CMS-Nursing-Home-Full-Deficiencies
Data source: Big Local News · About: big-local-datasette
This data as json, copyable, CSV
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2381 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 550 | D | 0 | 1 | YE7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to promote a resident's dignity while providing personal care for 1 of 22 (Resident #74) sampled residents. The findings included: The facility's Quality of Life -Dignity policy documented, .Bodily Privacy During Care and Treatment .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #74's room on 1/30/18 at 1:04 PM, revealed Certified Nursing Assistant (CNA) #1 entered the room, removed the resident's brief, turned and repositioned the resident. CNA #1 left Resident #74 fully exposed, with no cover. CNA #1 did not request permission from the resident to proceed with personal care. Interview with the Director of Nursing (DON) on 2/1/18 at 1:35 PM, in the conference room, the DON was asked if it was acceptable for a CNA to leave a resident fully exposed during personal care. The DON stated, No. | 2020-09-01 |
| 2382 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 690 | D | 0 | 1 | YE7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure services were provided as ordered for the care of an indwelling urinary catheter for 1 of 1 (Resident #59) sampled residents reviewed for indwelling urinary catheters. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].Cath (catheter) care (with)soap et (and) H2O (water) q (every) shift . Observations in Resident #59's room on 1/28/18 at 4:40 PM, revealed Certified Nursing Assistant (CNA) #3 performed catheter care for Resident #59 using plain water. CNA #3 then retrieved a urinal containing a small amount of yellow liquid and emptied the catheter drainage bag into the urinal. CNA #3 tapped the spigot of the urinary drainage bag on the inside of the urinal during drainage. Interview with the Director of Nursing (DON) on 2/1/18 at 9:10 AM, in the conference room, the DON was asked what she expected staff to use for catheter care. The DON stated, Soap and water. The DON confirmed plain water was not acceptable. | 2020-09-01 |
| 2383 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 693 | D | 0 | 1 | YE7V11 | Based on Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition, observation and interview, the facility failed to ensure management of a tube feeding was preformed by qualified personnel for 1 of 1 (Resident #74) residents reviewed with a feeding tube. The findings included: Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition page 110, documented, Nursing Intervention for People Receiving Enteral Nutrition. In caring for people with tube feedings, it is the nurse's responsibility to .administer the correct amount and type of feeding at the correct rate . Observations in Resident #74's room on 1/30/18 at 1:04 PM, revealed Certified Nursing Assistant (CNA) #1 entered the resident's room to turn and reposition the resident. CNA #1 immediately went to the feeding pump and put it on hold. When CNA #1 completed resident care, she reumed the feeding pump. Interview with the Director of Nursing (DON) on 2/1/18 at 1:35 PM, in the conference room, the DON was asked if it was acceptable for a CNA to put a feeding pump on hold and then resume the feeding. The DON stated, No | 2020-09-01 |
| 2384 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 812 | F | 0 | 1 | YE7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by improper storage of food in a cooler, expired food products, and a dirty deep fat fryer. The facility had a census of 79 with 77 of those residents receiving a meal tray from the kitchen. The findings included: Observations in the kitchen on [DATE] beginning at 8:00 AM, revealed the following: (a) 1 large package of bologna with an opening in the side of the package. Interview with the Certified Dietary Manager (CDM) on [DATE] at 8:15 AM, in the kitchen, the Dietary Manager confirmed the integrity of the package of bologna was broken. Observations in the kitchen on [DATE] beginning at 11:10 AM, revealed the following: (a) 2 cartons of fat free milk dated [DATE] in the milk cooler. (b) 1 carton of fat free milk dated [DATE] in the milk cooler. (c) 2 bottles of protein beverages dated [DATE] in the milk cooler. Interview with the CDM on [DATE] at 11:13 AM, in the kitchen, the CDM confirmed the milk and protein beverage were out of date and stated, .I know they are not supposed to be in there. (d) The deep fat fryer had black grease and food particles on top of the grease. Interview with the CDM on [DATE] at 11:16 AM, in the kitchen, the CDM was asked if the deep fat fryer was dirty. The CDM stated, It is due to be changed . (e) 1 container of vanilla pudding with an use by date of [DATE] in the reach-in cooler. Interview with the CDM on [DATE] at 11:20 AM, in the kitchen, the CDM stated,That should have gone out. The CDM removed it from the cooler. Observations in the kitchen on [DATE] at 11:17 AM, revealed the following : (a) The deep fat fryer had black grease with food particles on top of the grease. Interview with the CDM on [DATE] at 11:19 AM, in the kitchen, the CDM was asked if the deep fat fryer was dirty. The CDM stated, Yes, ma'am it is dirty . Interview with the CDM on [DATE] at 11:19 AM, in the dry food storage area, the CDM was asked if it was acceptable to have expired milk in the milk cooler. The CDM stated, No, ma'am. The CDM was asked if it was acceptable to have out dated protein beverages in the milk cooler. The CDM stated, No ma'am. The CDM was asked if it was acceptable for pudding with an expired use by date to be stored in the cooler. The CDM stated, No, ma'am. The CDM was asked if it was acceptable for bologna to be stored in a plastic bag with an opening in the side of the bag. The CDM stated, No ma'am. | 2020-09-01 |
| 2385 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 880 | D | 0 | 1 | YE7V11 | Based on policy review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse (LPN #1) nurses followed practices to prevent the potential spread of infection during medication administration. The findings included: The facility's Equipment Cleaning, Disinfecting and Maintenance policy documented, .The following equipment is cleaned/disinfected after each resident use and when visibly soiled (the list includes examples of multi-use items .Stethoscopes .after use . Observations in Resident #74's room on 1/31/18 at 1:14 PM, revealed LPN #1 went to the medication cart, retrieved a stethoscope, placed the stethoscope around her neck and returned to the bedside. LPN #1 placed the stethoscope on the Resident #74's abdomen, administered medication, and laid the stethoscope on the unsanitized overbed table. Then LPN #1 left the room, carried the stethoscope and laid it on the top of the unsanitized medication cart. LPN #1 did not clean the stethoscope before or after use. Interview with the Director of Nursing (DON) on 2/1/18 at 1:37 PM, in the conference room, the DON was asked should a stethoscope be cleaned before or after administering Percutaneous Endoscopic Gastrostomy (PEG) medications. The DON stated, Yes. | 2020-09-01 |
| 2386 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 600 | J | 1 | 0 | 98W311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview, the facility failed to prevent neglect for 1 of 4 (Resident #1) sampled residents reviewed with wandering/exit seeking behaviors which resulted in Immediate jeopardy (IJ) when Resident #1 exited the facility, crossed 2 side streets, and walked to a local grocery store, 0.7 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility neglected to ensure a safe environment for Resident #1 which placed Resident #1 in Immediate Jeopardy (IJ), The facility neglected to adequately supervise Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors. Resident #1 had a history of [REDACTED]. The resident exited the facility on 6/28/19 and was located 0.7 miles from the facility at a local grocery store. The facility had no knowledge the resident was missing until the resident was returned to the facility by the police. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600 was cited at a scope and severity of [NAME] F-600 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: Review of the facility's Abuse Prevention Policy & Procedure revised 1/23/17 documented, .the right to be free from .neglect .Neglect: The failure to fulfill a care-taking obligation to provide goods or services necessary to avoid physical harm, mental anguish or mental illness . Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] from a Geriatric Psychiatric Unit with [DIAGNOSES REDACTED]. Resident #1 resided on the Secure Unit in the facility. Closed medical record review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/8/19 revealed Resident #1 was assessed with [REDACTED]. The MDS documented Resident #1 had disorganized thinking, inattention, delusions, verbal behaviors, physical behavior symptoms 1-3 days during the assessment period, impaired vision, and wore corrective lens. These behaviors placed the resident at significant risk for physical injury or illness. The resident was unsteady when ambulating. There were no Nursing Risk Assessments completed after the resident was admitted on [DATE] and readmitted on [DATE] to alert staff that Resident #1 was an elopement risk. Closed medical record review of the quarterly MDS with an ARD of 6/12/19 revealed Resident #1 was assessed to have a BIMS score of 7 which indicated the resident was severely impaired for decision making, had hallucinations, other behavioral symptoms, and the wandering behavior occurred 1 to 3 days. The resident did not require any assistive devices and needed limited assistance with walking. Closed medical record review of Resident #1's comprehensive care plan dated 3/12/19 and reviewed 6/20/19 revealed Resident #1 had wandering tendencies and exit seeking behaviors due to Dementia. Interventions to address this behavior included placing the resident in an area where frequent observation was possible, to implement facility protocol for locating an eloped resident, designate staff to account for resident's location throughout the day, and alert staff to the wandering behaviors. Interview with the Administrator on 7/11/19 at 7:30 PM in the Administrator's Office, the Administrator was asked if Resident #1 had exited the facility unattended prior to 6/28/19 and the Administrator stated, .I believe he got out .but not off of the premises .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM in the Conference Room, LPN#1 confirmed Resident #1 had exited the Secure Unit without staff being aware on 5/20/19. Review of a nurses' note dated 6/28/19 at 6:00 PM documented .continued exit-seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave, and attempting to call on nurses' station phone w/o (without) permission. Will monitor behaviors . Review of the Resident Incident Report provided by the facility dated 6/28/19 revealed Resident #1 was confused and disoriented. The (named grocery store) employee notified the police department at 7:11 PM that the resident was in the store parking lot. The police returned the resident to the facility at 8:00 PM. Review of a nurses' note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .stated 'I just followed some man out' . Interview with the Administrator on 7/11/19 at 3:50 PM in the 100 Hall, the Administrator stated, .I was here that day (6/28/19) .I was leaving to go home .I walked outside and saw 2 police officers standing outside talking. I waved at them and went to my car. It was between 7 (7:00 PM) and 8 (8:00 PM) that night .I called into the facility and they said the police had just brought (Resident #1) back to the facility from (named grocery store) .the only thing we can figure out is he walked out of the exit door on secure unit with a family member .we are unable to determine which route he took to the grocery store .I treated this like a jeopardy .my first question was how did they (staff) not know he was gone . Interview with the DON on 7/11/19 at 5:40 PM in the Conference Room, the DON was asked about Resident #1. The DON stated, .wandering .saw him at the door .around shift change stand by the door (on 6/28/19) . Interviews on 7/12/19 throughout the day with LPN #2, CNA #1, CNA #2, and Activity Assistant #1, all confirmed that on 6/28/19 Resident #1 exhibited exit seeking behavior, seemed more focused on exiting the facility, and seemed more agitated. Telephone interview with LPN #3 on 7/12/19 at 5:03 PM, LPN #3 revealed Resident #1 was .very aggressive at times .watches the doors .push on doors .watch people coming in and out through the doors .hadn't been back long from geri (geriatric)-psych (psychiatric) . LPN #3 was asked about the evening of 6/28/19 when he exited the facility. LPN #3 stated, .he wasn't in the lobby when I came on shift. He sometimes goes to bed after supper so I thought he was in bed .day shift had reported he was exit seeking that day .I had started med (medication) pass .around 8:00 PM. The 100 hall nurse (LPN # 4) brought Resident #1 in through the door (of the Secure Unit). The police had just returned him to the facility. His daughter was with him .he (Resident #1) stated, 'I went for a walk and had to find someone to bring me back' . LPN # 3 further stated .He was very, very determined .very sneaky .watching us go in and out of door . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM in the Conference Room, the DON was asked how sending Resident #1 to a geri-psych facility addressed his exit seeking behavior and the DON stated, .adjusting his medications adding or decreasing and giving us other interventions that might help . The DON was asked if the staff should have been aware if a resident was missing from the facility for over an hour. The DON stated, .he wasn't gone that long . The Administrator was asked if the nurse responsible for the care of Resident #1 the evening of 6/28/19 was unaware the resident was missing from the facility prior to the police returning the resident to the facility at 8:00 PM. The Administrator stated, .yes that's true . The Administrator was asked if the employee at (Named grocery store) had not called 911 what could have happened to Resident #1. The Administrator stated, .I don't know .don't want to think about it . Interview with the Administrator, Regional Consultant for Clinical Services, and DON on 7/14/19 at 12:08 PM in the Conference Room, the Regional Consultant for Clinical Services stated, .the care plan was reviewed and updated .medications were changed .he was sent to geri-psych hospital. That is an intervention on his care plan and the activity was updated on 6/20/19 I don't think this meets criteria for an IJ . Interview with LPN #4 on 7/14/19 at 6:15 PM in the Conference Room, LPN #4 was asked about the night Resident #1 exited the facility and was located at a local grocery store, LPN #4 stated, .it was around 8:00 PM. The police walked down the 100 hall with Resident #1 and I assisted Resident #1 back to the Secure Unit . LPN #4 was asked if she was aware a resident was missing from the facility, LPN #4 stated, .no . Interview with the Regional Consultant for Clinical Services on 7/15/19 at 5:05 PM in the Conference Room, the Regional Consultant for Clinical Services was asked if the occurrence when Resident #1 exited the Secure Unit on 5/20/19 was documented on the 24 hour nurse report, the Regional Consultant for Clinical Services stated, .he did not actually leave so we did not consider that an incident .it's documented highly exit seeking behaviors noted . Interview with the DON on 7/16/19 at 5:23 PM in the Conference Room, the DON was asked if a resident should leave the Secure Unit unattended. The DON stated, .no The DON was asked if the staff should be unaware a resident was missing from the facility until the police returned the resident to the facility. The DON stated, .no . The facility's failure to supervise Resident #1, failure to respond to Resident #1's exit seeking behavior, and failure to know where Resident #1 was for 1 hour and 20 minutes resulted in neglect when Resident #1 eloped from the facility on 6/28/19 with a recorded high temperature of 86 degrees, crossed 2 side streets, and walked 0.7 miles to a local grocery store which was located 247 feet from a major 4 lane highway. Refer to F 689 The surveyor verified the A[NAME] by: 1. Head counts of all residents on the Secure Unit will be conducted by Licensed Nurses hourly on the Head Count Form. This was initiated on 7/15/19. The surveyor reviewed the Head Count Form and interviewed staff on each shift. 2. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 3. Director of Nursing and/or Designee will educate all licensed and registered nurses on the Elopement Risk Assessment, the Nursing Summary. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 4. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audits. 5. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audits. 6. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 7. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 8. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. Noncompliance of F-600 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction. | 2020-09-01 |
| 2387 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 657 | J | 1 | 0 | 98W311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, closed medical record review, and interview the facility failed to ensure care plans were revised for 1 of 4 (Resident #1) sampled residents reviewed to include new interventions for wandering, exit seeking behaviors, and elopement after Resident #1 a cognitively impaired and vulnerable resident with vision impairment eloped from the Secure Unit. The facility's failure to update Resident #1's care plan with new interventions to address Resident #1's exit-seeking behavior resulted in Resident #1 leaving the facility and being found 0.7 miles away at a grocery store. This failure placed Resident #1 in Immediate Jeopardy. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-657 was cited at a scope and severity of [NAME] A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's undated Care Plans-Comprehensive policy documented, .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 .develops and maintains a comprehensive care plan for each resident .Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed quarterly .care plan goals and objectives are defined .goals and objectives are reviewed and/or revised .significant change in the resident's condition .when the desired outcome has not been achieved .resident has been readmitted to the facility from a hospital/rehabilitation stay .nurse supervisor uses the care plan to complete the CNA's (Certified Nursing Assistant) daily work assignment sheets .CNA's are responsible for reporting to the nurse supervisor any changes in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved .changes in the resident's condition must be reported to the MDS (Minimum Data Set) Assessment Coordinator so that a review of the resident's assessment and care plan can be made .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans .when the resident has been readmitted to the facility from a hospital stay . 2. The facility's undated Care Planning-Interdisciplinary Team policy documented, .development of an individualized comprehensive care plan for each resident .Prior to attending the care planning conference, each discipline will be responsible for developing a problem identification list .any area of difficulty or concern that prevents the resident from reaching his/her fullest potential. Problems must be stated .short-term goals must be resident oriented, behaviorally stated, measurable. Approach-The specific action (s) or intervention (s) that the staff will take to assist the resident in meeting/achieving the short-term goals . 3. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Closed medical record review of the MDS dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status score of 7 which indicated Resident #1 was severely impaired cognitively. Closed medical record review of Resident #1's comprehensive care plan created on 3/12/19 documented, .3/12/19 .Has wandering tendencies and exit seeking behaviors at times d/t (due to) Dementia .Place resident in area where frequent observation is possible .Provide diversional activities .Redirect when wandering into other resident's rooms .Instruct visitors to inform staff when they are leaving the designated area with the resident .Implement facility protocol for locating an eloped resident .If wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them . There were no new interventions implemented until 6/28/19. Closed medical record review revealed Resident #1 was admitted to the hospital from 5/21/19 to 6/6/19 due to increased confusion, aggression toward staff at facility, anxiety, and noted instability. Interview with the Administrator on 7/11/19 at 7:30 PM, in the Administrator's Office, the Administrator was asked had Resident #1 ever left the facility before. The Administrator stated, .I believe he got out of the Secure Unit but not off of the premises .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM, in the Conference Room, LPN #1 was asked about when Resident #1 had exited the Secure Unit without awareness of the staff. LPN #1 stated, .I know he got out the doors (400 hall doors) on the 100 side of the unit .it was in the evening maybe around 5-6 (5:00 PM-6:00 PM). I walked back to the nurses' station and (Named Clinical Manager #1) brought him in through the door of the Secure Unit .I know I wrote a nurse's note about him leaving the unit but it's gone .I'll go talk to (Named Clinical Manager #1) she was the nurse that brought him to the unit .she will know the date . LPN #1 returned a few moments later and stated, .I asked (Named Clinical Manager #1), she said it was (MONTH) 20th (5/20/19) . LPN #1 was asked if an incident report or an assessment was done. LPN #1 stated, .no I didn't do an incident report .just a head to toe assessment to be sure he was ok .and a nurses note which is gone . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, in the Conference Room, Clinical Manager #1 was asked about when Resident #1 exited the Secure Unit to an unsecured area in the building. Clinical Manager #1 stated, .May 20th 2019 (5/20/19) .yes .possibly around 6 PM-7 PM (6:00 PM - 7:00 PM) .exit the Secure Unit through the 400 hall doors . Clinical Manager #1 was asked if there were any staff or visitors with the resident. Clinical Manager #1 stated, .no just him .he walked out the 400 hall doors and turned toward the 100 hall nurses station and started walking very fast toward the nurses station .I immediately escorted him back to the unit . Closed medical record review of the comprehensive care plan reviewed on 6/20/19 revealed there were no new interventions for the exit seeking behaviors that occurred on 5/20/19 when he was readmitted on [DATE]. Closed medical review of a Nurses' Note dated 6/28/19 at 6:00 PM documented, .continued exit seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave and attempting to call on nurse station phone w/o (without) permission . Closed medical review of a Nurse's Note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .resident stated 'I just followed some man out the door.' Told staff he just was going for a walk and got lost and knew he needed to find someone to take him back .checked on every 30 minutes throughout the night . Interview with MDS Coordinator #1 on 7/12/19 at 4:55 PM, in the Conference Room, MDS Coordinator #1 was asked who updated and initiated the care plans. MDS Coordinator #1 stated, .sometimes I do care planning but (Named MDS Coordinator #2) does most of it . MDS Coordinator #1 was asked if she attended the morning meetings. MDS Coordinator #1 stated, .yes .we go over the 24 hour nurse report book, go over incidents and orders that are written . MDS Coordinator #1 was then asked if Resident #1 had ever left the Secure Unit or the building. MDS Coordinator #1 stated, .I have no knowledge of him leaving the unit or the building . Interview with MDS Coordinator #2 on 7/13/19 at 9:43 AM, in the Conference Room, MDS Coordinator #2 was asked about the care plan process and who was involved. MDS Coordinator #2 stated, .we cover incident reports in the daily clinical meeting and update the care plans .the DON, the Administrator, Risk Management, (Named Clinical Manager #1) .the meetings are not held on the weekend. If it happens on the weekend it will be discussed Monday . MDS Coordinator #2 was asked if Resident #1 left the facility or the unit in (MONTH) (2019). MDS Coordinator #2 stated, .no .I don't recall that . MDS Coordinator #2 was asked if she had updated Resident #1's care plan. MDS Coordinator #2 stated, .I could have potentially updated the care plan . MDS Coordinator #2 was asked to review Resident #1's care plan and if there were any interventions related to Resident #1 exiting the Secure Unit in (MONTH) (2019). MDS Coordinator #2 stated, .No . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM, in the Conference Room, they were asked what facility action was taken when Resident #1 exited the Secure Unit to an unsecured area of the building on 5/20/19. The Administrator stated, .codes changed on secure unit doors (corridor) and exit door of secure unit (to the outside) .sent him to (Named geriatric psychiatric facility) . The Administrator and DON confirmed there were no new interventions put into place after this exit seeking behavior. The facility failed to ensure that the care plan was revised to include new interventions to prevent elopement for a cognitively impaired resident with known exit seeking behaviors and a history of elopement. Refer to F600 and F689 The surveyor verified the A[NAME] by: 1. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 2. Director of Nursing and/or Designee will educate all licensed and registered nurses on how to update care plans with appropriate interventions. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 3. The DON and/or Minimum Data Set (MDS) Nurse will update care plans for residents with past exit seeking behaviors beginning 7/15/19. The surveyor reviewed the care plans. Noncompliance of F-657 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction. | 2020-09-01 |
| 2388 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 689 | J | 1 | 0 | 98W311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, closed medical record review, and interview, the facility failed to ensure adequate supervision to prevent elopement for 1 of 4 (Resident #1) cognitively impaired, vulnerable, visually impaired residents who had wandering/exit seeking behaviors resulting in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with prior wandering and exit seeking behaviors, who was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer wandering outside of a grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's Accident-Incident-Elopement-Wandering Resident undated policy documented, .every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for wandering/elopement .should a wandering/elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the resident's medical record and review by the interdisciplinary team .responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse . 2. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Closed medical record review revealed there was no elopement risk assessment completed when Resident #1 was admitted to the facility on [DATE]. Closed medical record review of the Care Plan dated 3/12/19 and revised 6/28/19 revealed Resident #1 had wandering tendencies and exit seeking behaviors due to Dementia. The interventions included if wandering away from unit, instruct staff to stay with the resident, converse and gently persuade to walk back to designated area, place resident in an area where frequent observation is possible, provide diversional activities as needed, implement facility protocol for locating an eloped resident, designate staff to account for residents whereabouts throughout the day, alert staff to wandering behaviors, and approach wandering resident in a positive, calm, and accepting manner. Closed medical record review of the quarterly Minimum data Set (MDS) with an assessment reference date (ARD) of 6/12/19 revealed Resident #1 was assessed to have a BIMS of 7, which indicated severe cognitive impairment. The resident was visually impaired, had hallucinations and other behavioral symptoms not directed toward others which occurred 1 to 3 days of the assessment period. Resident #1 had wandering behaviors which occurred 1 to 3 days of the assessment period, needed limited assistance with walking, and required no assistive devices. Closed medical record review revealed Resident #1 was admitted to the hospital from 5/21/19 to 6/6/19 due to increased confusion, aggression toward staff at the facility, anxiety, and noted anxiety. The Psychiatric Evaluation dated 5/22/19 from this hospital stay documented, .Justification for hospitalization - Inpatient Failure or treatment at a lower level of care, hallucinations, delusions, agitation, anxiety, depression, resulting in a significant loss of functioning. Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care. Failure of social or occupational functioning, Inability to meet basic life and health needs . Interview with the Administrator on 7/11/19 at 7:30 PM, in the Administrator Office, the Administrator was asked if Resident #1 ever left the facility prior to 6/28/19. The Administrator stated, .I believe he got out of the Secure Unit but not off of the premises . The Administrator was asked when this occurred and what interventions were implemented to address it. The Administrator stated, .about 3 months ago .I'll have to check .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM, in the Conference Room, LPN #1 was asked when Resident #1 exited the Secure Unit without awareness of the staff. LPN #1 stated, yes .I was the nurse the day he stepped out of the unit .I know he got out the doors (400 hall doors) on the 100 side of the unit .it was in the evening maybe around 5-6 (5:00 PM-6:00 PM) because I had went to the 300 hall to give medications. I walked back to the nurses' station and (Named Clinical Manager #1) brought him in through the door of the Secure Unit .was (MONTH) 20th . LPN #1 was asked if an incident report or an assessment was done. LPN #1 stated, .no I didn't do an incident report just a head to toe assessment to be sure he was ok . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, in the Conference Room, Clinical Manager #1 was asked when Resident #1 exited the Secure Unit to an unsecured area in the building. Clinical Manager #1 stated, .May 20th 2019 (5/20/19) .yes .possibly around 6 PM-7 PM (6:00 PM-7:00 PM) .exit the Secure Unit through the 400 hall doors . Clinical Manager #1 was asked if there were any staff or visitors with the resident. Clinical Manager #1 stated, .no just him .he walked out the 400 hall doors and turned toward the 100 hall nurses station and started walking very fast toward the nurses station I immediately escorted him back to the unit . Review of Resident #1's medical record revealed there was no documentation of the incident on 5/20/19. There were no new interventions for the exit seeking behavior when the resident returned from the hospital on [DATE]. There was no investigation of the incident to determine how the resident left the Secured Unit. Closed medical record review revealed there was no elopement risk assessment completed when Resident #1 was readmitted to the facility on [DATE] from the hospital. Closed medical record review revealed documentation that Resident #1 displayed impaired cognitive status and exit seeking behaviors: a. A Nurse's Note dated 6/6/19 at 6:48 PM documented, .repetitive confusion noted with place. Periods of anxiety . b. Review of an Admission/Readmission Note dated 6/6/19 revealed Resident #1 had Chronic Repetitive Disruptive Behavior that could potentially cause harm to himself or other, Chronic Wandering Behavior and Hallucinations. c. A Nurse's Note dated 6/9/19 at 7:28 PM documented, .resident pulled fire alarm in dining room . d. A Nurse's Note dated 6/10/19 at 4:13 PM documented, .continues to ask where his (he is) at and who comes to see him . e. Review of a Long Term Care Observation nurses' note dated 6/14/19 revealed Resident #1 was anxious, agitated, had chronic repetitive behavior, and wandering that included wandering at night and hallucinations. Resident #1's current level of mental status was documented as severe impairment that affected all areas of judgment. f. Review of a Long Term Care Observation nurses' note dated 6/21/19 revealed Resident #1 had chronic repetitive behavior, short term memory loss, and was currently disorientated and confused. g. A Nurse's Note dated 6/28/19 at 6:00 PM documented, .continued exit seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave, and attempting to call on nurses' station phone w/o (without) permission . h. A Nurse's Note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .resident stated 'I just followed some man out the door.' Told staff he just was going for a walk and got lost and knew he needed to find someone to take him back .checked on every 30 minutes throughout the night . i. A Nurse's Note dated 6/29/19 documented, .start of shift (7:00 AM 6/29/19), resident watched one on one . Based on the National Weather Service records, the recorded high temperature for the facility area on 6/28/19 (the day of the elopement from the facility) was 86 degrees Fahrenheit. The facility is located near an abandoned factory, a public park, and a community center with public parking. Closed medical record review revealed Resident #1 was transferred to the psychiatric hospital on [DATE], after this elopement episode. Closed medical record review of the (Named Hospital) ADMISSION NURSING assessment dated [DATE] documented, .Reason for admission .per facility pt. (patient) having danger issues and has been combative and tries to elope .Has the patient been violent to others in the past 6 months? (Yes checked) . Behaviors .Other (checked) exit seeking .Potential for elopement (checked) . The History and Physical from this hospital stay dated 6/30/19 documented, .anger, agitated threatens to shoot people high elopement risk . 3. Interview with LPN #2 on 7/12/19 at 8:52 AM, in the Conference Room, LPN #2 was asked if Resident #1 had exited the building on 6/28/19. LPN #2 stated, .I work the 400 hall day shift .I worked day shift 7 AM-7 PM (7:00 AM-7:00 PM) .when he formulates a plan, he will execute it if he wants to get out .standing by the door, when someone was going out the door, he would try to talk to them, and try to go out behind them .he had left here and went to another facility but they couldn't handle his exit seeking, he got out of that facility while he was there .I talked to him the night he eloped about 6:20 PM .that was the last time I saw him that night .changed shift and went home . Interview with Certified nursing Assistant (CNA) #1 on 7/12/19 at 9:40 AM, in the Conference Room, CNA #1 stated, .(Resident #1) always watching the door, seemed to be more focused on who was coming in and out of door .that day in particular (6/28/19) he was waving at me out the window .I saw him about 6:40 PM leaned against the corner of the 400 hall near the exit door (to outside) . Interview with Activity Assistant #1 on 7/12/19 at 9:55 AM in the Conference Room, Activity Assistant #1 stated .(Resident #1) always exit seeking .seemed more agitated that day (6/28/19) . Interview with the police officer on 7/12/19 at 1:05 PM, at the (Named City) Police Department, the police officer was asked about the incident on 6/28/19. The police officer stated, .there is not a police report .just the 911 dispatch information .according to it (dispatch log) the call came in at 19:11 (7:11 PM) suspicious person .the person was confused and doesn't know where he is .sitting on bench out front .the officer arrived at 7:15 PM at the grocery store. I arrived at 19:26 (7:26 PM) .he was confused and seemed scared .I asked his name and where he was from .he told me his name and that he was from (Named city) .I asked some more questions about his family and I recognized his daughter's name. We have a mutual friend so I got on (Named social media website) to find the more information, contacted a friend and got in touch with his daughter .I took him back to the facility around 8:00 PM .(staff) didn't know a resident was missing from the nursing home . Interview with MDS Coordinator #2 on 7/13/19 at 9:43 AM, in the Conference Room, MDS Coordinator #2 was asked if Resident #1 left the facility or the unit in (MONTH) of 2019. MDS Coordinator #2 stated, .no .don't recall that . MDS Coordinator #2 was asked if she had updated Resident #1's care plan. MDS Coordinator #2 stated, .I could have potentially updated the care plan . MDS Coordinator #2 was asked to review Resident #1's care plan and if there were new interventions related to the resident exiting the Secure Unit in (MONTH) of 2019. MDS Coordinator #2 stated, .no .it was reviewed 6/20/19 . Telephone interview with the grocery store employee on 7/13/19 at 2:00 PM, the employee was asked what happened on 6/28/19. The employee stated, .it was later in the day .a regular customer came in the store and said there was a gentleman wandering around outside at the front of the store. The customer said you might want to call 911, so I did. We asked him his name and he told us, but we didn't know anyone to call. The police came and the officers asked who his children were .the officer got in touch with someone that knew the man's daughter the police put him in vehicle and left . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM, in the Conference Room, they were asked what facility action was taken when Resident #1 exited the Secure Unit to an unsecured area of the building on 5/20/19. The Administrator stated, .codes changed on secure unit doors (corridor) and exit door of secure unit (to the outside) .sent him to (Named geriatric psychiatric facility) . The Administrator and DON confirmed there were no new interventions put in place after the exit seeking behavior on 5/20/19. The surveyor verified the A[NAME] by: 1. Door Code was immediately reset by the Maintenance Director on 6/28/19. 2. Signage was posted on the back exit door on the unit not to utilize door except in an emergency. Signage was posted on all other exit and corridor doors reminding visitors to be aware of others potentially exiting with them on 6/28/19. The signage was viewed by the surveyor on 7/16/19. 3. Maintenance Director checked all the windows on the Secure Unit to ensure that [MEDICATION NAME] were in place that limit the windows opening more than 4 inches on 6/28/19. This was confirmed by the surveyor through observations and interview on 7/16/19. 4. Head counts of all residents on the Secure Unit will be conducted by Licensed Nurses hourly on the Head Count Form. This was initiated on 7/15/19. The surveyor reviewed the Head Count Form and interviewed staff on each shift. 5. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 6. Director of Nursing and/or Designee will educate all licensed and registered nurses on the Elopement Risk Assessment, the Nursing Summary and how to update care plans with appropriate interventions. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 7. The DON and designee re-assessed all residents in the building to determine any residents with exit seeking behaviors on 6/28/19 and 6/29/19. Results were no new residents identified as an elopement risk or added to the list. The assessments were reviewed by the surveyor. 8. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 9. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 10. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 11. Beginning 6/28/19 Maintenance Director or Designee checked all windows in resident rooms and will continue on a monthly basis to ensure that [MEDICATION NAME] are in place to limit opening to 4-6 inches on an ongoing basis. This began on 6/28/19. 12. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 13. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 14. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 15. The DON and/or Minimum Data Set (MDS) Nurse will update care plans for residents with past exit seeking behaviors beginning 7/15/19. The surveyor reviewed the care plans. 16. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-689 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction. | 2020-09-01 |
| 2389 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 835 | J | 1 | 0 | 98W311 | > Based on the Administrator's Job Description, Director of Nursing (DON) Job Description, medical record review, and interview, the Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to provide oversight and training of staff to prevent a cognitively impaired, vulnerable resident from eloping from the Secure Unit of the facility. The resident walked 0.7 miles to a local grocery store. The Administrator's failure to provide resident safety placed Resident #1 in Immediate Jeopardy when staff did not complete assessments related to elopement risks, investigate an incident when Resident #1 exited a Secure Unit of the facility to an unsecured area, failed to ensure Resident #1 was free from neglect, and failed to ensure a safe environment for Resident #1. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: The Nursing Home Administrator job description with a revision date of 6/2006 documented.lead and direct the overall operations of the facility in accordance with .government regulations and Company policy, with focus on maintaining excellent care for the residents .This facility expects their employees to promote an atmosphere .hospitality and comfort for its residents .oversee regular rounds to monitor delivery of nursing care .ensure residents needs are being addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .improvement of services . The facility's Director of Nursing Job description with a revision date of 6/2006 documented, .manage the overall operations of the Nursing Department in accordance with .policies, standards of nursing practice and governmental regulations so as to maintain excellent care of all residents' needs .plan, develop, organize, implement, evaluate and direct the nursing services department .assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .resident care of the nursing service department .participate in coordination of resident services .provide appropriate departmental in-service education .in compliance with .State and Federal Guidelines .complete investigative analysis .study .resident Incident Reports for corrective action .Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures .efficient operation .Assure residents are comfortable, clean .safe environment .Verify that medical and nursing care is administered .assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident .review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided . Interview with the Administrator on 7/11/19 at 3:50 PM in the 100 Hall, the Administrator was asked about the incident when Resident #1 eloped. The Administrator stated, .I was here that day (6/28/19) .I was leaving to go home .I walked outside and saw 2 police officers standing outside talking. I waved at them and went to my car. It was between 7 (7:00 PM) and 8 (8:00 PM) that night .I called into the facility and they said the police had just brought (Resident #1) back to the facility from (named grocery store) .the only thing we can figure out is he walked out of the exit door on Secure Unit with a family member .we are unable to determine which route he took to the grocery store .I treated this like a jeopardy .my first question was how did they (staff) not know he was gone . The Administrator was asked if Resident #1 had ever eloped before. The Administrator stated, .he left the Secure Unit 1 time and he was found on the 100 hall .we didn't investigate it as an incident because he didn't leave the facility .no incident report . Administration failed to update Resident #1's Care Plan with new interventions for his exit seeking behavior. Refer to F657 Administration failed to ensure supervision of residents with wandering/exit seeking behaviors. Administration neglected to ensure staff were knowledgeable of the location of the residents with wandering/exit seeking behaviors when a resident exited the Secure Unit and was not identified as missing until the police returned the resident to the facility. Refer to F600 and F689. The surveyor verified the A[NAME] by: 1. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 2. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 3. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 4. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 5. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 6. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 7. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-835 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction. | 2020-09-01 |
| 2390 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 865 | J | 1 | 0 | 98W311 | > Based on review of the Administrator job description, review of the Director of Nursing (DON) job description, Quality Assurance (QA) Coordinator job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to exit seeking behavior assessments, completion of incident investigations, completion of elopement assessments, developing plans of action and interventions for exit seeking behaviors, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns, and failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure the facility implemented and/or provided new interventions related to active exit seeking, and that staff ensured a safe environment for residents placed 1 of 4 (Resident #1) sampled residents in Immediate Jeopardy when Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors, was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer when Resident #1 was wandering outside of a local grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: The Nursing Home Administrator job description with a revision date of 6/2006 documented.lead and direct the overall operations of the facility in accordance with .government regulations and Company policy, with focus on maintaining excellent care for the residents .This facility expects their employees to promote an atmosphere .hospitality and comfort for its residents .ensure residents needs are being addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .improvement of services . The facility's Director of Nursing Job description with a revision date of 6/2006 documented, .manage the overall operations of the Nursing Department in accordance with .policies, standards of nursing practice and governmental regulations so as to maintain excellent care of all residents' needs .plan, develop, organize, implement, evaluate and direct the nursing services department .resident care of the nursing service department .participate in coordination of resident services .provide appropriate departmental in-service education .in compliance with .State and Federal Guidelines .complete investigative analysis .study .resident Incident Reports for corrective action .Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures .efficient operation .Assure residents are comfortable, clean .safe environment .Verify that medical and nursing care is administered .assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident .review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided . Review of the QA Coordinator job description revised 6/2008 documented, .reports to Director of Nursing .supports successful implementation and maintenance of clinical and quality initiatives and protocols for use at the facility .to assure the facility is following .regulations .Identify deficit(s) related to policy/procedures and develop draft policy for review .identify weakness .of clinical initiatives to provide/promote resident well-being .new clinical initiatives to correct weaknesses .develop a detailed report on findings to report to QA Committee. Report any high risk areas immediately .staff .to provide accurate information and correct negative trends .Identifies Safety and Risk Management issues and communicates areas of weakness to Administrator .conduct meaningful weekly Quality Assurance meetings .weekly Quality Services department meetings .Protect residents from neglect . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, Clinical Manager #1 was asked if she attended Interdisciplinary Team (IDT) Meetings. Clinical Manager #1 stated, .yes I attend the meetings . Clinical Manager #1 was asked if exit seeking behaviors were discussed in the meetings. Clinical Manager #1 stated, .I don't recall discussing exit seeking behavior or (discussing) him (Resident #1) leaving the Secure Unit in (MONTH) (2019) . Clinical Manager #1 was the staff member who saw Resident #1 leave the Secure Unit on (MONTH) 20, 2019. Interview with the QA Coordinator on 7/15/19 at 3:04 PM, in the Conference Room, the QA Coordinator was asked if any concerns related to behaviors and exit seeking behaviors had been identified. The QA Coordinator stated, .no . Interview with the QA Coordinator on 7/16/19 at 5:15 PM, in the Conference Room, the QA Coordinator was asked if the QA committee was effective. The QA Coordinator stated, .no .the things we put in place (indicating the A[NAME]) will help it to be better . 1. The facility's QA committee failed to identify areas of improvement related to active exit seeking behaviors. Refer to F600, F657, F689, F835 2. The facility's QA committee failed to identify an incident of elopement, failed to investigate the incident to determine the root cause of the incident, failed to identify appropriate plans of action, and failed to ensure new interventions related to the incident of elopement were added to the resident's care plan. Refer to F 600, F657, F689, F835 3. The facility's QA committee failed to identify that elopement risk assessments were not current and updated for residents of the facility's Secure Unit. Refer to F 600, F657, F689, F835 The surveyor verified the A[NAME] by: 1. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 2. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 3. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 4. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 5. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 6. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 7. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-865 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction. | 2020-09-01 |
| 2391 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-08-30 | 609 | D | 1 | 0 | BV6Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview the facility failed to report an allegation of resident to resident abuse for 2 of 3 (Resident #1 and #2) sampled residents reviewed. The findings include: The facility's ABUSE PREVENTION POLICY & PR[NAME]EDURE policy documented, .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions .An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach .The investigation protocol must be implemented and a report given to the appropriate agencies as specified by law and regulations . Medical record review revealed Resident #1 was admitted to the secure Dementia unit at the facility on 9/18/18 with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed Resident #1 had a cognitive status score of 8 of 15, indicating moderate impairment and had wandering behaviors. Observations in Resident #1's room on 8/30/19 at 10:10 AM, revealed the resident was ambulatory in her room without assistance, was well groomed and appropriately dressed, had clear speech, and was alert and oriented to person and place. Interview with Resident #1 her room on 8/30/19 at 10:10 AM, when asked if another resident at the facility had hit her, Resident #1 stated, No. Not even the men . Closed medical record review revealed Resident #2 was admitted to the secure Dementia unit in the facility on 7/16/19 with [DIAGNOSES REDACTED]. Review of the 30-day assessment dated [DATE] revealed Resident #2 had a cognitive status score of 0 of 15, indicating severe impairment, had difficulty focusing attention, displayed physical and verbal behavioral symptoms directed toward others, rejected care and wandered. The facility's SUMMARY OF INCIDENT AND INVESTIGATION dated 8/13/19 documented, .CNA (Certified Nursing Assistant) notified nurse on 8/13/19 at approximately 6:30 am that she saw (Named Resident #2) hit (Named Resident #1) on the left forearm 3 times .(Named Resident #2) has a BIM (Brief Interview for Mental Status) of 0 and does not have the ability of mental reasoning to understand what is right or wrong nor does he have the capacity to willfully act in such a manner .After complete investigation, this occurrence was unsubstantiated as abuse. It is determined that (Named Resident #2) did not act deliberately or willfully and that facility staff intervened immediately and appropriately . Review of the facility's investigation revealed Resident #2 was removed from the area immediately and placed on 1:1 observation. The Administrator/Abuse Coordinator was notified of the incident and skin assessment for Resident #1 revealed no bruising and no complaint of pain. Each of the residents' families were notified, the physician was notified and orders were received to transfer Resident #2 to a Psychiatric facility for evaluation and treatment. Telephone interview with CNA #1 on 8/30/19 at 11:55 AM, CNA #1 was asked if she had witnessed Resident #2 hit Resident #1 on 8/13/19. CNA #1 revealed she had heard Resident #1 say a few curse words and saw Resident #2 hit Resident #1 on the left forearm with his fist 3 times. Resident #2 was removed immediately and Resident #1 was assessed and had no complaint of pain or bruising noted. Interview with the Administrator on 8/30/19 at 1:30 PM, in the Administrator Office, the Administrator was asked why the altercation between Resident #1 and Resident #2 on 8/13/19 had not been reported to the State Agency as an abuse allegation. The Administrator confirmed the allegation was not reported to the State Agency and stated she did not report tbecause she determined abuse had not occurred. | 2020-09-01 |
| 2392 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 550 | D | 0 | 1 | PSHT11 | Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 5 of 23 (Certified Nursing Assistant (CNA) #1, #4, #6, #7, and #9) facility staff members referred to clothing protectors as bibs, did not use courtesy titles to address residents, used a personal cell phone while assisting a resident with a meal, stood over a resident to assist with a meal, and failed to knock before entering a resident's room. The findings included: 1. The facility's Assisting with Meals policy documented, .Residents shall receive assistance with meals in a manner that meets the individual needs .not standing over residents while assisting them with meals .avoiding the use of labels .bibs . The facility's Quality of Life-Dignity policy revised (MONTH) 2009 documented, .shall be treated with dignity and respect at all times .staff shall knock and request permission before entering residents' room .Staff shall speak respectfully to residents at all times .addressing the resident by his or her name of choice and not 'labeling' .demeaning practices and standards of care that compromise dignity are prohibited .promote dignity . 2. Observations in the 400 Hall Dining Room on 10/14/19 at 12:10 PM, revealed CNA #7 stated to Resident #57, .the bib is cold, isn't it . Observations in the 400 Hall Dining Room on 10/14/19 at 12:17 PM, revealed CNA #6 stated to Resident #57, .that's your food, baby . Observations in Resident #63's room on 10/15/19 at 5:15 PM, revealed CNA #4 looked at her cell phone while she assisted Resident #63 with her meal. Observations in the 200 Hall on 10/15/19 at 5:40 PM, revealed CNA #1 entered Resident #16's room to deliver his meal tray without knocking. Observations in the 200 Hall on 10/15/19 at 5:44 PM, revealed CNA #1 entered Resident #64's room to deliver his meal tray without knocking. CNA #1 then left the room, returned at 5:50 PM, and entered again without knocking. Observations in Resident #243's room on 10/16/19 at 12:40 PM, revealed CNA #9 stood to assist Resident #243 with her meal. Interview with Director of Nursing (DON) on 10/17/19 at 2:41 PM, in the Conference Room, the DON was asked should staff stand to assist a resident with a meal. The DON stated .no . The DON was asked should clothing protectors be referred to as bibs. The DON stated, .I wouldn't think so . Interview with the Director of Nursing (DON) on 10/17/19 at 3:45 PM, in the Conference Room, the DON was asked if he expected staff to knock before entering residents' rooms. The DON stated, Yes. | 2020-09-01 |
| 2393 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 565 | E | 0 | 1 | PSHT11 | Based on observation and interview, the facility failed to provide privacy during 1 of 1 meeting with active Resident Council members. The findings include: Observations in the Sunroom on 10/15/19 at 10:00 AM, revealed the Resident Council Meeting location was not completely private. A bi-fold screen was used to block the entrance from hall 500 to the Sunroom but was accessible to anyone on the 500 Hall. During the meeting there were three interruptions: a. A resident on the 500 Hall folded the bi-fold screen, wheeled through the Sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. b. A Certified Nursing Assistant (CNA) from the 500 Hall folded the bi-fold screen, wheeled a resident through the sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. c. The Activity Director entered the room during the meeting and assisted one of the residents to leave the room. Interview with Activity Assistant #2 on 10/17/19 at 9:36 AM in the 400 Hall, Activity Assistant #2 stated, The Resident Council Meeting should never be interrupted. | 2020-09-01 |
| 2394 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 577 | D | 0 | 1 | PSHT11 | Based on policy review, observation, and interview, the facility failed to ensure the survey results were readily accessible for all residents residing in the facility. The facility had a census of 98 residents. The findings include: 1. The facility's undated Resident Rights policy documented, .results of the most recent survey of the Center conducted by Federal or State surveyors and any plan of correction in effect to the Center. The Center must make the results available for examination in a place readily accessible to residents . 2. Observations in the Lobby on 10/14/19 at 9:05 AM and 10/15/19 at 11:42 AM, revealed a white binder labeled .Survey Results The results from surveys on 6/10/19, 7/2/19, and 8/30/19 were not available for the residents to review. Interview with the Administrator on 10/16/19 at 4:46 PM, in the Lobby, the Administrator was asked if the survey results were in the survey book from the surveys conducted (June, July, and Sept of 2019). The Administrator stated, .no they are not in there . The Administrator was asked if the survey results should be in the book available for residents to review. The Administrator stated, .yes . | 2020-09-01 |
| 2395 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 658 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, 1 of 2 nurses (Licensed Practical Nurse (LPN) # 4) failed to follow facility policy for administration of medications through a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach for nutrition and medication) when medications were pushed through the enteral tube and not allowed to flow per gravity. The findings included: The facilities Administering Medications through an Enteral Tube policy revised (MONTH) (YEAR) documented, .Administer medication by gravity flow . Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Thera liquid give 10 ml (milliliter) .peg .once a day .[MEDICATION NAME] formula capsule .once daily . The physician's orders [REDACTED].[MEDICATION NAME] 0.5 mg tablet per peg . The physician's orders [REDACTED].[MEDICATION NAME] 125 mg (milligram)/5 ml susp (suspension) give 7 ml .PEG 2 TIMES DAILY @ (at) 6 AM & (and) 6 pm . Observations in Resident #35's room on 10/15/19 at 5:09 PM, revealed LPN #4 poured 60 ml of water into Resident #35's PEG and pushed the water through the tube with the plunger. LPN #4 then administered the medications with water and pushed each medication through the tube with the plunger. LPN #4 poured 60 mL of water into the PEG tube and pushed the water through the tube with the plunger. LPN #4 did not allow the medications to flow by gravity, in accordance with the facility's policy. Interview with the Director of Nursing (DON) on 10/17/19 at 7:15 PM, in the Conference Room, the DON was asked should medications be pushed through a PEG tube. The DON stated, .no .should be by gravity . | 2020-09-01 |
| 2396 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 684 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow the physician's orders for wound care treatments for 1 of 4 (Resident #70) sampled residents reviewed for wound care. The findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #70 required staff assistance for all activities of daily living, and had Moisture Associated Skin Damage (MASD). The care plan dated 2/25/19 documented, .at risk for skin breakdown r/t (related to) decreased mobility, incontinence .Intervention .Treatments as directed . The Physician's Orders dated 10/7/19 documented, .Start Date .10/03/19 .RLE (Right Lower Extremity) AND LLE (Left Lower Extremity) EXCORIATION .CLEAN C (with) NS (Normal Saline), APPLY SSD (Silver [MEDICATION NAME])/[MEDICATION NAME]/[MEDICATION NAME]/ZINC TRIPLE CREAM EQUAL MIXTURE TO AFFECTED AREAS DAILY ET (and) PRN (as needed) X (times) 14 DAYS, THEN RE-EVALUATE . The Wound Assessment Report dated 10/15/19 documented, .MASD .apt (appointment) (with) .wound clinic on 10/15/19 .N.O. (new order) Cont (Continue) to apply SSD/[MEDICATION NAME]/[MEDICATION NAME]/zinc combined triple cream equal parts to affected areas daily . Observations in Resident #70's room on 10/16/19 at 10:55 AM, revealed Licensed Practical Nurse (LPN) #1 performed wound care to raised reddened areas to Resident #70's bilateral posterior upper thighs. LPN #1 wiped the wound with Aloe disposable wipes, and then applied SSD 1 percent (%) cream to the area. Interview with LPN #1 on 10/17/19 at 6:51 PM, in the 500 Hall, LPN #1 confirmed she applied SSD 1% cream to Resident #70's MASD wounds. LPN #1 was asked if the treatment was administered as ordered. LPN #1 stated, .This is what they sent from (Named Pharmacy) . Interview with the Director of Nursing (DON) on 10/17/19 at 6:54 PM, in the 500 Hall, the DON was asked if the SSD 1% cream was the treatment that was ordered. The DON stated, No. | 2020-09-01 |
| 2397 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 725 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility staffing schedules and interview, it was determined the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility had a census of 98 residents. The findings include: 1. Review of the quarterly MDS dated [DATE] revealed Resident #31 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #31 on 10/14/19 at 3:07 PM, in Resident #31's room, Resident #31 was asked about staffing at the facility. Resident #31 stated, Not at night time especially. They say it's just 1 or 2 (staff members) at night. Resident #31 was asked if he had to wait a long time for someone to help him if he called for help. Resident #31 stated, .takes an hour or 2 and sometimes 3 or 4, takes a long time . Even sometimes in the daytime they don't come as quick as they should. 2. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Interview with Resident #29 on 10/14/19 at 3:58 PM, in Resident #29's room, Resident #29 was asked about staffing at the facility. Resident #29 stated, Sometimes at night it's pretty bad, especially at bedtime .have to wait at least 30 minutes before they can go to bed .sometimes at night it's way more than 30 minutes . 3. Review of the admission MDS dated [DATE] revealed Resident #143 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #143 on 10/15/19 at 8:09 AM, in Resident #143's room, Resident #143 was asked about staffing at the facility. Resident #143 stated, A lot of times at night we only have 1 aide for 30-something patients .they (call lights) might go off 30 minutes to an hour before they're answered. 4. During the Resident Council Group meeting, which consisted of 12 alert and oriented residents, the Resident Council Group expressed staffing concerns, which included not enough help at night or on weekends, and 1 staff member works with 30 beds/residents. 5. Review of the Certified Nursing Aide (CNA) schedule revealed there were 3 CNAs scheduled for the night shift (6:45 PM - 7:00 AM) on Sunday 10/13/19. The facility had a census of 99 residents as of midnight 10/14/19. Review of the CNA schedule revealed there was 1 CNA scheduled for 6:45 PM - 11:00 PM, and 3 CNAs scheduled for 6:45 PM - 7:00 AM for the night shift on Monday, 10/14/19. The facility had a census of 99 residents. Review of the CNA schedule revealed there were 4 CNAs scheduled for 6:45 PM - 7:00 AM for the night shift on Tuesday, 10/16/19. The facility had a census of 96. 6. Interview with CNA #2 on 10/15/19 at 8:55 PM, in the Sunroom, CNA #2 was asked if she felt the facility had enough staff for her to get all of her assignments completed. CNA #2 stated, .not enough time to complete everything .way too many residents to care for . CNA #2 was asked how many residents she was assigned tonight. CNA #2 stated, Twenty-five .responsible for 32 at most . Interview with CNA #5 on 10/15/19 at 8:18 PM, in the Secured Unit Lobby, CNA #5 was asked if she felt there was enough staff. CNA #5 stated, No. CNA #5 was asked how many residents she was assigned. CNA #5 stated, .last night .I had 27 on my own .I need to spend more time with the residents . Interview with Licensed Practical Nurse (LPN) #4 on 10/16/19 at 10:55 AM, in the 100 Hall, LPN #4 was asked if she was off after today. LPN #4 stated, No I have to work 12 hour shifts until Saturday (10/19/19) .a nurse walked out . | 2020-09-01 |
| 2398 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 757 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the PHYSICIANS' DESK REFERENCE 69th EDITION, medical record review, observation, and interview, the facility failed to ensure medications administered were appropriately monitored for adverse effects for 1 of 6 (Resident #16) sampled residents reviewed for unnecessary medications. The findings include: 1. The PHYSICIANS' DESK REFERENCE 69th EDITION (YEAR) documented, .[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication) .INDICATIONS AND USAGE .[MEDICAL CONDITION] .Pituitary TSH ([MEDICAL CONDITION] Stimulating Hormone) Suppression .PRECAUTIONS .has a narrow therapeutic index .Regardless of the indication for use, careful dosage titration is necessary to avoid the consequence of over- or under-treatment .These consequences include .effects on .cardiovascular function, bone metabolism .cognitive function, emotional state, gastrointestinal function, and on glucose and lipid metabolism .The adequacy of therapy is determined by periodic assessment of appropriate labortory tests .frequency of TSH monitoring during [MEDICATION NAME] dose titration .is generally recommended at 6-8 week intervals until normalization .When the optimum replacement dose has been attained .It is recommended .a serum TSH measurement be performed at least annually . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Unspecified Sequelae of Other [MEDICAL CONDITION] Disease. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #16 had severe cognitive impairment and required supervision for all activities of daily living. A hospital discharge summary report dated 3/21/18 documented, .TSH ([MEDICAL CONDITION] Stimulating Hormone) .2/28/2018 .Result .6.44 .H (High) .Reference Range .0.45 - 5.0 .ulU/ml (micro-international units per milliliter) . The physician's orders [REDACTED].Start Date .6/30/18 .[MEDICATION NAME] 0.025 MG (milligrams) TABLET by mouth @ (at) 6am (6:00 AM) daily . The facility was unable to provide documentation that any laboratory testing for [MEDICAL CONDITION] function had been done since the abnormal result was obtained 2/28/18. Observations in Resident #16's room on 10/15/19 at 5:06 PM and 8:45 PM, 10/16/19 at 10:25 AM and 12:11 PM, and on 10/17/19 at 2:32 PM and 6:39 PM, revealed Resident #16 lying in bed with his eyes closed. Interview with the Director of Nursing (DON) on 10/17/19 at 9:01 PM, in the Conference Room, the DON was asked if TSH levels should be monitored for residents taking [MEDICATION NAME]. The DON confirmed these levels should be monitored. | 2020-09-01 |
| 2399 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 759 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the JoVE Science Education Database Nursing Skills. Preparing and Administering Intramuscular Injections, medical record review, observation, and interview, the facility failed to ensure 2 of 8 (Licensed Practical Nurse (LPN) #2 and #3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 29 opportunities, resulting in an error rate of 6.89%. The findings included: 1. The JoVE Science Education Database. Nursing Skills Preparing and Administering Intramuscular Injections documented, .The deltoid site (upper arm) .immunizations .maximum volume should never exceed 2 mL (milliliters) . The facilty's Administering Medications policy revised (MONTH) 2019 documented, .Medications are administered in a safe and timely manner, and as prescribed .The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions .Medications are administered in accordance with prescriber orders . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 120 mg (milligram) IM (intramuscular) q (every) 12 hrs (hours) x (for) 14 days . Observations in Resident #18's room on 10/16/19 at 9:15 AM, revealed LPN #2 injected 3 ml of [MEDICATION NAME] into Resident #18's left upper arm (deltoid site). Interview with the Director of Nursing (DON) on 10/17/19 at 8:23 PM, in the Conference Room, the DON was asked is it acceptable to give 3 ml of medication Intramuscular (IM) in the upper arm. The DON stated, .no . Failure of LPN #2 to administer an IM injection of [MEDICATION NAME] of less than 2 ml into the deltoid site resulted in medication error #1. 3. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog .152-200=3 units . Observations in Resident #34's room on 10/16/19 at 4:08 PM, revealed LPN #3 performed a blood glucose level check with a result of 153. Interview with LPN #3 on 10/16/19 at 4:10 PM, at the 400 Hall Nurses' Station, LPN # 3 stated, .doesn't get any insulin . Interview with the DON on 10/16/19 at 8:23 PM, in the Conference Room, the DON was asked how much insulin should Resident #34 receive for a blood glucose of 153. The DON stated, .3 units . The DON confirmed insulin should be administered as ordered. Interview with the Medical Director on 10/17/19 at 3:52 PM, in the Conference Room, the Medical Director was asked if he expected his medication orders to be followed. The Medical Director stated, .Yes ma'am, I expect all my orders to get carried out, they're not just suggestions . Failure of LPN #3 to administer insulin as prescribed resulted in medication error #2. | 2020-09-01 |
| 2400 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 760 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information, policy review, medical record review, and interview, the facility failed to ensure medications were administered free from significant medication errors for 1 of 24 (Resident #70) sampled residents. The findings include: 1. The (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information documented, .Take [MEDICATION NAME] once a day . 2. The facility's Medication and Treatment Orders policy with a revision date of 7/2016, documented, .Orders for medications must include .Dosage and frequency of administration .Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders . 3. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 2/25/19 documented, .insulin dependent diabetic .at risk for hypo/[MEDICAL CONDITION] and complications of the disease .Intervention .Medications .as directed per MD (Medical Doctor) .orders . The Physician admission orders [REDACTED].[MEDICATION NAME]-5mg (milligrams)-take 1 tab (tablet) po (by mouth) before meals . The Telephone physician's orders [REDACTED].Order Clarification .[MEDICATION NAME] 5mg po (by mouth) QD (every day) . Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 Monthly Consultant Pharmacist Report documented, .Please note the following medication(s) are dosed above the usual geriatric dosage .[MEDICATION NAME] 5mg tid (three times daily) .Recommendation .[MEDICATION NAME] 5mg daily . Telephone interview with the Pharmacist on 10/17/19 at 8:52 AM, the Pharmacist was asked if there had been a problem with Resident #70's diabetic medication, [MEDICATION NAME]. The Pharmacist stated, Yes .There's no way they are supposed to be given three times a day .it was supposed to be given once a day. It was some kind of mistake .She actually went without her meds a few days .It was 9/14 (9/14/19) by the time we got it straightened out . The Pharmacist confirmed Resident #70 ran out of [MEDICATION NAME] before it could be refilled again because it was administered three times daily instead of once daily. Interview with Licensed Practical Nurse (LPN) #5 on 10/17/19 at 9:33 AM, at the Hall 5 Nurses' Desk, LPN #5 was asked if there had been a problem with Resident #70 getting her [MEDICATION NAME] refilled. LPN #5 stated, Yes .it was scheduled for three times a day .insurance would only pay for one time a day. It was ordered .with meals, so the order was put in for 3 times a day. When she ran out, the insurance wouldn't pay for it to be refilled. LPN #5 was asked if it should have been ordered for only once a day instead of 3. LPN #5 stated, Yes. LPN #5 was asked if there was any documentation of the medication order error. LPN #5 provided a physician's telephone order dated 9/27/19 that documented, .Order Clarification .[MEDICATION NAME] 5mg po QD . Interview with the Director of Nursing (DON) on 10/17/19 at 1:00 PM, in the Conference Room, the DON was asked the facility's process for transcribing orders. The DON stated, We just take the hospital orders they sent to us and write them on a physician's orders [REDACTED]. The DON stated, We would clarify the order. The DON confirmed physician medication orders should include how many times a day the medication was to be administered. | 2020-09-01 |
| 2401 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 761 | D | 0 | 1 | PSHT11 | Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored when 1 of 9 (500 Lower Hall Medication Cart) medication storage areas was unlocked and unattended. The findings included: The facility's Storage of Medications policy revised (MONTH) 2019 documented .drugs and biologicals .are stored in locked compartments .unlocked medication carts are not left unattended . Observations in the 500 Hall on 10/15/19 at 8:16 PM, the 500 Lower Hall Medication Cart was left unlocked and unattended. Interview with the Director of Nursing (DON) on 10/17/19 at 2:41 PM, in the Conference Room, the DON was asked if medication carts are to be left unlocked. The DON stated, .no . | 2020-09-01 |
| 2402 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 812 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by a dirty hand-washing sink in the Kitchen, dishwashing racks stored on the floor in the Kitchen, opened, unlabeled and undated foods stored in the Kitchen and in 1 of 3 (,[DATE] Hall Nourishment Room) nourishment rooms, wet towel on the floor in the Kitchen, a dirty steam table in the Kitchen, raw chicken and frozen foods left sitting at room temperature in the Kitchen, and foods on the floor in the Kitchen. The facility had a census of 98 residents, with 91 of those residents receiving a meal tray from the kitchen. The findings include: 1. The facility's FOOD STORAGE policy with a revision date of [DATE], documented, .Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded .Use use-by-dates on all food stored in refrigerators .Remember to cover, label and date .Chicken should be stored on ice to maintain an optimal temperature .Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture .milk .should be stored .in refrigeration at 41 (degrees) F (Fahrenheit) or less .All foods should be stored .off the floor .Internal thermometers are to be in the warmest area of the refrigerator or freezer .Record temperatures from the internal thermometers .Employee food and resident food should not be stored together . 2. Observations in the Kitchen on [DATE] beginning at 8:45 AM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. Two dish racks on the floor in the dishware washer area. The Dietary Manager (DM) confirmed they were on the floor, and picked them up. c. A milk cooler filled with milk and no thermometer inside. The DM confirmed there were no thermometers in the milk cooler. The DM stated, Milk delivery was today .thermometers may have been taken out in the empty crates . d. Milk cooler with undated, unlabeled plastic container with orange-peach colored substance. The DM stated, It looks like a pureed dessert. e. A thawing single serve container of ice cream. The DM removed the ice cream. f. A wet towel on the floor beside the ice machine. The DM removed the wet towel from the floor and stated, We have been having problems with it .waiting on a part for it. g. A portable steam table empty with stained sides and all wells with crusty black dirty substance in the bottom of the wells. The DM stated, .Thermostat went out on the steam table .using this mobile one until the part for the other one comes in .supposed to be here the 25th ([DATE]) . h. Two large shallow baking pans containing uncovered raw chicken breasts. No dietary staff member was working with the foods. The DM stated, .preparing for lunch today . i. A reach-in cooler with 5 uncovered/unlabeled containers of mandarin oranges and 2 uncovered/unlabeled containers of blueberry crumble dessert. The DM stated, It looks like blueberry crumble leftover from Saturday ([DATE]). j. A reach-in cooler with 2 containers of parfait from the local grocery store dated ,[DATE]. The DM removed the parfaits. k. The main milk cooler full of milk with no thermometer. 3. Observations in the Kitchen on [DATE] at 9:56 AM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. A reach-in cooler with an opened bag containing 3 lettuce heads, with lettuce spilling out of the bag The DM removed the bag of lettuce. c. Twelve bags of frozen hushpuppies and 1 bag of frozen french fries beside the 3-compartment sink. No dietary staff member was working with the foods. The DM stated, They are making corn nuggets from those. d. An empty portable steam table with stained sides and all wells with crusty black dirty substance in the bottom of the wells. 4. Observations in the ,[DATE] Hall Nourishment Room on [DATE] at 5:35 PM, revealed the following: a. An unlabeled and undated large Styrofoam cup with a straw in it from a local restaurant half-filled with liquid in the resident refrigerator. The Regional Registered Nurse stated, I'm just going to toss it . b. A sandwich wrapped in a local restaurant paper wrapper on top of the microwave. The Regional Registered Nurse threw it in the trash. c. An uncovered/unlabeled/undated cup half full of ice and clear liquid and an unlabeled half-full bottle of water on the counter beside the microwave. The Regional Registered Nurse threw it in the trash. 5. Observations in the Kitchen on [DATE] at 12:00 PM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. A case of crushed pineapple and a case of brown sugar on the floor. The Registered Dietician stated, .We just got a shipment. 6. During the Resident Council Group meeting, which consisted of 12 alert and oriented residents, the Resident Council Group expressed concerns the ice cream was not served cold. 7. Interview with the DM on [DATE] at 8:20 AM, in the Conference Room, the DM was asked how foods should be stored in the refrigerator. The DM stated, Produce needs to be stored in refrigerator usually in the box or we unpack them into or a plastic box with a lid, covered, and dated when they come in .Produce is good for 1 week .leftovers, we cool it down and store it for 3 days in the cooler in plastic bins with lids, labels, and dates. The DM was asked if any foods should be stored uncovered, unlabeled, or undated. The DM stated, No. Everything should be labeled. The DM was asked if foods should be stored in boxes on the floor. The DM stated, No .He brings it in on a dolly .until we get it unpacked and put away, it is going to be on the floor. The DM was asked if the nourishment room refrigerators were managed by the kitchen staff. The DM confirmed they did, and confirmed anything that does not belong to the residents, and anything that was not labeled and dated was not acceptable. The DM was asked how often the steam table and the hand-washing sink were cleaned or wiped down. The DM stated, As often as possible between tasks. The DM confirmed there was no set schedule for cleaning the hand-washing sink or the steam table. The DM was asked if there should always be thermometers in the refrigerators and freezers. The DM stated, Yes. The DM was asked about the 2 pans of raw chicken on the stove top. The DM stated, It was marinating in herbs .She had just filled one of the sheet pans . The DM was asked if it should have been covered. The DM stated, I would say yes. | 2020-09-01 |
| 2403 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 842 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Resident Assessment Instrument (RAI) Manual, policy review, medical record review, observation, and interview, the facility failed to ensure accurate documentation related to pressure ulcers for 1 of 4 (Resident #31) sampled residents reviewed for pressure ulcers and medication administration related to insulin and intravenous (IV) antibiotics for 2 of 6 (Resident #59 and #61) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the RAI Manual, (YEAR) Minimum Data Set (MDS) 3.0 Updates, revealed that when a resident who is admitted to the nursing home without a pressure ulcer develops a pressure ulcer in the nursing home, is admitted to the hospital for acute condition changes and then readmitted to the nursing home with the same pressure ulcer, that pressure ulcer is not considered present on admission but is a facility acquired pressure ulcer. Medical record review revealed Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A weekly Wound Assessment Report dated 3/27/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date Wound Identified .8/29/2017 .Present upon admission .No .Stage 4 . A weekly Wound Assessment Report dated 4/2/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date wound identified .4/2/19 .Present upon admission .Yes .Assessment Occasion .Re-assessment .Resident out of the facility From Date .3/28/2019 .Thru Date .4/2/2019 . All weekly Wound Assessment Reports from 4/2/19 through 10/15/19 documented, .Date wound identified .4/2/2019 .Present upon admission .Yes . Observations in Resident #31's room on 10/16/19 at 10:08 AM, revealed wound care was performed on Resident #31's Stage 4 coccyx pressure ulcer. Interview with Licensed Practical Nurse (LPN) #1 on 10/16/19 at 3:10 PM, in the 400 Hall Dining Area, LPN #1 was asked if Resident #31 had a stage 4 coccyx pressure ulcer when he went out to the hospital on [DATE]. LPN #1 stated, He had it when he went out .was a Stage 4 .it is the same wound .it's the only wound he's had on his bottom . Interview with the Regional Director of Clinical Services on 10/16/19 at 6:02 PM, in the Front Lobby, the Regional Director of Clinical Services was asked should Resident #31's weekly wound assessment document that his pressure ulcer was present on admission when it was a facility acquired pressure ulcer. The Regional Director of Clinical Services stated, .Coming back from the hospital, if it was a facility acquired wound, the record should always reflect that it is a facility acquired wound . 2. Review of the facility's Administering Medications policy revised (MONTH) 2019 documented .medications are administered in accordance with prescriber orders, including any required time frame . Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#59 had scheduled accuchecks before meals and at bedtime with the following Humalog Sliding Scale Insulin: HUMALOG 100 UNIT/(per) ML (milliliters) .SLIDING SCALE .0-199=0U (units); 200-250=2U; 251-300=4U; 301-350=6U; 351-400=8U; 401 >=10U AND RECHECK IN 30 MINUTES . Review of the Medication Administration Record [REDACTED] a. 8/19/19 at 6:30 AM the blood glucose was 110 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. b. 8/19/19 at 5:30 PM the blood glucose was 127 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. c. 8/22/19 at 6:30 AM the blood glucose was 119 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. d. 8/27/19 at 6:30 AM the blood glucose was 113 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. e. 9/1/19 at 6:30 AM the blood glucose was 114 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. f. 9/5/19 at 6:30 AM the blood glucose was 118 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. g. 9/14/19 at 6:30 AM the blood glucose was 142 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. Review of the (MONTH) 2019 Medication Regimen Review by the Pharmacist for Resident #59 revealed the resident .appears to have been given a dose of SSI (sliding scale insulin) (1 unit) at 6:30 on (MONTH) 1st, 5th, and 14th. Blood sugars were 114, 118, and 142, respectively. Per the active order, the use of SSI starts at a blood sugar of 200 (2 units). Erroneous administration of SSI could lead to severe [DIAGNOSES REDACTED]. Please ensure that the nurses double check sliding scale instructions prior to administration . Interview with LPN #5 on 10/17/19 at 9:20 AM, in the 500 Hall, LPN #5 confirmed Resident #59's blood glucose level was never high enough to receive insulin. LPN #5 reviewed Resident #59's blood glucose record for (MONTH) and (MONTH) 2019 and confirmed Resident #59 did receive insulin three times each month. She also confirmed Resident #59 should never have received insulin for the blood glucose level documented. Interview with the Director of Nursing (DON) on 10/17/19 at 2:25 PM, in the Conference Room, the DON confirmed no insulin should have been administered with the blood glucose levels documented. Interview with the Medical Director on 10/17/19 at 3:44 PM, in the Conference Room, the Medical Director stated, I do not understand why this happened according to the sliding scale orders. Interview with the DON on 10/17/19 at 5:25 PM, in the Conference Room, the DON stated that both nurses responsible for the inaccurate documentation were new graduate nurses and it was a computer medication education issue. 3. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician's admission orders [REDACTED].[MEDICATION NAME] .80mg (milligrams) / (per) 2ml (milliliters) .420mg/NS (Normal Saline) .100ml .220ml/HR (hour) .q (every) 24 (hours) .D/C (discontinue) 10-19-19 . The (MONTH) 2019 Medication Administration Record [REDACTED]. [MEDICATION NAME] .was not administered .Resident not available . The NURSE notes dated 10/14/19 documented, .IV (Intravenous) antibiotics given at 1015 (10:15 AM) . Observations in Resident #61's room on 10/14/19 at 10:56 AM, revealed Resident #61 sitting in a wheelchair at bedside. [MEDICATION NAME] was infusing IV per pump at 220 ml/hr. Interview with the DON on 10/17/19 at 5:26 PM, in the Conference Room, the DON was asked about the documentation on the MAR indicated [REDACTED]. The DON stated, I think the problem with the documentation might be the LPNs are signing it off, and the RNs (Registered Nurses) are actually the ones giving it . | 2020-09-01 |
| 2404 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 880 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when isolation precautions were not followed for 1 of 2 (Resident #49) sampled residents reviewed and facility staff failed to protect resident's personal clothing from environmental contamination. The findings include: 1. The facility's Isolation - Categories of Transmission-Based Precautions policy revised (MONTH) (YEAR) revealed .when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC (The Centers for Disease Control) (CDC) precaution(s), instructions for use of PPE (personal protective equipment), and/or instructions to see a nurse before entering the room . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Pt (patient) to be in contact isolation r/t (related to)[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) in wound . Observations in the 500 Hall on 10/14/19 at 8:30 AM, revealed no isolation signs on Resident #49's door. Resident #49 had a roommate who was not in isolation. Observations in the 500 Hall on 10/14/19 at 9:00 AM, revealed Licensed Practical Nurse (LPN) #7 donned gloves to enter Resident #49's room. LPN #7 confirmed that she wore gloves only because his wounds were contained and he was not contagious. Observations on 10/15/19 in the 500 hall revealed the following: a. Certified Nursing Assistant (CNA) #3 entered Resident #49's room at 8:00 AM to deliver the breakfast tray. CNA #3 did not wear gloves or any Personal Protective Equipment (PPE) when she entered the room. b. CNA #4 entered Resident #49's room at 5:45 PM to deliver the supper tray. CNA #4 did not wear gloves or any PPE when she entered the room. Interview with CNA #3 and CNA #4 on 10/15/19 at 6:30 PM, in the 500 Hall, CNA #3 and CNA #4 stated the wounds were contained and PPE was not required. Interview with LPN #1 on 10/17/19 at 9:30 AM, LPN #1 confirmed staff should don gowns, gloves, and foot covers before entering Resident #49's room. LPN #1 was asked should Resident #49 and Resident #62 share a room. LPN #1 stated it was safe for Resident #49 and #62 to be in the same room because Resident #49 had a [MEDICAL CONDITION] and a suprapubic catheter and they did not share a bathroom. LPN #1 confirmed that Resident #49's [MEDICAL CONDITION] and catheter bags were emptied into the commode that Resident #62 used. 2. Review of the facility's Laundry and Linen policy revised (MONTH) 2014 documented, .The purpose of this procedure is to provide a process for the safe and aseptic handling .of linen .clean linen will remain hygienically clean (free of pathogens (germs)) . Interview with Laundry Assistant #1 on 10/17/19 at 9:00 AM, in the 500 Hall, Laundry Assistant #1 revealed three of four dryers were not working on Tuesday 10/15/19 so wet laundry was taken to the community laundromat to dry the resident clothes. Laundry Assistant #1 confirmed she did not disinfect the dryers prior to placing the resident's personal clothing in the dryers. | 2020-09-01 |
| 2405 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 584 | D | 0 | 1 | 38WC11 | Based on policy review, observation, and interview the facility failed to maintain a sanitary environment in 1 of 50 (Resident #21, 30, 48, and 66's shared bathroom) resident bathrooms. The findings include: 1. The facility's Cleaning and Disinfecting residents' Rooms policy with a revision date of 8/13 documented, .Housekeeping surfaces .will be cleaned on a regular basis .and when these surfaces are visibly soiled . 2. Observations in Resident #21, 30, 48, and 66's shared bathroom on 12/10/18 at 11:12 AM revealed bowel movement in the toilet, a brown substance smeared on the toilet seat, and crumpled used paper towels lying on top of the toilet tissue dispenser beside the toilet. Observations in Resident #21, 30, 48, and 66's shared bathroom on 12/10/18 at 2:39 PM and 4:35 PM revealed a brown substance smeared on the toilet seat and on top of the toilet tissue holder beside the toilet. Interview with Certified Nursing Assistant (CNA) #1 on 12/10/18 at 4:38 PM in Resident #21, 30, 48, and 66's shared bathroom, CNA #1 was asked who cleaned the bathrooms. CNA confirmed it was housekeeping staff. CNA #1 was asked how often they are cleaned. CNA #1 stated, They are here from 6 in the morning until .maybe 2. I don't see them after I come back from lunch. CNA #1 was asked if the smeared brown substance on the toilet seat and on the toilet tissue dispenser was acceptable. CNA #1 stated, No, not at all. CNA #1 was asked if the residents use that bathroom. CNA #1 stated, Yes, (Resident #30) does. Interview with the Director of Nursing (DON) on 12/12/18 at 2:27 PM in the conference room , the DON was asked how often he expected staff to make rounds in resident rooms and bathrooms. The DON stated, At least every 2 hours and PRN (as needed) . The DON was asked if it was acceptable for a resident bathroom to have unflushed bowel movement in the toilet, a brown substance smeared on the toilet seat and on the toilet paper dispenser in a resident's bathroom. The DON stated, No ma'am. | 2020-09-01 |
| 2406 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 604 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to ensure residents were free from physical restraints for 1 of 1 (Residents #77) resident reviewed for restraints. The findings include: The Physical Restraint Application policy dated (MONTH) 2010 documented, .Physical restraints are defined by Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily .The resident must be physically and cognitively able to self-release devices such as .seat belts with Velcro, or easy snap seat belts. If a resident cannot mentally and physically self-release, then the device is considered a restraint . Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed severe cognitive impairment and no use of physical restraints. The Care Plan dated 11/8/18 documented, .May use seat belt on wheelchair for safety. Check every 30 min (minutes) and release every 2 hours . The physician orders [REDACTED].MAY USE SEAT BELT ON W/C (wheelchair) TO PREVENT UNASSISTED TRANSFER D/T (due to) Dementia .CHECK EVERY 30 MINUTES AND RELEASE Q (every) 2 HRS (hours) . Observations in the 400 hall dayroom on 12/10/18 at 9:40 AM, 11:04 AM, and 5:22 PM, and on12/12/18 at 8:40 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion with a seat belt fastened across her lap. Observations in the 400 hall dayroom on 12/12/18 at 10:51 AM revealed Resident #77 seated in her wheelchair on a Pommel cushion. Interview with the Director of Nursing (DON) in the conference room on 12/10/18 at 1:13 PM, the DON was asked about the seat belt. The DON stated, .She has had it for at least 3 years . Interview with Certified Nursing Assistant (CNA) #2 on 12/12/18 at 8:47 AM on the 400 hall, CNA #2 was asked when the seat belt was removed from Resident #77. CNA #2 stated, .At transfer and at relaxed points. It stays on her . CNA #2 was asked if Resident #77 was on a schedule to get the seat belt removed. CNA #2 stated, No . Interview with Therapy Program Manager on 12/12/18 at 9:04 AM in the Therapy office, the Therapy Program Manager was asked if she Resident #77 had been evaluated for the need of the seat belt. The Therapy Program Manager stated, We have not evaluated her . Interview with Licensed Practical Nurse (LPN) #4 on 12/12/18 at 9:21 AM on the 400 hall, LPN #4 was asked if Resident #77 could release the seat belt on her own. LPN #4 stated, No . Interview with the DON on 12/12/18 at 11:36 AM in the conference room, the DON was asked if Resident #77 had a seat belt and Pommel restraint cushion. The DON confirmed she did. The DON was asked if the seat belt or the Pommel cushion were assessed as restraints before they were initiated. The DON stated, .I'm unable to give you a restraint assessment . Interview with the DON and the Administrator on 12/12/18 at 5:17 PM in the conference room, the DON was asked how he determined the seat belt and the Pommel cushion were not restraints if there were no restraint assessments conducted. The DON stated, I use nursing judgment . The DON was asked if on-going evaluations/assessments were done for the physical restraints. The DON stated, I will look for my assessment. The facility was unable to provide documentation that restraint assessments were conducted prior to initiation of the seat belt and Pommel cushion and was unable to provide documentation for ongoing quarterly restraint assessments for the seat belt and Pommel cushion. | 2020-09-01 |
| 2407 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 623 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to notify the Ombudsman of an emergency transfer for 1 of 4 (Resident #65) sampled residents reviewed for hospitalization . The findings include: 1. The facility's Transfer or Discharge Notice policy dated (MONTH) (YEAR) documented, a copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . 2. Medical record review revealed Resident #65 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].send to ER (emergency room ) . Review of the facility's Emergency Transfers from Facility form for (MONTH) (YEAR) revealed Resident #65 was not on the list. The facility was unable to provide documentation the Ombudsman had been notified when Resident #65 was transferred to the hospital on [DATE]. Interview with the Director of Nursing (DON) on 12/12/18 at 9:38 AM in the conference room, the DON confirmed Resident #65 was not on the (MONTH) Emergency Transfer form. | 2020-09-01 |
| 2408 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 641 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately assess residents for physical restraints for 1 of 18 (Resident #77) sampled residents reviewed. The findings include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, was totally dependent on staff for all activities of daily living (ADLs), and no use of physical restraints. The physician orders [REDACTED].MAY USE SEAT BELT ON W/C (wheelchair) TO PREVENT UNASSISTED TRANSFER D/T (due to) Dementia .CHECK EVERY 30 MINUTES AND RELEASE Q (every) 2 HRS (hours) . Observations in the 400 hall dayroom on 12/10/18 at 9:40 AM, 11:04 AM, and 5:22 PM and on 12/12/18 at 8:40 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion with a seat belt fastened across her lap. Observations in the 400 hall dayroom on 12/12/18 at 10:51 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion. Interview with the Director of Nursing (DON) on 12/12/18 2:47 PM in the conference room, the DON was asked whether the seat belt and Pommel cushion should be coded as restraints on the MDS assessments. The DON stated, It is not coded as a restraint, because it is not a restraint. The facility was unable to provide documentation that a restraint assessment was performed to determine if the seat belt and pommel cushion were restraints. | 2020-09-01 |
| 2409 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 656 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to follow care plan interventions related to pain assessments for 2 of 18 (Resident #40, and #64) sampled residents. The findings include: 1. The facility's Using the Care Plan policy documented, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .6. Documentation must be consistent with the resident's care plan . 2. Medical record review revealed Resident #40 was admitted to the facility under hospice care on 10/22/18 with the [DIAGNOSES REDACTED]. The Care Plan dated 11/3/18 documented, .Evaluate pain at least Q (every) shift and PRN (as needed). Administer pain medication as needed and evaluate effectiveness. Interview with Licensed Practical Nurse (LPN) #1 on 12/12/18 at 11:15 AM at the 100 hall nurse station, LPN #1 was asked if the Pain Assessments were completed for Resident #40. LPN #1 stated, We don't have them. Interview with the Director of Nursing (DON) on 12/12/18 at 2:45 PM in the conference room, the DON confirmed the pain assessments were not documented on the Medication Administration Record. The DON was asked if the pain assessments were documented for Resident #40 and if the care plan was being followed for Resident #40. The DON stated, No. 3. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Care Plan dated 11/20/18 documented, .At risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] Arthritis, RLS (restless leg syndrome)/Leg cramps. Muscle spasms .Assess and establish level of pain using numeric scale .Asses (assess) pain every shift and document on pain assessment flow sheet located on MAR (Medication Administration Record) . Interview with LPN #2 on 12/11/18 at 2:10 PM at the 500 hall nurses station, LPN #2 was asked if she performed pain assessments on her shift for each resident. LPN #2 stated, .If they are not on a pain medication I will not ask . Interview with the DON on 12/12/18 at 2:12 PM in the dining room, the DON was asked if pain assessments were performed for every resident on each shift. The DON stated, .We adopted a new electronic medication record in (MONTH) of this year, and that could explain why it is not on the MAR. The DON was asked if pain assessments should be documented on the MARs. The DON stated, Yes. The Don was asked if the care plan was being followed. The DON stated, No . | 2020-09-01 |
| 2410 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 697 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure pain assessments were completed according to the facility policy for 2 of 7 (Resident #40 and Resident#64) sampled residents reviewed for pain. The findings include: 1. The facility's Pain Assessment and Management policy with a revised date of (MONTH) (YEAR) documented, .The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .Document the resident's reported level of pain .Upon completion of the pain assessment, the person shall record the information obtained from the assessment in the resident's medical record . 2. Medical record review revealed Resident #40 was admitted to the facility under hospice care on 10/22/18 with the [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #40 was severely cognitively impaired, required extensive to total staff assistance for activities of daily living, and received scheduled pain medication or was offered as needed (PRN) pain medications. The Care Plan dated 11/3/18 documented, .at risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] and End Stage disease process .Resident will be kept comfortable while on hospice .Evaluate pain at least Q (every) shift and PRN. Administer pain medication as needed and evaluate effectiveness. The physician's orders [REDACTED].[MEDICATION NAME] HCL 50 MG (milligrams) TABLET GIVE 1/2 TABLET 25 MG BY MOUTH AS NEEDED EVERY 8 HOURS FOR PAIN .10/29/18 .[MEDICATION NAME] 300 MG CAPSULE BY MOUTH THREE TIMES DAILY . Interview with Licensed Practical Nurse (LPN) #1 on 12/12/18 at 11:15 AM at 100 hall's nurses station, LPN #1 was asked if the Pain Assessments were completed. LPN #1 stated, I couldn't find those pain assessments .We don't have them. Interview with the Director of Nursing (DON) on 12/12/18 at 2:45 PM in the conference room, the DON was asked if the pain assessment documentation was on the medication administration record. The DON stated, No. The DON was asked if the pain assessments were documented for Resident #40. The DON stated, No. There was no documentation on the electronic Medication Administration Record (MAR) that pain assessments were conducted after admission to the facility on [DATE]. 3. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 11/20/18 documented, .At risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] Arthritis, RLS (Restless Leg Syndrome)/Leg cramps. Muscle spasms .Assess and establish level of pain using numeric scale .Asses (assess) pain every shift and document on pain assessment flow sheet located on medication administration record . Review of the (MONTH) and (MONTH) MAR revealed no documentation of pain assessments having been performed. Interview with LPN #2 on 12/11/18 at 2:10 PM at the 500 hall nurses station, LPN #2 was asked if she did pain assessments on her shift for each resident. LPN #2 stated, .If they are not on a pain medication I will not ask . LPN #2 confirmed Resident #64 did not have physician orders [REDACTED]. Interview with the DON on 12/12/18 at 2:12 PM in the dining room, the DON was asked if every resident received a pain assessment on each shift. The DON stated, .it is not on the MAR. The DON was asked if pain assessments should be documented on the MAR. The DON stated, Yes. The facility was unable to provide documentation that the pain assessments were completed for each resident each shift and as needed. | 2020-09-01 |
| 4152 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 279 | D | 0 | 1 | HQE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop a plan of care that identified the resident's dental status for 1 of 2 (Resident #22) sampled residents of the 36 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, and dental problems of broken or loosely fitting dentures. Review of the comprehensive care plan dated 8/2/16 revealed no documentation of Resident #22's current dental status or dental needs. Observations in Resident #22's room on 11/15/16 at 7:43 AM, revealed Resident #22 was edentulous. Interview with Resident #22 on 11/14/16 at 12:33 PM, in Resident #22's room, Resident #22 was asked whether he had any problems with his teeth, gums, or dentures. Resident #22 stated, Yes, they broke .they are missing now. Resident #22 was asked whether staff was taking care of these problems satisfactorily. Resident #22 stated, No, I don't know what happened to my teeth . Interview with the Regional Director of Clinical Compliance (RDCC) on 11/16/16 at 10:11 AM, in the MDS office, the RDCC was asked if there was a care plan reflecting Resident #22's dental status. The RDCC stated, Dental triggered .there should have there been one for dental .His lower dentures are broken .the care planning decision is marked yes .there should have been a care plan for dental. The facility was unable to provide a care plan for Resident #22's dental status. | 2019-11-01 |
| 4153 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 332 | D | 0 | 1 | HQE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to ensure 1 of 5 (Licensed Practical Nurse (LPN) #1) staff nurses administered medications with a medication error rate of less than 5 Percent (%). A total of 5 medication errors were made out of 25 opportunities, resulting in a medication error rate of 20%. The findings included: The facility's Crushing Medications policy documented, .Crushed medications should be administered with .soft foods to ensure that the resident receives the entire dose ordered . Medical record reviewed revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].MAY CRUSH ALL CRUSHABLE MEDS (medications) MIXED IN PUDDING .[MEDICATION NAME] .0.75(milligrams) .STRESS B WITH ZINC TABLET GIVE 1 .[MEDICATION NAME] ([MEDICATION NAME]) 100 MG (MILLIGRAMS) CAPSULE .[MEDICATION NAME] .7.5 MG TABLET .[MEDICATION NAME] 100 MG 1 (TABLET) . Observations in Resident #5's room on 11/15/16 beginning at 9:26 AM, revealed LPN #1 administered [MEDICATION NAME] 0.75 mg, Stress Formula with Zinc, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 7.5 mg, and [MEDICATION NAME] 100 mg crushed in a cup mixed with pudding. LPN#1 left pill fragments in the cup and on the spoon. Interview with the Director of Nursing (DON) on 11/16/16 at 11:35 AM, in the DON's office, the DON was asked if is it appropriate for any of the crushed medications to be left in the cup or on the spoon after medication administration. The DON stated, No. | 2019-11-01 |
| 4154 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 371 | F | 0 | 1 | HQE411 | Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by carbon build-up on pans, the deep fryer, the flat grill, and the oven, and by dietary staff with exposed hair in the kitchen on 2 of 3 (11/14/16 and 11/15/16) days of the survey. The facility had a census of 89, with 86 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's POTS AND PANS - SANITIZING SOLUTION policy documented, .Pots and pans need to be free of black buildup deep scratches and dents . Observations in the kitchen on 11/14/16 at 6:30 AM, and on 11/15/16 at 11:33 AM, revealed carbon build-up and grease on 6 sheet pans. Interview with the Dietary Manager (DM) on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked if it was appropriate to have carbon and grease build-up on sheet pans in the clean area. The DM stated No, it's not acceptable. 2. The facility's DEEP-FAT FRYER policy documented, .Turn off the heating element, drain, rinse with warm vinegar water then rinse thoroughly with clear hot water .wipe the fryer completely dry .Clean the outside of the fry kettle with grease solvent . The facility's OVEN - CONVENTIONAL, GAS policy documented, .remove spills, spillovers, and burned food deposits . The facility's GRILL - GAS policy documented, .Scrape grill to loose burned-on particles .Wash back and side guards with soap and water . Observations in the kitchen on 11/14/16 at 6:30 AM, and on 11/15/16 at 11:33 AM, revealed carbon build-up on the deep fryer, the flat grill, and the oven. Interview with the DM on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked if it was appropriate to have carbon build-up on kitchen equipment. The DM stated, No, it's not acceptable. 3. The facility's PERSONAL HYGIENE policy documented, .Wear .a hair restraint .Hair must be .completely covered . Observations in the kitchen on 11/14/16 and 11/15/16 revealed the following Dietary Staff (DS) with exposed hair: a. 11/14/16 at 6:30 AM, DS #2 with bangs not covered b. 11/14/16 at 3:00 PM, DS #5 with sides and back of hair not covered c. 11/14/16 at 3:01 PM, DS #1 with back of hair not covered d. 11/15/16 at 11:33 AM, DS # 3 with back of hair not covered e. 11/15/16 at 11:33 AM, DM with sides of hair not covered f. 11/15/16 at 3:41 PM, DS #4 with beard not covered Interview with the DM on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked whether it was appropriate to have staff in the kitchen with hair not completely covered. The DM stated, No. | 2019-11-01 |
| 4155 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 412 | D | 0 | 1 | HQE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide dental services to meet the needs of 1 of 2 (Resident #22) sampled residents reviewed of the 36 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, and dental problems of broken or loosely fitting dentures. Review of the comprehensive care plan dated 8/2/16 revealed no documentation of Resident #22's current dental status or dental needs. Observations in Resident #22's room on 11/15/16 at 7:43 AM, revealed Resident #22 was edentulous. Interview with Resident #22 on 11/14/16 at 12:33 PM, in Resident #22's room, Resident #22 was asked whether he had any problems with his teeth, gums, or dentures. Resident #22 stated, Yes, they broke .they are missing now. Resident #22 was asked whether staff was taking care of these problems satisfactorily. Resident #22 stated, No, I don't know what happened to my teeth . Interview with the Marketing Director/Interim Social Worker (MDISW) on 11/16/16 at 7:51 AM, on the 300 hallway, the MDISW was asked if she had any information about Resident #22's broken and missing dentures. The MDISW stated, I have not heard of anything . Interview with the MDISW on 11/16/16 at 8:41 AM, in the conference room, the MDISW stated, I checked, and he is not on any (dental) list .MDS did not communicate it over, so that is why he was missed . Interview with the Regional Director of Clinical Compliance (RDCC) on 11/16/16 at 10:11 AM, in the MDS office, the RDCC was asked if there was a care plan reflecting Resident #22's dental status. The RDCC stated, Dental triggered .there should have there been one for dental .His lower dentures are broken . | 2019-11-01 |
| 4156 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 441 | D | 0 | 1 | HQE411 | Based on observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 5 (Licensed Practical Nurse (LPN) #1 and #2) staff nurses failed to clean a stethoscope before or after use, and failed to perform proper hand hygiene during medication administration. The findings included: Observations in Resident #5's room on 11/15/16 beginning at 9:26 AM, revealed LPN #1 placed the stethoscope on the resident's skin to check placement of a percutaneous endoscopic gastrostomy (PEG) tube. LPN #1 failed to clean the stethoscope before and after medication administration through Resident #5's PEG tube. Observations in Residents #77's room on 11/15/16 beginning at 10:53 AM, revealed LPN #2 used gloved hands to administer nasal spray medication to Resident #77. LPN #2 then went back to the medication cart in the hall, picked up a pen, opened the Medication Administration Record (MAR) binder, and began writing, all while still wearing the contaminated gloves. Interview with the Director of Nursing (DON) on 11/16/15 at 11:35 AM, in the DON's office, the DON was asked whether she expected staff to clean the stethoscope before and after checking PEG tube placement. The DON stated, Yes. The DON was asked whether it was appropriate to walk out of the room, touch a pen and chart while still wearing gloves that were worn during nasal spray administration. The DON stated, No. | 2019-11-01 |
| 5673 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2015-09-30 | 250 | E | 0 | 1 | DWQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of a job description, medical record review, and interview, the facility failed to ensure the Social Service Director (SSD) participated, reviewed and updated the plans of care during quarterly interdisciplinary care plan meetings for 13 of 17 (Residents #5, 7, 34, 36, 44, 58, 85, 88, 92, 93, 108, 109 and 118) sampled residents of the 27 residents included in the stage 2 review. The findings included: 1. The facility's Social Services Role and Policies policy documented, .Social services staff will participate as members of the interdisciplinary team (IDT), which reviews and plans the care of the resident . Social services will evaluate how the resident has adapted to the facility and whether there are any current personal needs. Social services will also determine whether there are any psychosocial adjustments or behavior problem . Social services will chart at least every 3 months. This documentation will include progress toward the care plan goals for identified psychosocial problems. Care plan approaches and problems will be re-evaluated at that time to ensure that they are working, and revisions will be done as needed . Duties include the following . 6. Participate as part of the interdisciplinary team in maintaining a plan of care . 2. The facility's SSD job description documented, .Participate in resident care planning by identifying the social and emotional needs of the residents in accordance with the medical assessment . Maintain progress notes for each resident as required by company policy and state and federal regulations, indicating response to the treatment plan and adjustment to facility life . 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 2/23/15, 5/14/15 and 8/5/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 4. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 4/20/15 and 7/27/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 5. Medical record review revealed Resident #34 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]., Hypertension, [DIAGNOSES REDACTED], Neuropathy, Edema, Abnormality of Gait, and Diabetes. Review of an IDT Care Plan Review Summary dated 3/10/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 6. Medical record review revealed Resident #36 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 2/23/15 and 8/11/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 7. Medical record review revealed Resident #44 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 3/10/15, 6/4/15, and 8/24/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 8. Medical record review for Resident #58 revealed the resident was admitted to the facility 12/9/09 with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 1/12/15, 4/7/15 and 6/29/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 9. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 3/31/15 and 6/23/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 10. Medical record review revealed Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 4/20/15 and 7/14/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 11. Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 4/13/15 and 7/14/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 12. Medical record review revealed Resident #93 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 3/2/15, 5/26/15, and 8/25/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. Interview with the Administrator on 9/29/15 at 2:35 PM, at the 100 Nurses Station, the Administrator stated, As far as I know there are no social notes on Resident #93. The Administrator was asked if that was the normal procedure. The Administrator stated, No, she should have social notes documenting the assessments. 13. Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 2/26/15 and 5/17/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 14. Medical record review revealed Resident #109 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 8/4/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 15. Medical record review revealed Resident #118 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 8/25/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 16. Interview with the Director of Nursing (DON) on 9/29/15 at 4:45 PM, in the conference room, the DON was asked what she expected from her SSD. The DON stated, I expect her (SSD) to provide a social assessment upon admission, and any needs they are aware of. Interview with SSD on 9/30/15 beginning at 4:43 PM in conference room, the SSD was asked about the missing quarterly social service assessments. The SSD stated, I was under the impression that the MDS (Minimum Data Set) quarterly was the quarterly assessments. The SSD confirmed that she knows about the residents, but just doesn't document it. The SSD was asked about the quarterly care plan summaries that do not contain any social services comments. The SSD stated, Yes, Ma'am, I'm supposed to put something in there. On some of these (care planning summaries), no, I do not (document). The SSD was asked about the care plan review summaries without her signature, and if that indicated she did not attend those particular meetings (IDT care plan review meetings). The SSD stated, No, not at all. It just means I didn't get to the computer to put it (social updates) in. The SSD confirmed that she does quarterly assessments in conjunction with the quarterly MDS assessments, and notes would be on the care plan review summaries. The SSD was asked if she had received a copy of her job description. The SSD stated, I might have when I first started. I just don't remember it. Interview with Administrator on 9/30/15 beginning at 4:43 PM in conference room, the Administrator was asked if she had ever gone over the social service regulations with the SSD. The Administrator stated, No ma'am. I'm being honest. When I came here, she (SSD) was already here. She had been here a year before I got here, and I just assumed she knew. | 2019-01-01 |
| 7335 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2014-08-20 | 371 | D | 0 | 1 | ECQ511 | Based on policy review, review of the kitchen cleaning schedule, observation, and interview, it was determined the facility failed to maintain kitchen sanitation as evidenced by 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, sides and back splash of the fryer and a dark brown grease inside the fryer on 2 of 3 (8/18/14 and 8/19/14) days of the survey. The findings included: 1. Review of the facility's Dietary Department Guidelines policy documented, .All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner . All areas of the dietary department will be cleaned on a regular schedule . 2. Review of the facility's kitchen cleaning schedule documented: .Sweep/mop under Everything . Each Shift . Deep Fryer . Daily . BEFORE LEAVING ON SUNDAY MAKE SURE THERE IS NOTHING ON THE FLOOR . 3. Observations in the kitchen on 8/18/14 at 9:38 AM, revealed 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, on the sides and back splash of the fryer. 4. Observations in the kitchen on 8/19/14 at 11:05 AM, revealed the 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, on the sides and back splash of the fryer was still present during the second day of the survey. 5. During an interview in the kitchen on 8/19/14 at 11:05 AM, the Dietary Manager was asked should the area around the fryer be clean. The Dietary Manager stated, Yes. | 2018-02-01 |
| 9365 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 278 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for hospice care, pressure sores and/or falls 2 of 35 (Residents #20 and 53) sampled residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #20 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].D/C (discharge) from Skilled Services to Hospice on 2/24/13 Hx (history) Dx (diagnosis) Lung CA (cancer) . Review of a significant change MDS dated [DATE] documented, .Section O . Special Treatments, Procedures, and Programs . Check all of the following treatments, procedures, and programs that were performed during the last 14 days . K. Hospice care . The box for hospice care was not checked. During an interview at the skilled nurses' station on 5/21/13 at 2:30 PM, Nurse #3 was asked to find the current order for hospice care for Resident #20. Nurse #3 stated, Here it is written on 2/22/13 . During an interview in the MDS office on 5/22/13 at 8:00 AM, MDS Nurse #2 stated, .we have to do a sig (significant) change on them when they go into hospice . MDS Nurse #1 was asked if the MDS was coded for hospice. MDS Nurse #1 stated to MDS nurse #2, .no you forgot to mark it . 2. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #53's nurses' notes dated 2/20/13 documented a 4:30 PM admission note that included, .also noted to inner buttocks 1.3 cm (centimeters) X (by) 0.3 cm open area . Review of the admission MDS assessment, dated 2/27/13 documented, .M0210. Unhealed Pressure Ulcer(s) . Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher . This pressure sore question was coded with a 0, indicating No. During an interview at the 500 hallway nurse's station on 5/21/13 at 8:10 AM, Nurse #2 stated Resident #53 was admitted with a Stage 1 to Stage 2 area with excoriation to buttocks. During an interview in the MDS office on 5/22/13 at 2:00 PM, MDS Nurse #2 confirmed the MDS dated [DATE] documented no pressure sores were assessed on admission. Further review of the nurses' notes for Resident #53 dated 4/6/13 documented the resident was found on floor at 6 PM. Review of the quarterly MDS assessment dated [DATE] documented, .J1800. Any Falls Since . Prior Assessment . This fall question was coded with 0, indicating No. During an interview in the MDS office on 5/22/13 at 2:00 PM, MDS Nurse #2 verified Resident #53's MDS was inaccurate, no fall was documented. | 2017-01-01 |
| 9366 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 279 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to have a care plan for vision for 1 of 35 (Resident #62) sampled residents included in the stage 2 review. The findings included: Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets ((MDS) dated [DATE] and 10/26/12 documented, Section B - Hearing, Speech, Vision . B0100 impaired - see large print but not regular print . Review of care plan dated 10/19/12 did not included care for vision. Observations in Resident #62's room on 5/21/13 at 8:00 AM, revealed Resident #62 sitting on side of bed working a puzzle using a magnifying glass. During an interview in Resident' #62's room on 5/22/13 at 7:45 AM, Resident #62 stated, I picked out me some frames for some glasses last week . I can't wait till (until) they (glasses) get here . During an interview in the MDS office on 5/22/13 on 9:00 AM, MDS Nurse #1 was asked should vision be care planned. MDS Nurse #1 stated, .vision should be in the care plan and it is not there . | 2017-01-01 |
| 9367 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 309 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure physician orders [REDACTED].#125) sampled residents included in the stage 2 review. The findings included: Review of the facility's Lab (laboratory) and Diagnostic Test Results-Clinical Protocol policy documented, .The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs . Medical record review for Resident #125 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the original physician's orders [REDACTED].#125 documented, .LAB ORDERS . CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) EVERY 6 MONTHS . The facility was unable to provide results of the CBC and BMP that were due in 3/13. During an interview in the conference room on 5/22/13 at 10:50 AM, the Director of Nursing (DON) was asked for the results of the CBC and BMP that was due in 3/13. The DON stated, .it's (3/13 lab work) not there . it wasn't done . | 2017-01-01 |
| 9368 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 314 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure pressure sore treatments were done for 1 of 2 (Resident #67) sampled residents reviewed with pressure ulcer of the 35 residents included in the stage 2 review. The findings included: Review of the facility's treatment of [REDACTED]. Responsibilities of team members include . Documentation . Medical record review for Resident #67 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Telephone Orders dated 5/3/13 documented, .Apply . Zinc Vaseline 1: (to) 1:1 comp (composition) to sacral area BID (two times a day) & (and) PRN (as needed) till (until) resolved . Review of the treatment record dated 5/3/13 through 5/31/13 revealed there was no pressure sore treatment documented for 5/15/13 and 5/16/13 on the 6:00 PM to 6:00 AM shift. Review of the Minimum Data Set ((MDS) dated [DATE] documented, .Section M Skin Conditions . M0700. Most Severe Tissue Type for Any Pressure Ulcer . 2. Granulation tissue . Observations in Resident #67's room on 5/21/13 at 3:30 PM, revealed Resident #67 with a stage 2 pressure sore on the sacrum area. During an interview in 400 hall nurses' station on 5/21/13 at 2:00 PM, Nurse #1 was asked should pressure sore treatments be documented. Nurse #1 stated, Yes . it (pressure sore treatments) should be documented on the treatment record . During an interview in 400 hall nurses' station on 5/21/13 at 3:00 PM, Nurse #2 was asked should pressure sore treatments be documented. Nurse #2 stated, .when treatments are done they should be documented on the treatment record . Nurse #2 was asked to verify the missing documentation for the pressure sore treatment on the treatment record for 5/15/13 and 5/16/13. Nurse #2 stated, .if (treatments were) done, it was not documented . | 2017-01-01 |
| 10878 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-04-30 | 309 | D | 1 | 0 | SKV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 563 Based on medical record review and interview, it was determined the facility failed to administer intravenous (IV) medications according to physician's orders [REDACTED].#6) sampled residents. The findings included: Medical record review for Resident #6 documented a original admission date of [DATE] with a readmission date of [DATE] post hospitalization with [DIAGNOSES REDACTED]. Review of the Physician Admission / Monthly Orders form dated 3/21/13 documented, Meropenem 500mg (milligrams) IV (intravenous) Q (every) 12 hrs (hours) until 3/25/13. A telephone order dated 3/22/13 documented, (Symbol for change) Meropenem 500mg IV to Meropenem 500mg IM (intramuscular) q (every) 12 hrs x (times) 5 days. The facility staff failed to document that they notified the MD that Meropenem did not come in IM form. Review of the department notes revealed the following: a. 3/21/13 at 3:04 PM - IV antibiotic not available at this time. Begain (begin) when available . 3/21/13 at 11:59 PM - .IV ABT (antibiotic) was not given this p.m. Unable to restart INT (intermittent intravenous access) R/T (related to) poor venous access. Will inform (name of physician) of same in a.m. and await any new orders . b. 3/22/13 at 10:59 PM - .IV ABT not given this pm. unable to restart INT . c. 3/23/13 at 2:40 PM - Asked by Hall 3 nurse to attempt IV access d/t (due to) resident has orders for Meropenem 500mg IV every 12 hours until 3/25/13. Assessed resident for peripheral IV access. BUE (bilateral upper extremities) noted to be swollen and large. Multiple area of bruising noted and mulitpe (multiple) old IV sites noted. Did not attempt peripheral IV access. There was no documentation on 3/24/13 of attempts to start the IV to administer Meropenem 500 mg IV and no documentation of attempts to notify the physician of resident not receiving IV antibiotic as ordered. During a telephone interview on 4/29/13 at 2:15 PM, the Director of Nursing (DON) was asked if the physician was notified that the Meropenem did not come in an IM administration route. The DON stated, They (nurses) called on-call doctor at 5:00 PM that Friday. He said to try to access (IV) again . During a telephone interview on 4/29/13 at 4:12 PM, the DON was asked what was the expectation or the policy of the facility if the nurses were not able to access a site to administer IV medications. The DON stated the facility does not have a policy. The nurses would try a couple of sticks and then notify another nurse in the building to try to start the IV. Every nurse would get another nurse to try for about 24 hours and then call doctor to see if it could be changed to IM. During a telephone interview on 4/29/13 at 4:15 PM, the DON was asked if the physician was called on 3/23/13 to notify the physician the facility was unable to start the IV to administer Meropenem 500 mg IV every 12 hours. The DON stated a nurse called the on-call physician on Saturday (3/23/13) and the on-call physician stated to keep trying to get access. It was not charted. During a telephone interview on 4/30/13 at 1:50 PM, the DON was asked if the facility attempted to start the IV to administer the Meropenem 500 mg IV or if the physician was notified of the inability of the facility to start the IV to administer the Meropenem on 3/24/13. The DON confirmed there was no documentation in the department notes on 3/24/13 and stated, I don't know about Sunday . The facility failed to start the IV and administer the Meropenem 500 mg IV every 12 hours as ordered. | 2016-04-01 |
| 10879 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-04-30 | 514 | D | 1 | 0 | SKV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 563 Based on medical record review and interview, it was determined the facility failed to maintain complete an accurate medical records for 1 of 6 (Resident #6) sampled residents. The findings included: Medical record review for Resident #6 documented a original admission date of [DATE] with a readmission date of [DATE] post hospitalization with [DIAGNOSES REDACTED]. Review of the Physician Admission / Monthly Orders form dated 3/21/13 documented, Meropenem 500mg (milligram) IV (intravenous) Q (every) 12 hrs (hours) until 3/25/13. Review of the department notes documented the following: a. 3/21/13 at 3:04 PM - IV antibiotic not available at this time. Begain (begin) when available . 3/21/13 at 11:59 PM - .IV ABT (antibiotic) was not given this p.m. Unable to restart INT (intermittent intravenous access) R/T (related to) poor venous access. Will inform (name of physician) of same in a.m. and await any new orders . Review of the Telephone Orders dated 3/22/13 documented, (Symbol for change) Meropenem 500mg IV to Meropenem 500mg IM (intramuscular) q (every) 12 hrs x (times) 5 days. The facility staff failed to document that they notified the MD that Meropenem did not come in IM form. Further review of the department notes documented the following: a. 3/22/13 at 10:59 PM - .IV ABT not given this pm. unable to restart INT . b. 3/23/13 at 2:40 PM - old IV sites noted. Did not attempt peripheral IV access . There was no documentation on 3/24/13 of attempts to start the IV to administer the Meropenem 500 mg IV and no documentation of attempts to notify the physician of the resident not receiving IV antibiotic as ordered. During a telephone interview on 4/29/13 at 2:15 PM, the Director of Nursing (DON) was asked if the physician was notified that the Meropenem does not come in an IM administration route. The DON stated, They (nurses) called the on-call doctor at 5:00 PM that Friday. He said to try to access (IV) again . The DON also confirmed the nurse did not document calling the physician and writing an order to change the route from IM back to IV. During a telephone interview on 4/29/13 at 4:15 PM, the DON was asked if the physician was called on 3/23/13 to notify the physician the facility was unable to start the IV to administer Meropenem 500 mg IV every 12 hours. The DON stated a nurse called the on-call physician on Saturday (3/23/13) and the on-call physician stated to keep trying to get access. It was not charted. The facility failed to ensure the medical record was accurate when the nurses failed to document that the MD was notified that Meropenem did not come in IM form and there was no documentation on 3/24/13 of attempts to start the IV to administer the Meropenem 500 mg IV and no documentation of attempts to notify the physician of the resident not receiving IV antibiotic as ordered. | 2016-04-01 |
| 12070 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 279 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to develop an interim care plan in the first 24 hours of admission for 4 of 20 (Residents #4, 8, 11 and 12) sampled residents. The findings included: 1. Review of the facility's Care Plans----Preliminary policy documented, .A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four hours of admission. 2. Medical record review for Resident #4 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. The first documented care plan for Resident #4 was dated 12/28/11. 3. Medical record review for Resident #8 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. 4. Medical record review for Resident #11 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide a dated interim care plan for the readmission date of [DATE]. 5. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. 6. During an interview in the conference room on 2/22/12 at 3:30 PM, the Director of Nursing (DON) was asked when should a care plan be initiated. The DON stated, .within the first 24 hours of admission. | 2015-10-01 |
| 12071 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 280 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to revise the comprehensive care plan to reflect the current status of a resident with pressure ulcers for 1 of 20 (Resident #8) sampled residents. The findings included: Review of the facility's care plan policy documented, .plan of care. shall be developed. To assure that the resident's immediate care needs are met. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 7/18/11 had no documented interventions for the [DIAGNOSES REDACTED]. During an interview in the conference room on 2/22/12 at 3:30 PM, the Director of Nursing (DON) was asked when the care plan should be initiated. The DON stated, .within the first 24 hours. | 2015-10-01 |
| 12072 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 282 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to follow the care plan for turning, repositioning and skin care for 1 of 17 (Resident #8) sampled residents. The findings included: Medical record review for Resident #8 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/29/11 documented, .Prone to skin breakdown. turn every 2 hours while in bed. Resident #8's medical record contained documentation of a hospitalized from [DATE] through 7/18/11 with a [DIAGNOSES REDACTED]. The facility was unable to provide documentation that the resident was turned and repositioned every two hours. During an interview in the conference room on 2/23/12 at 2:30 PM, the Director of Nursing (DON) was asked if there was documentation to verify that the resident was turned and repositioned every two hours. The DON stated, No. I don't think we have anything in the computer for that. The DON was asked if the facility had a policy for turning and repositioning a resident at risk for skin breakdown. The DON stated, There is no policy for turning every two hours. | 2015-10-01 |
| 12073 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 309 | E | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to follow physician's orders for constipation for 4 of 20 (Residents #3, 11, 15 and 16) sampled residents. The findings included: 1. Review of the facility's Tri-County Healthcare Standing Physician Orders documented, .3. Stool Softener/Laxative: PRN (as needed) Constipation. a. [MEDICATION NAME] S: 1 pill at HS (hour of sleep) prn. b. MOM (milk of magnesia) 30 ml (milliliters) prn. c. [MEDICATION NAME]: 2 tabs (tablet) prn. d. [MEDICATION NAME] tabs: 2 at HS prn. e. [MEDICATION NAME] Suppository 1 PR (per rectum) prn. f. Check for impaction prn and remove if indicated. 4. Enema of choice prn: Severe constipation. 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3's BM (bowel movement) Detail option 2 Roster had no BM documented from 10/18/11 through (-) 10/25/11 and from 11/27/11 - 12/1/11. The Medication Administration Record [REDACTED]. The facility failed to implement the physician's standing orders for constipation. 3. Medical record review for Resident #11 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #11's BM Detail option 2 Roster had no BM documented from 2/1/11 - 12/8/11, 1/8/12 - 1/12/12, 1/13/12 - 1/23/12, 1/23/12 - 2/2/12 and 2/12/12 - 2/18/12. The MAR indicated [REDACTED]. 4. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #15's BM - Yes/No (Only) Roster had no BM documented from 2/5/12 - 2/9/12. The facility failed to implement the physician's standing orders for constipation. During an interview in the conference room on 2/23/12 at 10:50 AM, the Director of Nursing (DON) was asked to review Resident #15's bowel movement record. The DON stated, .He (Resident #15) should have received something (for lack of a BM). Expect the nurse to review the BM record, if no BM third day they are to start the standing orders for constipation. 5. Medical record review for Resident #16 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. The physician's recertification orders dated 12/1/11 through 12/31/11 documented, .Milk of Magnesia Suspension take 30 ml by mouth as needed. Resident #16's BM Detail option 2 Roster had no BM documented from 12/5/11 - 12/9/11 and 12/24/11 - 12/28/11. The MAR indicated [REDACTED]. The physician's recertification orders dated 1/1/12 through 1/31/12 documented, .Milk of Magnesia Suspension take 30ml by mouth as needed. Resident #16's BM Detail option 2 Roster had no BM documented from 1/11/12 - 1/17/12 and from 1/29/12 - 2/1/12. The MAR indicated [REDACTED]. Review of the physician's recertification orders dated 2/1/12 through 2/29/12 documented, .Milk of Magnesia Suspension take 30ml by mouth as needed. Resident #16's BM Detail option 2 Roster had no BM documented from 2/18/12 - 2/22/12. The MAR indicated [REDACTED]. 6. During an interview in the conference room on 2/23/12 at 8:15 AM, the DON was asked who is responsible for the bowel management of the residents. The DON stated, .Nursing is to review the BM record per each unit. Expect Nursing to review the BM record and if no BM by third day begin the standing orders for constipation and if patient is on a stool softener then should go to the next level [MEDICATION NAME] | 2015-10-01 |
| 12074 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 314 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Clinical Practice Guidelines, policy review, medical record review and interview, it was determined the facility failed to follow the care plan intervention to turn every two hours to prevent the development of a pressure ulcer for 1 of 3 (Resident #8) sampled residents with pressure ulcers. The findings included: Review of the NPUAP Clinical Practice Guidelines documented, .Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours. A written schedule for systematically turning and repositioning the individual should be used. Review of the facility's Skin Program Policy documented, .The nursing department coordinates the response to patient needs.with an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk. Medical record review for Resident #8 documented an admission date of [DATE] with readmitted s of 7/18/11 and 8/19/11 and [DIAGNOSES REDACTED]. Review of the care plan documented an approach dated 6/17/11 for Staff to turn and repo (reposition) res (resident) q2hrs (every two hours) and prn (as needed). Review of Weekly Skin Integrity Assessment dated 7/9/11 documented, .Skin Condition Dry. Skin Intact. Review of a nurse's note dated 7/10/2011 documented, .reddened area to buttocks with bluish and blackened areas, with blisters. 2 small opened areas. Review of a nurse's note dated 7/11/2011 documented, .no change to residents buttocks, blistered area still dark discoloration, serosanguenous drainage present. The facility was unable to provide documentation that the resident was turned and repositioned every two hours. During an interview in the conference room on 2/23/12 at 2:30 PM, the DON was asked if there was documentation to verify that the resident was turned and repositioned every two hours. The DON stated, No. I don't think we have anything in the computer for that. The DON was asked if the facility had a policy for turning and repositioning a resident at risk for skin breakdown. The DON stated, There is no policy for turning every two hours. | 2015-10-01 |
| 12075 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 441 | E | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Association for Professionals in Infection Control and Epidemiology (APIC) Guide to the Elimination of Clostridium difficile in Healthcare Settings, policy review, medical record review, cleaning product efficacy review, observation and interview, it was determined the facility failed to ensure practices to prevent the potential spread of infection were maintained by utilizing an ineffective cleaning product for 4 of 4 (Residents #8, 14, 19 and 20) sampled residents with Clostridium difficile infection. It was also determined the facility failed to ensure practices to prevent the potential spread of infection when staff members failed to practice sanitary hand hygiene during 1 of 2 dining observations and during catheter care for sampled Resident #6. The findings included: 1. Review of the APIC Guide to the Elimination of Clostridium difficile in Healthcare Settings documented, .Disinfectants commonly used in healthcare settings include quaternary ammoniums and [MEDICATION NAME], neither of which are sporicidal. only chlorine-based disinfectants. kill spores. Review of the facility's Cleaning, Disinfection and Sterilization policy documented, .provide supplies and equipment that are adequately cleaned, disinfected or sterilized. a. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff (Clostridium difficile - an intestinal bacteria which has spores that can live on inanimate objects, such as beds and overbed tables, for up to six months). b. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff. c. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a discharge summary dated 2/23/11 documented, .resident developed [DIAGNOSES REDACTED] at (name of local hospital) .admitted into isolation. d. Medical record review for Resident #20 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff culture. During an interview in the unit 3 hallway on 2/22/12 at 12:30 PM, the Director of Environmental Services (DES) was asked which cleaning product was used for daily cleaning of [DIAGNOSES REDACTED] contact isolation rooms. The DES replied, .Broad-Cide. it kills everything. The DES was asked how long the contact time was for killing [DIAGNOSES REDACTED]. The DES stated, .there is no contact time for killing. The DES was asked which cleaning product was used for terminal cleaning of [DIAGNOSES REDACTED] contact isolation rooms. The DES replied, .Broad-Cide. The DES confirmed Broad-Cide is not a chlorine-based disinfectant. Review of the active ingredients of Broad-Cide 128 documented, Didecyl [MEDICATION NAME] ammonium chloride. The product that the facility use for cleaning did not effectively disinfect the organism of [DIAGNOSES REDACTED]. 2. Observations during meal tray pass in room [ROOM NUMBER] on 2/22/12 at 12:21 PM, Certified Nursing Assistant (CNA) #2 touched the resident's wheelchair legs and base of the overbed table, then prepared the meal tray without washing her hands. Observations during meal tray pass in room [ROOM NUMBER] on 2/22/12 at 12:30 PM, revealed CNA #1 moved the resident's chair and repositioned the resident, then prepared the meal tray without washing her hands. During an interview in the Director of Nursing's (DON) office on 2/22/12 at 5:00 PM, the DON was asked what is the expectation of hand hygiene if the staff touch the resident's environment. The DON confirmed the staff is to wash their hands after touching the resident's environment before preparing the meal tray. 3. Observations during catheter care for Resident #6 on 2/22/12 at 4:20 PM, revealed CNA #1 completed Foley catheter care and without changing her contaminated gloves touched the bed controls, resident's pillow, bed linen and overbed table, then removed her gloves. During an interview in the DON's office on 2/22/12 at 5:00 PM, the DON was asked what is the expectation of staff changing gloves and handwashing when going from a dirty area to a clean area during Foley catheter care. The DON state that she expects staff to change their gloves and wash hands when going from a dirty area to a clean area when providing care. | 2015-10-01 |
| 13806 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 332 | E | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observations and interviews, it was determined the facility failed to ensure 3 of 6 (Nurses #3, 5 and 6) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 5 errors were observed out of 40 opportunities, resulting in a medication error rate of 12.5%. The findings included: 1. Review of the facility's "Administering Medications through a Metered Dose Inhaler" policy documented, "...Allow at least one (1) minute between inhalations of the same medication..." Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in RR #1's room on 11/29/10 at 11:45 AM, revealed Nurse #3 administered two puffs of a [MEDICATION NAME] inhaler to RR #1. Nurse #3 did not pause between the puffs. Failure to pause at least one minute between the puffs resulted in medication error #1. 2. Medical record review for Resident #6 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #6's room on 11/30/10 at 6:25 AM, revealed Nurse #6 administered one eye into each of Resident #6's eyes. Failure to administer two eye drops into each eye resulted in medication error #2. During an interview on side three on 11/30/10 at 8:20 AM, Nurse #6 stated, "You're right I should have given two drops and I only gave one." 3. Review of the facility's "Insulin Administration" policy documented, "...8. Check the order for the amount of insulin..." Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #16's room on 11/30/10 at 7:15 AM, Nurse #6 performed a fingerstick blood sugar (FSBS) on Resident #16's with results of 120. Nurse #6 administered [MEDICATION NAME] R 2 units to Resident #16. The administration of 2 units of [MEDICATION NAME] R insulin resulted in medication error #3. During an interview on side 3 on 11/30/10 at 11:55 AM, the Director of Nursing stated, "It (referring to insulin dosage) was a transcription error. We did incident report, notified doctor and checked all other orders, didn't find any other problems." 4. Review of the facility's "Insulin Administration" policy documented, "...6. Gently roll the insulin vial between palm of both hands to resuspend the insulin..." a. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].M. @ (at) 6:45 AM (2) Bedside Glucose time change to 645 AM, 1130 AM, 445 PM, 800 PM c (with) [MEDICATION NAME] 5 units SQ (subcutaneous) as ordered due to mealtime changes to begin 11/17/10." Review of a physician's orders [REDACTED].@ 6:45 am." Observations in Resident #15's room on 11/30/10 at 6:45 AM, revealed Nurse #5 administered [MEDICATION NAME] 70/30 25 units to Resident #15. Nurse #5 did not roll the insulin vial to resuspend the insulin prior to drawing up the insulin. Failure to roll the insulin vial resulted in medication error #4. b. Medical record review for Resident #10 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #10's room on 11/30/10 at 7:20 AM, Nurse #6 administered [MEDICATION NAME] 70/30 165 units to Resident #10. Nurse #6 did not roll the vial of insulin prior to drawing up the insulin to resuspend the insulin. Failure to roll the vial of insulin resulted in medication error #5. | 2014-09-01 |
| 13807 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 465 | E | 0 | 1 | IDW711 | Based on observations and interviews, it was determined the facility failed to ensure the environment was clean and sanitary as evidenced by a soiled shower chair, a dark brown buildup on the tile, and feces on the drain in the shower stall in 2 of 2 (Shower rooms 1 and 2) shower rooms. The findings included: 1. Observations in Shower #2 on 11/29/10 at 9:35 AM and 3:25 PM and on 11/30/10 at 3:15 PM, revealed a clump of dark brown substance on the drain in the shower stall and a dark brown buildup covering the tile near the drain. During an interview in Shower #2 on 11/30/10 at 3:15 PM, Housekeeper #1 was asked what the dark brown buildup on the tile was and what was the brown substance on the drain. Housekeeper #1 stated, "I don't know what that is on the tile. It has been there for awhile. That's BM (bowel movement) on the drain." 2. Observations in Shower #1 on 11/29/10 at 3:35 PM and on 11/30/10 at 3:15 PM, revealed a bariatric shower chair in the shower stall with the safety belts soiled with brown stains. During an interview in Shower #1 on 11/30/10 at 3:15 PM, the Housekeeping Supervisor was asked if the shower chair was clean. The Housekeeping Supervisor stated, "No and I wouldn't want that belt around me. It's dirty." | 2014-09-01 |
| 13808 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 334 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, it was determined the facility failed to provide the influenza vaccine for 1 of 22 (Resident #7) sampled residents. The findings included: Review of the facility's "Vaccination of Residents" policy documented, "...Influenza Vaccination... all residents will be offered an influenza vaccine beginning in October of each year, unless medically contraindicated or the resident has already been vaccinated..." Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's telephone order dated 10/7/10 documented, "...Flu vac (vaccine) 0.5 ml (milliliters)..." The facility was unable to provide documentation that the flu vaccine had been administered to Resident #7. During an interview at the side 3 nurse's station on 11/29/10 at 2:40 PM, Nurse #8 was asked if Resident #7 received the flu vaccine. Nurse #8 reviewed the medical record and stated, "...It should have been documented on the MAR (medication administration record), nurse's notes, and care plan. I don't see that. I'm not sure that she got it." | 2014-09-01 |
| 13809 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 431 | D | 0 | 1 | IDW711 | Based on policy review, observations, and interviews, it was determined the facility failed to ensure a medication cart was locked and medications were not left unattended in 1 of 8 (Side 2 medication cart) medication storage areas. The findings Included: Review of the facility's "Storage of Medications" policy documented, "...The facility shall store all drugs and biological in a safe, secure, and orderly manner... Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others..." Observations on side 2 on 11/30/10 at 7:00 AM, revealed the side 2 medication cart was left unattended, unlocked and out of view of the nurse. Observations on side 2 on 11/30/10 at 7:31 AM, revealed a vial of Novolin 70/30 insulin was sitting on top of side 2's medication cart unattended. During an interview on side 2 on 11/30/10 at 7:10 AM, the surveyor told Nurse #6 that she had left the side 2 medication cart unlocked. Nurse #6 stated, "I know it's a bad habit, when I just step right in there (referring to resident's room) I forget." During an interview in the conference room on 12/1/10 at 10:00 AM, the Director of Nursing stated, "Med (medication) cart should always be locked." | 2014-09-01 |
| 13810 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 282 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and interviews, it was determined the facility failed to follow interventions on the care plan for floor mats and a pressure relief mattress for 1 of 22 (Residents #5) sampled residents. The findings included: Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan dated 1/27/10 documented, "...pressure relief mattress for comfort and prevention..." and dated 2/25/10 documented, "...low bed with mats in place..." Observations in Resident's #5's room on 11/29/10 at 4:00 PM and on 11/30/10 at 8:30 AM,10:05 AM, 12:05 PM and 2:20 PM, revealed there were no floor mats and a pressure relief mattress in place for Resident #5. During an interview in Resident #5's room on 11/30/10 at 2:40 PM, Nurse #7 verified there were no floor mats or a pressure relief mattress present. During an interview at side 1 nurses' station on 11/30/10 at 2:45 PM, the Director of Nursing confirmed that floor mats and pressure relief mattress were on the care plan but were not implemented for Resident #5. | 2014-09-01 |
| 13811 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 309 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined the facility failed to follow physician orders [REDACTED].#17 and 19) sampled residents. The findings included: 1. Medical record review for Resident #17 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].= (amount of insulin to be administered 18 AND CALL MD (Medical Doctor) IF NO RESULTS..." Review of the July 2010 diabetic record for Resident #17 revealed the following BS's above 300 that were not rechecked to determine the results of the insulin administered: a. 7/10/10-4:30 PM, BS-354. b. 7/15/10-4:30 PM, BS-314. c. 7/15/10-8:00 PM, BS-338. d. 7/17/10-11:30 AM, BS-321. e. 7/17/10-8:00 PM, BS-314. f. 7/21/10-11:30 AM, BS-311. g. 7/21/10-8:00 PM, BS-397. h. 7/22/10-11:30 AM, BS-307. i. 7/23/10-4:30 PM, BS-400. j. 7/23/10-8:00 PM, BS-381. k. 7/26/10-8:00 PM, BS-328. l. 7/28/10-4:30 PM, BS-310. m. 7/29/10-7:30 AM, BS-305. n. 7/29/10-8:00 PM, BS-380. o. 7/30/10-8:00 PM, BS-318. During an interview in the conference room on 12/1/10 at 10:45 AM, Nurse #8 stated, "They need to recheck it (BS) to see if the BS has gone down, that's the only way to know the results. Usually recheck it in 45 minutes to an hour unless the doctor has a specific order." 2. Medical record review for Resident #19 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 10/4/10 documented, "...Give Nov ([MEDICATION NAME]) R 15 u now Recheck in 2 hrs (hours) for BS 442..." The physician's orders [REDACTED]." Review of the October 2010 medication administration record (MAR) for Resident #19 documented the following BS results: a. 10/4/10 8 PM BS 441. b. 10/15/10 5:30 PM BS 433. The facility was unable to provide documentation of rechecks in 2 hrs of a BS over 400. Further medical record review revealed a physician's telephone order dated 10/4/10 documented, "...Give Nov R 15 u now Recheck in 2 hrs (hours) for BS 442..." Review of the daily skilled nurses notes documented, "...10/4/10 12:00 AM Rechecked blood sugar c result of 442. Called MD was ordered to give 16 units Nov R now then recheck in 2 hrs..." There was no documentation the BS was rechecked in 2 hours after administering the insulin. During an interview at the side 1 nurse's station Nurse #8 reviewed Resident #19's MAR and the nurses notes and stated, "...She (medication nurse) didn't recheck (BS) in 2 hrs..." | 2014-09-01 |
| 13812 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 280 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interviews, it was determined the facility failed to revise the comprehensive care plan for care of emergency bleeding for 2 of 22 (Resident #18 and 19) sampled residents. The findings included: 1. Review of the facility's "[MEDICAL TREATMENT], [MEDICAL TREATMENT]" policy documented, "...Check graft site for bleeding upon return post-[MEDICAL TREATMENT] and per MD (Medical Doctor) orders. If bleeding occurs, apply direct pressure until controlled. Notify MD and DON (Director of Nursing) if bleeding lasts longer than 30 minutes or is severe initiate EMS (Emergency Management Service) system." 2. Medical record review for Resident #18 documented an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/26/10 documented "[MEDICAL TREATMENT] as ordered. Assess site... q (every) d (day) for s/s (signs and symptoms) inf. (infection) or bleeding assess for thrill/bruit q shift..." The care plan did not address measures to be put in place to stop emergency bleeding. During an interview at the side 3 nurses' station on 12/1/10 at 1:00 PM, Nurse #9 stated, "(Care plan) says to check for it (emergency bleeding) but doesn't really say what to do for it." 3. Medical record review for Resident #19 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 2/23/10 documented "...Check shunt or port site for s/s of infections, pain or bleeding daily and PRN (as needed)..." The care plan did not address measures to be put in place to stop emergency bleeding. During an interview at the side 1 nurses' station on 12/1/10 at 1:52 PM, the DON stated, "It (care plan) should have interventions for a bleed but it wasn't included." | 2014-09-01 |
| 13813 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 441 | E | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy reviews, observations, and interviews, it was determined 5 of 24 staff members (Certified Nursing Assistants (CNA) #1, CNA #2, Rehabilitation Coordinator, Dietary Manager and Nurse #2) failed to ensure infection control practices were used to prevent the potential spread of infection by not using sanitary hand hygiene or touching food and straws with their bare hands. Two (2) of 6 nurses (Nurses #5 and #6) failed to clean the glucometer with a Super Sani-wipe. The findings included: 1. Review of the facility's "Hand-hygiene" policy documented, "...2. hand washing ...b. after contact ...with non-intact skin... d. before and after eating or handling food... 3. a. before or after direct contact with residents... g. after contact with resident's intact skin... i. after contact with inanimate objects (...equipment) in the immediate vicinity of the resident..." a. Observations in room [ROOM NUMBER] A on 11/30/10 at 7:45 AM, CNA #1 held the toast with his bare hand to put jelly and butter on it. Observations in room [ROOM NUMBER] A on 11/30/10 at 12:15 PM, CNA #1 removed a slice of bread from the wrapper with her bare hands. Observations in room [ROOM NUMBER] B on 11/30/10 at 12:20 PM, CNA #1 removed a slice of bread from the wrapper with her bare hands, opened the straw and touched the straw with her bare hand. b. Observations in room [ROOM NUMBER] on 11/30/10 at 7:18 AM, CNA #2 repositioned a resident, adjusted the bed with the bed control and moved a box under the bed and then began to set up the tray opening the butter and the sweetner. CNA #2 then began to fed the resident. CNA #2 did not wash her hands prior to tray set up or before she fed the resident. Observations in room [ROOM NUMBER] on 11/30/10 at 7:40 AM, CNA #2 did not wash her hands prior to delivery of the meal tray or prior to opening the milk and butter. CNA #2 left the room and proceeded to get the next tray without washing hands. Observations in room [ROOM NUMBER] on 11/30/10 at 7:45 AM, CNA #2 opened the straw and touched the straw with her bare hand. Observations in room [ROOM NUMBER] on 11/30/10 at 7:47 AM, CNA #2 opened the straw and touched the straw with her bare hand. Observations in room [ROOM NUMBER] on 11/30/10 at 7:50 AM, CNA #2 repositioned the resident, manipulated the pillow and bed linen and did not wash her hands prior to setting up the food tray. CNA #2 then touched the straw with her bare hand, and began feeding the resident. c. Observations in the main dining room on 11/30/10 at 11:30 AM, the Rehabilitation Coordinator opened a resident's straw and touched the straw with her bare hand then went to another resident and opened another straw with her bare hand. d. Observations in the main dining room on 11/30/10 at 11:30 AM, the Dietary Manager opened a resident's straw and touched the straw with her bare hand. e. During an interview at side 3 nurses' station on 12/1/10 at 7:45 AM, the Staffing Coordinator was asked what is the expectation of staff when passing meal trays. The Staffing Coordinator stated, "Wash hands prior to tray delivery, if touch resident or their environment will need to wash hands again. Don't touch straw or food with bare hands..." f. Observations in Resident #17's room on 11/29/10 at 11:48 AM, revealed Nurse #2 did not wash her hands after administering an injection. 2. Review of the facility's "Blood Glucose Meter Maintenance Policy & (and) Procedure" documented, "...Purpose: The Blood Glucose Meter should be cleaned and disinfected between each resident use... Procedure...2b. Take a clean wipe and thoroughly wipe and wet surface to disinfect. 3. When using the wipes to clean and disinfect the meter...follow all product label instructions. (2 minute dry Super Sani-wipes)..." a. Observations in Random Resident (RR) #5's room on 11/30/10 at 6:35 AM, Nurse #5 cleaned the glucometer with an alcohol pad not with a Super Sani-wipe as per policy. Observations in Resident #15's room on 11/30/10 at 6:45 AM, Nurse #5 cleaned the glucometer with an alcohol pad not with a Super Sani-wipe as per policy. After use of the glucometer Nurse #5 returned the glucometer to the medication cart drawer without cleaning it. b. Observations in Resident #7's room on 11/30/10 at 7:00 AM, Nurse #6 did not clean the glucometer prior to or after obtaining a blood glucose on Resident #7. Nurse #6 then entered Resident #16's room at 7:15 AM, Nurse #6 obtained a blood sugar with the same glucometer used on Resident #7 without cleaning it before or after use. Nurse #6 then entered Resident #10's room at 7:20 AM, with the same contaminated glucometer Nurse #6 obtained a blood sugar on Resident #10. Nurse #6 did not clean the glucometer prior to use on each resident nor did she clean the glucometer between residents or after each use. During an interview in the conference room on 12/1/10 at 10:00 AM, the Director of Nurses (DON) was asked what is the expectation of cleaning the glucometer. The DON stated, "They (nurses) should clean it (glucometer) between residents and are to clean it with the Sani-wipe cloths. We have packets made up and there is no excuse for that (not cleaning the glucometer prior to of after each use). They (nurses) can do better." | 2014-09-01 |
| 13814 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 371 | E | 0 | 1 | IDW711 | Based on policy review, observations, and interviews, it was determined the facility failed to ensure that staff had hair and beards covered in the kitchen on 2 of 3 (11/29/10 and 12/1/10) days and that dishes were air dried on 1 of 3 (11/29/10) days of kitchen observations. The findings included: 1. Review of the facility's "DRESS CODE" policy documented, "...B. Dietary staff ...Hair Nets..." Observations in the kitchen on 11/29/10 at 9:00 AM and 1:55 PM, revealed dietary staff #1 working at the ware washer and on the tray line. Dietary staff member #1's beard was not covered. Observations in the kitchen on 12/1/10 at 7:55 AM, revealed dietary staff member #1 was working on the tray line with his beard not covered. Observations in the kitchen on 12/1/10 at 7:55 AM, revealed dietary staff member #3 stocking supplies in the kitchen. Dietary staff member #3 was wearing a cap that partially covered his hair and his beard was not covered. Observations in the kitchen on 12/1/10 at 8:15 AM, revealed dietary staff members #1 and #3 were in the kitchen with no beard coverings on and dietary staff member #3's hair was partially uncovered. During an interview in the kitchen on 12/1/10 at 8:15 AM, the Dietary Manager (DM) was asked about hair coverings. The dietary manager stated, "They (staff members) wear caps but no beard covers. I don't think our policy says anything about beard covers." The dietary manager agreed that the facial hair was not covered. 2. Review of the facility's "Departmental Policies" documented, "...All pots and pans must be air dried after the final sanitizing rinse..." Observations in the kitchen on 11/29/10 at 9:00 AM, revealed dietary staff member #1 was removing clean dishes from the ware washer and drying the dishes with a towel. Observations in the kitchen on 11/29/10 at 1:55 PM, revealed dietary staff member #2 was removing clean dishes from the ware washer and drying the dishes with a towel. During an interview in the dietary office on 12/1/10 at 8:10 AM, the DM was asked about drying the dishes with a towel. The DM stated, "I thought it was okay to dry if you change towels when they (towels) are damp." | 2014-09-01 |
| 2897 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2017-07-19 | 157 | D | 0 | 1 | NDN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify the physician of a change in blood pressure (BP) reading for 1 of 2 (Resident #31) residents of 20 residents in the Stage 2 sample review. The findings included: Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the the most recent comprehensive Minimum Data Set (MDS) assessment completed on 4/17/17 revealed the resident was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 (0 - 7 equaled severe cognitive impairment) and required either extensive assistance or was totally dependent on staff for the provision of activities of daily living (ADLs) such as transfers, dressing, eating, toilet use, etc. Review of Physician's Orders for (MONTH) (YEAR) revealed Resident #31 was prescribed [MEDICATION NAME] (antihypertensive medication), 15 mg once a day for a [DIAGNOSES REDACTED]. The medication was initiated on 5/26/15. The Physician's orders did not include parameters for holding the medication (not administering when BP was below a specified level). BP measurements were to be taken once a week. Review of Resident #31's BP readings revealed: the following low BP readings documented on the following forms: 5/19/17-82/56 (Blood pressure log) 5/26/17-81/54 (Blood pressure log) 6/9/17-73/49 (Blood pressure log) 6/12/17-78/49 (Nursing Departmental Note) 6/22/17-66/38 (Nursing Departmental Note) There was no evidence the Physician was notified of Resident #31's low BP readings. Review of Doctor's Orders and Progress Notes dated 6/22/17 revealed the Physician was aware of the low BP reading and [MEDICATION NAME] was discontinued on this date. Interview with Licensed Practical Nurse (LPN) #4 on 7/19/17 at 4:49 PM, LPN #4 stated there should be nursing documentation of the low blood pressure readings and notification to the Physician. Interview with the Director of Nursing (DON) on 7/19/17 at 6:12 PM, the DON stated the Physician should have been notified of Resident #31's low BP readings, and verified Resident #31 had been prescribed a medication for high BP. The DON stated nurses should have notified the Physician of all low BP readings with a systolic BP of less than 80 and a nurse's note should have been written in each instance to document the low BP and notification to the physician. | 2020-09-01 |
| 2898 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2017-07-19 | 323 | D | 0 | 1 | NDN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to reassess a resident for the use of siderails and ensure 1 of 1 (Resident #57) residents of the 20 residents on the Stage 2 sample were free from potential accident hazards. The findings included: 1. Review of the facility policy and procedure entitled Safety and Supervision of Residents revised 12/08 revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to minimize the risk of accidents are facility-wide priorities .When accident hazards are identified, the PI (Performance Improvement)/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible .Employees shall be trained and in- serviced on potential accident hazards and how to identify and report accident hazards, and try to minimize risk of avoidable accidents . 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE],documented the resident required total assistance of 2 staff members for bed mobility and transfers. Review o the Task Care Plan for the nursing assistants (NA) identified the resident was to have 2 side rails up when the resident was in bed. Review of a nursing care plan dated 4/3/17 identified the resident was a fall risk .related to cognitive, functional & medical factors as evidenced by impaired safety awareness, poor judgement, weakness, balance instability and fall history . The approaches included to .Re-assess fall risk quarterly & PRN (as needed) .Observe for attempts to get up unassisted . Review of the Departmental Notes dated 7/15/17 documented, the resident was found in bed, with his legs hanging over the side rails. There were no further entries made in the electronic medical records regarding this incident. 3. Interview with the Licensed Practical Nurse (LPN) #2 on 7/19/17 at 11:19 AM, LPN #2 stated it was her expectation that the resident be reassessed for the use of side rails. She confirmed that there was no assessment done for Resident #57 after the 7/15/17 incident. Interview with the Director of Nursing (DON) on 7/19/17 at 3:23 PM, the DON stated she was unaware of the 7/15/17 incident involving Resident #57. She stated it was her expectation that staff should have alerted her and the MDS Coordinator. The resident needed to be reassessed for the use of side rails after this incident. | 2020-09-01 |
| 2899 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2017-07-19 | 327 | D | 0 | 1 | NDN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide adequate hydration and maintain fluid balance for 1 of 2 (Resident #31) residents of the 20 residents in the Stage 2 review. The findings included: 1. Review of the facility policy on Nutritional Assessment revised 1/20/14, under the heading of Dietitian indicated the Dietitian was to complete .a. An estimate of calorie, protein and fluid needs . and to determine .b. Whether the resident's current intake is adequate to meet his or her needs . 2. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician prescribed Comfort Measures and an order not to weigh the resident, both initiated on 8/16/16. Review of the Comprehensive Minimum Data Set (MDS) assessment completed on 4/17/17 revealed the resident was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 (0 - 7 equals severe cognitive impairment) and required extensive assistance of 1 staff for eating and drinking. Hydration did not triggered for in depth assessment. Review of the Physician's Orders for (MONTH) (YEAR) revealed Resident #31 was prescribed: [MEDICATION NAME] (diuretic) 20 mg a day initiated for [MEDICAL CONDITION] which increased fluid loss, [MEDICATION NAME] (laxative) 1 capful (17 grams) mixed with liquid daily for constipation, and Boost Plus Energy Drink 4 ounces, 4 times a day to promote nutrition. The annual Nutritional Review, dated 4/7/17 by the Dietitian or Dietary Manager listed the resident's favorite beverages were cranberry juice and sweet tea. The resident was listed as having Dehydration Risk Factors of urinary tract infection, constipation, taking laxative and diuretic medications. No assessment of the resident's fluid needs or fluid intake was found on the assessment. No assessment of the resident's risk for dehydration was noted, even though he had risk factors including poor appetite, urinary tract infection, constipation, and use of a diuretic (increasing fluid loss) medication. Review of the Care Plan dated 4/19/17 indicated a problem of Fluid status: risk for alteration related to cognitive & medical conditions as evidenced by memory deficits, reduced awareness of hydration needs, need for hydration reminders/assistance and diuretic regime. The goal was Risk for dehydration/altered fluid status will be minimized daily through review. Approaches included keeping fresh water in the room and within reach, encouraging with hydration, providing preferred beverages, observing for signs and symptoms of dehydration, observing for increased and decreased urinary output, notifying the Physician, documenting bowel movements and for signs and symptoms of constipation, observing for signs and symptoms of vomiting, sweating or diarrhea and administering diuretic as ordered. Review of Nursing Departmental Notes from 6/5/17 through 6/12/17 revealed documentation of the resident's decreased intake and refusal to eat, drink and take medications. However, there was no evidence an assessment for signs and symptoms of dehydration, such as an evaluation of mucus membranes, skin turgor, evaluation of vital signs, etc. was conducted by nursing staff. In addition, there was no evidence of laboratory tests being ordered to further determine the extent of the resident's fluid balance. There was no evidence Resident #31's daily fluid intake was assessed to determine if there was a fluid deficit and if so how much. There were no dietary notes or dietary assessments completed after 4/7/17 through 6/12/17 and there was no assessment of fluid intake in comparison to the resident's fluid needs was found in the nursing documentation. Observation on 7/19/17 at 7:15 AM revealed Resident #31 in bed with a full water pitcher with a straw on the overbed table. the water pitcher was not within reach of the resident as documented on the care plan and was located on the far edge of overbed table. Observations on 7/19/17 at 8:16 AM revealed none of the strawberry super shake or tea had been consumed. An 8 ounce carton of Boost supplement was visible on the tray and the resident had consumed 100% of the Boost supplement or a total of 8 ounces of fluid for the meal. The water pitcher remained on the far side of the overbed table out of reach of the resident. Observation on 7/19/17 at 12:01 PM revealed the resident had consumed none of the fluid offered for the meal. Interview with Certified Nursing Assistant (CNA) #2 confirmed she had attempted to feed Resident #31 lunch but he would not consume anything. Observation on 7/19/17 at 5:05 PM revealed Licensed Practical Nurse (LPN) #4 completed a physical assessment for hydration with the resident's daughter and surveyor in room. LPN #4 stated, His mouth is pink, lips are dry. LPN #4 checked skin turgor on the resident's forearm several inches above his wrist and stated it looked ok. She checked his urine and stated it was yellow. Interview with CNA #1 on 7/18/17 at 2:55 PM, CNA #1 stated Resident #31 required assistance with meals and required encouragement to drink. She stated fluids were offered to the resident when she went into the resident's room. CNA #1 stated fluid intake was recorded and she kept up with it. Interview with CNA #2 on 7/19/17 at 1:57 PM, she stated Resident #31 could hold the cup and drink with assistance at times, but most of the time he was totally dependent for eating and drinking. She stated Resident #31 did not typically eat or drink very much. The CNA stated, Today he had hardly anything for breakfast and lunch. He drank his supplement (Boost) this morning. At lunch, he did not drink at all. She stated she offered Resident #31 water throughout the day and it was not unusual for him to drink little. She stated the resident had consumed only one sip of water so far this day. The CNA stated she was the assigned care giver for the resident on day shift. When asked how much fluid was to be offered or how much the resident should be encouraged to drink, she stated she did not know. Interview with the Dietary Manager (DM) on 7/19/17 at 5:15 PM, the DM stated she completed the nutritional assessments and the Dietitian reviewed and signed off on them. She stated the CNAs completed the meal and fluid intake records and she accessed the data and ran reports to show average daily fluid intake for a 7-day period. She reported this was usually done prior to completing a nutrition review. She stated, If they (residents) are not drinking enough, we send more fluids. When asked how she knew how much a resident needed and how much to send if intake was poor, she stated she just increased fluids. She stated, I ask the aides how well people do. They tell me . The DM stated she was aware of Resident #31's decreased fluid intake and attempted to send preferred beverages to him. She stated he enjoyed cranberry juice at one time, but no longer drank it so it was no longer being sent. She stated chicken noodle soup had been added to his tray card for lunch and dinner in addition to sweet tea and strawberry shake that he had a history of [REDACTED]. Interview with the Registered Dietitian (RD) on 7/19/17 at 6:30 PM, the (RD) verified fluid needs were only calculated for residents who received nutrition via a feeding tube or for residents who had urinary tract infections. Interview with the Director of Nursing (DON) on 7/19/17 at 6:12 PM, the (DON) stated comfort measures should be defined in the Physician's orders. There was no standard set of interventions or policy for comfort measures (in relation to the provision of food or nutrition). The DON verified nursing staff should monitor and document fluid intake concerns. | 2020-09-01 |
| 2900 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2017-07-19 | 329 | D | 0 | 1 | NDN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure that 1 of 6 (Resident #57) residents of the 20 Stage 2 sampled residents was offered non-pharmacological interventions prior to the administration of an anti-anxiety ([MEDICATION NAME]) medication. The findings included: 1. Review of the facility policy entitled Behavioral Assessment and Monitoring revised 4/07 revealed, .The facility will comply with regulatory requirements related to the use of mediations to manage problematic behavior .If the resident is being treated for [REDACTED].will document ongoing reassessments of changes in the individual's behaviors, mood, function .The staff will document (either in the progress notes, behavior assessment forms, or other comparable approaches) about specific problem behaviors . This policy failed to identify non-pharmacological interventions prior to the administration of a medication when indicated. 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 5/28/16 revealed and order for [MEDICATION NAME] 0.5 milligrams (mg) to be administered by mouth every 4 hours as needed (PRN), for increased agitation. Review of the quarterly minimum data set assessment ((MDS) dated [DATE] revealed Resident #57 had a Brief Interview Mental Status (BIMS) score of 7 out of 15 which indicated the resident was severely cognitively impaired. Review of the care plan dated 4/3/17 revealed the resident was at risk for .Mood State; risk for related to cognitive, medical &(and) functional factors as evidenced by confusion, intermittent verbalization of sadness, agitation with sarcasm at times. Need for stimulating activities for optimal cognition, mood and psychosocial health . The approaches identified were .Dx (diagnosis) of anxiety. Administer anxiolytics as ordered for anxiety .Attempt to relieve anxiety/agitation with non-pharmacological techniques .prior to the use of prn (as needed) anxiolytics when appropriate . Review of the 4/17 Medication Administration Record [REDACTED]. There was no documentation that the resident was offered non-pharmacological interventions prior to the administration of the PRN [MEDICATION NAME]. Review of the 5/17 MAR indicated [REDACTED]. There was no documentation that the resident was offered non-pharmacological interventions prior to the administration of the PRN [MEDICATION NAME]. Review of the 6/17 MAR indicated [REDACTED]. There was no documentation the resident was offered non-pharmacological interventions prior to the administration of the PRN [MEDICATION NAME]. Interview with Licensed Practical Nurse (LPN) #2 on 7/19/17 at 10:50 AM. LPN #2 stated that before she administers the PRN [MEDICATION NAME] that she will document the behavior of the resident prior to the administration of the medication. LPN #2 stated that she attempts to redirect the resident but there will be times the resident cannot be redirected and will become verbally and physically aggressive. The LPN said that this should have been documented in the MAR indicated [REDACTED] Interview with the Director of Nursing (DON) on 7/19/17 at 4:50 PM, the DON presented an undated document entitled ASSESS FOR 'PHALTT' which directed staff to assess for .P-pain .H-hunger .A-anxiety .L-loneliness .T-toileting .T-thirsty .T-tired . and stated that nursing staff are to assess a resident for non-pharmacological interventions prior to the use of an antianxiety medication. Telephone interview with the Consultant Pharmacist on 7/19/17 at 6:04 PM, the Consultant Pharmacist stated that before an anti-anxiety medication is administered the staff should attempt non-pharmacological interventions. Interview with MDS Coordinator #1 on 7/19/17 at 6:28 PM, MDS Coordinator #1 stated .you don't want to automatically pop a pill into someone's mouth . She further stated it was important to rule out hunger, thirst, or even pain prior to the administration of an antianxiety. | 2020-09-01 |
| 5014 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2016-04-28 | 425 | E | 0 | 1 | F2H811 | Based on policy review, contract review, observation and interview, the facility failed to ensure the consulting pharmacy provided oversight as evidenced by Schedule II medications not secured by 2 locks in 3 of 5 (South hall, West hall and North hall medication carts) medication storage areas. The findings included: 1. The facility's Controlled Substances policy documented, .Scheduled II (2) Narcotics supply is to be kept under TWO locks at all times . 2. The CONSULTING PHARMACY SERVICES AGREEMENT documented, .DUTIES OF THE CONSULTANT PHARMACIST The following consultation services are required on a regular basis and will be provided on at least a monthly basis as defined below . 4. Meets all other responsibilities required of a consultant pharmacist as set forth in federal, state, and local laws, regulations, or rules . 3. Observations in the south hall medication room on 4/27/16 at 1:43 PM, revealed the south hall medication cart with the following Schedule II controlled medications that were not secured by 2 locks in the bottom drawer: a. Five sleeves of Hydrocodone-Acetominophen 5-325 milligrams (mg). b. Five sleeves of Hydrocodone-Acetominophen 7.5-325 mg. 4. Observations in the west hall medication room on 4/27/16 at 9:30 AM, revealed the west hall medication cart contained the following Schedule II controlled medications that were not secured by 2 locks in the bottom drawer: a. Four sleeves of Hydrocodone-Acetaminophen 5-325 mg. b. One sleeve of Hydrocodone-Acetaminophen 10-325 mg. c. One sleeve of Hydrocodone-Acetaminophen 7.5-325 mg. d. One sleeve of Oxycodone-Acetaminophen 7.5-325 mg. 5. Observations on the north hall on 4/27/16 at 9:30 AM, revealed the north hall medication cart bottom drawer contained the following Schedule II controlled medications that were not secured by 2 locks: a. Six sleeves of Hydrocodone-Acetaminophen 5-325 mg. b. Two sleeves of Hydrocodone-Acetaminophen 7.5-325 mg. c. One sleeve of Hydrocodone 10 mg . 6. Interview with Licensed Practical Nurse (LPN) #1 on 4/28/16 at 9:57 AM, at the South nurses' station, LPN #1 was asked if the pharmacist ever checked the medication carts. LPN #1 stated, No. Interview with LPN #2 on 4/28/16 at 10:14 AM, at the west nurses' station, LPN #2 was asked if the pharmacist ever checked the medication carts. LPN #2 stated, I don't remember them being here since I've been here. Interview with the Director of Nursing (DON) on 4/28/16 at 12:07 PM, in the DON's office, the DON confirmed that the schedule II medications should have been double locked. The DON was asked if the pharmacist did in-services and checked medication carts. The DON stated, No. | 2019-06-01 |
| 5015 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2016-04-28 | 431 | E | 0 | 1 | F2H811 | Based on policy review, observation and interview, the facility failed to ensure that medications were stored properly according to the facility's policy when scheduled 2 medications were not secured by 2 locks in 3 of 5 (South hall, West hall and North hall medication carts) medication storage areas. The findings included: 1. The facility's Storage of Medications documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . The facility's Controlled Substances policy documented, .Scheduled II (2) Narcotics supply is to be kept under TWO locks at all times . 2. Observations on the south hall on 4/25/16 at 8:14 AM, revealed the south hall medication cart was locked and unattended. The surveyor was able to reach into the gaps between all 3 large drawers and pull out bubble packs of medications, even though the cart was locked. Interview with Licensed Practical Nurse (LPN) #1 on 4/25/16 at 8:14 AM, on the south hall, LPN #1 was asked if it was safe to be able to pull medications out of the medication cart, even though it was locked. LPN #1 stated, No, never noticed you could do that. Observations in the south hall medication room on 4/27/16 at 1:43 PM, revealed the south hall medication cart contained the following sleeves of controlled medications that were not and could be accessed by unauthorized people due to a gap in bottom drawer of the medication cart: a. Five sleeves of Lorazepam 0.5 milligrams (mg). b. One sleeve of Lorazepam 1 mg. c. Five sleeves of Tramadol 50 mg. d. Four sleeves of Alprazolam 0.25 mg. e. One sleeve of Temazepam 30 mg. f. One sleeve of Clonazepam 1 mg. g. One sleeve of Temazepam 15 mg. h. One sleeve of Lorazepam 1 mg (half tablets). i. One sleeve of Modafinil 100 mg. j. Two sleeves of Lyrica 75 mg. k. One sleeve of Alprazolam 1 mg. The bottom drawer also revealed the following Schedule II controlled medications that were not secured by 2 locks (according to facility policy): a. Five sleeves of Hydrocodone-Acetominophen 5-325 mg. b. Five sleeves of Hydrocodone-Acetominophen 7.5-325 mg. 3. Observations on the west hall on 4/25/16 at 8:23 AM, revealed the west hall medication cart was locked, yet the surveyor was able to reach into the gaps between all 3 large drawers and pull out bubble packs of medications. Interview LPN #2 on 4/25/16 at 8:23 AM, on the west hall, LPN #2 was asked if it was safe to be able to pull medications out of the medication cart, even though it was locked. LPN #2 stated, No. Observations in the west medication room on 4/27/16 at 9:30 AM, revealed the west hall medication cart was locked and contained the following sleeves of controlled medications that could be accessed by unauthorized people due to a gap between the bottom drawer: a. Fifteen sleeves of Lorazepam 0.5 mg. b. Two sleeves of Diazepam 2 mg. c. Two sleeves of Tramadol 50 mg. d. Four sleeves of Alprazolam 0.5 mg. e. Four sleeves of Alprazolam 0.25 mg. f. One sleeve of Alprazolam 1 mg. g. Two sleeves of Lorazepam 1 mg. h. Two sleeves of Phenobarbitol 32.4 mg. i. One sleeve of Clorazepate 7.5 mg. j. One sleeve of Clonazepam 0.5 mg. The bottom drawer also revealed the following Schedule II controlled medications that were not secured by 2 locks (per facility's policy): a. Four sleeves of Hydrocodone-Acetaminophen 5-325 mg. b. One sleeve of Hydrocodone-Acetaminophen 10-325 mg. c. One sleeve of Hydrocodone-Acetaminophen 7.5-325 mg. d. One sleeve of Oxycodone-Acetaminophen 7.5-325 mg. 4. Observations on the north hall on 4/27/16 at 9:30 AM, revealed the north hall medication cart bottom drawer contained the following Schedule II controlled medications that were not secured by 2 locks (per facility policy): a. Six sleeves of Hydrocodone 5-325 mg. b. Two sleeves of Hydrocodone 7.5-325 mg. c. One sleeve of Hydrocodone 10 mg. 5. Interview with the Director of Nursing (DON) on 4/28/16 at 12:07 PM, in the DON's office, the DON was asked if it was acceptable to be able to pull medications out of a locked medicine cart. The DON stated, No. The DON confirmed that the schedule II medications should have been double locked. | 2019-06-01 |
| 6440 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2015-04-08 | 241 | D | 0 | 1 | G89H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to promote care in a manner to enhance and promote dignity and respect when 1 of 16 staff members (Certified Nursing Assistant (CNA) #1) stood over a resident while feeding. The findings included: Observations in room [ROOM NUMBER] on 4/6/15 at 11:25 AM, revealed CNA #1 stood over the resident while feeding. Interview with the Director of Nursing (DON) on 4/8/15 at 9:45 AM, in the DON's office, the DON was asked if it was acceptable to stand over a resident while feeding. The DON stated, No ma'am. | 2018-08-01 |
| 6441 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2015-04-08 | 323 | D | 0 | 1 | G89H11 | Based on observation and interview, the facility failed to ensure chemicals were stored securely in 1 of 3 (West hall) halls. The findings included: Observations in the west hall on 4/6/15 at 2:30 PM, revealed a mop bucket that contained a mop with a liquid substance in the bucket in the common bathroom. Interview with the Director of Nursing (DON) on 4/7/15 at 8:00 AM, in the west hall, the DON was asked what the liquid substance in the mop bucket was. The DON stated, Well sometimes they leave a bucket to clean up spills, but I don't know if it was water or a cleaning solution. We will have to ask (Named Housekeeping Supervisor). Interview with the Housekeeping Supervisor on 4/7/15 at 8:05 AM, in the west hall beside the resident bathroom, the Housekeeping Supervisor was asked what was the solution in the mop bucket on 4/6/15 that had been left in the resident bathroom. The Housekeeping Supervisor stated, That is a (named solution) cleaning solution we use. We also use this in spray bottles. We keep it (the cleaning solution) locked on our carts. The Housekeeping Supervisor was asked what the difference was to keep it locked up on a cart and unsecured in the resident bathroom. The Housekeeping Supervisor stated, No difference. | 2018-08-01 |
| 6442 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2015-04-08 | 371 | D | 0 | 1 | G89H11 | Based on policy review, observation and interview, the facility failed to ensure food was served under sanitary conditions when 2 of 16 (Certified Nursing Assistants (CNA #1 and 2) staff members failed to perform hand hygiene during dining observations. The findings included: 1. Review of the facility's Hand washing/Hand Hygiene policy documented, .All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors . 2. Observations in room 11 on 4/6/15 at 11:25 AM, revealed CNA #1 delivered a meal tray to room 11, the resident requested a straw CNA #1 left the room, went to the medication cart on the west hall and got 2 straws, returned to the room, opened the straw and placed the straw in the glass. CNA #1 placed her left hand on the bed rail, picked up the glass with her left hand and gave the resident a drink. CNA #1 placed her left hand back on the bed rail, used both hands to hold the glass for the resident to take a drink. CNA #1 again placed her left hand on the bed rail, pulled at her uniform top, placed her left hand on the bed rail and with her left hand gave the resident a drink. CNA #1 did not perform hand hygiene. 3. Observations in room 18 on 4/6/15 at 11:35 AM, revealed CNA #2 touched her uniform, pulled the over bed table to the resident's bedside and began to feed the resident without performing hand hygiene prior to feeding the resident. 4. Interview with the Director of Nursing (DON) on 4/8/15 at 9:45 AM, in the DON office, the DON was asked if it was acceptable to touch a bedrail or uniform while feeding a resident without performing hand hygiene. The DON stated, No ma'am. | 2018-08-01 |
| 6443 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2015-04-08 | 441 | D | 0 | 1 | G89H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 16 (Certified Nursing Assistants (CNA #1 and 2) staff members failed to perform hand hygiene after contact with contaminated sources prior to serving a meal or feeding a resident. The findings included: 1. Review of the facility's Hand washing/Hand Hygiene policy documented, .All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors . 2. Observations in room [ROOM NUMBER] on 4/6/15 at 11:25 AM, revealed CNA #1 delivered a meal tray to room [ROOM NUMBER], the resident requested a straw CNA #1 left the room, went to the medication cart on the west hall and got 2 straws, returned to the room, opened the straw and placed the straw in the glass. CNA #1 placed her left hand on the bed rail, picked up the glass with her left hand and gave the resident a drink. CNA #1 placed her left hand back on the bed rail, used both hands to hold the glass for the resident to take a drink. CNA #1 again placed her left hand on the bed rail, pulled at her uniform top, placed her left hand on the bed rail and with her left hand gave the resident a drink. CNA #1 did not perform hand hygiene. 3. Observations in room [ROOM NUMBER] on 4/6/15 at 11:35 AM, revealed CNA #2 touched her uniform, pulled the over bed table to the resident's bedside and began to feed the resident without performing hand hygiene prior to feeding the resident. 4. Interview with the Director of Nursing (DON) on 4/8/15 at 9:45 AM, in the DON office, the DON was asked if it was acceptable to touch a bedrail or uniform while feeding a resident without performing hand hygiene. The DON stated, No ma'am. | 2018-08-01 |
| 8172 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2014-01-15 | 164 | D | 0 | 1 | VR0E11 | Based on policy review, observation and interview, it was determined the facility failed to provide privacy for residents' when forms with resident's names were placed in a trash can instead of being shredded at 1 of 3 (South Side Nurses' Station) nurses' stations. The findings included: Review of facility's Confidentiality of Information . Policy Interpretation and Implementation policy documented, .The facility will safeguard all resident's records, whether medical, financial, or social in nature, to protect the confidentiality of the information . Observations at the south side nurses' station on 1/14/14 at 10:30 AM, revealed a trash can sitting outside the nurse's station next to the shredder and contained lists with residents names on them. During an interview at the south side nurses' station on 1/14/14 at 10:30 AM, Nurse #1 confirmed the papers had residents names. Nurse #1 was asked what their policy was on disposing of resident's information. Nurse #1 stated, .this information should have been shredded . During an interview in the Director of Nursing's (DON) office on 1/15/14 at 9:14 AM, the DON was asked what her expectations were for staff when disposing of resident information or resident rosters were. The DON stated, .a black marker is used to draw through the patient's name when disposing a patient's medication bubble pack and any patient information or rosters should be shredded . | 2017-08-01 |
| 8173 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2014-01-15 | 280 | D | 0 | 1 | VR0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of incidens0, observation and interview, it was determined the facility failed to revise the care plan to reflect new interventions implement after a fall for 2 of 15 (Residents #7 and #93) sampled residents of the 31 residents included in the stage 2 review. The findings included: 1. Review of the facility's Fall Risk Program Introduction For Residents and Families policy documented, .Addressing specific fall causes is the number one way to minimize the severity of fall injuries and frequency of all falls . When assessments have been completed appropriate interventions will be determined, once the risk factors have been identified . Review of the facility's Care Plan Policy documented, .Care plans should be reviewed and revised in order to reflect the resident's current status. Goals and interventions should be conveyed that will help the resident attain or maintain the highest practicable level of physical, mental and psychosocial well being . 2. Medical record review for Resident #7 documented an admission date of [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Incident Log documented falls on 3/8/13, 4/9/13, 5/15/13, 5/17/13, 6/6/13, 11/14/13 and 12/16/1, with no injuries. Review of the POS [REDACTED].Immediate Post-Incident Action: INSTRUCTED CNA (Certified Nursing Assistant) TO USE RSIDENT'S (Resident's) WALKER FOR ALL AMBULATION AND GAIT BELT FOR ALL TRANFERS (Transfers). Immediate Actions Taken: RESIDENT SHOES REPLACED WITH NONSKID SOLE SHOES AND STAFF INSTRUCTED TO USE WALKER AT ALL TIMES . The care plan dated 6/6/13 did not include these interventions that had been implemented. Observations in Resident #7's room on 1/13/14 at 3:00 PM, 1/14/14 at 8:05 AM and 4:00 PM, revealed Resident #7 seated in a large recliner with a chair alarm in place. During an interview in room [ROOM NUMBER] on 1/14/14 at 4:15 PM, the Minimum Data Set (MDS) Coordinator #1 was asked if there was an intervention on the care plan for the 11/14/13 fall. The MDS Coordinator #1 stated, .I can't tell a lie, couldn't find the update on the care plan . 3. Medical record review for Resident #93 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS documented brief interview for mental status score of 99, indicating the resident was unable to complete the interview because the resident was severely cognitively impaired. Review of the Resident Incident Report dated 1/5/13 documented, .SPITTING IN GARBAGE CAN fell OVER TO FLOOR ON LEFT SIDE SMALL ST (Skin Tear) TO L (Left) THUMB SMALL BLEEDING . The care plan dated on 12/26/13 did not include an intervention for the fall on 1/5/13. During an interview in room [ROOM NUMBER] on 1/14/14 at 3:00 PM, the MDS Coordinator #1 was asked when there is a fall should there be revised documentation on the care plan to reflect the intervention. The MDS Coordinator #1 stated, We just started putting the date on some of them (interventions) . | 2017-08-01 |
| 8174 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2014-01-15 | 371 | D | 0 | 1 | VR0E11 | Based on policy review, observation and interview, it was determined the facility failed to ensure food was dated when opened and used by the best dates on 2 of 3 (1/13/14 and 1/14/14) days of the survey. The findings included: 1. Review of the facility's Food Receiving and Storage policy documented, .Foods shall be received and stored in a manner that complies with safe food handling practices . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . 2. Observations in the walk-in freezer revealed the following: a. On 1/13/14 at 12:45 PM - a bag of unopened corn dogs with no expiration date. b. On 1/13/14 at 12:45 PM and 1/14/14 at 9:35 AM - an opened bag of chicken breasts and an opened bag of Salisbury steaks with no open date or expiration date on the packages. During an interview in the walk-in freezer on 1/14/14 at 9:40 AM, the Certified Dietary Manager (CDM) was asked about the open and expirations dates not being on open packages. The CDM stated, .I don't want to lie and will start putting dates on packages . 3. Observations in the dry storage room on 1/14/14 at 11:35 AM, revealed a large can of Apricots, Fruit Cocktail, Sliced Apples and Mandarin Oranges with no expiration dates. During an interview in the dry storage room on 1/14/14 at 11:40 AM, the CDM was asked about the cans not having expiration dates. The CDM stated, .dates may be on the boxes that the cans are taken out of . | 2017-08-01 |
| 8175 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2014-01-15 | 514 | D | 0 | 1 | VR0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined he facility failed to ensure assessments were accurate for 1 of 15 (Resident #7) sampled residents of the 31 residents included in the stage 2 review. The findings included: Medical record review for Resident #7 documented an admission date of [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Monthly Summary forms dated 5/26/13, 6/30/13, 8/25/13, 9/29/13,11/29/13 and 12/28/13 documented Resident #7 with limited range of motion on both sides for upper and lower extremities Review of the Monthly Summary forms dated 6/21/13 and 10/28/13 documented Resident #7 with no limitations in range of motion on both sides for upper and lower extremities. Review of the Monthly Summary forms dated 7/28/13 documented Resident #7 with limitations in range of motion on both sides for upper extremities. During interview at nurses' station #3 on 1/15/14 at 9:05 AM, Nurse #2 was asked about the discrepancies of the range of motion on the monthly summaries. Nurse #2 stated, .(Resident #7) has good days and bad days . should be how they are for the month . | 2017-08-01 |
| 10447 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 280 | D | 0 | 1 | VD1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to revise or update the care plan for [MEDICAL CONDITION] disorder and [MEDICAL CONDITION] safety precautions for 1 of 18 (Resident #14) sampled residents. The findings included: Review of the facility's Care Plan Policy documented, .Care plans should be reviewed and revised as often as necessary in order to reflect the resident's current status. Goals and interventions should be conveyed that will help the resident attain or maintain the highest practicable level of physical, mental, and psychosocial well being . Medical record review for Resident #14 documented an admission date of [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the hospital history and physical dated 10/22/11 through (-) 11/1/11 documented, .[MEDICAL CONDITION] disorder . Review of the physician's orders [REDACTED].Levetiracetam 500 mg (milligram) take 1 tablet po (by mouth) (sub [MEDICATION NAME]) once a day for [MEDICAL CONDITION] . Review of the care plan dated 10/20/11 and updated 12/12/11 contained no documentation of [MEDICAL CONDITION] disorder or [MEDICAL CONDITION] safety precautions. During an interview in the Minimum Data Set (MDS) office on 12/14/11 at 10:20 AM, the Director of Nursing (DON) was asked to review Resident #14's medical record. The DON stated, .No, there is no [MEDICAL CONDITION] disorder or [MEDICAL CONDITION] safety precautions documented on the care plan . it should include maintain patent airway, stay beside resident until [MEDICAL CONDITION] is over . | 2016-07-01 |
| 10448 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 283 | D | 0 | 1 | VD1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure each resident discharged from the facility had a recapitulation of the resident's stay for 2 of 2 (Residents #16 and 18) discharged residents reviewed. The findings included: 1. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Record of Discharge documented a discharge date of [DATE] and no recapitulation of the resident's stay. 2. Medical record review for Resident #18 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Record of Discharge documented a discharge date of [DATE] and no recapitulation of the resident's stay. 3. During an interview in the Minimum Data Set office on 12/14/11 at 2:40 PM, the Director of Nursing confirmed there is no recapitulation of the resident's stay documented upon discharge. | 2016-07-01 |
| 10449 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 309 | D | 0 | 1 | VD1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to follow the bowel movement (BM) protocol for 3 of 18 (Residents #2, 15 and 18) sampled residents. The findings included: 1. Review of the facility's BM Policy documented, .If a resident has no bowel movement in 3 days, 3-11 shift will administer laxative per standing order . 2. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the NURSE AIDE'S SIGNATURE SHEET had no BM documented on 10/2/11, 10/3/11, 10/4/11, 10/8/11, 10/9/11, 10/10/11, 10/20/11, 10/21/11, 10/22/11, 11/2/11, 11/3/11 and 11/4/11. Review of the MEDICATION RECORD for October and November 2011 had no laxative documented as being given on the third day of no BM on 10/4/11, 10/10/11, 10/22/11 and 11/4/11 as per the facility's policy. During an interview in the Minimum Data Set (MDS) office on 12/14/11 at 11:25 AM, the Director of Nursing (DON) confirmed no laxative had been given on the third day for no BM as per the facility's policy. 3. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the NURSE AIDE'S SIGNATURE SHEET had no BM documented on 9/7/11, 9/8/11, 9/9/11, 9/10/11, 9/21/11, 9/22/11, 9/23/11, 9/24/11, 9/28/11, 9/29/11, 9/30/11, 10/29/11, 10/30/11 and 10/31/11. Review of the MEDICATION RECORD for September and October 2011 had no laxative documented on the third day of no BM on 9/10/11, 9/24/11, 9/30/11 and 10/31/11 as per the facility's policy. During an interview in the MDS office on 12/14/11 at 11:25 AM, the DON confirmed no laxative had been given on the third day of no BM as per the facility's policy. 4. Medical record review for Resident #18 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the NURSE AIDE'S SIGNATURE SHEET had no BM documented on 10/28/11, 10/29/11, 10/30/11 and 10/31/11. Review of the MEDICATION RECORD for October 2011 had no laxative documented as being given on the third day of no BM on 10/31/11 as per the facility's policy. During an interview in the MDS office on 12/14/11 at 2:40 PM, the DON confirmed no laxative had been given on the third day of no BM as per the facility's policy. | 2016-07-01 |
| 10450 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 323 | D | 0 | 1 | VD1G11 | Based on observation and interview, it was determined the facility failed to maintain safe hot water temperatures in resident areas for 2 of 7 (water heaters #2 and 7) water heaters. The findings included: Observations of the hot water temperatures on 12/12/11 revealed the following: a. Southside resident restroom (water heater #7): 134 degrees Fahrenheit (F) at 9:15 AM. b. Southside shower room (water heater #7): 128 degrees F at 9:35 AM. c. Southside resident restroom (water heater #7): 130 degrees F at 11:20 AM. d. Westside resident restroom adjoining rooms 11 and 15 (water heater #2): 140 degrees F at 1:45 PM. e. Westside resident restroom adjoining rooms 18 and 20 (water heater #2): 120 degrees F at 1:47 PM. f. Westside resident restroom adjoining rooms 11 and 15 (water heater #2): 140 degrees F at 2:25 PM. During an interview on the South-side hall near the beauty shop on 12/12/11 at 9:45 AM, the Maintenance Supervisor was asked about the hot water temperatures. The Maintenance Supervisor confirmed that safe water temperature for resident use should be below 120 degrees F and the water heater settings are adjusted at the individual water heaters supplying each hall. | 2016-07-01 |
| 10451 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 328 | D | 0 | 1 | VD1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure residents received proper treatment for [REDACTED].#10 and 14) sampled residents receiving oxygen therapy. The findings included: 1. Review of the facility's Care Plan Policy documented, .Care plans should be reviewed and revised as often as necessary in order to reflect the resident's current status. Goals and interventions should be conveyed that will help the resident attain or maintain the highest practicable level of physical, mental, and psychosocial well being . 2. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the recertification orders signed 12/8/11 documented Oxygen (O2) at 3 liters per minute (L/M). Review of the care plan dated 10/27/11 documented no interventions for oxygen. Observations in Resident #10's room on 12/12/11 at 12:00 PM, 2:40 PM, 5:05 PM and on 12/13/11 at 8:45 AM and 10:50 AM, revealed Resident #10 receiving O2 at 2L/M. The oxygen was not being administered at the physician's prescribed rate of 3 L/M During an interview at nurse's station #3 on 12/14/11 at 10:35 AM, Nurse #2 was asked about the care plan for O2. Nurse #2 confirmed that Resident #10 had an order for [REDACTED]. 3. Medical record review for Resident #14 documented an admission date of [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the facility's 24 Hour Skilled Nursing Documentation Sheet dated 12/1/11 through 12/13/11 documented, .Oxygen continuous 2- (to) 3 liter/minutes 98% O2 Sat (saturation) . Review of the care plan dated 10/20/11 and updated 12/12/11 contained no documentation of oxygen therapy. Observations in Resident #14's room on 12/12/11 at 9:15 AM and 2:50 PM and on 12/14/11 at 8:40 AM, 9:15 AM and 10:55 AM, revealed Resident #14 lying in bed receiving O2 at 2 L/M. During an interview in the Minimum Data Set office on 12/14/11 at 10:20 AM, the Director of Nursing (DON) was asked to review Resident #14's medical record. The DON stated, .The nurse notes stated she (Resident #14) is on continuous oxygen . no, there is no order for continuous oxygen and oxygen therapy is not on the care plan . | 2016-07-01 |
| 13127 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2010-09-15 | 441 | D | 0 | 1 | JZLH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined the facility failed to ensure 1 of 5 nurses (Nurse #1) washed her hands to prevent the potential spread of infection. The findings included: Review of the facility's "Treatment/Wound Cleansing/Dressing changes" policy documented, "...14. Cleanse wound well ...16. ...remove your dressing field and throw in double bag garbage along with your gloves. 17. Wash hands..." Observations in Random Resident (RR) #1's room on 9/14/10 at 9:05 AM, revealed Nurse #1 cleansed the wound on RR #1's left heel with 4 by (x) 4's and wound cleanser. Nurse #1 applied [MEDICATION NAME] and the new dressing. Nurse #1 did not wash her hands between cleaning the wound and application of the medication and the new dressing. During an interview on the south hall 9/14/10 at 9:20 AM, Nurse #1 was asked why she did not wash her hands after cleaning the wound. Nurse #1 stated, "I never have done that (wash hands after cleansing the wound) before..." | 2015-05-01 |
| 1808 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2017-04-26 | 157 | D | 0 | 1 | 6ADV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify the physician of a medication recommendation by a consulting practitioner for one resident (#101) of 29 residents reviewed. The findings included: Resident #101 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE], revealed the resident was cognitively intact with a Brief Interview for Mental Status score of 13 points out a possible 15 points. Medical record review of the Behavioral Medicine Progress Note dated 2/07/17, revealed Reason for Visit (Chief complaint): f/u (follow-up) medication review for recent consult to initiate trazadone (antidepressant medication also used to treat [MEDICAL CONDITION]) r/t (related to) [MEDICAL CONDITION]. Medical record review of the facility Order Summary Report dated 4/05/17 revealed no order for the resident to receive [MEDICATION NAME]. Interview with the Director of Nursing on 4/25/2107 at 4:00 PM, in the conference room, confirmed the physician had not been notified of the recommendation from the Behavioral Medicine Progress Note for [MEDICATION NAME], and no order had been written. | 2020-09-01 |
| 1809 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2019-06-05 | 880 | D | 0 | 1 | K47S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation and interview the facility failed to maintain infection control practices for 1 resident (#52) of 3 residents observed for wound care. The findings include: Review of the facility policy Clean Dressing Change revised 12/09, revealed .Put on gloves .Remove soiled dressing, place in bag for disposal .Remove/dispose of gloves, wash hands, don clean gloves .Clean wound as ordered .Remove/dispose of gloves, wash hands, don clean gloves .Apply dressing and secure .Remove gloves .Wash hands . Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Orders revealed the following: 5/16/19 - [MEDICATION NAME] Powder (medication to treat wound) Apply .every day shift for wound care clean daily with iodine x 3 rinse with (normal saline) x 3 pat dry, apply collagen granules (medication to treat wound) to base of wound bed with (a wound dressing) cover with waterproof silicone dressing. 5/31/19 - Santyl Ointment (medication to debride wound) Apply to areas of slough (dead tissue) .topically every day shift. Observation of Resident #52's wound care on 6/5/19 at 10:15 AM, with the Wound Care Nurse (WCN) in the resident's room, revealed the WCN removed the soiled dressing from the resident's coccyx; removed and discarded the gloves; donned new gloves and did not wash the hands. Continued observation revealed the WCN disinfected the wound with iodine, removed the gloves, donned new gloves and did not wash the hands. Further observation revealed the WCN rinsed the wound with a 4 x 4 dressing soaked with normal saline, dried the wound, discarded the gloves and donned new gloves without washing the hands. Continued observation revealed the WCN applied Santyl ointment to the wound, discarded the gloves, donned new gloves and did not wash the hands. Further observation revealed the WCN applied the collagen granules to the wound, discarded the gloves, donned new gloves and did not wash the hands. Continued observation revealed the WCN completed the treatment and applied the dressing. Interview with the Wound Care Nurse on 6/5/19 at 10:25 AM, in Resident #52's room, confirmed she failed to wash her hands after glove removal during wound care. Interview with the Director of Nursing on 6/5/19 at 1:37 PM, in the conference room, confirmed during the observation of Resident #52's wound care, the facility's policy for infection control was not maintained when hands were not washed after glove removal. | 2020-09-01 |
| 1810 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2018-06-19 | 880 | D | 0 | 1 | KGE111 | Based on facility policy review, observation, and interview, the facility failed to ensure staff disinfected hands after glove removal and disinfect hands after the administration of medication for 1 of 3 nurses observed for medication administration. The finding included: Review of the facility policy, Hand Hygiene, last revised 2/2018, revealed Purpose: to decrease the risk of transmission of infection by appropriate hand hygiene .using an alcohol based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient .after removing gloves . Observation of a medication administration on 6/18/18, at 8:05 AM, in the 300 hallway, revealed Licensed Practical Nurse (LPN) #1 had prepared the resident's medication in a plastic medication cup. Continued observation revealed the following: 1. LPN entered the resident's room, gave the medication cup to the resident. 2. Resident swallowed several pills at at time. 3. Resident dropped 1 medication pill on the floor. 4. LPN donned gloves, picked up the 1 medication pill off the floor, removed the gloves with the pill inside the gloves, placed on bedside table. 5. LPN donned another pair of gloves, administered an insulin injection. 6. LPN removed the gloves, exited the room, returned to the medication cart without disinfecting the hands. Interview with LPN #1 on 6/18/18, 8:20 AM, in the 300 hallway, confirmed hands were not disinfected after glove removal nor after the administration of the insulin injection | 2020-09-01 |
| 4680 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-08-09 | 312 | D | 1 | 0 | 6ZST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review and interview the facility failed to provide showers per the care plan for 1 Resident (#5), of 4 residents reviewed for Activities of Daily Living, of 5 residents reviewed. The findings included: Review of the facility policy, Routine Resident Care revised (MONTH) 2008, revealed .Residents receive necessary assistance to maintain good grooming and personal .hygiene .Showers, tub baths, and/or shampoos are scheduled at least twice weekly and more often as needed . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident with a Brief Interview of Mental Status Score of 15/15 (cognitively intact), had no symptoms of [MEDICAL CONDITION], and was dependent for transfers, bathing, and personal hygiene. Medical record review of the current Care Plan revealed Resident #5 was to receive showers twice weekly on Wednesdays and Saturdays. (An average of 8 showers monthly). Medical record review of the Activity of Daily Living (ADL) Flow Sheets dated 6/30/16 to 7/30/16 revealed the resident was not showered on Wednesdays and Saturdays in accordance with the Care Plan, and received only 3 showers in a 30 day period between 6/30/16 to 7/30/16. No showers were documented as performed between 7/16/16 and 7/30/16 (14 consecutive days). Observation and interview with Resident #5 on 8/9/16 at 5:00 PM, in the resident's room, revealed the resident was alert, oriented to place and circumstances. The resident reported he did not regularly receive showers on Wednesdays and Saturdays and reported he frequently was not offered showers on his appointed shower days. Continued observation and interview revealed a noticeable smell of body odor present. The resident also reported the facility frequently delayed his showers. Resident #5 stated he could not recall when he last showered. Interview with the DON on 8/9/16 at 5:30 PM, in the Administrator's Office, confirmed the facility had failed to shower the resident in accordance with the care plan and facility policy, and confirmed no evidence was present in the medical record which indicated the resident had refused showers on the scheduled shower days. | 2019-08-01 |
| 4944 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 225 | D | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to notify the State Survey and Certification Agency of an allegation of abuse for 1 resident (#22) of 3 residents reviewed for an allegation of abuse of 42 residents reviewed. The findings included: Review of facility policy, Abuse & Neglect Prohibition, revised 6/13 revealed .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing .The facility will report all allegations and substantiated occurrences of abuse .to the state agency .as designated by state law . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored an 11 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderately impaired cognitive skills. Medical record review of the significant change of status MDS dated [DATE] revealed the resident scored 14 on the BIMS indicating the resident was independent with daily decision making. Review of a facility investigation dated 3/7/16 .in regards to the 'incident' on (MONTH) 3: With that being said, this is a recount of (Resident #22's) experience: It started off that the blinds were closed and couldn't see outside, so I leaned over to look outside (and my bed was up how I like it). I fooled around and my legs came off the bed, so I pushed the button to get help. So this guy came in and put my legs back on and said that I've messed up again. After that, he came to the end of the bed and started messing with my controls and putting my bed down. I asked what he was doing and he told me I couldn't have my bed up. I've been here for [AGE] years and never been told that. He lowered the bed and said 'I'll fix it so you can't ever raise it again.' After that, I probably told him he was acting like a pest. I wasn't happy. He was standing by the other bed, came running over, jumps on top of me, grabs me, and holds my arms, laughing like crazy . Interview with the Administrator on 4/19/16 at 3:30 PM, in the conference room revealed the facility had problems with computer compatibility to report the allegation of abuse, (Administrator became aware of the allegation of abuse on 3/4/16, when the resident's son contacted the Administrator) which occurred on 3/3/16. Continued interview confirmed the facility did not try to report the allegation of abuse to the State Survey and Certification Agency until 3/7/16 or 3/8/16. | 2019-06-01 |
| 4945 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 253 | D | 0 | 1 | EMXX11 | Based on review of facility policies, review of facility cleaning schedule, observation, and interview, the facility failed to maintain clean window draperies for 1 room of 28 rooms observed and to maintain safe and sanitary rooms for 4 of 28 rooms observed. The findings included: Review of facility policy, Drapery & (and) Cubicle Curtain Maintenance, release date 4/05 revealed .Cubicle curtains are cleaned when visibly soiled .draperies are vacuumed at least quarterly, and laundered or dry cleaned .to remove dust, soil, and foreign matter . Review of the Repair Requisition, undated revealed .communicate needed repairs to maintenance and the Administrator . Review of the (YEAR) Project Schedule, undated revealed .Sun (Sunday)-Bed Rails .Mon (Monday)-AC vents . Observation with the District Manager for Housekeeping and Laundry on 4/18/16 at 10:47 AM, in a semi-private room on the 200 Hallway revealed dust debris and grime on the window draperies. Further observation revealed behind B bed the baseboard on the floor with the wheels of the bed on top of the baseboard. Continued observation revealed the chair rail with splintered wood shards behind B bed. Further observation revealed drywall peeling away on the wall surrounding the heat/air conditioning unit (ac). Observation with the Maintenance Director on 4/18/16 at 11:00 AM, on the 300 Hallway of a semi-private room revealed cracks in the drywall surrounding the heat/ac unit. Continued observation in another semi-private room on the 300 Hallway revealed the chair rail laying on the floor behind 2 resident beds. Observation with the Maintenance Director on 4/18/16 at 11:15 AM, on the 100 Hallway in a semi-private room revealed peeling drywall on the walls around the heat/ac unit. Interview with the Maintenance Director on 4/18/16 at 3:20 PM, on the 200 Hallway confirmed the facility did not keep a log of laundered or cleaned draperies, was not aware of the splintered chair rail on the 200 Hallway, the fallen chair rail in the 300 Hallway room, and confirmed the facility failed to maintain 4 semi-private resident rooms in good repair. | 2019-06-01 |
| 4946 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 281 | J | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Nursing (YEAR) Drug Handbook, facility policy review, medical record review, review of a Medication Variance Report, review of the Individual Patient's Controlled Substances Record, and interview, the facility failed to ensure the correct dosage of a medication for 1 resident (#22) of 16 residents reviewed for medication administration of 42 residents reviewed. The facility's failure placed Resident #22 in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause, serious harm, injury, impairment or death.) The Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy on (MONTH) 25, (YEAR) at 10:50 AM, in the DON's office. The Immediate Jeopardy is effective 3/17/16 and is ongoing. The findings included: Review of the Nursing (YEAR) Drug Handbook revealed .Traditionally, nurses have been taught the 'five rights' of medication administration. These are broadly stated goals and practices to help individual nurses administer drugs safely .The right dose: Verify that the dose and form to be given is appropriate for the patient, and check the drug label with the prescriber's order . Review of facility policy, Medication Administration, revised 6/08 revealed Resident Medications are administered in an accurate, safe, timely, and sanitary manner .Medications are administered in accordance with written orders of the attending physician .Verify the medication label against the medication sheet for accuracy of drug frequency, durations, strength, and route. The nurse is responsible to read and follow precautionary or instructions on prescription labels. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], after admission to the hospital after and an overdose of [MEDICATION NAME] sulfate at the facility, with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) (YEAR) Physician's Recapitulation Orders revealed .[MEDICATION NAME] (opiate narcotic [MEDICATION NAME], can cause respiratory distress and death when taken in high doses) sul. (solution) w/syr (with syringe) .20 mg. (milligrams)/1ml. (milliliter) solution .1.25 mls (25 mg) sublingually (under the tongue) five times daily routine (7 AM, 12 PM, 5 PM, 10 PM, 3 AM) . Medical record review of a prescription for Resident #22 dated 3/10/16 revealed [MEDICATION NAME] sulfate 20mg/5ml, (6ml) PO/SL (by mouth/sublingually) at 7 AM, 12 PM, 5 PM, 10 PM, and 3 AM . Medical record review of the 3/16 Medication Record revealed on 3/10/16 the [MEDICATION NAME] 20 mg/5ml, (6ml) PO/SL at 7 AM, 12 PM, 5 PM, 10 PM, and 3 AM was transcribed onto the Medication Record to reflect the change in the concentration/strength of the [MEDICATION NAME] solution. Review of a Medication Variance Report dated 3/18/16 at 10:00 AM revealed Resident #22 received the wrong dose (concentration/strength) of [MEDICATION NAME]. Continued review of the Medication Variance Report revealed the resident was to receive [MEDICATION NAME] with a strength of 20 mg/5 ml oral solution, with a dose of 24mg/6 ml, but had received [MEDICATION NAME] 20 mg/ml with a dose of 120 mg/6 ml for 4 doses. Continued review of the Medication Variance Report revealed .Outcome .hospitalization .temporary change in level of consciousness .An error occurred that may have contributed to or resulted in temporary resident harm or required initial or prolonged hospitalization . Review of the Individual Patient's Controlled Substances Record, for Resident #22 revealed on 3/17/16 [MEDICATION NAME] Solution 20 mg/ml was obtained from the facility's emergency supply. Continued review of the Individual Patient's Controlled Substances Record revealed Licensed Practical Nurse (LPN) #1 signed out 6 ml (120 mg) of the [MEDICATION NAME] solution for administration to Resident #22 on 3/17/16 at 12:00 PM, 5:00 PM, and 10:00 PM. Continued review of the Individual Patient's Controlled Substances Record revealed LPN #2 signed out 6 ml (120 mg) of the [MEDICATION NAME] Solution for administration to Resident #22 on 3/18/16 at 3:00 AM. Medical record review of the 3/1/16 through 3/31/16 Medication Record revealed on the [MEDICATION NAME] 20 mg/5 ml, (6 ml) po/sl was circled as not administered at 7:00 AM on 3/18/16. Medical record review of a nursing note dated 3/18/16 revealed 7AM CNA (Certified Nursing Assistant #7) reports res. (resident) 'acting funny.' Spoke with res & (and) he talked cheerful & knew this nurses name. No distress at present .10AM-Upon entering room-res presents with decreased L[NAME] (level of consciouness). NP (Nurse Practitioner) & RN (Registered Nurse) Sup (supervisor) notified & following orders in MD (Medical Doctor) orders .12p Res. alert with resp (respirations) @ (at) 16, knows staff & agrees for further TX (treatment) & eval (evaluation) to be trans (transferred) to (named hospital) . Medical record review of the NP progress note dated 3/18/16 revealed .BP (blood pressure) 112/50 .HR (heart rate) 80 .RR (respiratory rate) 4 rpm (respirations per minute) Temp (temperature) 101.4 O2 (oxygen) Sat (saturation) 93% (percent) .RA (room air) .wheezing .awake, able to verbalize .[MEDICATION NAME] (opiate antidote) 0.8 mg IM (intramuscular) given, did not respond, another 0.8 mg given & respirations up to 12/min (minute). Another 1 mg [MEDICATION NAME] given & he improved to 16/min then O2 sat dropped to 83%, O2 applied at 2 LPM (liters per minute) & O2 remains at 93%, B/P dropped to 60/40 then improved, 1 mg [MEDICATION NAME] given & he briefly improved for several minutes, then resp. (respirations) decreased with 10 sec. (seconds) periods of apnea-Sent to ER (emergency room ) .1. Acute Respiratory Distress (difficulty breathing requiring medical intervention). 2. Hypoxemia (low level of oxygen). 3. [MEDICAL CONDITION] (malfunction of the brain manifested by an altered mental status). 4. [MEDICAL CONDITION] (low blood pressure). 5. Dyspnea (difficult or labored breathing, shortness of breath) . Medical record review of a NP order dated 3/18/16 at 10:40 AM revealed [MEDICATION NAME] 1.6 mg IM now, O2 to keep sats at 92% or above, PCXR (portable chest x-ray)-wheezing, fever, [MEDICATION NAME] (inhalation respiratory treatment) 1 unit dose now, [MEDICATION NAME] 1mg IM again now . Medical record review of a NP's order dated 3/18/16 at 11:00 AM revealed .Hold [MEDICATION NAME], Give 2 mg [MEDICATION NAME] now. Medical record review of a NP's order dated 3/18/16 at 11:30 AM revealed Send to ER. Medical record review of an Emergency Department note dated 3/18/16 revealed .The patient presents to the emergency department after a known overdose, that was accidental .Pt (patient) was at his rehabilitation center and he was given too much [MEDICATION NAME] overnight last night. Pt had decreased L[NAME] and has a history of dementia . Medical record review of a hospital History and Physical dated 3/18/16 revealed .Chief Complaint: Overdose .apparently was sent into the ER after he was difficult to arouse. There was concern he may have been given 6 times as prescribed him on [MEDICATION NAME] .he was given [MEDICATION NAME] at the facility and has some improvement .He is awake now and is answering questions . Medical record review of a hospital Discharge Summary dated 3/23/16 revealed .male with multiple medical problems .had a history of [REDACTED].and [MEDICAL CONDITION]. The patient also has mild dementia .was apparently sent to the ER after he was difficult to arouse. There was concern he may have been given 6 times (the dose) as prescribed on his [MEDICATION NAME] .The patient was admitted for further evaluation and management. Discharge Diagnoses: [REDACTED].The patient's [MEDICATION NAME] has been discontinued. The patient was placed on p.r.n. (as needed) [MEDICATION NAME]. Mentation has improved . Review of a facility investigation dated 3/21/16, prepared by the Director of Nursing (DON), revealed (Resident #22) had a physician's orders [REDACTED]. This concentration is what was being dispensed by the pharmacy. On 3/17/16, the last dose of this concentration was used at the 7am dose. The pharmacy was contacted and a request was made for CII (Controlled Substance Schedule II) Continuance of Therapy prescription was made. The pharmacy told the nurse that she would have to get the 12N dose from the ER Narcotic Drug Box. The concentration of the [MEDICATION NAME] Solution in the ER Drug box is 100 mg./5ml. (Resident #22) received 4 doses @ (at) 6ml/dose. Two nurses were involved in administering the wrong dose. When I was notified Friday, (MONTH) 18, (YEAR) of the error, I instructed both nurses to meet with the administrator and me on Monday before returning to work. At 8:00 am (LPN #1) came in to review the incident .I questioned her about reading the label and comparing with her MAR (Medication Administration Record). She stated that she was in a hurry and didn't check .10:30 am (LPN #2) came to speak with the administrator and me about the incident that occurred with (Resident #22). LPN #2 said that she gave 6 ml. @ the 3 am dose. When asked if she checked the label for concentration, she said no . Interview with the Physician/Medical Director on 4/18/16 at 3:25 PM in the conference room revealed the resident received the [MEDICATION NAME] due to severe general pain everywhere. Continued interview revealed the Physician had been notified the resident had received too much [MEDICATION NAME] on 3/17/16 and 3/18/16. Further interview revealed the resident also had an infection at the time of the medication error. Interview confirmed the wrong concentration of [MEDICATION NAME] had been administered. Continued interview revealed some of the possible side effects of too much [MEDICATION NAME] included respiratory depression, lethargy, and drowsiness. Interview revealed on a smaller patient the dosage of [MEDICATION NAME] administered to Resident #22 could have been deadly. Telephone interview with LPN #2 on 4/18/16 at 10:05 PM revealed LPN #2 didn't usually work on the unit where Resident #22 resided. Continued interview revealed LPN #2 should have noted the concentration of the [MEDICATION NAME]. Interview confirmed LPN #2 had incorrectly administered [MEDICATION NAME] Solution 20 mg/ml, 6 mls (120 mg) to Resident #22 on 3/18/16 at 3:00 AM. Interview with the Nurse Practitioner (who was present on 3/18/16, when the medication error was identified) on 4/19/16 at 11:15 AM in the conference room revealed RN #1 had notified the NP there had been an error in the administration of Resident #22's [MEDICATION NAME]. Continued interview revealed when the NP had first examined the resident on 3/18/16, the resident was in respiratory distress. Further interview revealed the resident had shallow breathing and was not breathing as many times per minute as the NP would like. Interview revealed the resident's respiratory rate had been 12 per minute and the NP would like the respiratory rate to be 16. Continued interview revealed the NP was at the resident's bedside during the time after the incorrect dosage of [MEDICATION NAME] had been administered to the resident, and the resident's oxygen saturation level had dropped to 83% and oxygen had been administered to the resident. Further interview revealed while in attendance to the resident it was discovered the resident had an elevated temperature and the NP had thought the resident might have pneumonia. Interview revealed the resident was transferred to the hospital related to fever, the resident's oxygen saturation level and blood pressure had dropped indicating the resident had some other medical condition in addition to the incorrect dosage of [MEDICATION NAME] on 3/18/16. Telephone interview with LPN #1 on 4/19/16 at 3:15 PM revealed the facility had used all of Resident #22's [MEDICATION NAME] solution, the pharmacy had been contacted to obtain a code to remove the medication from the facility's ER narcotic box. Continued interview confirmed LPN #1 did not check the medication label and had incorrectly administered [MEDICATION NAME] Solution 20 mg/ml, 6 mls. (120 mg) to Resident #22 on 3/17/16 at 12:00 PM, 5:00 PM, and 10:00 PM (3 consecutive doses). Continued interview revealed on the morning of 3/18/16 a CNA had reported the resident was acting funny however, LPN #1 had spoken to the resident and the resident had said hey nurse (name) and did act a little silly. Continued interview revealed the 7:00 AM dose of [MEDICATION NAME] was not administered to Resident #22 on 3/18/16 due to another resident had a medical emergency at that time and LPN #1 was so busy she had not administered the [MEDICATION NAME] to Resident #22. Interview with CNA #7 on 4/25/16 at 7:35 AM near the nursing station revealed on 3/18/16 when the CNA had entered Resident #22's room, the resident was hard to wake up was confused, did not know it was morning, didn't recognize CNA #7, who routinely provided care to the resident, and had reported something was wrong with the resident to LPN #1. In summary: On 3/17/16 the facility had used all the prescribed [MEDICATION NAME] sulfate solution ordered for Resident #22 on 3/17/16, notified the pharmacy and obtained [MEDICATION NAME] sulfate from the ER narcotic box. LPN #1 and LPN #2 did not check the label of the [MEDICATION NAME] sulfate to verify concentration/strength, and administered the wrong dosage (120 mg) of the [MEDICATION NAME] sulfate to the resident for 4 consecutive doses (3/17/16 at 12:00 PM, 5:00 PM, and 10:00 PM, and on 3/18/16 at 3:00 AM). The resident suffered respiratory depression, was administered [MEDICATION NAME] at the facility then transferred to the ER. The resident returned to the facility on [DATE]. | 2019-06-01 |
| 4947 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 309 | J | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, Controlled Drug Record review, and interview, the facility failed to administer scheduled pain medication prior to wound care for 2 (#150, #169) residents of 16 residents reviewed for medication administration of 42 residents reviewed. The facility's failure placed Residents #150 and #169 in Immediate Jeopardy (A situation which the provider's noncompliance has caused or is likely to cause serious harm, injury, impairment or death). The Administrator and the Director of Nursing were informed of the Immediate Jeopardy on 4/25/16 at 10:50 AM, in the Director of Nursing's office. The Immediate Jeopardy was effective from 3/17/16 and is ongoing. The findings included: Review of facility policy, Medication Administration, revised 4/08 revealed .Resident Medications are administered in an accurate .timely .manner .records the name, dose, route, and time .on the Medication Administration Record [REDACTED] Review of facility policy, Pain Management, revised 8/12 revealed .The goal of the Pain Management Program is that pain is identified and treated effectively and consistently .be proactive to make sure the resident achieves relief and remains free from pain .The Licensed Nurse when administering scheduled or routine pain medications, will record the drug administration . Medical record review revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Pain Evaluation dated 12/14/15 revealed .[DIAGNOSES REDACTED].Facial Wound .how much time have you experienced pain or hurting over the last 5 days .Frequently . Medical record review of the Non Pressure Skin Condition Record dated 12/15/15 and signed by wound care nurse revealed .wound to (right) jaw (and) partial mouth (second to) gunshot wound .Has severe pain . Medical record review of a physician's orders [REDACTED].Start ([MEDICATION NAME]) 1 mg (milligram) SQ (subcutaneous) q (every) 15 m (minutes) (before) wound care BID (twice a day) . Medical record review of the Controlled Drug Record dated 12/17/15 revealed only 1 dose of the [MEDICATION NAME] 1mg was signed out as administered on 12/19/15, 12/21/15, 12/23/15, 12/24/15, 12/25/15, (instead of 2 doses as ordered prior to wound care missing 5 doses) and no doses of the [MEDICATION NAME] was signed out as administered on 12/30/15. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed the resident had pain almost constantly. Medical record review of the Pain Evaluation dated 12/21/15 revealed .How much of the time have you experienced pain or hurting over the last 5 days .Almost Constantly .location .jaw, knee .back . Medical record review of the Non Pressure Skin Condition Record dated 12/21/15 and signed by wound care nurse revealed .(continue) wound care .(change) BID Resident (continues) to be resistant to touching or cleaning wound but will allow to some degree if pain med given prior to (treatment) . Medical record review of the Nurse Practitioner's Progress Note dated 12/21/15 revealed .Pain-generalized-much improved (with) [MEDICATION NAME] scheduled . Interview with the Director of Nursing (DON) on 4/20/16 at 1:24 PM, in the conference room and review of the Controlled Drug Record confirmed the [MEDICATION NAME] was not administered as ordered prior to wound care. Interview with the Physician on 4/21/16 at 2:32 PM, in the conference room confirmed the resident required pain medication prior to the wound care. Interview with the Wound Care Nurse on 4/22/16 at 8:01 AM, in the conference room confirmed the resident had pain during wound care. Medical record review revealed Resident #169 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #169 was discharged on [DATE]. Medical record review of the Pain Evaluation (Admission) dated 2/11/16 revealed .res (resident) denies pain - even when asked .offer meds (medications) .according to brother-in-law - res may have to be encouraged to take meds . Medical record review of the physician's orders [REDACTED]. NS (Normal Saline) Pat dry Pack wounds c (with) damp to dry [MEDICATION NAME] cover c abd pad & [MEDICATION NAME] (tape) Medical record review of the physician's orders [REDACTED]. Continued review revealed [MEDICATION NAME] 5/325 mg 1 tab po q 3 hours prn (as needed) pain. Further review revealed [MEDICATION NAME] 2 mg/ml, 1 ml 10 min b/f (before) wound care daily. Medical record review of the Medication Record dated for 3/2016 revealed no documentation [MEDICATION NAME] 2mg/ml (milligrams/milliters) 1 ml sq before wound care had been administered. Medical record review of the Controlled Drug Record dated 3/7/16 to 3/28/16 revealed [MEDICATION NAME] 2 mg/ml 1 ml sq b/f wound care was signed out 12 times out of 26 doses ordered (15 missed doses). Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview of Mental Status as a ''5'' (cognitive impairment), pain occasionally and rated as a 5 (on a 1 to 10 pain scale). Medical record review of the Care Plan - Pain dated 3/11/16 revealed .pain actual .administer [MEDICATION NAME] as ordered .medicate resident for pain prior to treatments . Medical record review of the physician's orders [REDACTED]. Medical record review of a Discharge Note dated 3/31/16 revealed .stay was complicated with pain management, depression . Interview with the Wound Care Registered Nurse on 4/20/16 at 10:00 AM, in the Conference Room revealed she instructed the medication nurse on duty to medicate the resident prior to wound care, returned to the medication nurse on duty to ask if the resident had been medicated, and had proceeded with wound care. Further interview confirmed the resident would .sometimes complain of pain .she would point at her umbilical area . Interview with the Medical Director/Physican on 4/21/16 at 2:30 PM, in the Conference Room confirmed Resident #169 would not ask for pain medication .she cried .she would never ask for it . Interview with the DON on 4/22/16 at 9:50 AM, in the DON office and review of the medication record of 3/16 confirmed no documentation of [MEDICATION NAME] administered prior to wound care on 3/4/16, 3/5/16, 3/6/16, 3/11/16, 3/13/16, 3/19/16, 3/20/16, 3/22/16, 3/23/16, 3/24/16, 3/25/16, 3/26/16, 3/27/16, 3/29/16, and 3/30/16. Further interview confirmed the facility failed to monitor and administer scheduled pain medication prior to wound care. Interview with the Medical Director/Physician on 4/25/16 at 9:50 AM, in the Conference Room confirmed she was not aware Resident #169 did not receive the scheduled [MEDICATION NAME] prior to wound care on a daily basis as ordered. | 2019-06-01 |
| 4948 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 314 | D | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to notify the Registered Dietician timely of the development of a pressure ulcer for 1 (#22) of 3 residents reviewed for pressure ulcers of 42 residents reviewed. The findings included: Review of facility policy, Skin Management, revised 8/12 revealed .A Registered Dietician will assess all residents identified with skin impairment for nutritional status in a timely manner . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Braden Scale-For Predicting Pressure Sore Risk dated 1/21/16 revealed the resident was at mild risk for the development of pressure ulcers. Medical record review of the Weekly Pressure Ulcer Record revealed an unstageable pressure ulcer on the sacrum with a date of onset 3/15/16, measured 4.1 cm (centimeters) x (by) 2.2 cm x 1.2 cm. Continued review of the Weekly Pressure Ulcer Record dated 3/15/16 revealed .has draining non-stageable pressure ulcer to sacrum-moderate serosanguineous fluid noted. Large portion of measured area (approx (approximately) 75% (percent)) is slough-remaining tissue red, purple & (and) black . Medical record review of a Medical Nutritional Therapy Review, prepared by the Registered Dietician (RD) dated 3/31/16 revealed .resident feeds himself. PO (by mouth) recorded as only approximately 50% from dietary. However, he has soda at bedside and a refrigerator in his room. Has continued to refuse to be weighed on hospital return despite multiple attempts by multiple people. Obviously has large nutrient needs for wound healing. Has Stage III pressure wound to coccyx .Will add Vit (vitamin) C, zinc sulfate to the [MEDICATION NAME] Vit he is already receiving and additional a.a. (amino acid) to aid in wound healing . Observation on 4/20/16 at 10:45 AM revealed the wound care nurse providing wound care to the resident with the assistance of Certified Nursing Assistant #8. Continued observation revealed the resident was assisted to position on the right side and a dressing was removed from the sacral area. Continued observation revealed the wound care nurse described the presssure ulcer as a Stage 3, measuring 1.0 x 2.3 x 1.0 cm (centimeters), with slough covering approximately 1/3 of the wound, no drainage noted, no tunneling or undermining. Interview with the Wound Care Nurse on 4/20/16 at 12:50 PM, at the nursing station revealed the resident refused to get out of bed to receive showers and was noncompliant with repositioning. Interview revealed the resident continued to lay on his back even though the Wound Care Nurse had educated the resident related to repositioning to relieve pressure and to increase blood flow to the area. Interview with the Director of Nursing (DON) on 4/20/16 at 2:00 PM in the Administrator's office confirmed the RD was not notifed of the development of Resident #22's pressure ulcer in a timely manner. Interview with the RD on 4/21/16 at 9:45 AM at the nursing station confirmed the RD was not notified of the development of the resident's pressure ulcer until 3/31/16. Continued interview revealed the resident was not receiving enough protein to promote wound healing and Juven was ordered on [DATE] when the RD became aware of the resident's pressure ulcer. Continued interview revealed the Vitamin C 500 mg BID and the Zinc Sulfate 220 mg were ordered to promote wound healing. | 2019-06-01 |
| 4949 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 333 | K | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of Medication Variance Report, and interview, the facility failed to prevent significant medication errors for 7 (#22, #150, #169, #178, #31, #93, #177) of 16 residents reviewed for medication administration of 42 residents reviewed. The facility's failure placed 7 (#22, #150, #169, #178, #31, #93, #177) residents in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause, serious harm, injury, impairment or death). The Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy on [DATE] at 10:50 AM in the DON's office. The Immediate Jeopardy is effective [DATE] and is ongoing. The facility was cited F 333 at a scope and severity of (K), which constitutes Substandard Quality of Care. The findings included: Review of facility policy, Medication Administration, revised ,[DATE] revealed Resident Medications are administered in an accurate, safe, timely, and sanitary manner .Medications are administered in accordance with written orders of the attending physician .Verify the medication label against the medication sheet for accuracy of drug frequency, durations, strength, and route. The nurse is responsible to read and follow precautionary or instructions on prescription labels. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], after admission to the hospital after and an overdose of [MEDICATION NAME] sulfate at the facility, with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) (YEAR) Physician's Recapitulation Orders revealed .[MEDICATION NAME] (opiate narcotic [MEDICATION NAME], can cause respiratory distress and death when taken in high doses) sol (solution) w/syr (with syringe) .20 mg. (milligrams)/1 ml. (milliliter) solution .1.25 mls (25 mg) sublingually (under the tongue) five times daily routine (7 AM, 12 PM, 5 PM, 10 PM, 3 AM) . Medical record review of a prescription for Resident #22 dated [DATE] revealed [MEDICATION NAME] sulfate 20 mg/5 ml, 6 ml PO/SL (by mouth/sublingually) at 7 AM, 12 PM, 5 PM, 10 PM, and 3 AM . Medical record review of the ,[DATE] Medication Record revealed on [DATE] the [MEDICATION NAME] 20 mg/5 ml, 6 ml PO/SL at 7 AM, 12 PM, 5 PM, 10 PM, and 3 AM was transcribed onto the Medication Record to reflect the change in the concentration/strength of the [MEDICATION NAME] solution. Review of a Medication Variance Report dated [DATE] at 10:00 AM revealed Resident #22 received the wrong dose (concentration/strength) of [MEDICATION NAME]. Continued review of the Medication Variance Report revealed the resident was to receive [MEDICATION NAME] with a strength of 20 mg/5 ml oral solution, with a dose of 24 mg/6ml, but had received [MEDICATION NAME] 20 mg/ml with a dose of 120 mg/6 ml for 4 doses. Continued review of the Medication Variance Report revealed .Outcome .hospitalization .temporary change in level of consciousness .An error occurred that may have contributed to or resulted in temporary resident harm or required initial or prolonged hospitalization . Review of the Individual Patient's Controlled Substances Record for Resident #22 revealed on [DATE] [MEDICATION NAME] Solution 20 mg/ml was obtained from the facility's emergency supply. Continued review of the Individual Patient's Controlled Substances Record revealed Licensed Practical Nurse (LPN#1) signed out 6 ml (120 mg) of the [MEDICATION NAME] solution for administration to Resident #22 on [DATE] at 12:00 PM, 5:00 PM, and 10:00 PM. Continued review of the Individual Patient's Controlled Substances Record revealed LPN #2 signed out 6 ml (120 mg) of the [MEDICATION NAME] Solution for administration to Resident #22 on [DATE] at 3:00 AM. Medical record review of the [DATE] through [DATE] Medication Record revealed on [DATE] the [MEDICATION NAME] 20 mg/5 ml, 6 ml po/sl was circled as not administered at 7:00 AM. Medical record review of a nursing note dated [DATE] revealed 7AM CNA (Certified Nursing Assistant #7) reports res. (resident) 'acting funny.' Spoke with res & (and) he talked cheerful & knew this nurses name. No distress at present .10 AM-Upon entering room-res presents with decreased L[NAME] (level of consciouness). NP (Nurse Practitioner) & RN (Registered Nurse) Sup (supervisor) notified & following orders in MD (Medical Doctor) orders .12p Res. alert with resp (respirations) @ (at) 16, knows staff & agrees for further TX (treatment) & eval (evaluation) to be trans (transferred) to (named hospital) . Medical record review of the NP progress note dated [DATE] revealed .BP (blood pressure) ,[DATE] .HR (heart rate) 80 .RR (respiratory rate) 4 rpm (respirations per minute) Temp (temperature) 101.4 O2 (oxygen) Sat (saturation) 93% (percent) .RA (room air) .wheezing .awake, able to verbalize .[MEDICATION NAME] (opiate antidote) 0.8 mg IM (intramuscular) given, did not respond, another 0.8 mg given & respirations up to 12/min (minute). Another 1 mg [MEDICATION NAME] given & he improved to 16/min then O2 sat dropped to 83%, O2 applied at 2 LPM (liters per minute) & O2 remains at 93%, B/P dropped to ,[DATE] then improved, 1 mg [MEDICATION NAME] given & he briefly improved for several minutes, then resp. (respirations) decreased with 10 sec. (seconds) periods of apnea-Sent to ER (emergency room ) .1. Acute Respiratory Distress (difficulty breathing requiring medical intervention). 2. Hypoxemia (low level of oxygen). 3. [MEDICAL CONDITION] (malfunction of the brain manifested by an altered mental state). 4. [MEDICAL CONDITION] (low blood pressure). 5. Dyspnea (difficult or labored breathing, shortness of breath) . Medical record review of a NP order dated [DATE] at 10:40 AM revealed [MEDICATION NAME] 1.6 mg IM (intramuscular injection) now, O2 to keep sats (saturation level) at 92% or above, PCXR (portable chest x-ray)-wheezing, fever, [MEDICATION NAME] (inhalation respiratory treatment) 1 unit dose now, [MEDICATION NAME] 1 mg IM again now . Medical record review of a NP's order dated [DATE] at 11:00 AM revealed .Hold [MEDICATION NAME], Give 2 mg [MEDICATION NAME] now. Medical record review of a NP's order dated [DATE] at 11:30 AM revealed Send to ER. Medical record review of an Emergency Department note dated [DATE] revealed .The patient presents to the emergency department after a known overdose, that was accidental .Pt (patient) was at his rehabilitation center and he was given too much [MEDICATION NAME] overnight last night. Pt had decreased L[NAME] and has a history of dementia . Medical record review of a hospital History and Physical dated [DATE] revealed .Chief Complaint: Overdose .apparently was sent into the ER after he was difficult to arouse. There was concern he may have been given 6 times as prescribed (to) him on [MEDICATION NAME] .he was given [MEDICATION NAME] at the facility and has some improvement .He is awake now and is answering questions . Medical record review of a hospital Discharge Summary dated [DATE] revealed .male with multiple medical problems .had a history of [REDACTED].and [MEDICAL CONDITION]. The patient also has mild dementia .was apparently sent to the ER after he was difficult to arouse. There was concern he may have been given 6 times as prescribed on his [MEDICATION NAME] .The patient was admitted for further evaluation and management. Discharge Diagnoses: [REDACTED].The patient's [MEDICATION NAME] has been discontinued. The patient was placed on p.r.n. (as needed) [MEDICATION NAME]. Mentation has improved . Review of facility investigation dated [DATE], prepared by the DON revealed (Resident #22) had a physician's orders [REDACTED]. This concentration is what was being dispensed by the pharmacy. On [DATE], the last dose of this concentration was used at the 7am dose. The pharmacy was contacted and a request was made for CII (Controlled Substance Schedule II) Continuance of Therapy prescription was made. The pharmacy told the nurse that she would have to get the 12N dose from the ER Narcotic Drug Box. The concentration of the [MEDICATION NAME] Solution in the ER Drug box is 100 mg./5 ml. (Resident #22 received 4 doses @ (at) 6ml/dose. Two nurses were involved in administering the wrong dose. When I was notified Friday, (MONTH) 18, (YEAR) of the error, I instructed both nurses to meet with the administrator and me on Monday before returning to work. At 8:00 am (LPN #1) came in to review the incident .I questioned her about reading the label and comparing with her MAR (Medication Administration Record). She stated that she was in a hurry and didn't check .10:30 am (LPN #2) came to speak with the administrator and me about the incident that occurred with (Resident #22). LPN #2 said that she gave 6 ml. @ the 3 am dose. When asked if she checked the label for concentration, she said no . Interview with the Physician/Medical Director on [DATE] at 3:25 PM, in the conference room revealed the resident received the [MEDICATION NAME] due to severe general pain everywhere. Continued interview revealed the Physician had been notified the resident had received too much [MEDICATION NAME] on [DATE] and [DATE]. Continued interview revealed the resident also had an infection at the time of the medication error. Continued interview confirmed the wrong concentration of [MEDICATION NAME] had been administered. Continued interview revealed some of the possible side effects of too much [MEDICATION NAME] included respiratory depression, lethargy, and drowsiness. Continued interview revealed on a smaller patient the dosage of [MEDICATION NAME] administered to Resident #22 could have been deadly. Telephone interview with LPN #2 on [DATE] at 10:05 PM revealed LPN #2 didn't usually work on the unit where Resident #22 resided. Continued interview revealed LPN #2 should have noted the concentration of the [MEDICATION NAME]. Interview confirmed LPN #2 had incorrectly administered [MEDICATION NAME] Solution 20 mg/ml, 6 mls (120 mg) to Resident #22 on [DATE] at 3:00 AM. Interview with the NP (who was present on [DATE], when the medication error was identified) on [DATE] at 11:15 AM, in the conference room revealed RN #1 had notified the NP there had been an error in the administration of Resident #22's [MEDICATION NAME]. Continued interview revealed when the NP had first examined the resident on [DATE], the resident was in respiratory distress. Continued interview revealed the resident had shallow breathing and was not breathing as many times per minute as the NP would like. Continued interview revealed the resident's respiratory rate had been 12 per minute and the NP would like the respiratory rate to be 16. Continued interview revealed the NP was at the resident's bedside during the time after the incorrect dosage of [MEDICATION NAME] had been administered to the resident the resident's oxygen saturation level had dropped to 83% and oxygen had been administered to the resident. Further interview revealed while in attendance to the resident it was discovered the resident had an elevated temperature and the NP had thought the resident might have pneumonia. Interview revealed the resident was transferred to the hospital related to fever, the resident's oxygen saturation level and blood pressure had dropped indicating the resident had some other medical condition in addition the incorrect dosage of [MEDICATION NAME] on [DATE]. Telephone interview with LPN #1 on [DATE] at 3:15 PM revealed the facility had used all of Resident #22's [MEDICATION NAME] solution, the pharmacy had been contacted to obtain a code to remove the medication from the facility's ER narcotic box. Continued interview confirmed LPN #1 did not check the medication label and had incorrectly administered [MEDICATION NAME] Solution 20 mg/ml, 6 mls (120 mg) to Resident #22 on [DATE] at 12:00 PM, 5:00 PM, and 10:00 PM (3 consecutive doses). Further interview revealed on the morning of [DATE] CNA (#7) had reported the resident was acting funny however, LPN #1 had spoken to the resident and the resident had said hey nurse (name) and did act a little silly. Interview revealed the 7:00 AM dose of [MEDICATION NAME] on [DATE] was not administered to Resident #22 due to another resident had a medical emergency at that time and LPN #1 was so busy she had not administered the [MEDICATION NAME] to Resident #22. Interview with CNA #7 on [DATE] at 7:35 AM, near the nursing station revealed on [DATE] when the CNA had entered Resident #22's room, the resident was hard to wake up was confused, did not know it was morning, didn't recognize CNA #7, who routinely provided care to the resident, and had reported something was wrong with the resident to LPN #1. In summary: On [DATE] the facility had used all the prescribed [MEDICATION NAME] sulfate solution ordered for Resident #22 on [DATE], notified the pharmacy and obtained [MEDICATION NAME] sulfate from the ER narcotic box. LPN #1 and LPN #2 did not check the label of the [MEDICATION NAME] sulfate to verify concentration/strength, and administered the wrong dosage (120 mg) of the [MEDICATION NAME] sulfate to the resident for 4 consecutive doses ([DATE] at 12:00 PM, 5:00 PM, and 10:00 PM, and on [DATE] at 3:00 AM). The resident suffered respiratory depression, was administered [MEDICATION NAME] at the facility then transferred to the ER. The resident returned to the facility on [DATE]. Medical record review revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a physician's orders [REDACTED].Start ([MEDICATION NAME]) 1mg SQ (subcutaneous) q 15 m (minutes) (before) wound care BID (twice a day) . Medical record review of the Controlled Drug Record dated [DATE] revealed only 1 dose of the [MEDICATION NAME] 1 mg was signed out as administered on [DATE], [DATE], [DATE], [DATE], [DATE], (instead of 2 doses as ordered prior to wound care missing 5 doses) and no doses of the [MEDICATION NAME] was signed out as administered on [DATE]. Medical record review of the Non Pressure Skin Condition Record dated [DATE] revealed .(continue) wound care .(change) BID (twice a day). Resident (continues) to be resistant to touching or cleaning wound but will allow to some degree if pain med given prior to (treatment) . Interview with the DON on [DATE] at 1:24 PM in the conference room and review of the Controlled Drug Record confirmed the [MEDICATION NAME] was not administered as ordered prior to wound care. Medical record review revealed Resident #169 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #169 was discharged home on [DATE]. Medical record review of the Medication Record dated [DATE] to [DATE] revealed no documentation [MEDICATION NAME] 2 mg/ml, 1 ml sq before wound care was administered. Medical record review of the physician's orders [REDACTED]. 2 mg/ml, 1 ml sq (subcutaneous) 10 min (minutes) b/f (before) wound care daily. Medical record review of the Controlled Drug Record dated [DATE] to [DATE] revealed [MEDICATION NAME] 2 mg/ml, 1 ml sq b/f wound care was signed out 12 times out of 26 doses ordered (14 missed doses). Interview with the Wound Care Registered Nurse on [DATE] at 10:00 AM, in the Conference Room revealed she asked the LPN to medicate the resident prior to wound care, returned to the LPN and asked if the resident had been medicated and proceeded with wound care. Interview with the DON on [DATE] at 9:50 AM in the DON office confirmed there was no documentation on the Medication Record the [MEDICATION NAME] was administered prior to wound care as ordered by the physician (14 doses not administered as ordered. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Physician's Recapitulation Orders dated [DATE] revealed .[MEDICATION NAME] ,[DATE] (2) tabs po q (every) 6 (hours) as needed pain . Medical record review of a Prescription dated [DATE] revealed .[MEDICATION NAME] XXX,[DATE] mg (milligram) 1 tab po QID (4 times daily) PRN (as needed) pain . Medical record review of the Pain Evaluation dated [DATE] revealed .[DIAGNOSES REDACTED].Generalized . Medical record review of the Individual Patient's Controlled Substances Record revealed the resident received 2 [MEDICATION NAME] ,[DATE] mg from [DATE] to [DATE] (4 times tablets daily). Review of the Medication Variance Report dated [DATE] revealed .Medication Involved .[MEDICATION NAME] ,[DATE] .Original MAR (Medication Administration Record) on Admission ,[DATE] (2) tabs QID PRN. On [DATE] (Physician) wrote a new (prescription) for [MEDICATION NAME] 1 tab ,[DATE] po QID PRN/pain .order change for prescription not transcribed to MAR .Actions Taken Pt (patient) has received (2) tabs QID or Q 6 (hours) since admission (without) a change documentation reflecting new (prescription) . Interview with RN (Registered Nurse)/Unit Manager #2 on [DATE] at 2:15 PM, in the hall confirmed the resident received 40 extra tablets of [MEDICATION NAME] from [DATE] to [DATE]. Interview with the DON on [DATE] at 8:10 AM, in the DON's office confirmed a significant medication error had occurred with the resident receiving the extra doses of the [MEDICATION NAME]. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of a Physician's Telephone Order dated [DATE] and timed 10 AM revealed .[MEDICATION NAME] (antibiotic) 80 mg IM (Intramuscular) Q (every) 12. Get trough/peak with 3rd dose (baseline for therapeutic dosing). Medical record review of Physician's Telephone Order dated [DATE] and timed 0930 (9:30 AM) revealed Hold [MEDICATION NAME]. Random [MEDICATION NAME] level in a.m. BMP (Basic Metabolic Panel) and pre-renal azotemia (abnormally high level of nitrogen in the blood). Medical record review of [MEDICATION NAME] Trough, Serum with collection date of [DATE] revealed result of 2.4 ug/mL (micrograms per milliliter), flagged as High with reference interval 0.0 - 2.0. Medical record review of [MEDICATION NAME], Random with collected date of [DATE] and timed 9:06 A.M. revealed result of 2.9 ug/mL. Peak range is 5.0 - 10.0 ug/mL. Trough range is 0.5 - 2.0 ug/mL. Medical record review of the Medication Record revealed the [MEDICATION NAME] was administered at 8:00 PM on [DATE] and at 8:00 AM on [DATE]. Review of a Medication Variance Report dated [DATE] revealed .Date and time Variance Occurred: [DATE] .Medication involved: Order written 0930 (9:30 AM) to hold [MEDICATION NAME] & (and) Obtain Random [MEDICATION NAME] level in AM [DATE]. Not taken off by nurse . Interview with RN #2 Unit Manager on [DATE] at 8:36 AM, in the conference room and review of the Medication Record confirmed the 8:00 PM dose of [MEDICATION NAME] on [DATE] and the 8:00 AM dose of [MEDICATION NAME] on [DATE] was given and should have been held per physician's orders [REDACTED].>Interview with the Medical Director on [DATE] at 9:54 AM, in the conference room confirmed if an order is written to hold the [MEDICATION NAME] the expectation is the dose will be held. Continued interview confirmed the order written by the nurse practitioner to hold the [MEDICATION NAME] was because the [MEDICATION NAME] level was elevated. Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Vitamin D level, dated [DATE] revealed .22.4 Low .ng/ml (nanogram/milliliters) .range 30.00 - 100.0 . Medical record review of the Physician's Telephone Orders dated [DATE] revealed Vit (Vitamin) D 50,000 IU (international units) to be given 2 x (times) weeks. Dg (diagnosis) Vit D deficiency. Medical record review of the Medication Record dated [DATE] revealed ''Vitamin D 50,000 IU to be given 2 x per week. Dg: VD (vitamin D) Deficiency. Further review revealed Vitamin D was administered from [DATE] through [DATE]. Medical record review of the facility investigation dated [DATE] revealed .wrong dose .wrong time .vit D . Further review revealed .done BID (twice a day) 2 x a week supposed to be 2 x weekly daily . Further review revealed .order improperly/not flagged as new to be taken off, chart check signed for ,[DATE] . Medical record review of the Medication Record dated [DATE] Vitamin D 50,000 IU to be given 2 x per week dg: VD Deficiency. Interview with the DON on [DATE] at 12:55 PM, in the Conference Room confirmed the Vitamin D was not transcribed from [DATE] until [DATE], transcribed incorrectly resulting in 7 missed doses from [DATE] to [DATE] and from [DATE] to [DATE], 5 incorrect doses (administered 2 times a day instead of once daily twice a week). Continued interview confirmed the facility failed to ensure the correct transcription of the Vitamin D medication. Medical record review revealed Resident #177 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Telephone Orders dated [DATE] at 1300 (1:00 PM), revealed .[MEDICATION NAME] (antibiotic) 500 mg po (by mouth) daily x (times) 7 days - UTI (Urinary Tract Infection) . Further review revealed the order signed off by the LPN #3 on [DATE] at 2:15 PM. Medical record review of the facility investigation dated [DATE] revealed .ordered @ (at) 1300 med should have been given by 5 pm. Avail (available) in EBox (emergency medication box) . Medical record review of the Medication Record dated ,[DATE] revealed [MEDICATION NAME] 500 mg po daily x 7 days UTI the first dose administered at 8:00 AM on [DATE]. Interview with the Unit Manager/Registered Nurse (#2) on [DATE] at 2:40 PM, at the 400 Nursing Station revealed the [MEDICATION NAME] was available in the facility to begin antibiotic treatment within 6 hours of when ordered. Interview with LPN #3 on [DATE] at 3:30 PM, in the conference room confirmed the medication order was signed off on [DATE] at 2:15 PM, and LPN #3 failed to administer the antibiotic when it was available for use in the facility. | 2019-06-01 |
| 4950 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 353 | E | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide sufficient staff to meet the needs of the residents in a timely manner for 7 residents (#22, #2, #17, #61, #26, #176, #7) of 20 interviewable residents who were dependent for needs of 42 residents reviewed. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #22's significant change in status assessment Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was independent with daily decision making, required extensive assist of 2 persons required with bed mobility and toileting. Interview with Resident #22 on 4/21/16 at 1:00 PM, in the resident's room revealed it often took a long time for the call light to be answered on all shifts. Continued interview revealed the resident usually needed to use the bedpan or be removed off the bedpan when the call light was pressed. Continued interview with Resident #22 revealed the staff would tell him they needed another person working. Continued interview revealed often it was approximately 1 hour before assistance was obtained to be removed from the bedpan. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's annual MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making, was totally dependent with 2 person assist required with transfer, dressing, and personal hygiene. Interview with Resident #2 on 4/21/16 at 1:15 PM, in the resident's room revealed the resident had given up 1 of her 3 a week showers because the facility did not have enough staff at times. Continued interview revealed the staff would tell her there was only 1 Certified Nursing Assistant (CNA) on her hall. Continued Interview revealed the resident was not receiving her weekend shower due to the facility not having enough staff on weekends. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #17's quarterly MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making, required extensive assistance of 1 person with bed mobility and personal hygiene, and was totally dependent with 1 person assistance with toileting. Interview with Resident #17 on 4/21/16 at 1:40 PM, in the resident's room revealed the resident did not think the facility had enough staff on any shift and it would take 2-3 hours for the staff to get a bedpan for the resident. Continued interview revealed the weekends were worse and the staff would tell Resident #17 they were aware of her waiting a long time but they were short staffed. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #61's quarterly MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making, required 2 person assistance with transfer, and required extensive 2 person assistance with bed mobility and dressing. Interview with Resident #61 on 4/21/16 at 2:10 PM, in the resident's room revealed the resident had a physician order [REDACTED]. Continued Interview revealed when the resident needed assistance with changing his [MEDICATION NAME] (an opening in the abdomen to allow urine to flow to the outside of the body) or [MEDICAL CONDITION] (an opening in the abdominal wall through which digested food passes) bag due to leaking the staff would want to try to reinforce the bag to his skin instead of assisting him in changing the bag. Continued interview revealed this happened all the time on weekends and the staff would tell him they were short staffed or they were the only CNAs working. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #26's significant change in status assessment MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making and required extensive assistance of 2 person with bed mobility and toileting. Interview with Resident #26 on 4/22/16 at 9:22 AM, in the resident's room revealed the resident did not think the facility had enough staff at times during the week and staffing was worse on weekends. Continued interview revealed it would take too long for staff to answer the call light and come change her brief when needed. Continued interview with Resident #26 revealed the staff would tell her they were the only CNAs working. Medical record review revealed Resident #176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #176 on 4/22/16 at 10:10 AM, in the resident's room revealed it took approximately 1 hour to receive her pain medication. Continued interview revealed staff would inform her they forgot her medication or they were so busy due to being the only one working the hall. Interview with the MDS Coordinator on 4/25/16 at 8:00 AM, in the MDS Coordinator's office revealed .(Resident #176) admission MDS has yet to be entered into the computer with an ARD (assessment reference date) .resident scored 15 (indicating the resident was independent with daily decision making) on BIMS . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #7's significant change in status assessment MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making, required extensive assistance of 2 person with bed mobility, and required total dependence of 2 person with toileting. Interview with Resident #7 on 4/22/16 at 10:10 AM, in the resident's room revealed nurses and CNAs' work 2 halls and it often took a long time for staff to bring the bed pan or remove the bed pan when needed. Continued interview revealed the resident had been left on the bedpan for over 1 hour. Continued interview revealed the staff would comment they were short staffed. Interview with CNA #4 on 4/22/16 at 10:18 AM, on the 100 Hall revealed CNA #4 was working the 200 Hall and was coming to ask for help from the CNA on the 100 Hall. Continued interview revealed the facility did not have sufficient staff to meet the needs of the residents on the weekends and when staff called out. Interview with CNA #5 on 4/22/16 at 10:23 AM, on the 100 Hall revealed there had been times when CNA #5 had told residents he/she would return to provide care after taking care of other residents. Continued interview revealed CNA #5 had worked short staffed when staff had called in sick. Interview with CNA #1 on 4/22/16 at 10:30 AM, on the 300 Hall revealed there had been times when CNA #1 had told residents he/she would return to provide care after taking care of other residents. Interview with CNA #2 on 4/22/16 at 10:33 AM, on the 300 Hall revealed there had been times when CNA #2 had told residents he/she could not give them a bath due to not enough staff. Continued interview revealed there were times when the facility did not have sufficient staff to meet the needs of the residents in a timely manner. Interview with CNA #3 on 4/22/16 at 10:40 AM, on the 400 Hall revealed there had been times when CNA #3 did not have enough help to meet the needs of the residents in a timely manner, especially on weekends. Continued interview with CNA #3 revealed .feel stressed when we are short staffed . Interview with Licensed Practical Nurse (LPN) #8 on 4/22/16 at 10:42 AM, on the 400 Hall confirmed there were times the facility did not have sufficient staff to meet the needs of the residents in a timely manner, especially on weekends. Interview with LPN #9 on 4/22/16 at 10:46 AM, on the 300 Hall revealed there were times when there was insufficient staff to meet the needs of the residents in a timely manner, especially when nurses had to work 2 hallways. Continued interview revealed when nurses work 2 hallways it was easier to make a medication error, especially on the weekends. Further interview confirmed LPN #9 was aware of times when there was insufficient staff available to complete showers and residents had to wait for pain medication. Interview revealed LPN #9 was aware Resident #61 was not gotten up out of bed due to insufficient staffing. Interview with LPN #6 on 4/22/16 at 10:57 AM, on the 200 Hall revealed LPN #6 was aware of times when there was insufficient staff available to meet the needs of the residents in a timely manner, especially on second shift. Continued interview confirmed LPN #6 was aware of times when there was insufficient staff available to complete showers on weekends and residents had to wait for pain medication. Interview with LPN #7 on 4/22/16 at 11:03 AM, on the 100 Hall confirmed there were times the facility did not have sufficient staff to meet the needs of the residents in a timely manner. Continued interview revealed LPN #7 was aware of times when there was insufficient staff available to give pain medication to residents in a timely manner. Continued interview with LPN #7 revealed .when stressed there is a higher likelihood to make a medication error . Interview with the Director of Nursing (DON) on 4/22/16 at 11:06 AM, in the DON's office revealed residents were not to be left on bedpans for 1 hour, residents were not to wait for a bedpan 2-3 hours, residents were not to be told there were residents ahead of them when care was requested, residents were not to wait 1 hour for pain medication, and residents were not to wait in getting their briefs changed. Continued interview confirmed the facility was not staffed with as many nurses or CNAs on the weekend as during the week and staffing was not adequate to meet the needs of the residents in a timely manner. | 2019-06-01 |
| 4951 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 441 | E | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to administer medications in a sanitary manner for 1 Resident (#26) of 30 observed opportunities, failed to provide meal services in a sanitary manner for 2 residents on 2 halls of 4 halls observed, and failed to follow physician's orders [REDACTED].#99) of 1 resident observed for isolation precautions. The findings included: Review of facility policy, Medication Administration, revised 6/08 revealed Resident Medications are administered in .sanitary manner .Follow sanitary practices . Review of facility policy, Hand Hygiene, dated 2012 revealed .To decrease the risk of transmission of infection by appropriate hand hygiene .Handwashing .the most important single procedure for preventing healthcare associated infections .after providing care to a resident . Review of facility policy, Contact Precautions, dated 2012 revealed .use contact precautions in addition to standard precautions for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident's environment .Hand hygiene should be completed prior to donning gloves .Gloves should be worn when entering the room .Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately .Contact Precautions .Multi-drug resistant organisms . Observation on 4/18/16 at 8:50 AM, during medication administration on the 100 Hall revealed Licensed Practical Nurse (LPN) #7 dropped a pill on top of the medication cart, picked up the pill with bare hands, placed the pill in the medication cup with the resident's other medications, and administered the medication to Resident #26. Interview with LPN #7 on 4/18/16 at 8:52 AM, on the 100 Hall confirmed she dropped the pill on top of the medication cart, then picked up the pill, placed the pill in the medication cup with the resident's other medications, and administered the medication to the resident. Interview with the Director of Nursing (DON) on 4/22/16 at 8:36 AM, in the DON's office revealed staff are expected to obtain and administer another pill and destroy the pill that was dropped. Continued interview with the DON confirmed the facility failed to administer medications in a sanitary manner for Resident #26. Observation on 4/18/16 at 12:14 PM on the 300 Hall revealed Certified Nursing Assistant (CNA) #1 set up the lunch tray for Resident #61, repositioned the resident, and left the room without washing or sanitizing her hands. CNA #1 then retrieved Resident #105's tray from the cart, set up the tray for Resident #105 and repositioned the resident. Interview with CNA #1 on 4/18/16 at 12:17 PM, on the 300 Hall confirmed she did not sanitize or wash her hands between resident contact. Interview with the DON on 4/22/16 at 8:36 AM, in the DON's office revealed the staff were expected to wash or sanitize the hands after every resident contact. Continued interview with the DON confirmed the facility failed to provide meal services in a sanitary manner. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Telephone Orders dated 4/10/16 revealed .Peg (percutaneous endoscopic gastrostomy) site culture . Medical record review of a laboratory report dated 4/11/16 revealed .Staphylococcus aureus .Methicillin resistant (MRSA) .Heavy growth .Abnormal .Beta [DIAGNOSES REDACTED] Streptococcus, group B .Abnormal . Medical record review of Physician's Telephone Orders dated 4/13/16 revealed .MRSA peg site .use isolation precautions for MRSA wound . Observation on 4/18/16 at 12:04 PM, outside Resident #99's room revealed no Isolation Cart with personal protective equipment (PPE) or signage on the door to alert anyone that Resident #99 was on isolation precautions. Interview with LPN #7 on 4/18/15 at 12:05 PM, on the 100 Hall revealed .he should be in isolation for MRSA .no one would know .in isolation . Observation on 4/18/16 at 12:17 PM, outside Resident #99's room revealed CNA #6 walked into Resident #99's room to deliver tray to roommate. Continued observation revealed CNA #6 assisted the resident in bed, touched the privacy curtain between the residents, rearranged the blankets on the bed, and walked out of the room without washing hands or putting any PPE on prior to entry. CNA #6 walked to the lunch cart, pulled a resident tray out and handed the tray to another CNA and walked to the computer on the wall and began charting without washing the hands. Interview with CNA #6 on 4/16/16 at 12:17 PM, on the 100 Hall revealed .no I did not wash my hands before going into the resident's room or when I came out of the resident's room . Continued interview revealed .I did not know the resident was in isolation because there is no sign on the door or an isolation cart . Interview with the DON on 4/22/16 at 8:45 AM, in the DON's office confirmed the facility failed to place the resident in isolation per physician's orders [REDACTED]. | 2019-06-01 |
| 4952 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 490 | K | 0 | 1 | EMXX11 | Based on medical record review, review of the Medication Variance Record and interview, the facility failed to be administered in a manner to ensure significant medication errors did not occur for 7 residents (#22, #150, #169, #178, #31, #93, #177) and failed to ensure pain medication was administered prior to wound care for 2 residents (#150, #169) of 16 residents reviewed for medication administration. The facility's failure to ensure significant medication errors did not occur placed all residents in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause serious harm, injury, impairment or death.) The Administrator and Director of Nursing (DON) were notified of Immediate Jeopardy on 4/25/16 at 10:50 AM, in the DON's office. The Immediate Jeopardy was effective 3/17/16 and is ongoing. The facility was cited an Immediate Jeopardy at F-281 (J); F-309 (J); F-333 (K); F490 (K); F-501 (K); F-520 (K). The facility was cited Substandard Quality of Care at F-309 (J); F-333 (K). The findings included: Interview with the Administrator on 4/25/16 at 1:24 PM, in the conference room confirmed the Administrator had not been involved in the process related to medication errors. Refer to F281 (J), F309 (J), F333(K). | 2019-06-01 |
| 4953 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 501 | K | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Medical Director Services Agreement, facility policy review, review of facility investigations, medical record review, and interview, the facility failed to ensure the Medical Director participated in the development and implementation of resident care policies to ensure Physician orders [REDACTED]. The facility's failure placed 7 residents (#22, #150, #169, #178, #31, #93, #177) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation had caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy on (MONTH) 25, (YEAR) at 10:50 AM in the DON's office. The Immediate Jeopardy was effective 3/17/16 and is ongoing. The facility was cited Substandard Quality of Care at F309 (J), F333 (K). The findings included: Review of the Medical Director Services Agreement revealed .Duties & (and) Responsibilities of Medical Director .Coordinate medical care in the Facility to insure the adequacy and appropriateness of the medical services provided, for example: Assist the Administrator and Director of Nurses in clinical program development and act as a consultant to the Director of Nurses in matters relating to resident care . Interview with the Medical Director on 4/25/16 at 10:35 AM, in the conference room revealed when asked what recommendations the Medical Director had made to the facility related to medication errors the Medical Director replied the nurses needed to be accountable for their mistakes and What other people do is out of my hands. Refer to F 281 (J), F309 (J) F333 (K), F 490 (K), F 520 (K) | 2019-06-01 |
| 4954 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 514 | E | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to maintain a complete and accurate medical record for 6 residents (#22, #178, #169, #17, #150, #125) of 42 residents reviewed. The findings included: Review of facility policy, Medication Administration, revised 6/08 revealed .Record the name, dose, route, and time of medication on the Medication Administration Record [REDACTED]. Review of facility policy, [MEDICAL CONDITION] Management, dated 2012 revealed .in accordance with state regulation: the Licensed Nurse will institute the appropriate Behavior Monitoring form associated with the drug category .To identify/target behaviors .document number of episodes of behaviors . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurse Practitioner's (NP) order dated 3/18/16 at 10:40 AM revealed [MEDICATION NAME] (opiate antidote) 1.6 mg (milligram) IM (intramuscular injection) now .[MEDICATION NAME] 1mg IM again now . Medical record review of a NP order dated 3/18/16 at 11:00 AM revealed .Give 2 mg [MEDICATION NAME] now. Medical record review of the 3/18/16 through 3/31/16 Medication Record revealed no documentation the resident had received the [MEDICATION NAME]. Interview with the Director of Nursing (DON), on 4/18/16 at 8:40 AM, in the DON's office confirmed there was no documentation on the 3/18/16 through 3/31/16 Medication Record the resident had received any [MEDICATION NAME] on 3/18/16. Telephone interview with Licensed Practical Nurse (LPN) #1 on 4/18/16 at 10:05 AM revealed LPN #1 had administered the [MEDICATION NAME] 1.6 mg IM to the resident on 3/18/16. Interview with the facility's Wound Care Nurse on 4/18/16 at 10:30 AM, in the DON's office revealed the Wound Care Nurse had administered [MEDICATION NAME] 1 mg IM and [MEDICATION NAME] 2 mg to Resident #22 on 3/18/16. Continued interview confirmed the Wound Care Nurse had not documented the administration of the [MEDICATION NAME] onto the 3/18/16 through 3/31/16 Medication Record. Medical record review revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of Physician's Telephone Orders dated 12/16/15 and timed 12:30 PM revealed .Start [MEDICATION NAME] 7.5 mg PEG (Percutaneous Endoscopic Gastrostomy) Q 8 hours scheduled .Start 1 mg SQ q 15 m (minutes) (before) wound care BID (twice a day) . Medical record review of Physician's Telephone order dated 12/31/15 and timed 1000 (10 AM) revealed .Change routine [MEDICATION NAME] before wound care to prn before wound care at current dose/route. Medical record review of the Medication Record dated 12/16/15-12/31/15 revealed no documentation the [MEDICATION NAME] 0.1 ml had been administered 15 minutes before wound care. Continued review of the Medication Record revealed no documentation why the [MEDICATION NAME] had not been administered. Interview with the DON on 4/20/16 at 1:24 PM, in the conference room and review of the Medication Record confirmed the [MEDICATION NAME] was not documented as administered 12/16/15-12/31/15. Continued interview confirmed the facility failed to ensure complete documentation of the Medication Record. Medical record review revealed Resident #169 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #160 was discharged on [DATE]. Medical record review of the physician's orders [REDACTED]. 2 mg/ml (milliliters), 1 ml sq (subcutaneous) 10 min (minutes) b/f (before) wound care daily. Medical record review of the Medication Record dated 3/4/16 to 3/30/16 revealed no documentation of administration of [MEDICATION NAME] to Resident #169. Medical record review of the Controlled Drug Record dated 3/7/16 to 3/28/16 revealed [MEDICATION NAME] 2 mg/ml 1 ml sq b/f wound care was signed out 12 times. Interview with the DON on 4/22/16 at 9:50 AM, in the DON's office confirmed the [MEDICATION NAME] was not documented on the Medication Record from 3/4/16 to 3/30/16. Further interview confirmed the facility failed to ensure the medication record was complete. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Physician's Recapitulation Orders dated 7/17/15 revealed .[MEDICATION NAME] 5/325 (2) tabs po (by mouth) q (every) 6 (hours) as needed pain . Medical record review of a Prescription dated 7/24/15 revealed .[MEDICATION NAME] .5/325 mg 1 tab po QID (4 times daily) PRN (as needed) pain . Review of the Medication Variance Report dated 7/24/15 revealed .Medication Involved .[MEDICATION NAME] 5/325 .Original Medication Administration Record [REDACTED]. On 7/24/15 (Physician) wrote a new (prescription) for [MEDICATION NAME] 1 tab 5/325 po QID PRN/pain .order change for prescription not transcribed to MAR .Actions Taken Pt (patient) has received (2) tabs QID or Q 6 (hours) since admission (without) a change documentation reflecting new (prescription) . Medical record review of the Medication Administration Record [REDACTED]. Review of the Individual Patient's Controlled Substances Record revealed the following: 7/24/15-4 doses [MEDICATION NAME] signed out, 7/27/15-5 doses [MEDICATION NAME] signed out, 7/28/15-4 doses [MEDICATION NAME] signed out, 7/29/15-3 doses [MEDICATION NAME] signed out, 7/30/15-4 doses [MEDICATION NAME] signed out. Interview with the DON on 4/20/16 at 10:00 AM, in the DON's office confirmed the Prescription for the change in dosage of the [MEDICATION NAME] had been placed in the file bin and had not been discovered promptly. Interview with the DON on 4/21/16 at 12:45 AM, in the DON's office confirmed the documentation on the Medication Administration Record [REDACTED] Medical record review revealed Resident #17 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Record for 2/16 revealed: [MEDICATION NAME] (narcotic pain medication) 10 mg/325 mg 1 tablet by mouth 6 times daily with 2 doses not documented as administered. [MEDICATION NAME] Diskus ([MEDICATION NAME] inhaler) 250 mcg (micrograms)/50 mcg powder. Inhale 2 puff twice daily with 1 dose not documented as administered. Carvedilol (cardiac medication) 12.5 mg tablets,1 tablet by mouth twice daily with 2 doses not documented as administered. Duloxetine (antidepressant) HCL 60 mg capsule, 1 cap by mouth twice daily with 2 doses not documented as administered. [MEDICATION NAME] Sodium (low [MEDICAL CONDITION] medication) 125 mcg tablet, 1 tab by mouth every day with 1 dose not documented as administered. Medical record review of the Medication Record for 3/16 revealed: [MEDICATION NAME] (medication to lower blood pressure) 5 mg tablet, 1 tab by mouth every day with 1 dose not documented as administered. [MEDICATION NAME] (anti-psychotic medication) 10 mg tablet, 1 tab by mouth at bedtime with 5 doses not documented as administered. [MEDICATION NAME] (anti-depressant medication) HCL 150 mg tablet, 1 tab by mouth at bedtime with 5 doses not documented as administered. Carvedilol with 6 doses not documented as administered. Duloxetine with 5 doses not documented as administered. Medical record review of the Medication Record for 4/16 revealed: Carvedilol with 5 doses not documented as administered. Duloxetine with 4 doses not documented as administered. [MEDICATION NAME] with 4 doses not documented as administered. [MEDICATION NAME] (diuretic) 20 mg tablet, 1 tab by mouth every morning with 4 doses not documented as administered. [MEDICATION NAME] (steroid) 2.5 mg 1 po q am with 4 doses not documented as administered. [MEDICATION NAME] (anticonvulsant) 25 mg 1 po 1 am, on every even day x (times) 10 doses, the d/c (discontinue) with 4 doses doses not documented as administered. Interview with the DON on 4/21/16 at 9:05 AM, in the front office confirmed the medications for Resident #17 were not documented as administered for the months of 2/16, 3/16, and 4/16. Continued interview confirmed the facility failed to ensure complete and accurate documentation of the medication record. Medical record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] .50 mg tablet 1.5 (75 mg) tab by mouth every morning . [MEDICATION NAME] .0.25 mg 2 tabs (0.5 mg) by mouth every evening (10 PM) . [MEDICATION NAME] .0.25 mg 1 tab by mouth twice daily (8 AM & 4 PM) . Medical record review of the Behavior/Intervention Monthly Flow Record dated 4/1/16 revealed no documentation for behaviors on day shift or night shift for 4/11/16, 4/12/16, 4/13/16, 4/14/16, 4/15/16, and 4/17/16. Interview with LPN #10 on 4/20/16 at 10:06 AM, on the 100 Hall revealed .The nurses assess for behaviors every shift and we document the behavior or zero if the resident is not having any behaviors . Interview with the DON on 4/21/2016 at 8:55 AM, in the conference room confirmed the facility failed to document behaviors every shift for Resident #125. | 2019-06-01 |
| 4955 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 520 | K | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the Quality Assurance (QA) Committee failed to identify and develop plans of action to ensure physician orders [REDACTED].#22, #150, #169, #178, #31, #93, #177) of 16 residents reviewed for medication administration. The facility's failure to ensure significant medication errors did not occurr placed 7 residents (#22, #150, #169, #178, #31, #93, #177) in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause serious harm, injury, impairment or death.) The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 4/25/16 at 10:50 AM, in the DON's office. The Immediate Jeopardy was effective 3/17/16 and is ongoing. The facility was cited an Immediate Jeopardy at F-281 (J); F-309 (J); F-333 (K); F-490 (K); F-501 (K); F-520 (K). The facility was cited Substandard Quality of Care at F-309 (J); F-333 (K). The findings included: Interview with the Administrator on 4/25/16 at 11:00 AM, in the DON's office confirmed the QA Committee had not identified medication errors as a problem. Further interview confirmed the facility failed to ensure the nurses were following the physician orders [REDACTED]. Interview with the Administrator on 4/25/16 at 11:05 AM in the DON office confirmed pain was identified as a problem but the QA Committee did not develop a plan of care to identify the residents not getting medications as ordered. Further interview confirmed the facility did not develop an audit to identify specific medications or audit medications administered and to ensure the medications were administered as ordered. Refer to F281 (J), F309 (J), F333 (K), F490 (K), F501 (K), F520 (K) | 2019-06-01 |
| 6518 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2015-04-15 | 315 | D | 0 | 1 | VLFE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to develop an individualized bladder re-training program for 1 resident (#106) of 3 residents reviewed for incontinence, of 29 residents reviewed. The findings included: Review of the facility policy, Bowel and Bladder Management, revision date (MONTH) 2012, revealed, .when a resident is identified as incontinent, he/she will be evaluated .and if appropriate, bowel and/or bladder re-training program is indicated .bowel and bladder reports from Care Tracker will be monitored for a 7-day period to establish voiding/bowel movement patterns and assist with establishing the Plan of Care. Medical record review of the behavioral medicine note dated 4/3/15 revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed as always continent and the Brief Mental Status Interview (BIMS) score 15/15, indicating resident was cognitively intact. Medical record review of the Evaluation for Bowel and Bladder Training dated 12/26/14 revealed no incontinence of bladder or bowel. Continued review of Evaluation for Bowel and Bladder Training dated 3/25/15 revealed occasionally incontinent. Comments: pad to bed for occ incontinence. Plan for mangagement: check for occasional urinary incontinent episodes walker @ bedside for (Independent) I toileting. Medical record review of the Quarterly MDS dated [DATE] revealed the resident was assessed as occasionally incontinent and the BIMS score 15/15 indicating resident was cognitively intact. Medical record review of the Custom Catch Report dated 3/28/15-4/14/15 revealed the resident had 7 episodes of incontinence between the hours of 10 PM and 6 AM. Medical record review revealed no documentation a bladder re-training program had been developed for the resident. Observation and interview with (Resident #106), on 4/15/15 at 1:10 PM in the residents room, revealed the resident awake, lying on the bed. The resident stated sometimes at night I wake up and can't get to the bathroom in time. Continued interview revealed the resident stated she recently had attempted to go to the rest room at night and had been incontinent of urine on the floor on 2 occasions. Interview with Registered Nurse (RN) #1, on 4/15/15 at 1:08 PM in the conference room, confirmed the resident was not reassessed when a decline from continent to occasionally incontinent of urine occurred and an individualized bladder re-training program had not been developed for the resident. | 2018-07-01 |
| 8649 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 164 | D | 0 | 1 | IFG311 | Based on observation and interview, the facility failed to ensure the privacy of one resident (#7) during one of two medication administration passes observed. The findings included: Observation with Licensed Practical Nurse (LPN) #2 on February 10, 2014, at 8:45 a.m., on the 100 hallway, revealed LPN #2 prepared medications at the medication cart, using the Medication Administration Record [REDACTED]. Continued observation revealed LPN #2 left the MAR indicated [REDACTED]. Interview with LPN #2 on February 10, 2014, at 8:57 a.m., in the hallway, confirmed the resident's information on the MAR indicated [REDACTED]. | 2017-05-01 |
| 8650 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 242 | D | 0 | 1 | IFG311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accommodate preferences for one resident (#67) of thirty residents reviewed. The findings included: Resident #67 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status exam indicating the resident was cognitively intact. Continued interview revealed the resident required extensive assistance from two persons for activities of daily living and personal hygiene, and was totally dependent with assistance of two persons for transfers. Review of the Mental and Behavioral Health Visit Notes dated November 25, 2013, January 7, 2014, and January 21, 2014, revealed, .wants to get up and out of .room to distract .and help .cope but says staff don't always follow through on getting .up .really needs to get out of .room occasionally because the isolation is feeding .depression .states has asked to get up and out of .room but staff can't seem to find the time .feels discouraged and defeated . Medical record review of the physicians recapitulation orders dated February 1 through February 28, 2014, revealed, .Up in chair daily; out of bed daily as per pt (patient) request . Observation on February 11, 2014, at 10:30 a.m., and February 12, 2014, at 10:00 a.m., in the resident's room, revealed the resident was in bed. Observation and interview with the resident in the resident's room, on February 11, 2014, at 10:30 a.m., confirmed the resident required assistance and the use of a lift for transfers to get out of the bed. Continued interview confirmed the resident had not been able to get out of the bed as often as desired due to not enough staff to get me up. Stated, I am aware of the extra time and attention it takes to get me up because of my size and having to use the lift. They (staff) tell me they will get me up, but they never do. Interview with the Director of Nursing (DON), in the activities room, on February 12, 2014, at 7:45 a.m., confirmed no knowledge the resident had not been assisted to get out of bed when requested. | 2017-05-01 |
| 8651 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 253 | D | 0 | 1 | IFG311 | Based on observation and interview, the facility failed to keep the hallways free of odors for two of four hallways. The findings included: Observation during the survey from February 10-12, 2014, of the one hundred hallway, revealed unpleasant, foul odors. Continued observation revealed the unpleasant, foul odors were in two rooms on the 100 hall. Interview with the Director of Nursing on February 12, 2014, at 8:55 a.m., in one of the rooms on the 100 hall, confirmed was aware of the rooms having unpleasant, foul odors due to the facility not able to regularly clean the air mattress used for the residents in the room. Continued interview revealed the resident in one room (private room) was aware of the odor and had asked the facility to hang cloves in the room to help with the odors. Observation during the survey from February 10-12, 2014, revealed the three hundred hallway had a foul odor, and appeared to be from one room. Continued observation revealed the odor was a strong urine smell. Interview with Licensed Practical Nurse #1 on February 12, 2014, at 9:40 am, in the three hundred hallway, confirmed the smell was urine smell coming from the room. | 2017-05-01 |
| 8652 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 279 | D | 0 | 1 | IFG311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the care plan for one resident (#67) with concerns of not getting out of bed; one resident (#13) for [MEDICAL TREATMENT] access; and one resident (#73) for [MEDICAL CONDITION] for a total of three of thirty residents reviewed. The finding included: Resident #67 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status exam indicating the resident was cognitivelly intact. Continued review revealed the resident required extensive assistance from two persons for activities of daily living and personal hygiene, and was totally dependent with assistance of two persons for transfers. Review of the Mental and Behavioral Health Visit Notes from the Licensed Clinical Social Worker (LCSW) dated November 25, 2013, January 7, 2014, and January 21, 2014, revealed, .want to get up and out of .rooom to distract .and help .cope but says staff don't always follow through on getting .up .really needs to get out of .room but staff can't seem to find the time .feels discouraged and defeated . Medical record review of the physician's recapitulation orders dated February 1 through February 28, 2014, revealed, .Up in chair daily; out of bed daily as per pt (patient) request . Medical record review of the care plan dated October 4, 2013, revealed the physician's orders [REDACTED]. Observation on February 11, 2014, at 10:30 a.m., and on February 12, 2014, at 10:00 a.m., in the resident's room, revealed the resident was in the bed. Observation and interview with the resident, in the resident's room, on February 11, 2014, at 10:30 a.m., confirmed the resident required assistance and use of a lift for transfers to get out of the bed. Continued interview confirmed the resident had not been able to get out of the bed as often as desired due to not enough staff to get me up. Stated, I am aware of the extra time and attention it takes to get me up because of my size and having to use the lift. They (staff) tell me they will get me up, but they never do. Interview on February 12, 2014, at 10:35 a.m., with the Minimum Data Set (MDS) Coordinator, in the MDS office, confirmed no knowledge of the LCSW's notes regarding the resident's concerns about not getting up, out of the bed. Continued interview confirmed the resident's care plan had not been revised to reflect the resident's preferences to be out of the bed daily. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a [MEDICAL TREATMENT] access (shunt) in the left upper arm and received [MEDICAL TREATMENT] three days a week at an out patient clinic. Medical record review of the care plan dated January 30, 2014, revealed the care plan did not address the resident's [MEDICAL TREATMENT] access (shunt) located in the left arm or the standard of practice which requires no needle sticks or blood pressure checks in the arm of the access. Observation on February 11, 2014, at 3:15 p.m., revealed the resident was in the resident's room watching TV. Interview with the Director of Nursing (DON) on February 12, 2014, at 8:40 a.m., in the DON's office, confirmed the care plan did not address the resident's [MEDICAL TREATMENT] access in the left upper arm. Resident #73 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Medical record review of the care plan updated November 18, 2013, and February 6, 2014, revealed the care plan did not address the resident's [MEDICAL CONDITION]. Interview with the DON on February 11, 2014, at 3:55 p.m., at the main nurses' station, verified the resident was receiving [MEDICATION NAME] for [MEDICAL CONDITION], and was initiated on November 7, 2013. Observation on February 11, 2014, at 4:30 p.m., revealed the resident was in the resident's room watching TV. Interview with the MDS Coordinator on February 11, 2014, at 4:45 p.m., in the MDS's office, confirmed the care plan did not address the resident's [MEDICAL CONDITION]. | 2017-05-01 |
| 8653 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 441 | D | 0 | 1 | IFG311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to change soiled clothing for one resident (#13) of thirty residents reviewed, and failed to prevent cross-contamination during ice pass for two of two ice passes observed. The findings included: Observation on February 11, 2014, at 10:15 a.m., of resident #13 resting in bed, revealed a large dark spot on the resident's gown. Continued observation revealed the dark spot was located on the left side just above the waistline, and was irregular in shape, measuring approximately two inches by two inches. Continued observation revealed the spot appeared to be dried blood. Continued observation revealed the resident had a dialysis access in the left upper arm. Interview with resident #13 on February 11, 2014, at 10:15 a.m., in the resident's room, confirmed the resident had gotten blood on the gown from the dialysis treatment the day before (February 10, 2014). Continued interview confirmed the resident returned to the facility between 5:00 p.m. and 6:00 p.m. Interview with the Director of Nursing on February 12, 2014, at 12:59 p.m., in the Activities room, confirmed the soiled gown was to be changed when the resident returned to the facility on [DATE]. Observation on February 12, 2014, at 7:30 a.m., on the 100 hallway, revealed certified nurse aide (CNA) #5 retrieved a water glass from room [ROOM NUMBER], held the glass over the ice container, filled the glass with ice from the container, and returned the glass to the resident's room. Continued observation revealed CNA #5 repeated this practice for another resident in room [ROOM NUMBER] before leaving the hallway. Interview with CNA #5 on February 12, 2014, at 12:55 p.m., confirmed the resident's water glass was not to be held over the ice container while filling the glass with ice. Interview with the Director of Nursing on February 12, 2014, at 12:55 p.m., confirmed the resident's water containers were not to be held over the ice container when filling the water containers. | 2017-05-01 |
| 8654 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 463 | D | 0 | 1 | IFG311 | Based on observation and interview, the facility failed to ensure the call lights were in working order for three of fifty-one rooms observed. The finding included: Observation with medical records staff member on February 12, 2014, at 10:00 a.m., in the one hundred hallway revealed one call light in one of 14 rooms was not working. Observation of the four hundred hallway, revealed the call lights in two rooms of seventeen rooms were not working. Interview with the medical records staff member at the time of observation confirmed the call lights were not working. | 2017-05-01 |