 through 1/31/18 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. Review of the 2/1/18 through 2/22/18, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for six of twenty-two days. On the above days the wandering behavior had: -Placed her at significant risk for three of twenty-two days. -Significantly intruded on the privacy or activities of others for three of twenty-two days. The 2/1/18 through 2/22/18, 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. Review resident 1's interdisciplinary progress notes (IPN) revealed: An 11/24/17 LSW quarterly MDS note indicated a history of wandering and physical behavior as well as wandering and exit seeking. A 12/8/17 entry by LPN N indicated resident 1 had been grabbed on the arm by another resident (3) and was trying to shake her hand off. -When resident 3 would not let go resident 1 forcefully shoved her. Upon request for more information of the 12/8/17 incident from the DON: -There was no resident-to-resident altercation event report completed. -An investigation had not been completed to identify the cause of the above altercation. -There was no notification to the physician or either family regarding the event. -A SD DOH event report had not been completed and sent to the SD DOH. A 12/24/17 incident regarding a fall with a head injury. Review of the 12/24/17 fall report by RN O revealed CNA D had observed resident 2 threaten to back into resident 1 if she did not move. RN O had documented, Report is that he did back into her then backed into her causing her to lose her balance. Resident 1 fell hitting her head. Upon request for more information from the DON: -Resident 1's physician and power of attorney had been notified. -There was no documentation in resident 2's record of the resident-to-resident altercation. -There was no notification to resident 2's physician or family about the event. -An investigation had not been completed to identify the cause of the altercation. -A SD DOH event report had not been completed and sent to the SD DOH. A 1/15/18 note by LPN P at 5:29 p.m. indicated the resident was found on the floor with both legs in one pant leg. The fall was not witnessed. Another head injury was noted. Upon request for more information from the DON: -An investigation had not been completed to identify the cause of the above fall. -A SD DOH event report had not been completed and sent to the SD DOH. A 1/24/18 note by RN O at 9:48 p.m. indicated the resident had a fall at 3:15 p.m. Caused by aggressive behavior of another resident. -Resident 1 received another head injury after being pushed by resident 2. -The LSW was made aware of verbal and physical aggression of the other resident. Upon request for more information from the DON: -A fall report had been completed for resident 1. -Resident 1's physician and power of attorney had been notified. -An resident-to-resident altercation report had not been completed for resident 2. -There was no notification to resident 2's physician or family about the event. -An investigation had not been completed to identify the cause of the above altercation. -A SD DOH event report had not been completed and sent to the SD DOH. Two other resident-to-resident altercations had occurred between residents 1 and 2 that were not documented in resident 1's medical record. Those events were recorded in resident 2's behavior tracking record: On 1/28/18 CNA D had documented resident 2 hit resident 1 in the back. Upon request for more information from the DON: -A resident-to-resident report had not been completed for residents 1 or 2. -Residents' 1 and 2's physicians and families or power of attorney had not been notified. -An investigation had not been completed to identify the cause of the altercations. -SD DOH event reports had not been completed and sent to the SD DOH. On 1/31/18 CNA G had documented resident 2 hit resident 1 in the left upper chest shoulder, witness by (CNA K) and housekeeper and he was mocking (resident 1), making crying sound after hitting her. Upon request for more information from the DON: -Resident-to-resident reports had not been completed for residents 1 and 2. -Residents' 1 and 2's physicians' and family or power of attorney had not been notified. -An investigation had not been completed to identify the cause of the altercation. -SD DOH event reports had not been completed and sent to the SD DOH. Review of resident 1's 2/14/18 annual MDS assessment revealed: She displayed no physically or verbally aggressive behavior symptoms toward others in the seven day look-back period. No behavioral symptoms directed toward others such as	2020-09-01
161	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	609	E	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to: Ensure the South Dakota Department of Health had been notified of reportable incidents for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment. A thorough investigation had been completed for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who were cognitively impaired with reportable incidents. Findings include: 1. Review of resident 1and 2's closed records and residents 3, 4, and 5's active medical records and investigation reports revealed: The residents had been subject to falls and resident-to-resident altercations. The South Dakota Department of Health (SD DOH) had not been notified of all but one event (2/22/18). All reviewed events had not been thoroughly investigated to: -Discover the cause of the event. -Implement safeguards to prevent further potential abuse. 2. Review of the provider's 8/17/17 Care Plans - Comprehensive policy and procedures revealed: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan is designed to: -a. Incorporate identified problem areas; -b. Incorporate risk factors associated with identified problems; -d. Reflect the resident's expressed wishes regarding care and treatment goals; -g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process. 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: -a. When there has been a significant change in the resident's condition/ -b. When the desired outcome is not met; -d. At least quarterly. Review of the provider's 6/1/16 Care Planning - Interdisciplinary Team policy and procedures revealed: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: -a. The resident's Attending Physician; -b. The Registered Nurse who has responsibility for the resident; -d. The Social Services Worker responsible for the resident; -e. The Activity Director/Coordinator; -h. The Director of Nursing (as applicable); -i. The Charge Nurse responsible for resident care; -j. Nursing Assistants responsible for the resident's care; Review of the provider's (MONTH) (YEAR) Abuse/Neglect/Exploitation Investigations policy revealed: All reports of resident abuse, neglect, exploitation and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect exploitation or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The individual conducting the investigation will, as a minimum: -a. Review the competed documentation forms; -b. Review the resident's medical record to determine events leading up to the incident; -c. Interview the person(s) reporting the incident; -d. Interview any witnesses to the incident; -e. Interview the resident (as medically appropriate ); -f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; -g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; -h. Interview the resident's roommate, family members, and visitors; -i. Interview other residents to whom the accused employee provides care or services; and -j. Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interviews: -a. Each interview will be conducted separately and in a private location; -b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process. 5. Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports. 6. The individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process. 7. Should the ombudsman decline the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. 8. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator. 9. Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator. 10. The individual in charge of the investigation will consult daily with the Administrator concerning the progress/findings of the investigation. 11. The Administrator will keep the resident and his/her representative informed of the progress of the investigation. 12. The results of the investigation will be recorded on approved documentation forms. 13. The investigator will give a copy of the completed documentation to the Administrator within 5 working days of the reported incident. 14. The Administrator will inform the resident and his/her representative of the results of the investigation and corrective action taken within 5 days of the completion of the investigation. 15. 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 others as may be required by state or local laws, within five (5) working days of the reported incident. 16. Should the investigation reveal that a false report was made/filed, the investigation will cease. Residents, family members, ombudsmen, state agencies, etc., will be notified of the findings. 17. Inquiries concerning abuse, neglect and exploitation reporting and investigation should be referred to the Administrator or the Director of Nursing Services. Review of the provider's (MONTH) (YEAR) Abuse, Neglect and Exploitation-Clinical Protocol policy revealed: 1. The nurse will assess the individual and document related findings. Assessment data will include: -a. Injury assessment. -b. All current medications. -d. Vital signs. -e. Behavior over last 24 hours. -g. All active diagnoses. 2. The nurse will report findings to the physician. 3. As part of the initial assessment, the physician will help identify individuals who have a history of being abused, neglected, or exploited. 4. The physician and staff will help identify risk factors for abuse within the facility. 5. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect. Review of the provider's (MONTH) (YEAR) Reporting Abuse to State Agencies and Other Entities/Individuals policy revealed: All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. 1. Should a suspected crime or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and/or written) of such incident: -a. The South Dakota State Department of Health. 5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident using the 5-Working Day Investigation Report. Review of the provider's undated Resident-to-Resident Altercations policy revealed: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to Social Services, the Director of Nursing Services and to the Administrator. 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitor, or to the staff. Occurrences of such incidents shall be promptly reported to Social Services, Director of Nursing Services, and to the Administrator. 2. If two residents are involved in an altercation, staff will: -a. Separate the residents, and institute measures to calm the situation; -b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; -c. Notify each resident's representative (sponsor) and Attending Physician of the incident; -d. Review the events with Social Services and Director of Nursing, including interventions to try to prevent additional incidents; -e. Consult with the Attending Physician to identify treatable conditions such as acute [MEDICAL CONDITION] that may have caused or contributed to the problem; -f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; -g. Document in the resident's clinical record all interventions and their effectiveness; -h. Consult psychiatric services as needed for assistance in assessing the resident. -i. Complete an Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; -j. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; -k. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 3. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator. Review of the provider's (MONTH) (YEAR) Charting and Documentation policy revealed: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. 3. All incidents, accidents, or changes in the resident's condition must be recorded. 7. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: -a. The date and time the procedure/treatment was provided; -c. The assessment data and/or any unusual findings obtained during the procedure/treatment; -f. Notification of family, physician or other staff, if indicated; -g. The signature and title of the individual documenting. Refer to F600, F610, F657, F658, F726, F744, F745, and F842.	2020-09-01
162	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	610	H	1	0	Z0T511	> Based on record review, interview, and policy review, the provider failed to ensure a thorough investigation had been completed and documented for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who were cognitively impaired and had been subject to resident-to-resident altercations. Findings include: 1. Review of resident 1, 2, 3, 4, and 5's medical records revealed: They had been subject to resident-to-resident altercations. Thorough investigations had not been documented and maintained. *The South Dakota Department of Health (SD DOH) had not been notified of all but one event (2/22/18). Refer to F600, F609, F657, F658, F726, F744, F745, and F842.	2020-09-01
163	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	657	E	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to ensure care plans were updated to reflect individual needs and interventions for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5). Findings include: 1. Review of resident 1's 9/1/17 through 11/15/17 Behavior Detailed Entry Reports revealed:For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for twenty-six of thirty days. Of those days the wandering behavior had: --Placed her at significant risk for twenty-six of thirty days. --Significantly intruded on the privacy or activities of others for twenty-five of twenty-six days. -The 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behaviors. For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for twenty-three of thirty-one days. Of those days the wandering behavior had: --Placed her at significant risk for twenty-one of thirty-one days. --Significantly intruded on the privacy or activities of others for twenty-three of thirty-one days. -The 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. For (MONTH) 1 through (MONTH) 15, (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for nine of fifteen days. Of those days the wandering behavior had: --Significantly intruded on the privacy or activities of others for nine of fifteen days. -On 11/13/17 at 1:30 p.m. she was Physically abusive. Hit others. --There was no further documentation in the medical record regarding who she had hit or what had prompted the behavior. -The (MONTH) 1 to 15 from 6:00 p.m. through 6:30 a.m. entries revealed on 11/7/17 at 3:45 a.m. she had screamed at staff. --There was no further documentation in the medical record regarding what had prompted the behavior. Review of resident 1's 11/15/17 quarterly Minimum Data Set (MDS) assessment revealed: She had exhibited physically aggressive behavior symptoms toward others one to three days per week. She had not exhibited behavioral symptoms not directed toward others such as pacing, rummaging, hitting or scratching, or disruptive sounds in the seven day look-back period. She had overall presence of behavioral symptoms. Those symptoms put her at risk for physical illness or injury. Those symptoms put other residents at risk for physical injury. She wandered one to three days per week. That wandering significantly intruded on the privacy or activity of other residents. Wandering also placed the resident at significant risk of getting into a potentially dangerous place. Her behavior had worsened compared to the prior MDS assessment. For 11/16/17 through 2/14/18: -The (MONTH) 16 through (MONTH) 30, (YEAR): --6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for seven of fifteen days. Of those days the wandering behavior had: --Placed her at significant risk for seven of fifteen days. --Significantly intruded on the privacy or activities of others for seven of fifteen days. -The (MONTH) 15 through (MONTH) 30,2017 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-one of thirty-one days. -Of those days the wandering behavior had: --Placed her at significant risk for seventeen of thirty-one days. --Significantly intruded on the privacy or activities of others for eighteen of thirty-one days. -The (MONTH) (YEAR), 6:00 p.m. through 6:30 a.m. entries revealed: --On 12/10/17 at 8:00 p.m. she had refused assistance with dressing. --On 12/11/17 at 10:00 p.m. she was Physically abusive. Hit staff. -There was no further documentation of behavior in December. For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for ten of thirty-one days. -Of those days the wandering behavior had: --Placed her at significant risk for four of thirty-one days. --Significantly intruded on the privacy or activities of others for five of thirty-one days. -The (MONTH) (YEAR), 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. For (MONTH) 1 through 22, (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for six of twenty-two days. -Of those days the wandering behavior had: --Placed her at significant risk for three of twenty-two days. --Significantly intruded on the privacy or activities of others for three of twenty-two days. -The (MONTH) 1 through 22 (YEAR), 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. Review of her interdisciplinary progress notes (IPN) revealed: An 11/24/17 LSW quarterly MDS note indicated a history of wandering and physical behavior as well as wandering and exit seeking. A 12/8/17 note by LPN N indicated resident 1 had been grabbed on the arm by another resident (3) and was trying to shake her hand off. When the other resident would not let go she forcefully shoved the other resident. A 12/24/17 incident regarding a fall with a head injury. Review of the 12/24/17 fall report by registered nurse (RN) O revealed the CNA D had observed resident 2 threaten to back into resident 1 if she did not move. RN O documented, Report is that he did back into her then backed into her causing her to lose her balance. Resident 1 fell , hitting her head. A 1/15/18 note by LPN P at 5:29 p.m. indicated the resident was found on the floor with both legs in one pant leg. Another head injury was noted. A 1/24/18 note by RN O at 9:48 p.m. indicated the resident had a fall at 3:15 p.m. Caused by aggressive behavior of another resident. -Resident 1 received another head injury after being pushed by resident 2. The LSW was made aware of verbal and physical aggression of the other resident. Two other resident-to-resident altercations occurred between residents 1 and 2 that were not documented in resident 1's medical record. Those events were recorded in resident 2's behavior tracking record:On 1/28/18 CNA D had documented resident 2 hit resident 1 in the back and resident 3 in the chest. On 1/31/18 CNA G had documented resident 2 hit resident 1 in the left upper chest shoulder, witness by (CNA K) and housekeeper and he was mocking (resident 1), making crying sound after hitting her. Review of resident 1's 2/14/18 annual MDS assessment revealed: She displayed no physically or verbally aggressive behavior symptoms toward others in the seven day look-back period. No behavioral symptoms not directed toward others such as pacing, rummaging, hitting or scratching, or disruptive sounds had been exhibited in the seven day look-back period. She had no overall presence of behavioral symptoms. No behavioral symptoms had been acknowledged to have a negative impact on herself or others. She rejected care one to three days in the seven day look-back period. She wandered one to three days per week. That wandering significantly intruded on the privacy or activity of other residents. Wandering also placed the resident at significant risk of getting into a potentially dangerous place. Her behavior had remained the same compared to the prior MDS assessment on 11/15/17. Further review of resident 1's IPN and interview with LPN B revealed: On 2/21/18 at 6:05 p.m. LPN B documented, Patient (resident) was struck by another resident, in the chest she is fine no marks or bruising so far, made her nervous. Interview on 3/8/18 at 1:00 p.m. with LPN B revealed she did not know who had struck resident 1, nor when the event had occurred. Interview on 3/8/18 at 1:07 p.m. with CNA G revealed she had witnessed resident 2 punch resident 1 in the chest. -CNAs G and D placed her in a chair and called LPN B to come check her. No reports had been completed at that time. On 2/22/18 at 10:53 a.m. the LSW documented a care conference was held with the LSW, RN clinical coordinator/MDS coordinator, dietary manager, and resident 1's power of attorney (attended by phone). The LSW had documented: -She was on a one-to-one list once weekly for activities. -She had lost thirteen pounds in six months. -The primary physician saw her on 2/13/18 and stated she was tolerating her medication well. -She was requiring more assistance with her activities of daily living. -She was unable to formulate words and continued with echolalia. -There were no concerns noted during the conference. There was no documentation by the IDT members of the falls, head injuries, or numerous episodes of physical aggression and mocking toward resident 1 by resident 2. Review of resident 1's 1/16/17 wandering care plan revealed:She frequently wandered. Her goals were she: -Would not wander out of the facility. -Would not intrude on or endanger others. Interventions included: -To maintain a safe environment. -To prompt activity attendance daily to keep her occupied. -Staff were to observe her location and provide safety. A 1/16/17 Fall care plan revealed she was at risk for falls. Her goal was for no falls. Interventions included: -She would receive supervision with transfers, locomotion, and walking. -Staff were to prompt her to ask for assistance. -Prompt her to attend activities that did not put her at risk for falls. -Safety training and education as needed. -Provide a safe environment. -Frequent observation. Resident 1's care plan had not addressed or been updated to address interventions regarding: Falls with head injuries. Pacing as acknowledged by the primary physician. Episodes of physical behavior directed toward staff. The episode of physical aggressive behavior toward resident 3. Multiple episodes of verbal and physical aggression by resident 2 toward resident 1. Echolalia and disruptive sounds that reportedly placed her at risk of resident 2's aggression. Review of the undated pocket care plan utilized by the direct care staff on the memory unit at the time resident 1 had resided there revealed: Fall risk. Independent with walking. Wander device on. Make sure she has on non-skid foot wear. There was no mention of the concerns below, or any interventions for her: -Aggressive episode with resident 3. -Wandering on the unit and frequent intrusions in other residents rooms. -Echolalia and repeated verbal vocalizations and the impact it might have on other residents. -Her frequent falls and head injuries as a result of physical aggression by another resident. 2. Review of resident 2's medical record revealed: A 9/8/17 admitted . He resided on the MCU. [DIAGNOSES REDACTED]. Was on the antipsychotic medication [MEDICATION NAME]. Review of the 9/8/17 admission Minimum Data Set (MDS) assessment for resident 2 revealed: A Brief Interview for Mental Status (BIMS) score had been a four. A score of zero through seven meant his cognition was severely impaired. No physical and verbal behaviors were identified. Wandering occurred four to six days but less than daily. The activity preferences that were marked very important to him were to: -Listen to music he liked. -Keep up with the news. -Go outside to get fresh air when the weather was good. -Participate in religious services or practices. Review of resident 2's IPN by the social worker (SW) revealed: On 9/21/17 he documented an admission social service note that revealed:. -(Resident name) is alert with short and long term memory impairments requiring cueing and supervision. -He is able to make his needs known and some decisions by himself. -Family makes larger important decisions. -He scored a 4/15 on his BIMS suggesting cognition is severely impaired. -(Resident name) has a [DIAGNOSES REDACTED]. -(Resident name) was able to complete the PHQ-9 assessment; he scored a 0/27 indicating no depression concerns at this time. -He is very social and likes to visit with whoever will visit with him. -Wandering behavior noted during look back period. -His wife is PO[NAME] -Requests to be asked about going home on comprehensive assessments only. -Care plan written. -Review face sheet, history and physical, nurses' notes, progress notes, medication list, behavior log, resident assessments and per staff observation. On 10/11/17 the SW had documented a care conference note that revealed: Care conference held 10/4/17. -LSW, RN case manager, dietary manager, and (wife's name) were present. We discussed how resident 2 was transitioning and how well he was doing. -We did speak about how he does sometimes sundown during the late afternoon. -(Wife's name) states he has been doing that for some time. -She also states that he gets agitated when she visits him. -She does try to limit her time with (resident 2 name) to prevent him from becoming to agitated. She did request that he be brought out of the secured unit to attend large activities such as entertainers or parties. -Activities department was notified of her request. -No new concerns noted at this time. On 12/5/17 the SW had documented a social services quarterly MDS note that revealed: (Resident name) is alert with short and long term memory impairments requiring cueing and supervision. He is able to make his needs known and some decisions by himself. Family makes larger important decisions. He scored a 5/15 on his BIMS suggesting cognition is severely impaired. (Resident name) has a [DIAGNOSES REDACTED]. (Resident name) was able to complete the PHQ-9 assessment; he scored a 0/27 indicating no depression concerns at this time. -He is very social and likes to visit with whoever will visit with him. -Wandering behavior noted during look back period. -His wife is PO[NAME] -Requests to be asked about going home on comprehensive assessments only. Care plan reviewed/updated. Reviewed face sheet, history and physical, nurses' notes, progress notes, medication list, behavior log, resident assessments, and per staff observation. On 12/13/17 the SW had documented a care conference note that revealed: Care conference held this date. -LSW, RN case manager, dietary manager, and (wife's name) were present. We discussed (resident's name)food preferences and his intake. We discussed that he liked canned fruit, French toast, bacon, cereal, and chocolate ensure. -He is also on a finger food diet which allows him to be more independent with dining. He has lost twenty plus pounds. (Resident's name) did have a week when he did mention suicide and it was the week he had his [MEDICATION NAME] decreased. -His [MEDICATION NAME] has since been increased. No further concerns. It was also discussed that he loves attending musical activities. No other concerns discussed besides his weight loss. Review of resident 2's IPN by the activity director revealed: On 9/18/17 she did an interview with the resident. -He found it important to take care of his personal belongings, have a shower, and family involved in discussions about his care. -He enjoys listening to country western music, keep up with the news, go outside when the weather is good, and participate in religious activities. On 12/5/17 she did an interview with the staff. -He found it important to chose his clothing, have snacks between meals, and have his wife involved in discussions about his care. -He enjoys doing things with groups of people such as going to parties, listening to music/entertainers, going outdoors, and being involved in religious activities. -He is in the MCU but participated outside of the unit often. -His wife also visits often. -He is on the one on one list for at least once a week for activities visits where he enjoys walking, talking, music, and dancing. -Care plan reviewed. There was no revision date to the problem, goal, and interventions to reflect those activities desired by the resident. Review of resident 2's 9/11/17 initial activities evaluation revealed: His current interests were religious services, religious studies, and walking. Frequency of Activities: Not sure was checked. Other comments: Resident has Alzheimers and was unable to answer any of my questions. Review of resident 2's activities flow sheet from 1/1/18 through 2/22/18 revealed: January (YEAR): -Bingo was documented five times. -Religious event was documented five times. -Craft event was documented two times. -Music and entertainment was documented one time. -Activity cart was documented one time. -One-to-one/reminisce was documented three times. -There were fifteen out of thirty-one days activities had not occurred. February (YEAR): -Bingo was documented five times. -Religious event was documented zero times. -Pastor visit was documented one time. -Arts/Crafts/Coloring was documented one time. -Music and entertainment was documented three times. -One-to-one/reminisce was documented three times. -Outside Memory Lane, other was documented two times. -There were ten out of twenty-two days activities had not occurred. Review of the One on ones and memory care individualized activities per resident flow sheet revealed resident 2 was to have conversation, walking, talking, music, religious (devotions/rosary), and outdoors when nice. Review of resident 2's 9/18/17 activity care plan revealed: Problem: Resident finds it important to do his favorite activities both in and outside of the memory care unit. Goal: Resident will be involved in activities of interest such as going outdoors, listening to music, and participating in religious activities. Interventions: Provide resident with activities calendar and remind of scheduled activities. -Encourage resident participation in activities of interest. -Respect residents right to refuse. -Offer one on one activities visits if resident declines to participate for a prolonged period of time. There was not any information regarding his preferences, likes, or past likes. Review of resident 2's 9/18/17 wandering care plan revealed: Problem: Resident wanders throughout secured memory care unit. Goals: Resident will not wander out of facility. -Will have no injuries related to wandering. -Will not intrude on or endanger others. Interventions: Maintain safe, clutter free environment. -Provide orientation to facility layout and room as needed. -Redirect when wandering. -Ensure resident wears appropriate, well fitting footwear minimize the risk of slipping. -Prompt activity attendance daily to keep resident occupied. -Observe resident's location to ensure safety. No revision and/or updates were made to his problem, goal, and interventions. No problem, goal, and interventions were documented for agitation stated on his care plan. No problem, goal, and interventions were documented for aggressive behavior stated on his care plan. Review of resident 2's 10/5/17 [MEDICAL CONDITION] care plan revealed: Problem: Resident requires the use of a [MEDICAL CONDITION] medication. Goals: Will be at lowest therapeutic dose of medication through next review date. -Will have reduction is symptoms noted through next review date. Interventions: MD consult as needed. -Will monitor behavior. -Activities to evaluate for interests and skills/abilities. -Administer medication as ordered by MD and assess for effectiveness and side effects. -Treat side effects per MD order should they occur. -Physician/Pharmacist will work together to ensure resident is on lowest therapeutic dose. There were physician orders [REDACTED]. -On 9/8/17 he was admitted and was on [MEDICATION NAME] 1 mg daily for mood stabilization. -On 10/16/17 he was discontinued on the [MEDICATION NAME]. -On 2/2/18 he was started on [MEDICATION NAME] 2.5 mg daily for aggression. -On 2/8/18 the [MEDICATION NAME] was ordered to be increased to 5 mg daily for aggression starting 2/9/18. No revisions and/or updates were made to his problem, goal, and interventions. Review of the undated pocket care plan utilized by the direct care staff on the memory unit at the time resident 2 had resided there revealed: He liked to swear. He ambulated independently. He was on a regular diet. No information on interventions for activities for him. No types of distractions and interventions for agitation and/or aggressive behaviors. Interview on 3/7/18 at 11:11 a.m. with the LSW regarding resident 2's care planning process revealed he: Was aware of his aggressive behaviors by reports heard at stand-up meetings. Was aware of his verbally aggressive behaviors toward spouse. -She had reported to him the resident had accused her of drinking and/or having an affair. Was aware of resident 2 pushing other residents in the memory care unit. He agreed his care plan and My pocket care plan: -Did not address his behaviors on the care plan. -Did not address his depression/mood on the care plan. -Were not individualized for him. Interview on 3/8/18 at 11:14 a.m. with the activity director regarding resident 2 revealed: He enjoyed conversation and was very chatty. He liked to go outside when the weather was nice. He enjoyed coffee and cookies. He went out of MCU for rosary on Wednesdays and for church on Sundays. He went out of MCU with his spouse for music and entertainment events. She agreed his care plan and My pocket care plan were not individualized for him. 3. Review of resident 3's medical record revealed: An 8/8/17 admitted . She resided on the MCU. [DIAGNOSES REDACTED]. Was on the antipyschotic medication [MEDICATION NAME]. Review of the 2/5/18 quarterly MDS assessment revealed: BIMS score of 99 indicating she was unable to be interviewed. Ability to understand and make self understood was coded sometimes understands. Had inattention and disorganized thinking. Being short-tempered, easily annoyed was coded as occurring for several days. had a history of [REDACTED]. Review of the quarterly MCU assessment for 11/8/17 and 2/8/18 for resident 3 revealed it had been coded yes for exhibits pacing, agitation and/or aggressive behavior, and wanders. Review of resident 3's IPN notes from 12/6/17 through 3/6/18 revealed on: 12/8/17: Grabbing the arm of another resident when the other resident was trying to shake it off and (resident 3) would not let go. The other resident forcefully shoved (resident 3) once she had had enough. 12/11/17: Has been pulling on another resident most of the shift, resident does not re-direct easily and one-on-one was not successful. This writer had to physically place her body in between residents before (resident) would walk away. As soon as this writer moved away, (resident) continued to pull on other resident. 12/18/17: Pulling on other residents, attempting to have resident's ambulate w/her. Staff intervened several times. 1/5/18: Notified that CNA head a loud noise in the hallway and upon investigation noted that resident was getting up off the floor holding the back of her head. Resident restless, agitated and would not sit still for examination. Did not (get) a 3x3 hematoma to the back of resident's head. 1/5/18: Has been grabbing at resident's and staff throughout the day. Redirection not effective. Staff has had to intervene between resident grabbing at other resident's on several occasions. Attempted to redirect bu unsuccessful. Grabs at other resident hands, arms and follows them around. Another resident did swat at her arms to get away from even as staff member was attempting to break resident up. 1/8/18: Up pacing in the halls tries to help everyone whether they want help or not will grab other residents and try to pull them down the hallways no s/s no noted increased pain. 1/30/18: Received a skin teat (tear) to (R) lower forearm. Another resident was reaching for her arm and when she pulled away causing a 4x3.2 cm (centimeter) skin tear/bruise to area. 2/14/18: Category:Nursing Note. Refer to care plan for goals and interventions to assist with providing resident's care. Review of resident 3's behavior flow sheets from 12/1/17 through 3/7/18 revealed on: 12/10/17 at 9:16 a.m.: Physically abusive. Grabs other residents arms, pulls and twists. 1/5/16 at 9:05 p.m.: Physically abusive. Physical altercation with another resident. 1/6/18 at 5:13 p.m.: Physically abusive. Grabbing and hitting, squeezing residents hands, pulling staff and residents. 1/29/18 at 9:41 p.m.: Physically abusive. Grabbing residents. 3/3/18 at 4:22 p.m.: Socially inappropriate. Grabbing and holding on to staff and residents. Review of resident 3's undated and unsigned activities evaluation revealed: Her current interests were animals/pets, family/friend visit, music, and walking. Time for activities was coded morning and afternoon. Other comments: Especially enjoys family visits. Outdoors. Review of resident 3's activities flow sheet from (MONTH) (YEAR) through (MONTH) 7, (YEAR) revealed: December (YEAR): -One-to-one was done weekly. -Art/crafts were documented five times. -Social event was documented one time. -Games was documented two times. -Walk was documented one time. -There were eighteen out of thirty-one days activities had not occurred. January (YEAR): -One-to-one activity had been documented three out of five weeks as occurring. -Social event was documented one time. -Activity cart was documented one time. -Manicure/beauty shop was documented one time. -Arts/crafts/coloring was documented one time. -There were twenty-three out of thirty-one days activities had not occurred. February (YEAR): -One-to-one was documented four out of five weeks as occurring. -Art/crafts/coloring was documented four times. -Exercise/movement/cycle was documented one time. -Manicure/beauty shop was documented one time. -Activity cart was documented one time. -There were fourteen out of twenty-eight days activities had not occurred. March 1 through 7, (YEAR): -One-to-one had not occurred the week of (MONTH) 25 through (MONTH) 3, (YEAR). -There were two out of seven days activities had not occurred. Review of resident 3's IPN note for 2/6/18 by the activity director revealed She is in the memory care unit and on the activities one on one list for at least once a week where she enjoys walking, talking and going outdoors if the weather is nice. Care plan reviewed. Review of resident 3's 8/18/17 care plan revealed: Problem: Wanders throughout secured memory care unit. -Goal: Will not intrude on or endanger others. -Interventions: Redirect when wondering. Prompt activity attendance daily to keep resident occupied. Problem: Needs encouragement to join activities in the memory care unit. -Goal: Will join in activities of interest. -Interventions: Provide with activities calendar and orient to activities in memory care unit. Continue one--on-one visits with resident having conversations, walking, and going outdoors. There were no problems, goals, or interventions for behaviors. There was not any information regarding her preferences, likes, or past likes. Review of the undated My pocket care plan memory care revealed no information on interventions for behaviors or activities for resident 3. Review of the One-on-ones and memory care individualized activities per resident flow sheet revealed resident 3 was to have walk and talk, and music. 4. Review of resident 4's medical record revealed: An admission date of [DATE]. She resided on the MCU. [DIAGNOSES REDACTED]. Review of resident 4's 12/21/17 quarterly MDS assessment revealed: BIMS score of 99 indicating she was unable to be interviewed. Was able to understand others. Was able to express her needs and wants. Wandering had been coded as Significant risk of getting to (into) a potentially dangerous place and intrude on the privacy or activities of others. She had displayed being short-tempered and easily annoyed. She had received an antipsychotic, antianxiety, and antidepressant medication. Review of resident 4's quarterly MCU assessment for 4/29/17, 6/29/17, 9/27/17, and 12/26/17 revealed: She required a calm and structured environment to maintain comfort and dignity. Was known to wander. Exhibited pacing, agitation, and/or aggressive behavior. Review of resident 4's IPN notes from 12/3/17 through 3/6/18 revealed on: 12/11/17: This writer had to remove a butter knife from resident's grip; resident picked up knife after another resident started pulling on her. This is habitual, the grabbing on this resident by another, and this resident has already shoved other resident away once before. 1/2/18: Refer to care plan for goals and interventions to assist with providing resident's care. 1/22/18: Notified by staff member that resident slapped another resident at dinner table, in the chest. Then a few minutes ago resident was arguing over a coffee mug in dining w/another resident who she had taken the coffee mug from and slapped her in her face. Staff member attempted to redirect resident from one another. Redirected easily but then begins to follow residents around unit closely again. 2/13/18: Has been crying on and off all morning. Pacing the hallways, banging on the exit doors, windows, and clinging to other resident's crying uncontrollable. 3/4/18: Crying all shift, unable to console with different attempts towards redirection. Review of resident 4's behavior flow sheets from 12/1/17 through 3/7/18 revealed on: 12/7/17 at 2:10 p.m.: Physically abusive. Shoved others. Shoved staff. Grabbing, pulling, on others. 12/7/17 at 2:11 p.m.: Verbally abusive. Cursed. Screamed at staff. Screamed at others. 12/10/17 at 8:46 a.m.: Socially inappropriate. Crying, yelling for her husband, going into other residents rooms, yelling for someone named (name). 12/10/17 at 8:06 p.m.: Socially inappropriate. Disruptive sounds. Crying excessively. 12/20/17 at 2:22 p.m.: Verbally abusive. Cursed. Excessive curing throught the day. 1/19/18 at 10:49 a.m.: Verbally abusive. Screamed at others. Cursed. 1/22/18 at 3:55 p.m. Physically abusive. Slapped (resident) in chest and (resident) in the face. 2/3/18 at 9:56 a.m.: Verbally abusive. Screamed at staff. Screamed at others. Cursed. 2/15/18 at 12:22 p.m.: Verbally abusive. Cursed. 3/1/18 at 8:42 a.m.: Verbally abusive. Cursed. Review of resident 4's undated and unsigned activities evaluation revealed her current preferences were marked for: Animals/pets. Arts/crafts. Beauty/barber. Bingo. Community outings with husband. Current events/news. Family/friend visits. Music, radio, religious services, religious studies. Social/parties. Television. Revie	2020-09-01
164	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	658	G	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure two of two closed resident records (1 and 2) who had cognitive impairment and resided on the memory care unit (MCU): Had notified the residents' (1 and 2) physicians of significant changes as required. Had provided appropriate emergency response for one of one sampled resident (1) with a fall with a major injury. Had identified, assessed and documented specific targeted behaviors for both residents. Reviewed and modified the interdisciplinary care plans to identify specific interventions to address behavioral and mood-related symptoms for both residents. Findings include: 1. Observation on 3/8/18 at 1:00 p.m. of an undated and unsigned note posted at the Warren unit nurses' station revealed: (Medical director's name) and his team DO NOT want to receive faxes!!! If it is important and needs to be addressed right away you need to call him. If it can wait, then write out a fax and put it in the medical records folder (at each nurses station) and (medical records staff name) will get it to him when he comes out that week. Observation on 3/8/18 at 1:00 p.m. of an undated Charting guidelines posted at the Warren unit nurses' station revealed: Chart any behaviors as an IPN note. If behavior needs to continue to be monitored put on pass along to chart for two to three days. Event report: front and back fully completed, call family, fax MD, IPN Note. Surveyor: 2. Review of resident 1's 2/22/18 resident transfer form had indicated: The resident's name. She was a female. Date of the transfer was 2/22/18. Payment source was Other. Under vitals at time of transfer: Could not. Too worked up. Speech and mental impairments had been checked. Additional pertinent information indicated Has dementia on locked unit. The above form had not indicated: -The name of the physician or facility transferring from. -The name of the facility transferring to. -The name of the guardian. -Her diagnoses. -The time of the injury. -Her condition at the time of the transfer. -The reason for the transfer. -A signature of the nurse providing the information. Surveyor: 3. Review of resident 2's 2/23/18 resident transfer form had indicated: The resident's name. He was a male. Date of the transfer was 2/23/18. Payment source was Other. Under vitals at the time of transfer: N/[NAME] Mental and hearing impairments had been checked. Important medical information: NKD[NAME] Under advance directives yes and copy attached had been checked. Code status: DNR. Additional pertinent information indicated, He was suspected of hurting, hitting, punching, or pushing another resident multiple times. The form had not indicated: -The name of the guardian and contact information. -[DIAGNOSES REDACTED]. -His condition at the time of the transfer. -A signature of the nurse providing the information. -The date the nurse completed the resident transfer form. 4. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding the 2/22/18 at 5:40 p.m. resident-to-resident altercation revealed she: Had not received any orientation on how to complete a hospital transfer form for resident 1. Did not receive any event report checklists and/or guidelines to follow to complete a resident-to-resident altercation. Had to call the other two night nurses working that date for directions on how to: -Contact the emergency response system. -Complete the required mandatory reporting forms. Had faxed resident 2's event report form to the primary care physician (PCP) at 6:00 p.m. Interview on 3/7/18 at 12:43 p.m. with the medical director regarding the 2/22/18 resident-to-resident altercation revealed he: Thought the MCU was an appropriate placement for resident 2. Stated resident 2's Behaviors were ramped up just recently. Had seen resident 2 on 2/2/18 for aggressive behaviors, anger and aggression, and had ordered an antipsychotic medication. Stated in his own professional opinion it was Hard to say if they should have moved resident 1, probably should of stabilized her neck with a bump to her head. Agreed it was a problem if LPN B had no formal orientation to the emergency response protocol. Assisted with writing the MCU admission criteria. Deferred to the director of nursing for the protocols on wandering, pacing, agitation, and aggressive behavior. Interview on 3/7/18 at 4:04 p.m. with the administrator and the director of nursing (DON) regarding MCU policies and protocols revealed the facility did not have: Policies and procedures for the MCU. Protocols for wandering, pacing, agitation, and aggressive behavior. Interview on 3/7/18 at 4:35 p.m. with LPN C regarding the 2/22/18, 5:40 p.m. resident-to-resident altercation revealed she had: Came on duty at 6:00 p.m. Notified the LSW and supervisor on duty at 6:00 p.m. of the event. Not notified the PCP of resident 2's continued aggressive behaviors. Felt the fax was sufficient notification to the medical director since it: -Was so late the doctor would not do anything with it. -Would be taken care of in the morning. -Stated she would call if a situation was very serious. Further interview on 3/8/18 at 2:38 p.m. with the administrator and the DON regarding immediate notification of significant changes for residents 1 and 2 revealed: LPN B had made multiple phone calls and should have known how to call the emergency response system for resident 1. LPN B or C should have notified resident 2's doctor by a phone call versus a fax. 5. Review of the provider's undated MCU admission criteria revealed: Individuals who are being considered for admission will exhibit at least two of the following characteristics: -a. Primary [DIAGNOSES REDACTED]. -b. Displays impaired judgement. -c. Requires a calm and structured environment. -d. Exhibits pacing, agitation, and/or aggressive behavior. -e. Resident is known to wander. The individual is able to participate in and benefit from consistent, daily programming in a therapeutic environment. 6. Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., (YEAR), revealed professional standards in nursing practice for: p. 316, communication includes: -Communication is the key to nurse-patient relationships and the ability to deliver patient-centered care. -Patient safety also requires effective communication among members of the health care team as patients move from one caregiver to another or from one care setting to another. pp. 356 to 358, written documentation includes: -Documentation is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health record. -Nursing documentation needs to be accurate and comprehensive. -To enhance communication and promote safe patient care, document assessment findings and patient information as soon as possible after you provide care. -Record all facts. -Begin each entry with date and time and end with your signature and credentials. p. 367, incident reports includes: -When an incident occurs, document an objective description of what happened; what you observed: and the follow-up actions taken, including notification of the patient's health care provider in the patient's medical record. -Remember to evaluate and document the patient's (resident) response to the incident. p. 382, nursing assessment for falls includes: -Apply ANA (American Nurses Association) and TJC (The Joint Commission) standards of providing interventions in a safe and appropriate manner. *Evidenced based clinical practice guidelines for a post fall assessment of a witnessed suspected fall includes: -Do not move a resident who was experiencing neck pain, abnormal neurological check, altered mental status, and poor historian. -A nursing assessment should include vital signs, injuries, loss of consciousness/neuro checks, range of motion, resident activity, and resident behavior. -Communication to the MD, nursing leadership, and appropriate interdisciplinary care team members. 7. Refer to F600, F609, F610, F657, F658, F679, F726, and F745.	2020-09-01

CMS-Nursing-Home-Full-Deficiencies

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