CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2019-05-31 | 609 | D | 1 | 1 | 4KQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to report an allegation of abuse for 1 of 3 (Resident #53) sampled residents reviewed for abuse. The findings include: The facility's Patient Protection .for Allegations/Incidents of Abuse . policy revised 12/11/17 documented, .The patient has the right to be free from abuse .5. Identification Policy .Any patient event that is reported to any partner by patient .will be considered an allegation of .abuse .if it meets any of the following criteria .patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others .6. Reporting Policy .It is the policy of this facility that abuse allegations .are reported per Federal and State Law . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 13, which indicated the resident was cognitively intact for decision making, required extensive assistance with activities of daily living, and had functional limitations in range of motion with impairment in both of her lower extremities. Review of the facility investigation of Resident #53's allegation of abuse revealed no documentation the abuse allegation was reported to the State. Interview with the Administrator on 5/29/19 at 5:09 PM in the Conference Room, the Administrator was asked when he was made aware of the allegation of abuse by Resident #53. The Administrator confirmed he was made aware of the allegation on 5/16/19, the day the allegation was made. The Administrator was asked if the allegation was reported to the State and the Administrator stated, .No. Interview with Resident #53 on 5/30/19 at 7:55 AM, in Resident #53's room, Resident #53 was asked if she had ever been abused or mistreated in the facility. Resident #53 stated, Well, uh .an aide .she just was rough . Resident #53 confirmed she reported the incident. Resident #53 stated she reported, That I thought she was physically and verbally abusing me. Resident #53 was asked if she was satisfied with the way the investigation was handled by the facility. Resident #53 stated, Yeah, I didn't want to make a big deal about it . Resident #53 confirmed that she felt safe in the facility. | 2020-09-01 |
| 2 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2019-05-31 | 641 | E | 0 | 1 | 4KQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately assess residents for the use of unnecessary medications and pressure ulcers for 7 of 17 (Resident #4, #24, #27, #30, #45, #51, and #254) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #4 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 13, which indicated no cognitive impairment, and the resident received anticoagulant medications daily during the 7-day look-back period. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Interview with the MDS Coordinator on 5/30/19 at 12:48 PM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to anticoagulant use. 2. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS of 14, indicating no cognitive impairment, and received anticoagulant medications 5 of the 7 days of the look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED] Interview with the MDS Coordinator on 5/30/19 at 12:50 PM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to anticoagulant use. 3. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS of 15, which indicated no cognitive impairment, and received antianxiety medications, antidepressant medications, anticoagulant medications, and diuretic medications 5 of the 7 days of the look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the MDS Coordinator on 5/30/19 at 9:59 AM in the Conference Room, the MDS Coordinator was asked if the admission MDS dated [DATE] was coded correctly for antianxiety, antidepressant, anticoagulant and diuretic medications. The MDS Coordinator stated, No. 4. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS of 15, which indicated no cognitive impairment, and received antidepressant and anticoagulant medications 7 days, antibiotics 2 days, diuretics and opioids 6 days of the 7-day look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The quarterly MDS dated [DATE] documented a BIMS of 12, which indicated moderate cognitive impairment, and received antidepressant, hypnotic, anticoagulant, and diuretic medications 5 days of the 7-day look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the MDS Coordinator on 5/30/19 at 9:18 AM in the Conference Room, the MDS Coordinator was asked if the admission MDS dated [DATE] was coded correctly for anticoagulants, antibiotics, diuretics and opioids. The MDS Coordinator stated, No. The MDS Coordinator was asked if the quarterly MDS dated [DATE] was coded correctly for antidepressants, hypnotics, anticoagulants and diuretics. The MDS Coordinator stated, No. 5. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS of 10, which indicated moderate cognitive impairment, and received anticoagulant medications daily during the 7-day look-back period. Review of the (MONTH) 2019 and (MONTH) 2019 MARs revealed no anticoagulant medication was administered. Interview with the MDS Coordinator on 5/30/19 at 12:51 PM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to anticoagulant use. 6. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS of 13, which indicted no cognitive impairment, and was coded for anticoagulant administration daily during the 7-day look-back period. Review of the annual MDS dated [DATE] revealed a BIMS of 14, which indicated no cognitive impairment, and was coded for anticoagulant administration daily during the 7-day look-back period. Review of the (MONTH) 2019 and (MONTH) 2019 MARs revealed anticoagulant medications were not administered. Interview with the MDS Coordinator on 5/30/19 at 10:45 AM in the Conference Room, the MDS Coordinator confirmed the MDS was coded incorrectly for anticoagulant administration. 7. Medical record review revealed Resident #254 was admitted to facility on 5/14/19 with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a BIMS score of 6, which indicated severe cognitive impairment, and was not coded for Unhealed Pressure Ulcers, Other Ulcers, Wounds and Skin Problems. Review of the physician's orders [REDACTED]. Review of the Weekly Wound Assessment Record dated 5/15/19 revealed an Unstageable Pressure Ulcer to the back of the right calf. Review of the Care Plan dated 5/21/19 revealed an Unstageable Pressure Wound to the back of the right calf. Interview with the MDS Coordinator on 5/30/19 at 10:10 AM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to Unstageable Pressure Ulcers and Skin Problems. | 2020-09-01 |
| 3 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2019-05-31 | 689 | D | 0 | 1 | 4KQP11 | Based on observation and interview, the facility failed to ensure the environment was free from accident hazards when 1 of 2 (Sling Lift) resident transfer lifts was not functioning properly. The findings include: Observations in Resident #36's room on 5/31/19 at 10:35 AM revealed Certified Nursing Assistant (CNA) #1 and #2 used a sling lift to transfer Resident #36 from his bed to his wheelchair. The lift malfunctioned momentarily and left Resident #36 suspended over his bed in the sling. The lift began working again, and the CNAs were able to lower Resident #36 into his wheelchair. Interview with CNA #2 outside Resident #36's room on 5/30/19 at 10:42 AM, CNA #2 was asked if there had been problems with the sling lift. CNA #2 stated, Here lately, yes. We have told maintenance. CNA #2 was asked how long the lift had been malfunctioning. CNA #2 stated, I'm not sure, maybe a week. Interview with CNA #3 on the West Hall on 5/30/19 at 10:43 AM, CNA #3 was asked if she had any problems with the sling lift. CNA #3 stated, Once in awhile it will get stuck .It's been reported to maintenance. We were just talking about it Monday. CNA #3 was asked what she was told by the maintenance staff. CNA #3 stated, He said he would look at it and try to oil it up or something. Interview with CNA #4 at the nurses station on 5/30/19 at 10:46 AM, CNA #4 was asked if she had any problems with the sling lift. CNA #4 stated, A little bit. CNA #4 was asked how long that had been going on. CNA #4 stated, It's been recent .I've noticed it usually happens more on bigger patients that it struggles with . Interview with the Director of Maintenance on 5/30/19 at 12:22 PM in the Conference Room, the Director of Maintenance was asked if he worked on the patient lifts. The Director of Maintenance stated, Not much .I just check the batteries. The Director of Maintenance was asked if he had been notified of a problem with the sling lift. The Director of Maintenance confirmed he had been notified. The Director of Maintenance was asked when he was first made aware of the problem. The Director of Maintenance stated, It's sporadic. Two or 3 months ago, we swapped the batteries. Interview with the Director of Maintenance on 5/30/19 at 1:17 PM in the Conference Room, the Director of Maintenance stated, .A service call was put in last Thursday, and then (Central Supply CNA) made a follow-up call yesterday because he hadn't come out yet. Interview with CNA #6 on 5/30/19 at 2:31 PM in the Conference Room, CNA #6 was asked if she ever had problems using the sling lift. CNA #6 stated, It's horrible. Something is wrong with the cord that connects the remote to the lift .You have to move the cord thingie around or it won't work. Sometimes it will and sometimes it won't. It has been reported . Interview with the Director of Nursing (DON) on 5/30/19 at 2:53 PM in the Conference Room , the DON was asked if the sling lift had been serviced recently. The DON stated, They are coming Tuesday. The DON was asked why the lift needed to be serviced. The DON stated, (Central Supply CNA) called them about something about it. Interview with the Administrator on 5/30/19 at 5:23 PM in the Conference Room, the Administrator was asked if he was aware the staff were having problems with the sling lift. The Administrator stated, I've heard a lot of discussion about the lift today. The Administrator was asked how often the lift was serviced. The Administrator stated, .Annually . The Administrator was asked if he was concerned the staff continued to use the sling lift even though it had not been working properly. The Administrator stated, No . Interview with the Central Supply CNA on 5/31/19 at 8:10 AM in the Conference Room, the Central Supply CNA was asked about the problem with the sling lift. The Central Supply CNA stated, The tilt wasn't working. The maintenance man looked at it. It was Tuesday (5/28/19) when I put the call (lift service call) in. They were closed on Monday (5/27/19) . The Central Supply CNA was asked if the sling lift was still being used for resident transfers. The Central Supply CNA confirmed it was still in use. The Central Supply CNA was asked how long she had known they were having problems with it. The Central Supply CNA stated, Last week one of the techs (CNAs) came to me . | 2020-09-01 |
| 4 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2017-08-16 | 371 | D | 0 | 1 | RSCD11 | Based on observation and interview the facility failed to ensure food was properly stored in 1 of 1 (Nurses Station) nourishment refrigerators. The findings included: Observations in the medication room nourishment refrigerator on 8/15/17 at 3:20 PM, revealed 3 cans of strawberry yogurt with expiration date of 8/4/17 and 3 cans of Glucerna Therapeutic Nutrition Classic Butter Pecan with expiration date of 5/1/17. Interview with Licensed Practical Nurse (LPN) #1 on 8/15/17 at 3:20 PM, in the medication room, LPN #1 was asked should expired food be kept in the refrigerator. LPN #1 stated, No it should not. Interview with LPN #2 on 8/16/17 at 1:04 PM, at the nurses' station, LPN #2 was asked what is the process for ensuring expired foods are removed from the refrigerator in the medication room. LPN #2 stated, It is dietary's responsibility for checking and removing expired food from the refrigerator .we stand at the door and allow them to go in and check everything and if something is expired then they remove it and replace it. Interview with the Dietary Manager (DM) on 8/16/17 at 1:08 PM, in the dining room, the DM was asked what the process is for removing expired food from the refrigerator in the medication room. The DM stated, Every night they go and rotate the oldest to the front and new to the back and check the dates and that is suppose to be done nightly. The DM was asked should you expect to find expired food in the refrigerator. The Dietary Manager stated, No. Interview with the Director of Nursing (DON) on 8/16/17 at 1:11 PM, at the nurses' station, the DON was asked what is the process for ensuring the nourishment refrigerator in the medication room is free of expired food. The DON stated, Dietary comes out and checks the refrigerator .we open the door and stand there while they check it but I expect my nurses to check for expiration dates prior to administering medications or food to a resident. | 2020-09-01 |
| 5 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2018-08-22 | 641 | D | 0 | 1 | X6JV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the resident's status for hospice and cognition for 2 of 12 (Resident #32 and 41) sampled residents reviewed. 1. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The significant change Minimal Data Set ((MDS) dated [DATE] failed to document that hospice services had been provided during the assessment period. Interview with the MDS Coordinator on 8/22/18 at 2:26 PM, in the MDS office, the MDS Coordinator was asked if the MDS dated [DATE] should have been marked to reflect the resident was receiving hospice services. The MDS coordinator stated, Yes. 2. Medical record review revealed Resident # 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not have a Brief Interview for Mental Status (BIMS) which is a score that indicates the resident's cognitive function. The MDS was not completed (blank) in the cognitive assessment area. Interview with the MDS Coordinator on 8/21/18 at 2:23 PM, in the MDS office, the MDS Coordinator was asked if the BIMS score and cognitive function section of the MDS was completed. The MDS Coordinator stated, No. | 2020-09-01 |
| 6 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2018-08-22 | 728 | E | 0 | 1 | X6JV11 | Based on review of the RULES OF TENNESSEE DEPARTMENT OF HEALTH BOARD FOR LICENSING HEALTH CARE FACILITIES DIVISION OF HEALTH CARE FACILITIES CHAPTER 1200-08-06 STANDARD FOR NURSING HOMES 1200- 6-.15, CNA (Certified Nursing Assistant) INSTRUCTOR job description, the Nurse Aide Training Program (NAT) sign in sheets, the Tennessee State tested Nurse Aide Exam results, the (NHC) OAKWOOD Time Schedule as Worked schedules, the Partner Time Collection Report, and interview, the facility failed to ensure 13 of 22 (Nursing Assistant (NA) #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) NAs enrolled in the facility's Nurse Aide Training Program (NAT) were supervised by the NAT instructor when they worked in the facility. The findings included: 1. The RULES OF TENNESSEE DEPARTMENT OF HEALTH BOARD FOR LICENSING HEALTH CARE FACILITIES DIVISION OF HEALTH CARE FACILITIES CHAPTER 1200-08-06 STANDARD FOR NURSING HOMES 1200- 6-.15 documented, .The provision of direct individual care to residents by a trainee is limited to appropriately supervised clinical experiences .a program instructor must be present or readily available on-site during all clinical training hours . 2. The facility's .CNA INSTRUCTOR job description documented, .The CNA instructor is to direct and sustain the CNA Training program in the Center in order to maintain adequate CNA staffing .Arrange and provide a clinical experience for the student that insures they are prepared for the skill test . 3. Review of the NAT program sign in sheets for the facility's NAT program held in (MONTH) and (MONTH) (YEAR) revealed a total of 22 students were enrolled in the program, which included NA #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13. 4. Review of the Tennessee State tested Nurse Aide Exam (Certified Nursing Assistant Examination) results revealed NA #1, 2, 3, 4, 5, 6, and 7 failed the examination. NA #8, 9, 10, 11, 12, and 13 have not taken the Tennessee State tested Nurse Aide Exam (Certified Nursing Assistant Examination). 5. Review of the NHC (National Healthcare Corporation) OAKWOOD TIME SCHEDULE AS WORKED for the period between 6/18/18 and 8/26/18 and review of the NAT instructor's Partner Time Collection Report (clocked hours) for the period between 6/18/18 and 8/26/18 revealed the following: [NAME] NA #1 worked 25 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #1 for all or part of 25 of 25 shifts NA #1 worked. B. NA #2 worked 17 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #2 for all or part of 17 of 17 shifts NA #2 worked. C. NA #3 worked 20 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #3 for all or part of 20 of 20 shifts NA #3 worked. D. NA #4 worked 37 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #4 for all or part of 37 of 37 shifts NA #4 worked. E. NA #5 worked 27 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #5 for all or part of 27 of 27 shifts NA #5 worked. F. NA #6 worked 26 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #6 for all or part of 26 of 26 shifts NA #6 worked. [NAME] NA #7 worked 9 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #7 for all or part of 9 of 9 shifts NA #7 worked. H. NA #8 worked 5 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #8 for all or part of 5 of 5 shifts NA #8 worked. I. NA #9 worked 3 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #9 for all or part of 3 of 3 shifts NA #9 worked. [NAME] NA #10 worked 8 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #10 for all or part of 8 of 8 shifts NA #10 worked. K. NA #11 worked 11 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #11 for all or part of 11 of 11 shifts NA #11 worked. L. NA #12 worked 4 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #12 for all or part of 4 of 4 shifts NA #12 worked. M. NA #13 worked 8 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #13 for all or part of 8 of 8 shifts NA #13 worked. The facility failed to ensure the NAs received appropriate clinical supervision by the NAT instructor for all or part of the shifts they worked. 6. Interview with NA #13 on 8/21/18 at 3:50 PM, in the Conference Room, Na #13 was asked who was supervising her during that shift. NA #13 stated, (named CNA #1). NA #13 was asked who was responsible for her. NA #13 stated, I'm not sure. Na #13 was asked if she helped toilet residents and helped use the lift on residents. NA #13 stated, Yes. Phone interview with NA #12 on 8/22/18 at 10:08 AM, NA #12 confirmed she was able to change a brief on her own and independently assisted residents who needed to be fed. Phone interview with NA #9 on 8/22/18 at 10:21 AM, NA #9 stated, .I can do anything, from feeding to changing briefs to showering .help residents with anything they need .do it without supervision . He confirmed the instructor is not always in the facility when he worked and stated, my other classmates help me out . Interview with the NAT instructor on 8/22/18 at 10:57 AM, in the Conference Room, the NAT instructor was asked if the NAs are supervised by her throughout the entire shift for all the shifts NAs were scheduled. The NAT instructor stated, No, they are not .I was off from 7/6 to 7/12, so they were not supervised during that time .I was not able to supervise them from 7/16 to 7/27 because I was doing another class and at (another location) .was off some of those Saturdays and Sundays. The NAT instructor was asked if it was appropriate for NAs to care for residents independently. The NAT instructor stated, No, ma'am. Interview with CNA #1 on 8/22/18 at 11:48 AM, in the Conference Room, CNA #1 was asked if the NAT instructor supervises the NAs on the evening shift. CNA #1 stated, She's not here every evening of the week . Interview with NA #8 on 8/22/18 at 2:15 PM, in the North Hall, NA #8 confirmed she works independently with residents, and her instructor is not always in the facility on the evening shift. | 2020-09-01 |
| 7 | NHC HEALTHCARE, DICKSON | 445004 | 812 CHARLOTTE ST | DICKSON | TN | 37055 | 2019-08-01 | 686 | D | 0 | 1 | 4FC811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide timely assessments and treatments for pressure ulcers for 1 of 4 (Resident #87) sampled residents reviewed for pressure ulcers. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/4/19 documented, .has alteration in skin r/t (related to) dark and reddened areas to (R) (right) foot . The Admission assessment dated [DATE] documented, .bilat (bilateral) red heels and outer rt (right) heel dark purple area (possible SDTI) (suspected deep tissue injury) . Review of the wound assessments revealed no assessments were completed for Resident #87's sDTI from admission until 7/9/19. Review of the Treatment Administration Records dated (MONTH) and (MONTH) 2019 revealed there was no documentation of wound care treatment for [REDACTED]. Medical record review revealed the pressure ulcer to the right heel remained an unstageable pressure ulcer and had not worsened. Observations in Resident #87's room on 7/18/18 at 2:05 PM, revealed Resident #87, she had a unstageable pressure injury to the right lateral heel. Interview with the Director of Nursing (DON) on 7/31/19 at 2:38 PM, in the Education Room, the DON was asked if Resident #87 was admitted with any pressure ulcers. The DON stated, .she had a suspected deep tissue injury .outer right heel . The DON was asked if weekly skin assessments and treatments should have been done. The DON stated, Yes. The DON was asked when the wound assessments and treatments began. The DON stated, .we started (MONTH) 2nd . The facility was unable to provide documentation that wound assessments and treatments were provided for Resident #87's pressure ulcer that was identified on 6/4/19, until 7/2/19. | 2020-09-01 |
| 8 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2019-01-16 | 842 | D | 0 | 1 | 6O2811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure Physician order [REDACTED].#340 and #341) of 3 residents reviewed of 29 residents sampled. The findings include: Medical record review revealed Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form, undated, revealed the physician had not signed and dated the resident's POLST form. Medical record review revealed Resident #341 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form dated 1/4/19 revealed the POLST form was not signed by the resident and the health care professional preparer of the form. Interview with the Director of Nursing (DON) on 1/16/19 at 8:47 AM, in the DON's office, confirmed the POLST forms were to be completed within 24 hours of admission to the facility. Continued interview confirmed the facility failed to ensure the POLST forms were complete for Resident #340 and #341. | 2020-09-01 |
| 9 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2020-02-20 | 574 | C | 0 | 1 | UNET11 | Based on facility policy review, admission packet review, interview, and observation, the facility failed to support each resident's rights by ensuring the required State Survey Agency's contact information was made available for 3 of 3 residents (Resident #1, Resident #2, and Resident #16). Interviews obtained during the resident group meeting revealed the residents had not been given information on how to file a complaint with the State Survey Agency. This failure had the potential to affect all 43 residents of the facility who may want to exercise their right to file a complaint directly with the State Survey Agency. Findings include: Review of the facility's policy titled, Patient Rights and Responsibilities-Siskin West Subacute, undated, revealed the residents had the right to .contact the Tennessee Department of Health directly at (telephone number) to lodge any concerns you may have about your care. Review of the facility's policy titled, Resident Rights, undated, located in the facility's admission packet provided during the entrance conference, revealed at the time of admission, and periodically through their stay, the facility would inform each resident, orally and in writing, of their rights. The policy stated the resident had the right to voice grievances to the facility, or other agency or entity that hears grievances, without discrimination or reprisa,l and without fear of discrimination or reprisal. The policy also stated the resident had the right to be afforded the opportunity to contact these agencies. The policy stated the resident had the right to immediate access to any of the following: any representative of the Secretary of the U.S. Department of Health and Human Services, any representative of the State, the resident's individual physician, the State's long-term care ombudsman, and the agency responsible for the protection of, and advocacy system for, mentally or developmentally disabled individuals. Review of an untitled and undated form, located in the Admission Packet provided by the facility during the entrance conference, revealed residents could report a complaint or grievance to the Administrator, Director of Nursing, and/or Director of Quality/Grievance Officer. Residents could also report a complaint or grievance directly to the Ombudsman, CMS (Centers for Medicare & Medicaid Services), or to the State of Tennessee Department of Health. There was no contact information for the State of Tennessee Department of Health on the form. Interviews with Resident #1, Resident #2, and Resident #16 on 2/19/2020 at 10:39 AM, during the group meeting in the third-floor chapel, revealed the residents had not been given information on how to contact the State Survey Agency to formally complain about the care they received. Resident #16, who was the Resident Counsel President, stated, it would be good to know or have just in case. Observation and interview with the Administrator on 2/20/2020 at 1:00 PM, in the entry way of the first floor, revealed information about how to contact the State Survey Agency was hanging on the wall in a picture frame. Interview with the Administrator revealed the area between the parking garage and the lobby of the first-floor was not a common area where residents of the facility frequented, but visitors did. Interview with Certified Nurse Aide (CNA) #7 on 2/20/2020 at 1:29 PM, at the second-floor nurses' station, revealed to her knowledge, there was no information posted about how to contact the State Survey Agency. Interview with Licensed Practical Nurse (LPN) #5 on 2/20/2020 at 1:33 PM, at the second-floor nurses' station, revealed to her knowledge, there was no posting or information about how to contact the State Survey Agency. Interview with the Administrator on 2/20/2020 at 1:41 PM, at the second-floor nurses' station, revealed she had updated the admission packet today to include how to contact the State Survey Agency. Interview with LPN #8 on 2/20/2020 at 1:45 PM, at the third-floor nurses' station, revealed to her knowledge, there were no postings with information about the State Survey Agency. The LPN stated if a resident needed the State Survey Agency's number, they could always ask someone at the nurses' station and they would get the number for them. | 2020-09-01 |
| 10 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2020-02-20 | 679 | D | 0 | 1 | UNET11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of activity calendars, observations, and interviews, the facility failed to provide activities for 4 of 25 sampled residents (Resident #131, Resident #132, Resident #230, and Resident #232) who resided on the Sub-Acute Unit. Failure to provide residents with an activity program has the potential to affect the residents' physical, mental, and psychosocial well-being. Findings Include: Review of the St. Barnabas/Siskin West Policy Activities Department updated/revised 12/2018 indicated the definition of an activity was any activity other than activities of daily living that enhanced the resident's well-being. The policy indicated the activities would be person-centered and highlight the resident's quality of life. The procedure indicated the AD would visit the resident after admission to obtain likes and dislikes. The procedure further indicated the AD would educate the resident on happenings on the unit and she would provide an activity calendar for the resident. The policy stated, .should the patient/resident decline to attend activities .they will be provided with in-room options or 1:1 (one on one) opportunities .puzzles, books, magazines, movies and music. Resident #131 was admitted to the facility on [DATE] for occupational and physical therapy following a motor vehicle accident. Review of the Baseline Care Plan dated 2/17/2020, revealed it did not address Resident #131's activity preferences. Review of Resident #131's Resident Activities Assessment Preferences for Customary Routine Activities dated 2/19/2020, revealed it was very important for the resident to do her favorite activities; and it was somewhat important for the resident to have books, newspapers, and magazines to read, to listen to music she liked, to do things with groups of people, to go outside to get fresh air when the weather was good, and to participate in religious services or practices. Review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/23/2020 revealed Resident #131 was cognitively intact. Observations of Resident #131 conducted through-out the day on 2/18/2020, 2/19/2020, and 2/20/2020, in the resident's room, revealed Resident #131 had not been approached to attend activities and had not been observed in activities, either at her bedside, or in a group setting. Review of the Activity Calendar posted on the hallway by the nurses station on the 2nd floor Subacute Unit on Wednesday 2/19/20 at 8:49 AM, indicated good morning rounds were to be done at 9:00 AM; tai ji (Tai Chi) at 10:30 AM; at 2:00 PM Oliver visits; bingo was at 2:15 PM; and chili tasting was at 2:45 PM. During interview with Resident #131 on 2/19/2020 at 3:49 PM, at her bedside, Resident #131 was asked if she participated in the activities provided by the facility. The resident stated No, I didn't realize they had activities. Resident #131 was asked if anyone had come around and asked if she wanted to attend the activities, or to bring her a magazine or newspaper, and the resident stated, No. The resident was asked, if she were asked to participate in activities would she, and the resident stated, It would depend on the activities. The resident was asked if she would have attended this afternoon's bingo and chili tasting, and Resident #131 stated, I would have liked that. Resident #132 was admitted to the facility on [DATE] for occupational and physical therapy following a right total knee arthroplasty. Review of Resident #132's Baseline Care Plan dated 2/13/2020, showed it did not address the resident's activity preferences. Review of the admission MDS with an ARD of 2/19/2020 revealed Resident #132 was cognitively intact. Review of the Resident Activities Assessment, Preferences for Customary Routine Activities dated 2/19/2020, revealed it was very important to Resident #132 to listen to music he liked; and somewhat important to have books, newspapers, and magazines to read, keep up with the news, to do things with groups of people, to do his favorite activities, and to go outside to get fresh air when the weather was good. Observations conducted through-out the day on 2/18/2020, 2/19/2020, and 2/20/2020, in the resident's room, revealed Resident #132 had not been approached to attend activities and had not been observed in activities, either at his bedside, or in a group setting. During interview with Resident #132 on 2/19/2020 at 2:04 PM, the resident was asked if he had participated in any of the activities since he had been in the facility. Resident #132 stated, No. Resident #132 was asked if he was aware there were activities offered at the facility, and the resident stated, No, no one has told me anything about any activities. Resident #132 was questioned if the staff were to ask, would he participate in activities, and the resident stated, I probably would. Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Social History/Admission assessment dated [DATE], revealed Resident #230 had a mini mental score of 15, which indicated Resident #230 had intact cognition. Record review of Resident #230's initial Resident Activities Assessment Preferences for Customary Routine Activities dated 2/17/2020, indicated it was very important to the resident to have animals around, keep up with the news, and participate in religious services. Observation on 2/18/2020 at 9:39 AM, revealed Resident #230 was in his room. There was an activity calendar posted in the resident's room. Interview with Resident #230 on 2/18/2020 at 9:39 AM, revealed no one had informed him of any activities going on that day. Resident #230 stated Lord I did not even know that the activity calendar was posted in the room. He stated he had not read the calendar and did not think anyone had ever come to him to discuss activities. Resident #230 stated he would be interested in going to activities according to the time of day. He stated he liked working in the yard. Observation on 2/18/2020 at 2:18 PM, revealed Resident #230 was sitting up in a chair in his room. There was not an activity person in his room or on the unit, even though pet therapy was listed on the activity calendar in his room and on the big activity calendar in the hallway by the nurse's station. Interview with Resident #230 on 2/18/2020 at 2:18 PM, in his room, revealed someone had been in earlier and asked if he wanted a magazine, and that was all. Observation of Resident #230 on 2/19/2020 at 9:00 AM, revealed he was sitting up in a chair in his room and was getting ready to go to therapy at 9:45 AM. Resident #230 stated no one had been by and invited him to any activities that day, but he had a calendar that might tell what was going on. Observation on 2/19/2020 at 3:32 PM, in the dining/activity room on the 2nd floor Subacute Unit, revealed no chili tasting activity was taking place, which was listed as an activity on the calendar for 2:45 PM. Observation on 2/19/2020 at 3:35 PM, in the dining/activity room on the 3rd floor, showed a chili tasting event was occurring. Resident #230 was not in attendance. Review of the Activity Calendar posted on the hallway by the nurse's station on the 2nd floor Subacute Unit indicated on Thursday (MONTH) 20, 2020 showed there would be seven activities that day. The calendar indicated that at 8:30 AM the news would be done; 9:00 AM would be good morning rounds; 10:00 AM would be coffee activity; 11:00 AM papers were to be delivered; 11:30 AM would be bible story time; and at 2:30 PM Wheel of Fortune would be played. Interview with Registered Nurse (RN) #6 on 2/20/2020 at 12:23 PM, revealed she had not discussed any activities with Resident #230. During interview with Resident #230 on 2/20/2020 at 12:35 PM, he was in his room and his wife was at the bedside. Resident #230 stated he did not go to the chili tasting yesterday and no one had been by for morning coffee that morning. Resident #230 state he needed to get out more and socialize. Resident #230 further stated he liked chili. Resident #232 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #232's Social History/Admission assessment dated [DATE], revealed the resident had a mini mental score of 15, which indicated intact cognition. Record review of Resident #232's initial Resident Activities Assessment Preferences for Customary Routine Activities dated 2/13/2020 revealed it was very important to the resident to keep up with the news and to go to religious services. Observation and interview on 2/18/2020 at 1:04 PM, revealed Resident #232 was sitting in his room watching television. During interview, Resident #232 stated he was not aware of any activities that the facility provided. Resident #232 stated he did not think anyone had ever discussed activities with him. He stated he might go to an activity, but it depended on what time it was. He stated he liked music. Resident #232 stated he had not gone to the sing a long that was posted on the calendar for the past Saturday, and he had not been invited to go. Interview with Licensed Practical Nurse (LPN) #5 on 2/20/2020 at 11:30 AM, in the dining/activity room on the 2nd floor Subacute Unit, revealed some residents would say they were bored and they had cabin fever. LPN #5 stated she would tell the residents they were welcome to come out in the hallway and visit. LPN #5 stated she would tell the resident about the books and puzzles available on the unit and there were puzzles and activities upstairs on the 3rd floor. LPN #5 stated she would give the residents the activity calendar and told them how to get to it on the 3rd floor. Interview with the Director of Nursing (DON) on 2/20/2020 at 2:24 PM, in her office, revealed very rarely did a subacute person go to activities because they were mainly interested in getting well and going home. The DON stated the subacute stays were only two weeks and then they go home. The DON stated there was an activity calendar in each room and a big calendar in the hallway that the subacute residents passed by when going to therapy. The DON stated she was not sure if the subacute had to have documentation activities were done. The DON stated the residents in the subacute unit wanted to just go home and she felt it did not pose any risk to the residents if they did not go to activities. Interview with the AD on 2/20/2020 at 10:30 AM, in her office on the 3rd floor, revealed she had been the Activity Director for 4 years. The AD stated she used to have 3 Activity Assistants, but now it was only her. She used to have more volunteers and now she has fewer. The AD stated the nurses did the initial activity assessment, she would check over the assessment, then she would go talk to the residents and gave the residents an activity calendar, and she would go over it with the resident. She offered the residents cards, magazines, puzzles, Sudoku, and CD players. She told the residents where the books and puzzles could be located. The AD stated most of the rehab residents were more self-directed and could do their own interests. Most of the rehab residents wanted to do their rehabilitation, go home, and were not much interested in activities. The AD stated the facility has 50's singing once a month and church services on Sundays and Tuesdays. If the resident filled out that religious services or music was important to them, then she tried to get them to the services. The AD stated she did not work on the weekends and could not say if Resident #230 or Resident #232 had attended any religious services on the weekends. She did not keep track of who attended the weekend activities. Pet therapy had been cancelled because of the weather. Resident #230 and Resident #232 had not participated in the chili tasting activity yesterday and had not attended any facility activity. The AD had tried to come down to the 2nd floor yesterday to do an activity, but had only been there a few minutes and the 3rd floor paged her, and she had to go back up there to do their activity. She stated the residents on the 3rd floor liked to get her attention and looked to her for activities. The AD stated she tried to get to the 2nd floor to at least pass out books and magazines. During interview with the Administrator on 2/20/2020 at 1:30 PM, in the conference room, the Administrator was asked what her expectations were related to activities for the Sub-Acute Unit residents. The Administrator stated I expect the sub-acute residents to be asked if they want to participate in activities whenever there are activities going on, or if they want to do a bedside activity. The Administrator added the Activity Director told her she hasn't had the chance to get to the subacute residents this week. | 2020-09-01 |
| 11 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2020-01-02 | 580 | D | 1 | 0 | 14S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to notify the physician in a timely manner of a malfunction of a Percutaneous Endoscopic Gastrostomy (PEG) tube (flexible feeding tube inserted through the abdominal wall and into the stomach for nutrition, fluids, and medications) for 1 resident (#2) of 3 residents reviewed for PEG tubes. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 5/9/19 revealed Resident #2 was care-planned for Infection Potential related to Feeding Tube, and Nutritional Status, Dependent on Tube Feed with interventions including (caloric, fiber fortified nutritional tube feeding) at 60 milliliters an hour for 18 hours, assess for changes in condition and notify medical staff, and MD (medical doctor) to replace PE[NAME] Medical record review of the Resident Progress Notes dated 9/1/19 at 1:38 PM, for Resident #2 revealed .in am, previous shift .nurse reported perforation to PEG tube. Noted large hole at end of catheter. Removed without difficulty and replace with new 24F (French) 20 cc (cubic centimeters) tube .restarted without concerns per supervisor .Husband updated, left message with NP (Nurse Practitioner) . Further review revealed no documentation the physician or the NP was made aware of the PEG tube perforation and the removal and reinsertion of a new PEG tube. Medical record review of the Physician's Orders on 9/1/19 revealed no documentation of an order to reinsert the PEG tube. Medical record review of an untitled typed letter, dated 10/14/19, and signed by the Unit Supervisor RN revealed .pt. (patient) had a removable gastric tube in place that had perforated and some of the balloon was visible from tube site entrance .nurse notified house supervisor .replaced with facility gastric tube . Interview with the Compliance Registered Nurse (RN) (former Unit House Supervisor) on 1/2/20 at 12:15 PM, in the Conference Room, confirmed she was the supervisor on duty on 9/1/19 when the Licensed Practical Nurse (LPN) (no longer employed at the facility), notified her of the perforated PEG tube. Continued interview confirmed she and the LPN removed the perforated PEG tube, reinserted a new PEG tube without notifying the physician. Interview with the Compliance RN, the Director of Nursing, and the Corporate Consulting RN on 1/2/20 at 1:50 PM, in the Conference Room, confirmed the facility did not notify the physician or NP of the PEG perforation and removal and reinsertion of the PEG tube. | 2020-09-01 |
| 12 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2018-03-20 | 655 | D | 0 | 1 | 48GW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a baseline care plan to address the care and treatment of [REDACTED].#459) of 49 sampled residents reviewed for baseline care plans. The findings included: Medical record review revealed Resident #459 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge orders dated 3/9/18 revealed Resident #459 was discharged with an indwelling urinary catheter. Medical record review of a baseline care plan dated 3/9/18 revealed no care plan for the care and treatment of [REDACTED]. Interview with the Director of Nursing on 3/20/18 at 7:22 AM, in the conference room, confirmed Resident #459's care plan failed to address the treatment and care of the indwelling urinary catheter. | 2020-09-01 |
| 13 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2018-03-20 | 684 | D | 0 | 1 | 48GW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview the facility failed to obtain a physician's order for an indwelling urinary catheter for 1 resident (#459) of 3 residents reviewed for urinary catheters of 49 sampled residents reviewed. The findings included: Review of the facility policy, Electronic Health Record IMAR System, dated 4/24/15 revealed .admission orders [REDACTED]. Medical record review revealed Resident #459 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of hospital discharge orders dated 3/9/18 revealed .MD (Medical Doctor) order for (urinary catheter) .Catheter this admission: yes . Medical record review of Physician's Orders dated 3/9/18 revealed no order for an indwelling urinary catheter. Observation of Resident #459 on 3/18/18 at 11:00 AM and 2:00 PM, in the resident's room, revealed the resident had an indwelling urinary catheter. Observation of Resident #459 on 3/19/18 at 9:25 AM and 3:00 PM, in the resident's room, revealed the resident had an indwelling urinary catheter. Interview with Licensed Practical Nurse (LPN) #1 and LPN #2 at 3:30 PM, the 400 hall nursing station, revealed they were unaware Resident #459 had an indwelling urinary catheter and there was no physician's order. Interview with the Director of Nursing on 3/20/18 at 7:22 AM, in the conference room, confirmed the admitting nurse failed to properly reconcile admission orders [REDACTED]. Continued interview confirmed .We missed it . | 2020-09-01 |
| 14 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2018-03-20 | 689 | D | 0 | 1 | 48GW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide new interventions after a fall for 1 resident (#40) of 6 residents reviewed for falls of 49 residents reviewed. The findings included: Review of the facility's NHC FALLS PROGRAM undated revealed .Purpose: To identify patients at risk for falling and to implement the appropriate interventions .3) Implement appropriate interventions 4) Evaluate the effectiveness of the interventions . Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 1 staff to transfer, dress, toilet, complete personal hygiene, and the resident was non-ambulatory and total assistance of 1 staff for bathing. Review of the POS [REDACTED]. The new intervention was to keep the resident in high traffic areas. Review of the POS [REDACTED]. The new intervention was to educate staff to keep the resident in high traffic areas. Observation and interview with Resident #40 on 3/20/18 at 9:15 AM in the dining area revealed he was sitting in his geri chair (in the down position) at the table finishing his breakfast. States he falls because he is clumsy. I'm 96, old people fall Observation of Resident #40 on 3/20/18 at 2:30 PM, in the dining area revealed the resident sitting in the geri chair asleep, with the chair reclined. Interview with the Licensed Practical Nurse (LPN) Risk Manager on 3/20/18 at 2:45 PM, in the conference room revealed after reviewing the 9/21/17 and 10/8/17 Post Falls Investigations confirmed the new intervention for the 9/21/17 fall was to keep the resident in a high traffic area, this would include educating the staff of the new intervention, and would be added to the Certified Nurse Assistant work sheet. Continued interview confirmed Resident #40 received a hematoma to his forehead with the 10/8/17 fall, and the resident was in his room, which is not in a high traffic area. Further interview confirmed the new intervention to educate staff to keep the resident in a high traffic area was not a new intervention. | 2020-09-01 |
| 15 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-01-18 | 602 | E | 1 | 0 | GSLM11 | **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 prevent misappropriation of resident's medication for 5 residents (#1, #3, #4, #5, and #6) of 9 residents reviewed for abuse. The findings included: Review of the facility policy Resident Rights - Abuse of Residents revised [DATE] revealed, .any type of resident abuse .or misappropriation of resident property is strictly prohibited .misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of a resident's belonging or funds without the resident's consent . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Medical record review of Resident #1's Physicians Orders revealed an order dated [DATE] for [MEDICATION NAME] (pain medication) 0.25 milliliters (ML) sublingual (under the tongue) as needed (PRN) every 1 hour for pain. Continued review revealed the order was discontinued on [DATE]. Further review revealed an order dated [DATE] for [MEDICATION NAME] 0.5 ml sublingual PRN every 3 hours as needed for pain. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #3 was moderately cognitively impaired. Medical record review of the Physician Orders revealed an order for [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #4 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating Resident #4 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 2 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 2, indicating Resident #5 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML sublingual every 4 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #6 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 0 (zero), indicating Resident #6 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 4 hours as need for pain. Review of a facility investigation dated [DATE] revealed the facility became aware of a possible drug diversion at approximately 11:45 PM on [DATE]. Further review revealed during the narcotic count at shift change between 2nd and 3rd shift, Licensed Practical Nurse (LPN) #3 observed a vial of [MEDICATION NAME] prescribed for Resident #1, which appeared to have the tamper resistant seal altered. Continued review revealed the vial was full as if no medication had been administered. Further review revealed LPN #3 immediately notified LPN #2, the night shift supervisor, of her concern and at that time LPN #2 immediately notified the Director of Nursing (DON). Continued review revealed the vial of [MEDICATION NAME] was delivered to the facility the afternoon of [DATE] and Resident #1's Medication Administration Record [REDACTED]. Continued review revealed on [DATE] the DON began a facility wide investigation. Further review revealed during a narcotic audit the facility identified 3 additional residents' (#4, #5, and #6) vials of [MEDICATION NAME] were altered. Further review revealed, after reviewing the staffing assignment sheets and schedules, the facility was able to identify Registered Nurse (RN) #1 provided care to, and had access to, the residents' medications. Further review revealed on [DATE], during the facility's monthly narcotic waste, the DON and the Pharmacist found a vial of [MEDICATION NAME] prescribed for Resident #3, which had been placed in the narcotic waste bin after the order was discontinued on [DATE]. Continued review revealed the vial of [MEDICATION NAME] was noted to have been altered. Further review revealed the DON reviewed the staffing assignment sheets and RN #1 provided care to Resident #3 on [DATE], the day the [MEDICATION NAME] was discontinued. Review of the police report dated [DATE] revealed .responded to (facility) in reference to a theft of medication .advised (RN #1) .had stolen liquid [MEDICATION NAME] from four different residents at the facility. (RN #1) stole the medication .While on scene I observed a bottle of [MEDICATION NAME] that had been diluted .(RN #1) was subjected to a drug screen, in which the first sample showed invalid due to the temperature of the urine at the time. (RN #1) was subjected to a second drug screen, in which she tested positive for [MEDICATION NAME] . Continued review revealed RN #1 admitted to stealing the [MEDICATION NAME]. Review of the Urine Drug Screen Laboratory Report dated [DATE] revealed RN #1 was positive for [MEDICATION NAME]. Interview with RN #1 via phone on [DATE] at 10:33 AM, confirmed she had taken [MEDICATION NAME] from various residents over a two week period in (MONTH) (YEAR). Continued interview confirmed she was unable to identify the residents specifically. Interview with the DON on [DATE] at 9:16 AM, in the conference room, confirmed she was made aware of possible drug diversion on [DATE] at approximately 11:45 PM by LPN #2. Further interview confirmed LPN #2 reported the vial of [MEDICATION NAME] ordered for Resident #1 was delivered to the facility on [DATE], the tamper resistant seal showed signs of having been tampered with, and Resident #1's MAR indicated [REDACTED]. Continued interview confirmed during the course of their investigation the facility identified 4 additional residents (Residents #3, #4, #5, and #6) whose vials of [MEDICATION NAME] were altered. Further interview confirmed after reviewing the staffing assignment sheets and schedule, the facility was able to determine RN #1 provided care to the affected residents. Continued interview confirmed initially RN #1 denied having any knowledge of the altered [MEDICATION NAME] but eventually admitted to the misappropriation of the [MEDICATION NAME]. Further interview confirmed RN #1 was suspended on [DATE] and remained on suspension until being terminated on [DATE]. Interview with the DON on [DATE] at 10:10 AM, in the conference room, confirmed through the facility's investigation they were able to identify RN #1 had taken [MEDICATION NAME] from 5 residents (Residents #1, #3, #4, #5, and #6) and the facility had failed to prevent misappropriation of resident's medication. | 2020-09-01 |
| 16 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2020-02-20 | 625 | D | 1 | 0 | D8DU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to provide a bed hold notice for 1 resident (Resident #1) transferred to a psychiatric facility of 3 transferred residents reviewed. The findings included: Review of the facility's policy titled, Bed Hold Policy dated 10/19/2019 showed .Residents and/or responsible parties will be fully informed of options regarding the holding or releasing of a bed when the resident is temporarily transferred from the facility or is on a therapeutic leave.Upon admission to the facility the resident and/or their representative will be notified in writing of (named facility) Bed Hold Policy.In the event that the resident is transferred out of the facility temporarily, or the resident goes out on a therapeutic leave a copy of the Bed Hold Agreement will be given to the resident or their representative.This process will be followed for all transfers, regardless of payer type. A copy of the Bed Hold Agreement will be placed in the residents Business Office File and a copy of the bed hold agreement will be provided to the resident or their representative. Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to a psychiatric facility. Resident #1 was readmitted to the facility on [DATE], but was discharged again to the psychiatric facility on 7/24/2019 and did not return to the facility. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #1 had short and long term memory loss and exhibited physical and verbal behaviors directed towards others. Review of a Physician's Telephone Order dated 6/8/2020 showed .transfer to (named psychiatric facility).psych eval (psychiatric evaluation). Review of a Physician's Telephone Order dated 7/23/2020 showed .send to (named psychiatric facility) for evaluation + (and) tx (treatment). Medical record review showed no documentation a bed hold notice was provided to the resident or the resident's representative prior to the resident being transferred to the psychiatric facility on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 5:20 PM, the Administrator stated .I looked through the entire chart and could not find it.did not find a progress note.only thing we have is a resident agreement.does not mention bed hold.both times the resident was sent out to a psych facility.behaviors.combative.nothing for either transfer. The Administrator confirmed the facility did not give the resident or the resident representative a bed hold notification prior to the transfer on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 5:30 PM, the Nurse Manager confirmed a bed hold policy was not given to the family prior to transferring the resident on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 6:00 PM, the Social Worker confirmed a bed hold policy was not given to the resident or the resident's representative prior. During a telephone interview on 2/20/2020 at 6:30 PM, Resident #1's representative stated she was not made aware of the facility's bed hold policy either verbally or in writing. | 2020-09-01 |
| 17 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-04-26 | 609 | D | 1 | 0 | 6SJ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility investigation, observation, and interviews, the facility failed to report an injury of unknown origin for 1 resident (#3) of 5 residents reviewed. The findings included: Review of the facility policy Resident Rights Abuse of Residents dated 11/14/16 revealed .an injury of unknown origin .must be reported to the Executive Director .Resident Incidents must be reported immediately .not later than 24 hours if the events that cause the allegation do not involve abuse .to other officials (including law enforcement, state survey agency, and adult protective services) .in accordance with applicable law and regulations . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident had short and long term memory problems and was severely cognitively impaired for daily decision making skills. Further review revealed the resident required extensive to total assist for activities of daily living (ADL) with 1-2 person assist. Review of a facility investigation dated 3/28/18 revealed Certified Nurse Assistant (CNA) #1 noted bruising to Resident #3's left forehead, which was not present earlier in the day. Further review revealed CNA #1 reported the bruising to Licensed Practical Nurse (LPN) #5. Continued review revealed LPN #5 reported the injury to the Director of Nursing (DON). Interview with CNA #1 on 4/25/18 at 11:30 AM, in the 1 South Breakroom, revealed .I was on my way to lunch . (another CNA) was pushing her (Resident #3) out of the dining room .I brushed her (Resident #3's) hair back from her face and that is when I noticed the bruise .it was purple .reported to the nurse .got her (Resident #3) up and dressed that morning and did not see anything then . Interview with LPN #2 on 4/25/18 11:40 AM, in the 1 South Breakroom, revealed .immediately went and assessed her (Resident #3) .she had a hematoma to the top left of her hairline .the bruising was coming down toward her eye .notified the DON .the Nurse Practitioner was in the facility and came and assessed her .notified the family . Observation on 4/25/18 at 12:00 PM revealed Resident #3 was seated in her wheelchair in the dining room. Continued observation revealed the resident had a slight purplish discoloration from her hairline down the left side of her forehead. Interview with the Administrator on 4/26/18 at 1:30 PM, in his office, confirmed the injury of unknown origin was not reported to Adult Protective Services, Law Enforcement, or the Ombudsman and the facility failed to follow facility policy. | 2020-09-01 |
| 18 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-04-26 | 656 | D | 1 | 0 | 6SJ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interviews, the facility failed to ensure the comprehensive care plan was person centered for bathing for 2 residents (#1 and #2) of 5 residents reviewed. The findings included: Review of the facility policy Bathing dated 3/7/14 revealed .All Residents complete bathing needs will be met twice weekly, or at a schedule based on resident preference . Review of the facility policy Comprehensive Resident Centered Care Plan dated 11/2/16 revealed .The care plan incorporates the resident's strengths and abilities as well as areas requiring support . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's care plan dated 2/5/18 revealed .provide care as needed by the resident to complete his/her daily care needs . Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident required extensive assist with transfers, bathing, and dressing with 1-2 person assist. Continued review revealed the resident had a functional limitation of 1 upper and 1 lower extremity. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's care plan dated 3/22/18 revealed .provide care as needed by the resident to complete his/her daily care needs . Review of the admission MDS dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident required extensive assist for transfers, dressing with 2 person assist, and was totally dependent for personal hygiene and bathing with 1-2 person assist. Interview with Certified Nursing Assistant (CNA) #1 on 4/25/18 at 2:45 PM, on 1 South Household hallway, revealed .most residents get 2 showers a week unless they request more . Interview with Licensed Practical Nurse (LPN) #6 on 4/26/18 at 12:15 PM, in the therapy gym office, revealed . care plan should address the resident's preference and frequency of bathing . Interview with the Director of Nursing (DON) on 4/26/18 at 1:15 PM, in the DON's office, confirmed the care plans for Resident #1 and Resident #2 did not adequately reflect their bathing needs and were not person centered. | 2020-09-01 |
| 19 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2019-05-02 | 609 | D | 1 | 0 | ZMPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to ensure an allegation of abuse was reported immediately to the facility Administrator and to other officials (including the State Survey Agency and Adult Protective Services) for 1 resident (#1) of 4 residents reviewed for Abuse on 4 nursing units of 4 sampled residents. The findings included: Review of facility policy Resident Rights - Abuse of Residents revised 11/14/16 revealed .Reporting .1. Any witnessed or allegations of abuse .must be reported to the Executive Director, Administrator or Charge Nurse/Nurse Supervisor .a. Resident Incidents must be reported immediately .to other officials (including law enforcement, state survey agency, and adult protective services) in accordance with applicable law and regulations . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's 30 day MDS dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #3's annual MDS dated [DATE] revealed the resident was cognitively intact. Medical record review of a Psychiatric Progress Note for Resident #3 dated 4/10/19 revealed the resident was attention seeking and inappropriate verbally with staff related to sexuality. Review of a facility investigation dated 4/25/19 revealed Resident #3 reported he witnessed Resident #2 place his hand down the front of Resident #1's pants and Resident #3 told Resident #2 to stop. Continued review revealed Resident #2 replied .I was just checking to see if she (Resident #1) was wet to change . Further review revealed Resident #3 changed details of the alleged incident multiple times during the facility investigation and stated he was not able to see if Resident #2 put his hand under her blanket or inside Resident #1's pants. Continued review revealed Licensed Practical Nurse (LPN) #2 reported while she was feeding Resident #3 in his room on 4/22/19 or 4/23/19, Resident #3 reported the incident to her. Further review revealed Resident #3 also reported the incident to LPN #3 on 4/24/19. Interview with LPN #2 on 5/2/19 at 1:00 PM, in the Administrator's office, confirmed Resident #3 reported the alleged incident to her on 4/22/19 or 4/23/19. Further interview revealed she did not report the allegation because .in my mind .I thought it really didn't happen . Telephone interview with LPN #3 on 5/2/19 at 2:35 PM confirmed she did not report the allegation of abuse because she thought it was .old news . Further interview with LPN #3 confirmed she was aware she should have reported the allegation immediately, but failed to do so. In summary, Resident #3 reported an allegation of abuse to facility staff on 4/22/19 or 4/23/19, but the staff did not report the allegation to the Administrator or the State Survey Agency until 4/25/19. | 2020-09-01 |
| 20 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 281 | D | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Lippincott Manual of Nursing Practice, facility staffing files, facility policy, medical record review, and interview, the facility employed one Licensed Practical Nurse (LPN #9) with an expired license who administered insulin to 3 diabetic residents (#5, #16, and #14) of 17 residents reviewed. The findings included: Review of Lippincott Manual of Nursing Practice, Ninth Edition, chapter 2, revealed, .Licensure is granted by an agency of state government and permits individuals accountable for the practice of professional nursing to engage in the practice of that profession, while prohibiting all others from doing so legally . Review of the facility staff certification documents on [DATE] revealed LPN #9's license to practice nursing expired on [DATE]. Review of the facility's staffing files revealed LPN was hired on [DATE]. Medical record review of the facility's Insulin Administration Policy revised (MONTH) 2010 revealed, .Procedure .check blood glucose per physician order [REDACTED]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED].(increase) chemsticks (blood sugar testing) to AC/HS (before meals and bedtime) . Medical record review of Physician order [REDACTED].Humalog (fast-acting insulin for diabetics) 6 (units) with lunch and supper .hold if (blood glucose) (less than) 150 . Medical record review of Resident #5's electronic Medication Administration Record [REDACTED]. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 15 times out of 62 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 16 times out of 54 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar per physician order [REDACTED]. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (fast-acting insulin insulin for diabetics) .(6 units) .two times daily .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 10 times out of 27 opportunities. Medical record review of Resident #16's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 12 times out of 37 opportunities. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED].[MEDICATION NAME] .12 units .give extra 4 units if (blood glucose) (greater than 300)) . Medical record review of Resident #14's eMAR dated [DATE] at 1:00 PM revealed a blood sugar of 274 with documentation LPN #9 administered 10 units of insulin instead of the ordered 12 units. Continued review revealed the 5:30 PM blood sugar was 191, indicating Resident #14 continued to have high blood sugar. Interview with the DON on [DATE] at 2:35 PM, in the DON's office, confirmed nurses are to follow the physician's orders [REDACTED]. Interview with the Administrator and DON on [DATE] at 6:30 PM, confirmed, LPN #9 did not have a current license to practice nursing since the hire date in (MONTH) (YEAR). Continued interview confirmed since his employment, LPN #9 failed to follow physician's orders [REDACTED]. | 2020-09-01 |
| 21 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 282 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of Brunner and Suddarth's Textbook of Medical Surgical Nursing, medical record review, Review of Consultant Pharmacist Reports, and interview, the facility failed to administer insulin and follow diabetic care plans per the physicians orders for 8 residents (#1, #4, #6, #7, #13, #5, #16, #18) of 17 residents reviewed for insulin, of 24 residents reviewed. The facility's failure to follow diabetic care plans resulted in an insulin overdose and hospitalization for Resident #1. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on 7/27/17 at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .when PRN (as needed) medications are administered, the nurse must record .date and time administered .dosage .medications shall be administered as prescribed by the physician .must be administered with the written orders of the attending physician .nurses administering the medications must initial the resident's MAR .Should a drug be withheld .nurse must enter an explanatory note Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration (less than) 45 . by the level .causes of DKA (Diabetic Ketoacidosis, a serious complication of diabetes) .missed dose of insulin . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Continued review revealed the resident was transferred to the hospital on [DATE] after receiving an overdose of insulin. Review of the eMAR dated 9/12/16 at 9:00 PM, revealed a sliding scale (based on blood sugar results) for Humalog (short acting) insulin 100 units subcutaneous four times daily starting 8/25/16. Blood sugar 415 notify MD. Blood sugar is 0-150 (give) 0 units, Blood Sugar is 151-200 (give) 2 units Blood Sugar is 201-250 (give) 4 units Blood Sugar is 251-300 (give) 6 units Blood Sugar is 301-350 (give) 8 units Blood Sugar is 351-400 (give) 10 units Blood Sugar is 401-415 (give) 12 units Continued review revealed the blood sugar on 9/11/16 at 9:00 PM was 247 and 100 units of Humalog insulin instead of 4 units, was administered to the resident. Medical record review of Resident #1's care plan with a goal date of 12/8/16, revealed .Observe and record s/sx (signs and symptoms)of elevated blood sugar levels .Administer medication as ordered for elevated blood sugars .Observe for s/sx (signs and symptoms) of decreased blood sugar levels: weakness cold clammy nervous .Resident at risk for alteration in weight due to .cancer . Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #4's care plan with a goal date of 9/28/17 revealed .Observe and record s/sx (signs and symptoms) of elevated blood sugar levels .Administer medication as ordered for elevated blood sugars .Observe for s/sx of decreased blood sugar levels: weakness cold clammy nervous . Medical record review of the eMAR dated 7/18/17 revealed .Humalog (fast acting)(sliding scale .Blood Sugar is 301-350 .8-units . Continued review revealed on 7/18/17 at 5:30 PM the resident's blood sugar was 310 and 6 units was given when 8 units should have been administered to the resident per Physician's Orders. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #6's care plan with a goal date of 9/28/17 revealed .Insulin as ordered .Labs for blood sugars as ordered: accuchecks (blood sugar test) as ordered . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R (short acting .(give) Three Times (daily) .Blood Sugar is 151-200 .(give) 4 units .Blood Sugar is 251- 300 .(give) 6 units . Continued review revealed there was no sliding scale for blood sugar results of 201-250 on the MAR. Further review revealed on 6/30/17 the blood sugar was 214 and 6 units of insulin which was an incorrect dose of insulin, according to the MAR. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] (insulin) .Blood Sugar is 151-200 . (give) 4 units .Blood Sugar is 251- 300 .(give) 6 units . Continued review revealed there was no sliding scale for blood sugar results of 201-250 on the eMAR. Further review revealed the following: 7/2/17 at 9:00 PM-blood sugar 215-4 units of insulin given, which was the amount for a result of 151-200 on the eMAR. 7/4/17 at 9:00 AM-blood sugar 152-2 units of insulin given (should have received 4 units) 7/5/17 at 9:00 PM-blood sugar 215-4 units of insulin given, which was the amount for a result of 151-200 on the eMAR. Telephone Interview with LPN #10 on 7/20/17 at 4:05 PM, confirmed the insulin administration could have been an error. Further interview confirmed she was not aware there was a missing range for insulin administration (201-250) on Resident #6 on 6/30/17 when she administered the insulin. Interview with LPN #11 on 7/20/17 at 1:45 PM, in the 300 nurse's station, confirmed she failed to follow the care plan for diabetic management. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #7's care plan with a goal date of 9/8/17 revealed .Insulin as ordered .Labs for blood sugars as ordered: accuchecks (blood sugar test) as ordered .medicate with .insulin as ordered . Review of the Consultant Pharmacist's Medication Regimen Review dated 1/1/17-1/17/17 revealed, .Documentation/charting issues .Humalog 6 units bid (twice daily) with hold parameter for BS Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog (short acting insulin) .Sliding Scale Insulin .Blood Sugar is 151-200 (give) 2 Units . Continued review revealed on 3/19/17 at 5:00 PM the Blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 251-300 .(give) 6 units . Continued review revealed on 4/19/17 at 8:00 AM the resident's Blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 0-150 .(give) 0 Units .Blood Sugar is 201-250 (give) 4 units . Continued review revealed on 5/7/17 at 9:00 PM the Blood Sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on 5/9/17 at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 201-250 (give) 4 units .Blood Sugar is 251-300 (give) 6 Units . Continued review revealed the following: 6/8/17 at 9:00 PM the resident's Blood Sugar was 256 and 4 units given when the resident should have received 6 units. 6/10/17 at 12:00 PM the resident's Blood Sugar was 236 and 6 units was given when the resident should have received 4 units. 6/30/17 at 5:00 PM the resident's Blood Sugar was 217 and 2 units was given when the resident should have received 4 units. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 201-250 (give) 4 units .Continued review revealed the following: 7/4/17 at 5:00 PM the Blood Sugar was 212 and 2 units given when the resident should have received 4 units. 7/13/17 at 5:00 PM the Blood Sugar was 243 and 2 units given when the resident should have received 4 units. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #13's care plan with a goal date of 8/23/17 revealed .Insulin as ordered .Labs for blood sugars as ordered: accuchecks (blood sugar test) as ordered . Medical record review of the MAR indicated [REDACTED].Humalog .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on 4/26/17 at 12:00 PM, the blood glucose was 194 and 4 units were given to the resident when the resident should not have received any insulin. Medical record review of the MAR indicated [REDACTED]. Further review revealed on 5/3/17 at 12:00 PM, the blood glucose was 294 and 10 units were given to the resident when the resident should have received only 4 units. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Care Plan dated 8/11/14 revealed, .Potential for increased or decreased blood sugar levels .status .active .blood sugar (less than) 70 or (greater than) 110 .accuchecks as ordered .medicate .insulin as ordered . Medical record review of a Physician's Order dated 2/15/17 revealed, .Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated 2/16/17 at 5 PM revealed a blood sugar of 100 with documentation indicating 4 units of insulin had been given, when no insulin should have been given. Medical record review of Resident #5's eMAR dated 2/25/17 at 8 AM revealed a blood sugar of 102 with documentation indicating 4 units of insulin had been given, when no insulin should have been given when no insulin should have been given. Medical record review of Resident #5's eMAR dated 2/26/17 at 8 AM revealed a blood sugar of 130 with documentation indicating 4 units of insulin had been given, when no insulin should have been given. Medical record review of Resident #5's eMAR dated 3/6/17 at 8 AM revealed a blood sugar of 137 with documentation indicating 4 units of insulin had been given, when no insulin should have been given. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's MAR means medication was given. Further interview confirmed the care plan was not followed. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the Physicians Orders. Further interview confirmed when a nurse failed to follow the insulin order it put the residents at risk for harm. Interview with LPN #2 on 7/26/17 at 5:52 PM, via telephone confirmed she did not follow physician's orders and the care plan when giving Resident #5 insulin outside of parameters. Medical Record Review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #16's Care Plan with a goal date of 10/24/17 revealed, .Potential for increased or decreased blood sugar levels .accuchecks (test to check blood sugar) as ordered .Administer medication as ordered for elevated blood sugar levels .Insulin as ordered or sliding scale . Medical record review of Physician's Orders on the (MONTH) (YEAR) eMAR revealed, .[MEDICATION NAME] (short acting insulin) .(4 units) .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's eMAR dated 1/2/17 at 9:00 AM revealed a blood sugar of 88 with documentation indicating 4 units of insulin had been given when no insulin should have been given. Medical record review of Resident #16's eMAR dated 1/3/17 at 9:00 AM revealed a blood sugar of 77 with documentation indicating 4 units of insulin had been given when no insulin should have been given. Medical record review of Resident #16's eMAR dated 1/6/17 at 9 AM revealed a blood sugar of 76 with documentation indicating 4 units of insulin had been given when no insulin should have been given. Medical record review of Resident #16's eMAR dated 1/10/17 at 9:00 AM revealed a blood sugar of 115 indicating 4 units of insulin had been given. Medical record review of Physicians Orders dated 5/15/17 revealed, .[MEDICATION NAME] 6 units .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's eMAR dated 6/26/17 at 12 PM revealed a blood sugar of 176. Further review revealed .(insulin) Not Administered (Outside Parameters) . Interview with LPN #8 Nurse Manager, on 7/25/17 at 3:58 PM, in the DON office, confirmed LPN #5 and #6 administered insulin when it was not needed and LPN #7 held insulin when it should have been administered. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #18's Care Plan with a goal date of 10/27/17 revealed, .Diabetes .potential for complications .administer medications as ordered for elevated blood sugar levels .will have (blood sugar levels) between 70-110 (every day) this 90 days .accuchecks as ordered . Medical record review of the Consultant Pharmacist's Medication Regimen Review for Resident #18 dated 4/1/17-4/11/17 revealed, .there is no space for recording (blood sugar) on EMAR with the order so unclear if this has been done consistently . Medical record review of Physician's Orders dated 4/20/17 revealed, .Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 110 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of Resident #18's eMAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's eMAR dated (MONTH) (YEAR) revealed blood sugars over 400 on 5/2 at 4:46 PM, 5/6 at 1:10 PM, 5/6 at 5:06 PM, 5/7 at 7:39 AM, 5/7 at 4:34 PM, 5/8 at 4:40 PM, 5/23 at 9:48 AM, 5/30 at 7:52 AM, and at 5/30 at 11:30 AM. Further review revealed no documentation if additional 4 units of insulin were administered. Interview with LPN #8, Nurse Manager, on 7/26/17 at 11:10 AM, confirmed there was no way to determine if additional units of insulin were given or held. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the Physicians Orders. Further interview confirmed when a nurse failed to follow the insulin order it put the residents at risk for harm. Interview with the Administrator on 7/26/17 at 6:42 PM, in the DON office confirmed not following physician orders per care plans was a .problem . Interview with the Medical Director on 7/27/17 at 8:00 AM, confirmed, .anytime there is a parameter (ordered) you check the parameter . Refer to F 333 | 2020-09-01 |
| 22 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 309 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility documents, review of Emergency Medical Service documents, review of hospital records and interview, the facility failed to provide insulin management and monitoring for 1 diabetic resident of 17 residents reviewed for insulin medication administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of insulin, aspirating, and being sent to the hospital and placed on a ventilator (machine to assist with breathing). The facility failed to ensure insulin was administered according to correct blood sugar parameters per physician's orders [REDACTED].#6, #7, #12, #13, #14, #20, #22) of 17 residents reviewed for insulin medication administration, of 24 residents reviewed. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was transferred to the hospital on [DATE] after receiving an overdose of insulin. The resident died on [DATE]. Medical record review of a physician's orders [REDACTED].pureed diet and nectar thick liquids. Pt (patient) allowed to have mech (mechanical) soft/canned peaches, pears and jello. No straws . Medical record review of a Nurses note dated [DATE] revealed .resident having xtrem e (extreme) difficulties swallowing anything/liquids are tolerated better than food . Medical record review of a Speech Therapy note dated [DATE] revealed .Pt seen for 1:1 (one to one) skilled dysphagia (difficulty swallowing) therapy .pt recommended pureed diet and nectar thick liquids to decrease risk of aspiration . Medical record review of a Physicians Order dated [DATE] revealed Patient to be on nectar thick liquids Medical record review of the Medication Administration Record [REDACTED].Humalog (insulin) 100 unit/ml (milliliter) .Four Times Daily XXX[DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed on [DATE] at 9:00 PM the resident's blood sugar was 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. Review of a facility document Medication Error Report dated [DATE] revealed .based on CS ([MEDICATION NAME] blood sugar)- 247 at 9:00 PM, Agency nurse (temporary nurse from outside source) Administered 100 units of Humalog vs (versus) the ordered 6 units (should have been 4 units) .Sent to ER (emergency room ), admitted to CCU (critical care unit) on vent (ventilator to aid in breathing) . Review of a clinical note dated [DATE] at 6:39 AM, revealed Instant Glucose (sugar) given. Chocolate pudding and orange (juice) given. Review of an Emergency Medical Service (EMS) record dated [DATE] revealed at 6:00AM, .Unresponsive .Blood glucose reading/level: low comments: 30 (below 70 is considered low) .Upper Right Lung Rhonchi (abnormal breath sounds): Upper Left Lung Rhonchi; Lower Right Lung; Rhonchi: Lower Left Lung; Rhonchi .Glasco Coma Scale (scale to assess consciousness) GCS .6 (less than 8 is considered comatose) .Respiratory Effort: Labored .Narrative .Altered Mental Status and [DIAGNOSES REDACTED] .Pt (patient) was found unresponsive with low blood sugar. Nursing staff tried to feed the PT (patient) pudding and orange juice. Then activated 911. Pt found unconscious and unresponsive .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a procedure note from the hospital dated [DATE] revealed .Probable aspiration, possible foreign body .No food particles were seen, but the secretions were very thick and could be consistent with the pudding that the patient had eaten earlier in the day . Review of a hospital critical care progress note, dated [DATE] revealed .Acute [MEDICAL CONDITION]: Requiring mechanical ventilation day 15. Unable to wean due to severe [MEDICAL CONDITION] (disease, damage, or malfunction of the brain) apnea .Aspiration pneumonia: Required FOB (fiber optic [MEDICATION NAME]) with mucous plug removal from R (right) main stem (an airway passage within the lung) at admission . Interview with the Administrator and Director of Nursing (DON) on [DATE] at 4:30 PM, in the DON's office, confirmed LPN #1 was an agency nurse working at the facility on [DATE] on a night shift. Further interview confirmed the LPN administered 100 units of insulin to Resident #1 in error. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 6:55 PM, by phone, confirmed she did work at this facility for approximately 1 month through an agency. Continued interview confirmed she administered 100 units of insulin to Resident #1 in error. Continued interview confirmed .I read the dosage wrong . Continued interview confirmed the LPN gave the 100 units of insulin at around 9:00 PM. Further interview confirmed she knew something was not right because the resident was sleeping hard .couldn't waken him up .trying to give him pudding and orange juice . Continued interview confirmed the LPN noticed the resident to be breathing very deeply and he was hard to wake up. She attempted to give him [MEDICATION NAME] (medication to increase blood sugar), and also gave him thickened juice and fed him pudding to bring his sugar up. Further interview confirmed she called EMS and he was sent to the hospital. Interview with the Medical Director (MD), also Resident #1's physician, on [DATE] at 10:35 AM, in the conference room confirmed LPN #1 called the MD in the early morning of [DATE] after she had administered the 100 units of insulin. Continued interview confirmed the MD instructed the LPN to follow the [DIAGNOSES REDACTED] protocol, start an IV, and if unable to start an IV send the resident to the hospital. Continued interview confirmed the resident should not have received pudding or juice if the resident was lethargic or unconscious. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .[MEDICATION NAME] R .TID (three times daily) .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed a missing sliding scale for blood sugar results of ,[DATE] on the MAR. Further review revealed on [DATE] the blood sugar was 214 and 6 units of insulin was given. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . with no sliding scale for results between 201 - 250. Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 4 units .Blood Sugar is 251.00- 300.00 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the MAR. Further review revealed the following: [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin given [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin given [DATE] at 9:00 AM-blood sugar ,[DATE] units of insulin given Interview with LPN #11 on [DATE] at 1:45 PM, in the 300 nurse's station confirmed she failed to follow the physician's orders [REDACTED]. Interview with LPN #10 on [DATE] at 4:05 PM, by phone confirmed she was not instructed how to enter orders by order set and put the insulin order in manually. Continued interview confirmed she was not aware she made an error while entering the insulin order on Resident #6 on [DATE] when she administered the insulin. Medical record review revealed Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog XXX,[DATE] give 0 units XXX,[DATE] give 2 units . Medical record review of the (MONTH) (YEAR) MAR from a Physicians order dated [DATE] revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 151XXX,[DATE].00 2 Units . Continued review revealed on [DATE] at 5:00 PM the blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 251XXX,[DATE].00 6 units . Continued review revealed on [DATE] at 8:00 AM the blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 0XXX,[DATE].00 0 Units .Blood Sugar is 201XXX,[DATE].00 4 units . Continued review revealed on [DATE] at 9:00 PM the blood sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on [DATE] at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 4 units .Blood Sugar is 251XXX,[DATE].00 6 Units . Continued review revealed on [DATE] at 9:00 PM the Blood Sugar was 256 and 4 units was given when the resident should have received 6 units; on [DATE] at 12:00 PM the Blood Sugar was 236 and 6 units was given when the resident should have received 4 units; and on [DATE] at 5:00 PM the Blood Sugar was 217 and 2 units was given when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 4 units . Continued review revealed on [DATE] at 5:00 PM the Blood Sugar was 212 and 2 units was given when the resident should have received 4 units, and on [DATE] at 5:00 PM the Blood Sugar was 243 and 2 units was given when the resident should have received 4 units. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the MAR indicated [REDACTED]. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED].Humalog .(4 units) .before meals Starting [DATE] .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on [DATE] at 12:00 PM, the blood sugar was 194 and 4 units of insulin was administered to the resident when the resident should not have received any insulin. Continued review of the (MONTH) MAR indicated [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED].[MEDICATION NAME] (insulin) .12 units with meals give extra 4 units if BG > (greater than) 300 . Continued review revealed the following: [DATE] 1:00 PM blood sugar 345- 12 units given (should have received 16 units) [DATE] 1:00 PM blood sugar 325- 12units given (should have received 16 units) [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 320- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) [DATE] 8:00 AM blood sugar 394- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 325- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 324- 12 units given (should have received 16) [DATE] 8:00 AM blood sugar 322- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 358- 12 units given (should have received 16) [DATE] 5:30 PM blood sugar 333- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 346- 12 units given (should have received 16) [DATE] 5:30 PM blood sugar 323- 12 units given (should have received 16) [DATE] 5:30 PM blood sugar 399- 12 units given (should have received 16) [DATE] 8:00 AM blood sugar 284- 16 units of insulin (should have received only 12) [DATE] 5:30 PM blood sugar 387- 16 units of insulin (should have received only 16) [DATE] 1:00 PM blood sugar 274- 10 units of insulin (should have received only 12) Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the nurses failed to follow the Physicians Orders. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] .sliding scale .Blood Sugar is 150XXX,[DATE].00 1 Units .Blood Sugar is 200XXX,[DATE].00 2 Units .Blood Sugar is 300XXX,[DATE].00 4 units .Blood Sugar is > 349.00 5 units . Continued review revealed on [DATE] at 5:00 PM the blood sugar was 353 and 6 units insulin was given (should have received 5 units); on [DATE] at 5:00 PM blood sugar was 216 and 1 unit insulin given (should have received 2 units); and on [DATE] at 5:00 PM blood sugar was 343 and 5 units insulin was given (should have received 4 units). Medical record review of the MAR indicated [REDACTED].Humalog .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed on [DATE] at 5:00 PM blood sugar was 192 and 4 units was given (should not have received any insulin) and on [DATE] at 8:00 AM blood sugar was 204 and no insulin was given (should have received 4 units). Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED].Humalog .(4units) .Administer 4 units .with meals if BS > 200 . Continued review revealed: [DATE] at 12:00 PM blood sugar 156- 4 units insulin given [DATE] at 8:00 AM blood sugar 88- 4 units insulin given [DATE] at 8:00 AM blood sugar 85- 4 units insulin given [DATE] at 9:00 AM blood sugar 96- 4 units insulin given [DATE] at 9:00 AM blood sugar 155- 4 units insulin given [DATE] at 9:00 AM blood sugar 170- 4 units insulin given [DATE] at 9:00 AM blood sugar 98- 4 units insulin given [DATE] at 5:00 PM blood sugar 156- 4 units insulin given [DATE] at 9:00 AM blood sugar 154- 4 units insulin given [DATE] at 5:00 PM blood sugar 145- 4 units insulin given [DATE] at 9:00 AM blood sugar 108- 4 units insulin given [DATE] at 9:00 AM blood sugar 143- 4 units insulin given [DATE] at 8:00 AM blood sugar 134- 4 units of insulin given [DATE] at 8:00 AM blood sugar 182- 4 units of insulin given Interview with the Administrator on [DATE] at 8:00 AM, in the conference room confirmed the nurses failed to follow the physician's orders [REDACTED]. Further interview confirmed this put the residents at risk for potential harm. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the facility had a critical insulin administration error on [DATE] and since that time have failed to recognize and assess factors placing the diabetic residents at risk. | 2020-09-01 |
| 23 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 329 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of Physicians' Desk Reference (PDR), Brunner & Suddarth's Textbook of Medical Surgical Nursing, medical record review, review of facility investigations, interview, and review of the Consultant Pharmacists reports, the facility administered medications unnecessarily for 9 residents (#1,#5, #7, #13, #14,#16,#18, #20, #22,) of 17 residents reviewed. The facility's failure resulted in Resident #1 receiving 100 units of insulin, instead of 4 units, and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on 7/27/17 at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of Physicians' Desk Reference (PDR) 69 Edition, (YEAR), pg 2044 - 2045, revealed, .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .In emergency situations, for adults who are unconscious and cannot swallow, an injection of glucogon (medication used to increase blood sugar) can be administered .[MEDICAL CONDITION] . (defined as) elevated blood glucose level .greater than 110 . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order dated 8/25/16 revealed .Humalog (fast-acting insulin) .Sliding Scale Insulin .Four Times Daily .Blood Sugar is 201.00-250.00 .(give) 4 units . Medical record review of the Electronic Medication Administration Record [REDACTED].Humalog 100 unit/ml (milliliter) .Four Times Daily .8/26/16 Sliding Scale Insulin .Blood Sugar is 201.00-250.00 - 4 units . Indicating the resident was to receive 4 units of Humalog insulin for a blood sugar reading of 201-250. Continued review revealed on 9/11/16 at 9:00 PM, the resident's blood sugar was 247 and 100 units of insulin was administered instead of 4 units. Medical record review of the Medication Error Report dated 9/12/16 revealed .based on CS (fingerstick lab to determine blood sugar) (blood sugar)- 247 at 9 PM, Agency nurse Administered 100 units of Humalog vs (versus) the ordered 6 units (order indicated 4 units was to be given) .Sent to ER (emergency room ), admitted to CCU (critical care unit) on vent (ventilator to assist breathing) . Review of the Emergency Medical Service or Ambulance Service (EMS) record dated 9/12/16 revealed at 6:00AM, .Unresponsive .Blood glucose reading/level; low comments: 30 (blood glucose reading was 30 with any level under 70 considered low) .Upper Right Lung Rhonci (continuous rattling lung sounds caused by obstruction or secretions): Upper Left Lung Rhonci; Lower Right Lung; Rhonci: Lower Left Lung; Rhonci . At 6:15 AM, .Blood Glucose Reading/Level: 216 . and at 6:16 AM, .Medication Administration [MEDICATION NAME] 50% Syringe (intravenous solution to raise blood sugar levels) .Result after improved .Blood Glucose Reading/Level: 130 .Glasco Coma Scale GCS (neurological scale used to assess conscious state) .6 (less than 8 is considered comatose) .Respiratory Effort: Labored . Further review of the EMS record revealed, .Altered Mental Status and [DIAGNOSES REDACTED] .Pt (patient) was found unresponsive with low blood sugar .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a signed statement by Licensed Practical Nurse (LPN) #1 on 9/12/16, revealed the LPN was scheduled to work at the facility on 9/11/16 from 7 PM to 7 AM. Further review revealed she checked the resident's blood sugar at approximately 8:30 PM and it was 247. Continued review revealed .I read the (insulin order) to say 100 units of Humilin R Insulin, I gave the 100 units and continued with med pass .walked the halls and noticed my male patient/resident breathing heavily around 11:30 PM, I checked his blood sugar at this time and it was 197 .went back to check on sliding scale around 5am .checked blood sugar and (blood sugar) 30. MD (Physician) was called and ordered instant glucose .start an IV (intravenous catheter in a vein to administer fluids and medications) .and if IV can't be started to send to ER .(emergency room ) . Interview with LPN #1 on 7/17/17 at 6:55 PM, via telephone, confirmed 100 units of insulin was administered to Resident #1 in error. Further interview confirmed she .read the dosage wrong .realized 1 or 2 hours later when he was sleeping .I went back and looked at the order . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an eMAR dated (MONTH) (YEAR) with a physician's orders [REDACTED].Humalog 100 units/ml .Four Times Daily Starting 3/18/2017 Sliding Scale Insulin .Blood Sugar is 201.00-250.00 (give) 4 units . Continued review revealed on 7/10/17 at 12:00 PM, Resident #7's blood sugar was 236 and 6 units of insulin was given, 2 more units of insulin than was necessary. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an eMAR with a physician's orders [REDACTED].Humalog 100 unit/ml .before meals Starting 04/18/2017 .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on 4/26/17 at 12:00 PM, Resident #13's blood glucose was 194 and 4 units were given to the resident, which was not necessary according to the physician's orders [REDACTED]. Medical record review of the eMAR with a physician's orders [REDACTED].#13's blood glucose was 181 and 4 units were given to the resident, which was not necessary according to the physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the physician's orders [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen for Resident #14 dated 3/1/17-3/14/17 revealed .Med Occurrence-transcription discrepancy resulting in error .1/30/17 order to increase [MEDICATION NAME] (fast-acting insulin) to 10 u (units)w (with) / each meal if 'BG (blood glucose or blood sugar) > 300 give 4 additional units'. The order on the eMAR states to give 4 additional units if BG 300 on several occasions in (MONTH) and the additional doses should have been given)(notified nurse (name) to correct this date 3/13/17; she stated the dose was given for BS (blood surgar) > 300) . Medical record review of the MARs for the time period revealed documentation did not clearly indicate when the additional insulin was administered or not administered. Medical record review of a physician's orders [REDACTED].Increase [MEDICATION NAME] to 12 (u) units w (with) meals TID (3 times a day) + (plus) extra 4 u if BG > 300 . Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] 100 unit/ml .Three Times Daily Starting 5/3/17 .give 12 units with meals (give extra 4 units if BG > 300) . Continued review revealed on 6/2/17 the blood sugar was 284 and 16 units of insulin was given, 4 more units of insulin than was necessary. Interview with the DON on 7/26/17 at 2:35 PM, in the conference room, confirmed when a nurse failed to follow the insulin order, residents were at risk for potential harm. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen report dated 4/1/17-4/11/17 revealed .Documentation/charting issues .Humalog is only to be given when blood sugar is above 200. It was documented as given 5 times so far this month when it should have been held . Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].[MEDICATION NAME] 100 unit/ml .Four Times Daily Starting 2/20/217 .sliding scale .Blood Sugar is 150.00-199.00 (give) 1 Units .Blood Sugar is 200.00-249.00 (give) 2 Units .Blood Sugar is 300.00-349.00 (give) 4 units .Blood Sugar is > 349.00 (give) 5 units . Continued review revealed on 3/1/17 at 5:00 PM Resident #20's blood sugar was 353 and 6 units of insulin was given, 1 unit of insulin more than necessary, and on 3/12/17 at 5:00 PM, the resident's blood sugar was 343 and 5 units of insulin was given, 1 unit of insulin more than was necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].Humalog 100 units/ml .Two Times Daily .Starting 4/18/17 .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed on 5/6/17 at 5:00 PM, Resident #20's blood sugar was 192 and 4 units of insulin was unnecessarily given (should not have received any insulin). Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].Humalog 100 unit/ml .Administer 4 units .with meals if BS > 200 . Continued review revealed the blood sugar on 2/18/17 at 12:00 PM, was 156 and 4 units of insulin was given to the resident, which was unnecessary according to the physician's orders [REDACTED]. Further review revealed at 5:00 PM the blood sugar level was 94. Medical record review of the (MONTH) (YEAR) eMAR revealed the blood sugar on 3/5/17 at 8:00 AM, was 85 and 4 units of insulin was administered, which was not necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED]. Further review revealed the insulin was administered when and not necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED]. Humalog 100 unit/ml .(4units) .Two Times Daily Starting 4/10/2017 .Administer 4 units .for BG > 200 . Continued review revealed the following unnecessary insulin administration: 4/14/17 at 9:00 AM blood sugar 96-4 units of insulin given 4/15/17 at 9:00 AM blood sugar 155- 4 units insulin given 4/16/17 at 9:00 AM blood sugar 170- 4 units insulin given 4/20/17 at 9:00 AM blood sugar 98-4 units insulin given 4/21/17 at 5:00 PM blood sugar 156-4 units insulin given 4/23/17 at 9:00 AM blood sugar 154-4 units insulin given 4/27/17 at 5:00 PM blood sugar 145- 4 units insulin given 4/29/17 at 9:00 AM blood sugar 108-4 units insulin given 4/30/17 at 9:00 AM blood sugar 143- 4 units insulin given Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].#22's blood sugar was 134 and 4 units of insulin was given unnecessarily, and on 5/17/17 at 8:00 AM, the resident's blood sugar was 182 and 4 units of insulin was given unnecessarily. Interview with the Administrator on 7/26/17 at 8:00 AM, in the conference room, confirmed the nurse failed to follow the physician's orders [REDACTED]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated 2/16/17 at 5:00 PM revealed a blood sugar of 100 with documentation LPN #2 gave 4 units of insulin when it was not needed. Review of Resident #5's eMAR dated 2/25/17 at 8:00 AM revealed a blood sugar of 102 with documentation LPN #3 gave 4 units of insulin when it was not needed. Medical record review of Resident #5's eMAR dated 2/26/17 at 8:00 AM revealed a blood sugar of 130 with documentation LPN #4 gave 4 units of insulin when it was not needed. Medical record review of Resident #5's eMAR dated 3/6/17 at 8:00 AM revealed a blood sugar of 137 with documentation LPN #2 gave 4 units of insulin when it was not needed. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's MAR meant medication was given. Further interview confirmed LPNs #2, #3, and #4 administered insulin when it was not needed per the physician's orders [REDACTED]. Interview with LPN #2 on 7/26/17 at 5:52 PM, via telephone, confirmed she administered insulin outside of parameters for Resident #5. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].(4 units) .two times daily .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's eMAR dated 1/2/17 at 9:00 AM revealed a blood sugar of 88 with documentation LPN #5 gave 4 units of insulin when it was not needed. Medical record review of Resident #16's eMAR dated 1/3/17 at 9:00 AM revealed a blood sugar of 77 with documentation LPN #5 gave 4 units of insulin that was not needed. Medical record review of Resident #16's eMAR dated 1/6/17 at 9:00 AM revealed a blood sugar of 76 with documentation LPN #5 gave 4 units of insulin that was not needed. Medical record review of Resident #16's eMAR dated 1/10/17 at 9:00 AM revealed a blood sugar of 115 with documentation LPN #6 gave 4 units of insulin that was not needed. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office confirmed LPN #5 and LPN #6 administered insulin when it was not necessary per physician's orders [REDACTED]. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 110 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of Resident #18's eMAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's eMAR dated 6/30/17 at 12:00 PM revealed a blood sugar of 104 with documentation RN #1 gave 4 units of insulin when it was not needed. Medical record review of Resident #18's eMAR dated 7/2/17 at 12:00 PM, revealed a blood sugar of 100 with documentation RN #1 gave 4 units of insulin when it was not needed. Interview with LPN #8, Nurse Manager, on 7/25/17 at 3:58 PM, in the DON's office, confirmed RN #1 administered insulin when it was not indicated by the physician's orders [REDACTED]. Interview with the DON on 7/26/17 at 2:35 PM, in the DON's office, confirmed if a nurse administered insulin to a resident with a blood sugar of 100, and the physician's orders [REDACTED]. | 2020-09-01 |
| 24 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 333 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of Physicians' Desk Reference (PDR), Brunner & Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, facility policy review, medical record review, review of Consultant Pharmacy Reports, and interview, the facility failed to prevent significant medication errors for 12 (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20 and #22) of 17 residents reviewed for insulin administration. The facility's failure resulted in Resident #1 receiving 96 more units of insulin than ordered. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of Physicians' Desk Reference (PDR) 69th Edition, (YEAR), pg 2044 - 2045, revealed, .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .In emergency situations, for adults who are unconscious and cannot swallow, an injection of glucogon (medication used to increase blood sugar) can be administered .[MEDICAL CONDITION] . (defined as) elevated blood glucose level .greater than 110 . Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .medications shall be administered as prescribed by the physician .If a dose seems excessive .the nurse should contact the physician .the nurse should compare the drug and dosage schedule to the resident's MAR (Medication Administration Record) and with the drug label . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident died on [DATE]. Medical record review of the Physicians Order dated [DATE] revealed .Humalog (fast acting) .Sliding Scale Insulin .Four Times Daily .Blood Sugar is 201XXX,[DATE].00 .(give) 4 units . Medical record review of the electronic Medication Administration Record [REDACTED].Humalog (insulin) 100 unit/ml (milliliter) .Four Times Daily XXX[DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE]XXX,[DATE] units . Continued review revealed on [DATE] at 9:00 PM the resident's blood sugar was 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. Review of a signed statement by LPN #1 dated [DATE], revealed the LPN was scheduled to work at the facility on [DATE] from 7:00 PM to 7:00 AM. Further review revealed she checked the resident's blood sugar at approximately 8:30 PM and it was 247. Continued review revealed .I read the (insulin order) to say 100 units of Humilin R Insulin, I gave the 100 units and continued with med pass .walked the halls and noticed my male patient/resident breathing heavily around 11:30 PM, I checked his blood sugar at this time and it was 197 .went back to check on sliding scale around 5am .checked blood sugar and 30 (below 70 considered low). MD (physician) was called and ordered instant glucose .start an IV (intravenous catheter in a vein to administer fluids and medications) .and if IV can't be started to send to ER (emergency room ) Further review revealed the resident was sent to the ER. Continued review revealed the EMS (Emergency Medical Service or Ambulance) started an IV on the resident and the resident was taken to the hospital. Review of an EMS record for Resident #1 dated [DATE], revealed at 6:00 AM, .Unresponsive .Blood glucose reading/level; low comments: 30 .Upper Right Lung Rhonchi (abnormal breath sound): Upper Left Lung Rhonchi; Lower Right Lung; Rhonchi: Lower Left Lung; Rhonchi . Further review revealed at 6:15 AM, .Blood Glucose Reading/Level: 216 . and at 6:16 AM .Medication Administration [MEDICATION NAME] 50% Syringe 25 (25 ml of IV solution with [MEDICATION NAME] to increase blood sugar) .Intravenous; Result after improved .Blood Glucose Reading/Level: 130 .Glascow Coma Scale (scale to detect level of consciousness) .6 (below 8 indicates comatose) .Respiratory Effort: Labored . Further review revealed, .Altered Mental Status and [DIAGNOSES REDACTED] (low blood sugar) .Pt (patient) was found unresponsive with low blood sugar .Then activated 911. Pt found unconscious and unresponsive .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a Clinical Note dated [DATE] at 6:25 AM revealed Insulin dose is listed incorrectly, 100 units were given. On call Dr (physician) was called; orders were to start IV, if IV can't be started, then send to ER .Sent to ER. Last blood sugar 215 at 5:45 am . Phone interview with LPN #1 on [DATE] at 6:55 PM, confirmed, LPN #1 did not start an IV because she was not IV certified. Further interview confirmed she did not ask for help. Review of a Clinical Note dated [DATE] at 6:39 AM, reveaIed Instant Glucose given. Chocolate pudding and orange (juice) given. Review of a Medication Error Report dated [DATE] revealed CS (blood sugar) - 247 at 9 PM, Agency nurse Administered 100 units of Humalog vs (versus) the ordered 6 units (4 units per the MAR) .Sent to ER, admitted to CCU (Critical Care Unit) on vent (ventilator to aid in breathing) . Medical record review of a critical care progress note dated [DATE], from the hospital, revealed, .Acute [MEDICAL CONDITION]: Requiring mechanical ventilation day 15. Unable to wean due to severe [MEDICAL CONDITION] (abnormal brain function), apnea (temporarily stop breathing) .Aspiration pneumonia (lung infection after inhaling food) . Medical record review of a Medicine Progress Report dated [DATE], from the hospital, revealed .Patient remains intermittently alert but totally unresponsive to voice. He opens his eyes, though he does not track movement . Interview with the Administrator and Director of Nursing (DON) on [DATE] at 4:30 PM, in the DON's office, confirmed LPN #1 was an agency nurse that was working at the facility on [DATE] night shift. Further interview confirmed the LPN administered 100 units of insulin to Resident #1 in error. Interview with the Medical Director on [DATE] at 10:35 AM, in the conference room, confirmed LPN #1 made a significant medication error. Continued interview confirmed she directed the LPN to monitor the resident closely after the insulin overdose, but at the time the blood sugar was maintained. Further interview confirmed the next call she received from LPN #1 was early morning and the blood sugar was low. The Physician instructed the LPN to follow the hypoglycemic protocol, if the resident was cooperative to administer the [MEDICATION NAME], start an IV, and if unable to start the IV, to send the resident to the ER. Continued interview confirmed the hypoglycemic episode of Resident #1 could have led to the resident becoming unstable. Interview with LPN #1 on [DATE] at 6:55 PM, by phone, revealed she worked night shift on [DATE]. Continued interview confirmed she did administer 100 units of insulin to Resident #1 by error. Continued interview confirmed .I read the dosage wrong . Continued interview confirmed the LPN gave the 100 units of insulin at around 9 (9:00) PM; the resident's blood sugar was 237 at that time. Further interview confirmed she knew something was not right because the resident was sleeping hard .couldn't wake him up .trying to give him pudding and orange juice . Continued interview confirmed she went back to check the insulin order and realized the error (unsure of what that time was). Further interview confirmed LPN #1 did not start an IV because she was not IV certified and she did not ask for help. Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated [DATE] revealed .Humalog .sliding scale .Four Times Daily Starting [DATE] .Blood Sugar is 301XXX,[DATE].00 (give) 8-units . Continued review revealed on [DATE] at 5:30 PM the blood sugar was 310 and 6 units was given when 8 units should have been administered to the resident. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the Physician's Orders were not followed. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .[MEDICATION NAME] R .TID (three times daily) .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the eMAR. Further review revealed on [DATE] the blood sugar was 214 and 6 units of insulin was given, the dosage for the ,[DATE] range on the eMAR. Medical record review of the facility's Sliding Scale A parameters dated [DATE] revealed, XXX,[DATE] give 6 units . Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .TID .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the EMAR. Further review revealed the following: [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin (range not indicated on eMAR) [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin (range not indicated on eMAR) [DATE] at 9:00 AM-blood sugar ,[DATE] units of insulin (4 units ordered) Interview with LPN #11 on [DATE] at 1:45 PM, in the 300 nurse's station, confirmed she failed to follow the Physician's Order for the sliding scale insulin. Interview with LPN #10 on [DATE] at 4:05 PM, by phone confirmed the insulin administration could have been an error. Further interview confirmed she was not instructed how to enter orders in the electronic record by order set and she put the insulin order in manually. Continued interview confirmed she was not aware she made an error while entering the insulin order on Resident #6 on [DATE] when she administered the insulin. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed .Documentation/charting issues .Humalog 6 units bid (twice a day) with hold parameter for BS Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .TID (three times a day) XXX,[DATE] give 0 units XXX,[DATE] give 2 units . Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 151XXX,[DATE].00 (give) 2 Units . Continued review revealed on [DATE] at 5:00 PM the blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the (MONTH) (YEAR) eMAR with a Physicians order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 251XXX,[DATE].00 (give) 6 units . Continued review revealed on [DATE] at 8:00 AM the blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 0XXX,[DATE].00 0 Units .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed on [DATE] at 9:00 PM the blood Sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on [DATE] at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units .Blood Sugar is 251XXX,[DATE].00 (give) 6 Units . Continued review revealed the following: [DATE] at 9:00 PM the Blood Sugar was 256 and 4 units given when the resident should have received 6 units. [DATE] at 12:00 PM the Blood Sugar was 236 and 6 units given when the resident should have received 4 units. [DATE] at 5:00 PM the Blood Sugar was 217 and 2 units given when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed the following: [DATE] at 5:00 PM the Blood Sugar was 212 and 2 units given when the resident should have received 4 units. [DATE] at 5:00 PM the Blood Sugar was 243 and 2 units given when the resident should have received 4 units. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed on [DATE] at 6:00 PM the resident's blood sugar was 286 and received 4 units of insulin when the resident should have received 6 units. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed .Documentation/charting issues .This patient has an order to get Humalog insulin when blood sugar is above 200 before meals. It has been documented as given 8 times this month when blood sugar was below 200 . Medical record review of the eMAR with a Physicians Order dated [DATE] revealed .Humalog 100 unit/ml .(4 units) .before meals Starting [DATE] .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on [DATE] at 12:00 PM, the blood glucose was 194 and 4 units were given to the resident when the resident should not have received any insulin. Medical record review of the (MONTH) (YEAR) eMAR revealed on [DATE] at 8:00 AM the blood sugar was 181 and 4 units were given to the resident when the resident should not have received any insulin. Further review revealed [DATE] at 12:00 PM, the blood glucose was 294 and 10 units were given to the resident when the resident should have received only 4 units. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed XXX[DATE] order to increase [MEDICATION NAME] to 10 u/w/each meal (units with each) and if BG > 300 give additional 4 units .(numerous med errors may have occurred; I can't determine from eMAR when additional doses were given but BG has been > 300 on several occasions in (MONTH) and the additional dose should have been given) (notified nurse (name) to correct this date [DATE]; she stated the dose was given for BS > 300) . Medical record review of the (MONTH) (YEAR) eMAR revealed a Physcians order dated [DATE] .[MEDICATION NAME] .12 units with meals (give extra 4 units if BG > 300) . Continued review revealed the following: [DATE] 1:00 PM blood sugar 345- 12 units given (should have received 16 units) and at 5:30 PM the blood sugar was 397, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 325- 12 units given (should have received 16 units) and at 5:30 PM the blood sugar was 441, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 347, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 320- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 238, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 304- 12 units given (should have received 16). Continued review revealed no documentation for a blood sugar at 5:30 PM. [DATE] 12:00 PM the blood sugar was 325, indicating Resident #14 continued to have high blood sugar and again only received 12 units (should have received 16) and at 5:30 PM the blood sugar was 397, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 324- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 429, indicating Resident #14 continued to have high blood sugar. [DATE] 8:00 AM blood sugar 322- 12 units given (should have received 16) and at 1:00 PM the blood sugar was 358, indicating Resident #14 continued to have high blood sugar and again only received 12 units (should have received 16). Continues review revealed no documentation for the 5:30 blood sugar. [DATE] 5:30 PM blood sugar 333- 12 units given (should have received 16) and at on [DATE] at 8:00 AM the blood sugar was 216, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 346- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 429, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar 323- 12 units given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 232, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar 399- 12 units given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 328, indicating Resident #14 continued to have high blood sugar. Medical record review of the (MONTH) (YEAR) eMAR revealed the following: [DATE] 8:00 AM blood sugar-284 - 16 units of insulin given (should have received only 12) [DATE] 5:30 PM blood sugar-,[DATE] units of insulin given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 173, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-274 - 10 units of insulin given (should have received 12) and on [DATE] at 8:00 AM the blood sugar was 191, indicating Resident #14 continued to have high blood sugar. Medical record review of the (MONTH) (YEAR) eMAR revealed the following: [DATE] 1:00 PM blood sugar-330 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 169, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-307 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 205, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-327 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 187, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar-316 - 12 units of insulin given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 150, indicating Resident #14 continued to have high blood sugar. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the nurses failed to follow the Physicians Orders. Continued interview confirmed when a nurse failed to follow the insulin order it put the resident at risk for harm. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] 100 unit/ml .Four Times Daily Starting [DATE] .sliding scale .Blood Sugar is 150XXX,[DATE].00 1 Units .Blood Sugar is 200XXX,[DATE].00 2 Units .Blood Sugar is 300XXX,[DATE].00 4 units .Blood Sugar is > 349.00 5 units . Continued review revealed the following: [DATE] 5:00 PM blood sugar 353- 6 units insulin given (should have received 5 units) [DATE] 5:00 PM blood sugar ,[DATE] unit insulin given (should have received 2 units) [DATE] 5:00 PM blood sugar 343- 5 units insulin given (should have received 4 units) Review of the Consultant Pharmacist's Medication Regimen report dated [DATE]-[DATE] revealed .Documentation/charting issues .Humalog is only to be given when blood sugar is above 200. It was documented as given 5 times so far this month when it should have been held . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog 100 units/ml .Two Times Daily .Starting [DATE] .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed the following: [DATE] 5:00 PM blood sugar 192- 4 units given (should not have received any insulin) [DATE] 8 AM blood sugar 204- 0 units (should have received 4 units) and at 5:00 PM the blood sugar was 293 indicating resident #20 continued to have high blood sugar. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog 100 unit/ml .(4units) .Before meals Starting [DATE] .Administer 4 units .with meals if BS > 200 . Continued review revealed the blood sugar on [DATE] at 12:00 PM was 156 and 4 units of insulin was given to the resident when no insulin should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed the blood sugar on [DATE] at 8:00 AM was 85 and 4 units was given to the resident when no insulin should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed the blood sugar on [DATE] was 149 and 4 units of insulin was given to the resident when no insulin should have been administered. Medical record review of the MAR indicated [REDACTED]. Humalog 100 unit/ml .(4units) .Two Times Daily Starting [DATE] .Administer 4 units .for BG > 200 . Continued review revealed the resident received insulin when it should not have been administered on: [DATE] at 9:00 AM blood sugar ,[DATE] units of insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 5:00 PM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 5:00 PM blood sugar 145- 4 units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar 143- 4 units insulin given Medical record review of the MAR indicated [REDACTED]. Continued review revealed on [DATE] at 8:00 AM, the blood sugar was 182 and 4 units of insulin was given when no insulin should have been administered. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated [DATE] revealed, .Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated [DATE] at 5:00 PM revealed a blood sugar of 100 with documentation LPN #2 gave 4 units of insulin when it was not ordered. Review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 102 with documentation LPN #3 gave 4 units of insulin when it was not ordered. Medical record review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 130 with documentation of LPN #4 gave 4 units of insulin when it was not ordered. Medical record review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 137 with documentation of LPN #2 gave 4 units of insulin when it was not ordered. Interview with LPN #8 Nurse Manager on [DATE] at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's eMAR mean medication was given. Further interview confirmed LPNs #2, # 3, and #4 administered insulin when it was not needed per the physician's orders. Continued interview confirmed Resident #5's initial order had been transcribed incorrectly. Further interview confirmed RN #1 should have administered the insulin, resulting in a significant medication error. Interview with LPN #2 on [DATE] at 5:52 PM, via telephone, confirmed she administered insulin outside of parameters for Resident #5. Medical Record Review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders documented on the (MONTH) (YEAR) MAR, revealed, .[MEDICATION NAME] (short acting insulin) .(4 units) .two times daily .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Physicians Orders dated [DATE] revealed, .[MEDICATION NAME] 6 units .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's MAR indicated [REDACTED]. Further review revealed LPN #7 did not administer 6 units of insulin. Interview with LPN #8, Nurse Manager, on [DATE] at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's eMAR mean medication was given. Further interview confirmed not documenting a reason why a medication was held when it should have been given is considered a medication error. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders dated [DATE] revealed, .Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 100 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of a Consultant Pharmacist's Medication Regimen Review for Resident #18 dated [DATE]-[DATE] revealed, .The hold parameter and order for additional units if (blood sugar) (greater than) 400 were not transcribed in the MAR . Medical record review of Resident #18's MAR indicated [REDACTED]. Medical record review of Resident #18's Vital Sign documentation on ,[DATE] /17 at 8:05 AM revealed a blood sugar of 405. Medical record review of Resident #18's MAR indicated [REDACTED]. Medical record review of Resident #18's MAR indicated [REDACTED]. Interview with the Pharmacy Consultant on [DATE] at 1:00 PM, by phone, confirmed pharmacy reviews were conducted on every resident monthly. Further interview confirmed an electronic monthly audit was completed at that time. The pharmacist reviews the MAR indicated [REDACTED]. Continued interview confirmed it was not her responsibility to check for administration errors but if she notes errors or discrepancies she includes them in the monthly report. Interview with the Administrator on [DATE] at 8:00 AM, in the conference room, confirmed the nurses failed to follow the Physician's orders for sliding scale insulin. Further interview confirmed this put the residents at risk for potential harm. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the facility had a critical insulin administration error on [DATE] and since that time had failed to recognize and assess factors placing the diabetic residents at risk for [DIAGNOSES REDACTED] or [MEDICAL CONDITION] continued interview confirmed, if a nurse administered insulin to a resident with a blood sugar of 100, and the physician's order stated hold for less than 120, it would be considered a medication error. | 2020-09-01 |
| 25 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 490 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigations, review of the Pharmacist Consult Reports, and interview, the facility failed to be administered in a manner to ensure there were not significant medication errors, errors in insulin administration, errors in transcribing insulin orders, and to ensure staff monitored and documented blood sugars, and followed Physicians Orders for insulin administration for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Review of the Consultant Pharmacist's Medication Regimen for January, (MONTH) and (MONTH) (YEAR) revealed documentation from the Consultant Pharmacist indicating ongoing reported insulin errors, transcription errors, and problems with documentation of blood sugar levels. Medical record review for Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, and #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Interview with the Nursing Home Administrator on [DATE] at 7:45 AM, in the DON's office confirmed a serious insulin error involving Resident #1 occurred on [DATE] in the facility. Continued interview confirmed monthly Consultant Pharmacist Reports were sent to the Director of Nursing (DON) and the Administrator received a report through email. Further interview confirmed she did not review the reports and was not aware of the ongoing errors in transcription, documentation of blood glucose levels, or administration of insulin. Continued interview confirmed it was the Administrator's responsibility to over-see the actions of the facility staff. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F501 (E), F514 (E), F520 (E) | 2020-09-01 |
| 26 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 501 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Medical Director Contract, facility policy review, review of facility investigations, review of Consultant Pharmacists Reports, medical record review, and interview, the facility failed to ensure the Medical Director participated in the development and implementation of facility policies to ensure Physicians orders were followed, insulin was administered as ordered, and blood glucose levels were monitored and documented for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of the Medical Director Contract dated [DATE] revealed .SERVICES TO BE PERFORMED BY PROVIDER .Provide medical services in accordance with accepted professional standards of practice and use only qualified duly licensed, certified or registered health care professionals in the performance of these services .Responsible for the overall coordination of medical care at the Facility .shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident policies and providing oversight and supervision of medical services and medical care of residents .Evaluate and take appropriate steps to correct any problems associated with any possible inadequate care Provider identifies or about which Provider receives a report . Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Medical record review for Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Interview with the Medical Director (MD) on [DATE] at 8:00 AM, by phone, and on [DATE] at 8:00 PM, in the Director of Nursing (DON)'s office, confirmed the facility had a critical insulin error for Resident #1 on [DATE]. Continued interview confirmed she took this error to Quality Assurance (QA). The MD stated the goal of Quality Assurance (QA) was to look for the .etiology in errors . Continued interview confirmed there were not any pharmacy reports or major trends in insulin errors discussed in the QA meetings; .I felt we were doing pretty good . Further interview confirmed the MD did not receive copies of the monthly Pharmacy Reports. Further interview revealed the MD was involved in generating protocols and procedures regarding medication administration, but did not do inservices and was not involved in hitting the floor to monitor or audit for errors. Her expectations were education occurred. Further interview confirmed the Consult Pharmacist Reports indicated ongoing transcription errors of insulin orders, errors in administration of insulin, and missing documentation of blood glucose levels occurring in the facility in January, March, April, (MONTH) and (MONTH) (YEAR). Continued interview confirmed she was not aware of the Consultant Pharmacist Reports. Further interview confirmed the Medical Director was responsible for ensuring implementation of resident policies and providing oversight and supervision of medical services and medical care of residents. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F490 (E), F 514 (E), F520 (E) | 2020-09-01 |
| 27 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 514 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, review of Brunner and Suddarth's Textbook of Medical Surgical Nursing, medical record review, and interview, the facility failed to provide sufficient documentation to determine the status or progress after the implementation of care for 4 diabetic residents (#5, #6, #16, and #18) of 17 residents reviewed for insulin, of 24 residents reviewed. The findings included: Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .when PRN (as needed) medications are administered, the nurse must record .date and time administered .dosage . Review of the facility's Insulin Administration Policy revised (MONTH) 2010 revealed, .Procedure .check blood glucose per physician order .Documentation .resident's blood glucose results, as ordered . Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Care Plan Dated 8/11/17 revealed, .Potential for increased or decreased blood sugar levels .[DIAGNOSES REDACTED] (low blood sugar) .Goals .blood sugar (greater than) 70 or (less than) 110 (every) day .accuchecks (lab to monitor blood sugar levels) as ordered .insulin as ordered .see MAR (Medication Administration Record) . Medical record review of Physician Orders dated 3/21/17 revealed, .(increase) chemsticks (blood sugar testing) to AC/HS (before meals and bedtime) . Medical record review of Physician Orders dated 3/27/17 revealed, .Humalog (insulin) 6 (units) with lunch and supper .hold if (blood glucose) (less than) 150 . Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed 27 administrations of insulin, without documentation of the resident's blood sugar, out of 60 opportunities. Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed 26 administrations of insulin, without documentation of the resident's blood sugar, out of 62 opportunities. Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed 28 administrations of insulin, without documentation of the resident's blood sugar, out of 54 opportunities. Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed, 24 administrations of insulin without documentation of the resident's blood sugar, out of 41 opportunities. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Order on Resident #16's MAR dated 5/15/17 revealed, .[MEDICATION NAME] (insulin) .(6 units) .two times daily .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's MAR dated (MONTH) (YEAR) revealed 25 administrations of insulin, without documentation of the resident's blood sugar, out of 27 opportunities. Medical record review of Resident #16's MAR dated (MONTH) (YEAR) revealed 34 administrations of insulin, without documentation of the resident's blood sugar, out of 37 opportunities. Interview with Licensed Practical Nurse (LPN) #8, Nurse Manager, on 7/25/17 at 3:58 PM, in the Director of Nursing (DON) office, confirmed there was incomplete documentation in the medical record. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Consultant Pharmacist's Medication Regimen Review for Resident #18 dated 4/1/17-4/11/17 revealed, .there is no space for recording (blood sugar) on EMAR (Electronic Medication Administration Record) with the order so unclear if this has been done consistently . Medical record review of Resident #18's MAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's MAR dated (MONTH) (YEAR) revealed blood sugars over 400 on 5/2 at 4:46 PM, 5/6 at 1:10 PM, 5/6 at 5:06 PM, 5/7 at 7:39 AM, 5/7 at 4:34 PM, 5/8 at 4:40 PM, 5/23 at 9:48 AM, 5/30 at 7:52 AM, and at 5/30 at 11:30 AM. Further review revealed no documentation if the additional 4 units of insulin were administered per physician order. Interview with LPN #8, Nurse Manager, on 7/26/17 at 11:10 AM, in the DON's office, confirmed if there was not a physical monitor (a space on the MAR for nurse to document the number of insulin units) placed on the MAR with the insulin order, then there was no place to document the amount of insulin given. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R (insulin) .Three Times Daily Starting 6/28/2017 .Blood Sugar is 151.00-200.00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of 201-250 on the MAR. Further review revealed on 6/30/17 the blood sugar was 214 and 6 units of insulin was given. Medical record review of the MAR dated (MONTH) (YEAR) revealed the following: 7/2/17 at 9:00 PM-blood sugar 215-4 units of insulin given 7/5/17 at 9:00 PM-blood sugar 215-4 units of insulin given 7/4/17 at 9:00 AM-blood sugar 152-2 units of insulin given Interview with LPN #10 on 7/20/17 at 4:05 PM, by phone, confirmed she was not aware there was an incomplete scale order on Resident #6's MAR. Interview with LPN #7 on 7/20/17 at 5:20 PM, by phone, confirmed she entered the insulin order in the computer for Resident #6 on 6/28/17. Further interview confirmed she entered the order manually instead of picking an order set from the library and made an error during the order entry. Interview with the Administrator on 7/19/17 at 11:00 AM, in the DON's office, confirmed a 24 hour chart check was completed nightly by the night shift nurse to ensure orders and documentation was correct. Interview with the DON on 7/26/17 at 2:35 PM, in the DON's office, confirmed nurses were not entering insulin orders correctly. Further interview confirmed insulin orders were not to be put in manually unless it was a scale other than scale A or B. Continued interview confirmed transcription errors should be identified during the 24 hour chart checks. Interview with the Administrator on 7/26/17 at 6:42 PM, in the DON office, confirmed documentation was .not as good as it should be . Interview with the Administrator on 7/27/17 at 7:45 AM, in the DON office, confirmed blood sugars should be documented on the MAR. Continued interview confirmed if no blood sugars were documented, .how are we supposed to know . if the correct dose had been given. Refer to F333 | 2020-09-01 |
| 28 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 520 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Monthly Pharmacist's Medication Regimen Review, review of facility investigations, medical record review, and interview, the facility failed to identify and address problems with errors in insulin administration, transcribing insulin orders, monitoring and documenting blood sugars, and following Physicians Orders for insulin administration for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Medical record review for Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Review of the Consultant Pharmacist's Medication Regimen for January, (MONTH) and (MONTH) (YEAR) revealed documentation from the Consultant Pharmacist indicating problems with insulin errors, transcription errors, and problems with documentation of blood sugar levels. Interview with the Director of Nursing (DON) on [DATE] at 2:35 PM, in the DON's office, confirmed she received the monthly Consultant Pharmacist's Medication Regimen reports, as well as the Administrator. Continued interview confirmed the Quality Assurance (QA) members met monthly and after the critical insulin error on [DATE], it was brought to QA meeting. The DON initiated insulin education for nurses and initiated medication observation audits monthly after [DATE].We probably should have done better . The Medical Director, Administrator and Director of Nursing met monthly to discuss any pertinent problems. Interview with the Medical Director (MD) on [DATE] at 8:00 AM, by phone, confirmed the goal of QA was to look for the .etiology in errors . Continued interview confirmed there were not any pharmacy reports or major trends in insulin errors discussed in the QA meetings.I felt we were doing pretty good . Further interview confirmed the MD did not receive copies of the monthly Pharmacy Reports and the QA Team failed to identify ongoing insulin administration errors, errors in transcription of insulin orders, and lack of blood sugar monitoring. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F490 (E), F501 (E), F514 (E) | 2020-09-01 |
| 29 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 550 | G | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation and interview, the facility failed to maintain dignity by not providing timely assistance with toileting for 1 resident (#89) and not providing incontinence care for 1 resident (#80) of 52 residents sampled. This failure resulted in psychosocial harm to Resident #89 and Resident #80. The findings include: Review of the facility Dignity Policy dated 1/1/17 revealed .Each resident shall be cared for in a manner that promote and enhances quality of life, dignity, respect and individuality .1. Residents shall be treated with dignity and respect at all times .11. Demeaning practices and standards of care that compromise dignity are prohibited . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) 14 day assessment dated [DATE] revealed Resident #89 had an indwelling catheter and was frequently incontinent of bowel. Medical record review of the unscheduled MDS assessment dated [DATE] revealed the Resident's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident required extensive 2 person assist for bed mobility, transfers, and toileting. Interview with Resident #89 on 8/14/18 at 9:47 AM in the resident's room, confirmed .They are real short on day shift. I have called out because I need the bed pan and they did not get to me for a while and I had an accident on myself. It made me feel shamed . Interview with the Director of Nursing (DON) on 8/20/18 at 3:11 PM in the conference room, confirmed .she (Resident #89) was not treated with respect and dignity . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS dated [DATE] revealed the resident scored a 0 on the BIMS indicating the resident was severely cognitively impaired. Continued review revealed Resident #80 required 1 person assist for bed mobility, locomotion on unit, eating, toileting, dressing and hygiene. Continued review revealed the resident was always incontinent of urine and bowel and was not managed on a bowel and bladder incontinence program. Medical record review of the quarterly care plan, undated, revealed the resident was always incontinent .nursing to check every 2 hours and change if wet/soiled and clean skin with mild soap and water .apply moisture barrier . Continued review revealed Bowel Continence: incontinent of bowel movement .check for incontinence .every 2 hours .clean and dry skin if wet or soiled . Further review revealed Resident #80 required extensive assistance with bathing, hygiene, dressing and grooming with goal .will be odor free . Medical record review of the ADL (Activities of Daily Living) Verification Worksheet revealed Resident #80 was provided incontinence care on 8/13/18 at 12:54 AM with the next incontinence care documented on 8/13/18 at 6:40 PM at time lapse of 17 hours and 46 minutes. Observation of Resident #80 on 8/13/18 at 10:48 AM, in the 2 South dining room, revealed the resident with front of pants and perineal area wet. Observation of Resident #80 on 8/13/18 at 11:59 AM, in the dining room, revealed the resident with front of pants and perineal area wet and had a strong urine odor. Observation of Resident #80 on 8/13/18 at 4:03 PM, in the resident's room, revealed the resident sitting in a wheelchair in his room. Continued observation revealed Resident #80's pants and the bottom front of his shirt were wet and soiled with a brown and dark yellow ring at the bottom of the shirt and had a strong urine odor. Interview with Licensed Practical Nurse (LPN) #1 on 8/13/18 at 4:06 PM, in the resident's room, confirmed the resident's pants and shirt were wet with urine and he was in need of incontinence care. Continued interview revealed the last time resident had been provided incontinence care or toileted was unknown. Further interview confirmed the resident had a strong odor of urine. Interview with the DON on 8/15/18 at 3:50 PM, in the conference room, confirmed a resident wet with urine and with a strong odor of urine, sitting in the dining room area, could be offensive to other residents and could result in feelings of embarrassment for the resident. | 2020-09-01 |
| 30 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 554 | D | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of a facility statement, medical record review, observation, and interview, the facility failed to complete an interdisciplinary team (IDT) assessment for self-administration of medications by 1 resident (#131) of 8 residents reviewed during initial pool process, of 52 residents sampled. The findings include: Review of the facility Administering Medication Policy Statement, revised 12/12, revealed .25. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . Review of facility policy Self-Administration of Medication dated 10/18/17 revealed .1. A resident will not self-administer his or her medications until a determination has been made by the interdisciplinary team that the resident can safely perform this task .2. The household Clinical Mentor, (nurseUnit Manager) at the request of the resident, will assess the resident to determine the resident's ability to self-administer his or her medications .findings of the assessment will be documented in the resident's clinical record . Review of a facility statement signed by the Administrator and dated 8/15/18, revealed There is no resident who self-administers medications. Medical record review revealed Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's care plan dated 5/15/18, revealed the resident was at risk for unstable blood pressure related to Hypertension, .Administer B/P (blood pressure) meds (medications) as ordered .at risk for altered tissue perfusion related to anticoagulant (blood thinner) therapy .Administer meds (Aspirin) at same time daily . Medical record review of a current physician's orders [REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #131 required 2 person assistance with bed mobility and 1 person assistance for transfers, dressing, toileting and personal hygiene. Continued review revealed a Brief Interview for Mental Status (BIMS) Score of 3, indicating severe cognitive impairment. Observation and interview with Resident #131 on 8/13/18 at 9:36 AM, in the resident's room, revealed a cup of pills sitting on the resident's over bed table. Interview with the resident revealed the resident requested to have the medications after breakfast. Further interview revealed the resident had not participated in a care plan meeting to determine if self-administration of medication was appropriate. Interview with Licensed Practical Nurse (LPN) #1 on 8/13/18 at 9:47 AM, on the 2 South hall, confirmed LPN #1 left the medications on the over bed table .because resident likes to take her medication after she eats . Continued interview confirmed the medication was [MEDICATION NAME], SamE, a baby aspirin, and a [MEDICATION NAME]. Observation of the resident on 8/14/18 at 8:29 AM, in the resident's room, revealed a cup of pills sitting on the resident's over bed table. Interview with LPN #1 on 8/14/18 at 8:41 AM, on 2 South, revealed the resident had requested to take the medications after breakfast. Continued interview revealed LPN #1 was unaware if self-administration of medication was care planned for the resident, or if there was written documentation of an IDT assessment for the resident to self-administer medications. Interview with the Director of Nursing (DON) on 8/15/18 at 3:50 PM, in the conference room, confirmed no residents in the facility had been assessed for self-administration of medications. Continued interview confirmed medications were not to be left with residents for self-administration. | 2020-09-01 |
| 31 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 656 | D | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop and implement a person-centered care plan to address the resident's need for assistive devices during meal times for 1 resident (#54) of 52 sampled residents. The findings include: Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident required 1 person assistance with dressing and personal hygiene, and 2 person assistance with transfers and set up help for eating. Continued review revealed the resident was on a mechanically altered diet, had an identified weight loss, and had no oral or dental issues. Continued review revealed the resident scored 14 on the Brief Interview For Mental Status (BIMS), indicating he was cognitively intact. Medical record review of the quarterly Care Plan, undated, revealed .potential for weight loss .tremors of hands decrease his ability to self feed, dysphagia, swallowing difficulty .Staff to assist .when tremors are increased .Complete set-up and provide assistance with .eating . Continued review revealed at risk for Aspiration/Choking due to Dysphagia/Cough with intervention to .Assist .no straws .plate guard and weighted utensils with all meals . Medical record review of a clinical nurse's note dated 4/4/18 revealed .resident stated at lunch he couldn't feed himself, requested for staff to feed him . Observation of Resident #54 on 8/13/18 at 10:06 AM, in the resident's room, revealed the resident was eating a pureed breakfast provided in divided plate with no plate guard, had hand tremors and was noted to have food on clothing. Further observation revealed no weighted utensils in use. Observation of Resident #54 on 8/14/18 at 9:23 AM, in the resident's room, revealed the resident lying in bed, with the pureed breakfast meal provided in a divided plate with no plate guard, and regular eating utensils present. Continued observation revealed the resident had difficulty feeding himself due to the shakiness/tremors of the hands related to the disease process of [MEDICAL CONDITION]. Observation of Resident #54 on 8/15/18 at 8:35 AM, in the resident's room, revealed his pureed breakfast was served in a regular plate, with regular eating utensils, and a bowl. Continued observation revealed the resident had obvious tremors of the upper extremities bilaterally. Observation of Resident #54 on 8/18/18 at 9:20 AM, in the resident's room, revealed the resident had breakfast food of pureed consistency on a regular plate with regular eating utensils, and nectar thick liquids. Continued observation revealed no plate guard and weighted utensils had been provided. Observation of Resident #54 on 8/20/18 at 9:15 AM, in the resident's room, revealed the resident had breakfast food pureed consistency in a divided plate and nectar thick liquids. Further observation revealed no plate guard or weighted utensils had been provided. Interview and observation with Resident #54 on 8/18/18 at 10:00 AM, in the resident's room, revealed the resident had never used weighted silverware and did not want to utilize. Continued interview revealed had used a plate guard and it made eating easier. Observation of resident revealed resident had a regular plate without a plate guard. Interview on 8/18/18 at 10:15 AM during the resident observation with Licensed Practical Nurse (LPN) #1 confirmed the facility had failed to provide Resident #54 with a divided plate, a plate guard, and weighted utensils to promote self-feeding at meal time. | 2020-09-01 |
| 32 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 657 | K | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to revise 7 residents' (#119, #28, #34, #39, #40, #47, and #80) care plans after falls with effective interventions to prevent further falls of 52 sampled residents, placing residents #119, #28, #34, #39, #40, #47, and #80 in Immediate Jeopardy (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's failure is likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The IJ was effective 11/10/17, and is ongoing. The findings include: Review of the facility policy Care Planning-Interdisciplinary Team dated 1/1/17 revealed .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .which includes, but is not limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; d. The Social Services Worker responsible for the resident; e. The Activity Coordinator; f. Therapists (speech, occupational, recreational, etc.), as applicable; g. Consultants (as appropriate); h. The Director of Nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the resident .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan .The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan .is at the discretion of the Care Planning Committee . Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #119's ongoing care plan revealed the resident was at risk for falls and interventions implemented included on 12/24/15: non-slick footwear that fits and assist with transfers as needed; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions; keep personal items within easy reach; bed to be in lowest position with wheels locked; call light within reach when in room; invite/escort to activities of choice; instruct/remind to call for assist with mobility/transfers; use of proper assistive device wheelchair/walker. On 1/8/16 a sensor alarm in chair was added; on 2/5/16 a bed sensor was added; on 4/15/16 floor mat due to resident transfers self to from wheel chair was added; on 5/9/16 posey grip in wheelchair due to increased falls was added; 10/14/16 toileting as needed and Call Before You Fall signs was added; and on 5/30/17 anti-tip bars and anti-lock brakes to wheelchair was added. Medical record review revealed Resident #119 had 9 falls from 7/1/17 - 7/10/18 with dates of falls 7/1/17, 8/20/17 (resulting in a laceration to the forehead requiring sutures), 10/15/17, 11/10/17 (resulting in a bone [MEDICAL CONDITION] leg), 11/16/17, 11/19/17, 4/13/18 (resulting in a femur fracture), 6/27/18, and 7/10/18. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #119 required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and was dependent for toileting. Continued review revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Medical record review of the Care Plan dated 12/24/15 and revised 7/10/18 revealed the care plan was not revised with the interventions indicated by falls investigations including to toilet every 2 hours (10/15/17 fall), toilet more frequently and utilize bean bag (11/16/17 fall), and for Velcro noodles to mattress rail (7/10/18 fall). Interview with Nurse Mentor (nurse Unit Manager) #1 on 8/18/18 at 9:25 AM in the Mentor's office, confirmed .All of us are responsible to make sure the intervention is to be implemented (revised) on the care plan .Ultimately the mentor is responsible . Interview with the Director of Nursing (DON) on 8/18/18 at 10:36 AM in the conference room, confirmed the care plan had not been revised to include new interventions for toileting interventions (10/15/17 fall and 11/16/17 fall) and Velcro noodles to the mattress (7/10/18 fall) . Medical record review revealed Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #28 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #28's current care plan, not dated revealed, (Resident #28) is at risk for falls d/t (due to): Decreased mobility, LT (left) [MEDICAL CONDITION] s/p (status [REDACTED]. Actual Falls: 5/19/17, 6/17/17, 2/15/18 with FX (fracture) L (left) distal femur (resolve) Interventions: Assist (Resident #28) to wear non-slick footwear that fits. Attempt to engage (Resident #28) in ADL's (Activities of Daily Living) that improve strength, balance and posture. Instruct (Resident #28) on safety measures to reduce the risk of falls (posture, changing positions, use of handrails.) Keep areas free of obstructions to reduce the risk of falls or injury. Keep nurse call light within reach, Instruct (Resident #28) to use call bell or call out of assistance. Keep personal items within easy reach; bed to be in lowest position with wheels locked. Review of an Incident/Accident Report revealed Resident #28 had a fall on 2/15/18 at 9:45 AM, in the resident's room with injury. Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: Ensure w/c (wheelchair) is within reach while in bed . Medical record review revealed the resident's care plan was not revised to include the intervention to keep the wheelchair within reach while the resident was in bed. Review of an Incident/Accident Report revealed Resident#28 had a fall on 6/7/18 at 2:00 PM in the dining room, CNA (Certified Nurse's Assistant) observed res. (resident) topple forward from her w/c to the floor. Res. remained alert. Skin tear noted to left forearm. Res. did hit her head on right forehead. No bruising @(at) this time . Additional comments and/or steps taken to prevent recurrence: Res. cautioned re: leaning forward in w/c . Medical record review of the resident's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 6/7/18. Interview with Licensed Practical Nurse (LPN) #4 on 8/17/18 at 4:36 PM, in the secure unit, revealed the Household Nurse Mentor for each unit was responsible for updating a resident's care plan after a fall. Interview with Household Nurse Mentor #1 on 8/17/18 at 5:05 PM, in the secure unit nurse's office, revealed the Mentor was responsible for updating Resident #28's care plan with new fall interventions. Continued interview and review of the resident's care plan with the Nurse Mentor confirmed the resident's care plan had not been revised after the resident's fall on 2/15/18 to keep the resident's wheelchair within reach, and confirmed the facility failed to update the resident's care plan after the resident's fall on 6/7/18. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #34 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #34's current care plan, not dated, revealed, (Resident #34) is at risk for falls related to Decreased Mobility, Scoliosis, Narcotic and [MEDICAL CONDITION] Medication Use . Continued review revealed the following interventions: .Assist with toileting as needed. Attempt to engage (Resident #34) in ADL's that improve strength, balance and posture. Fall risk assessment as indicated. Keep call light within reach and remind how to use as needed. Keep room free from clutter, walkways clear. Keep frequently used items within reach. Monitor medications for changes that may effect falls. Footwear will fit properly and have non-skid soles. Instruct (Resident #34 on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .Goals: Resident #34 will have no falls this review period . Review of an Incident/Accident Report revealed Resident #34 had a fall on 2/25/18 at 4:30 AM in the resident's room .Heard someone crying and found pt (patient) on the floor in her room. She states she was going to BR (bathroom) and fell . C/O (complain of) lt (left) hip pain. Skin tear to Lt elbow . Continued review revealed, Additional comments and/or steps taken to prevent recurrence: Call before you fall posted . Medical record review of the resident's care plan revealed Resident #34's care plan was not revised to reflect the resident's fall on 2/25/18 or the new intervention to post the call before you fall sign. Review of an Incident/Accident Report revealed the resident had a fall on 6/16/18 at 9:55 PM in the resident's room .I was told by CNA (Certified Nurse Assistant) that resident was on the floor in her room, went to assess resident, she had skin tear to lt. hand, bump on left side of head and was c/o lt hip pain . Further review revealed, .Additional comments and/or steps taken to prevent recurrence .Call before you fall, posey grip (rubberized mat for resident to sit on while in wheelchair to prevent sliding from chair) . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall the resident had on 6/16/18 or the new intervention to add the posey grip to the wheelchair. Review of an Incident/Accident Report revealed the resident had a fall on 7/14/18 at 7:05 PM in the resident's room .Resident's roommate was calling for help (staff) and I went to the room and resident was on the floor in front of the sink and blood was pooled around her head . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: Call before you fall. Encourage out of room more . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall on 7/14/18 or the intervention to .encourage out of room more . Interview and review of the resident's care plan on 8/18/18 at 12:08 PM with the DON, in the conference room, revealed the Household Nurse Mentors on the units were responsible for ensuring revisions to the care plan were completed after a fall. Continued interview confirmed Resident #34's care plan had not been revised to reflect any of the resident's falls, and did not accurately reflect the fall interventions. Medical record review revealed Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #39 required extensive assistance with bed mobility and 1 person assistance for transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 7, indicating severe cognitive impairment. Medical record review of Resident #39's care plan with a goal date of 6/10/18, revealed the resident was .at risk of falls d/t (due to) weakness, Left sided weakness s/p (status [REDACTED]. Review of the facility documentation revealed the resident had a total of 9 falls between 4/3/18 and 8/11/18. Medical record review revealed Resident #39's care plan was updated to reflect 5 dates the resident had falls: 4/3/18, 4/15/18, 6/7/18, 6/27/18 (fall was actually 6/26/18 according to Icident/Accident Report) and 6/30/18. Continued review revealed the only times the resident's care plan was revised to reflect a new intervention after a fall were 6/7/17 - Call before you fall sign; 6/27/18 (for the 6/26/18 fall) - Pool noodles to bed; 6/30/18 - Frequent rounds; and 7/2/18 - Scoop mattress ordered. Interview with Household Nurse Mentor #2 on 8/15/18 at 7:40 AM, on the 400 unit confirmed the resident's care plan was not revised to reflect new or effective interventions to address Resident #39's continued falls. Interview with the DON on 8/16/18 at 9:30 AM, in the conference room confirmed the facility failed to revise the resident's care plan and failed to implement new or effective interventions to address the resident's continued falls. In summary, Resident #39 had 9 falls between 4/3/18-8/11/18. Interventions on the falls investigation were not consistently placed on the care plan. There were 6 falls with no intervention added to the care plan. Medical record review revealed Resident #40 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #40 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #40's care plan dated 5/23/18, revealed Resident #40 is at risk of falls due to weakness, History of Falls, Dementia and Hypertension. Interventions including wear non-slick footwear that fits; instruct the resident on safety measures to reduce risk of falls; attempt to engage in activities of daily living (ADL's) that improve strength; balance and posture, and keep areas free of obstacles to reduce the risk of falls or injury Medical record review of facility documentation revealed the resident had a total of 4 falls between 6/27/18 and 8/2/18. Medical record review of Resident #40's care plan dated 8/6/18 revealed the care plan was not updated to reflect the resident had falls on the following dates: 6/27/18, 7/16/18, 7/30/18 and 8/2/18. Continued review revealed the resident's care plan was not revised to reflect new or effective interventions to address the resident's continued falls resulting in the resident sustaining a head injury. Observation and interview with LPN Nurse Mentor #2 on 8/17/18 at 10:00 AM, in the resident's room, confirmed the resident was in bed with the head of the bed up, fall mats to both sides of the bed were without alarms, and the call light was out of reach of the resident. Further observation revealed the Nurse Mentor took the Call Before You Fall sign off the closet door and asked the resident to read the sign. Continued observation revealed Resident #40 held the sign in her hand, smiled, and stated nice. The resident was not able to read the Call Before You Fall sign. Further interview confirmed .She doesn't use the call bell, she hollers for us . Continued interview confirmed the Call Before You Fall sign was not an appropriate intervention for Resident #40 and re-education on the use of a call light for a severely cognitively impaired resident was not an appropriate fall prevention intervention. Interview with the DON on 8/20/18 at 11:15 AM, in the conference room confirmed the resident had multiple falls without appropriate interventions put in place. In summary, Resident #40 had 4 falls between 6/27/18 and 8/2/18. Interventions on the falls investigation were not placed on the care plan. There were no new interventions added to the care plan after each fall. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #47 required extensive assistance of I person with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #47's comprehensive care plan with an effective date of 4/5/18 revealed, .at risk for falls d/t weakness, RT (related to) acetabular fracture (a break in the socket portion of the hip joint) s/p (status/post) fall, vision impairment, [MEDICAL CONDITION], dementia, anxiety, [MEDICAL CONDITION] disorder, [DIAGNOSES REDACTED] and [MEDICAL CONDITION] med use . Continued review of the care plan revealed, .Actual falls 4/9/18, 4/10/18, 4/11/18, 4/14/18, 4/23/18, 4/25/18, 4/26/18, 4/27/18, 5/6/18 .Goals .will maintain current level of mobility with no increase in the incidence of falls/injuries .Interventions .Assist .to wear non-slick footwear that fits .attempt to engage .in ADLs that improve strength, balance, and posture .instruct .on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .keep areas free of obstructions to reduce the risk of falls or injury .keep nurse call light within easy reach .Instruct .to use call bell or call out for assistance .keep personal items within easy reach; bed to be in lowest position with wheels locked .bean bag provided to reduce the risk of falls .self-releasing lap buddy to reduce the risk for falls with injury . Continued review revealed none of the interventions documented on the care plan had been dated to illustrate when the interventions were initiated and implemented. Review of an Incident/Accident Report dated 4/5/18 and timed 7:30 PM revealed Resident #47 .crawled from his room into (another room). Multiple skin tears on bilateral elbows and L (left) knee bruise . Continued review revealed .Additional comments and/or steps taken to prevent recurrence: call before you fall, bed in low position Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 4/5/18 or the intervention to post call before you fall sign. Review of an Incident/Accident Report dated 4/9/18 and timed 10:30 PM revealed the resident had a fall in the resident's room without injury .called to resident room. CNA report that resident had been on floor mat by bed on knees . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: call before you fall, increased rounds . Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the new intervention of increased rounds. Review of an Incident/Accident Report dated 4/11/18 and timed 2:45 PM revealed, .sitting in wheelchair in day room with spouse. Leaned forward and slid out of chair. Landed on buttock . Continued review revealed, .Additional comments and/or steps to prevent recurrence: Informed spouse of need for full time sitter . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the recommendation for the family to hire a sitter. Medical record review of a nurse note dated 4/25/18 revealed, .resident was transferred to floor (to another unit) .he has been getting out of his w/c since he arrived to floor, causing his personal alarm to go off, staff has been able to prevent resident from falling or scooting on the floor up to this point, he has wandered in the area between staff bathroom and med room and scooted himself out of his chair and onto the floor .transferred back to his chair after assessment for injury . Medical record review of the resident's care plan revealed the use of a personal emergency alarm for the resident was not included on the resident's care plan. Review of an Incident/Accident Report dated 4/25/18 and timed 11:30 PM revealed, .CNA notified this nurse that resident was lying in floor beside bed . Review of a Fall Investigation Tool dated 4/25/18 revealed, .intervention .fall mats . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the use of fall mats for the resident. Review of an Incident/Accident Report dated 6/13/18 and timed 11:50 AM revealed, .called to room by PT (physical therapy) staff. Pt (patient) was already back in bed but was asleep on mat beside bed when physical therapy found him .he says 'I did not fall or get hurt' . Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: offer rest periods, know whereabouts . Medical record review of Resident #47's care plan revealed the care plan was not revised to reflect the fall on 6/13/18 and was not revised to reflect the interventions of offering rest periods and .know whereabouts . Observation and interview on 8/18/18 at 3:50 PM, in the resident's room, with CNA #17 revealed no call before you fall sign posted. Interview with CNA #17 confirmed fall mats were located on each side of the resident's bed (not on the resident's care plan). Continued interview revealed the CNA had never known the resident to have had any alarms or seatbelts since the time the resident was moved to the secure unit (approximately 2 months ago). Continued observation in the resident's room also revealed no bean bag chair was in the resident's room as documented on the resident's care plan. Interview and review of Resident #47's care plan with the DON on 8/20/18 at 3:45 PM, in the conference room, revealed the Household Nurse Mentor was responsible for ensuring revisions to the resident's care plan after a fall. Continued interview and review of Resident #47's care plan confirmed the resident's care plan was not revised to reflect the fall on 6/13/18 or the interventions of offering rest periods and .know whereabouts . Continued interview confirmed the resident's current plan of care did not accurately reflect the actual interventions which were observed to be in place at this time. Medical record review revealed Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS dated [DATE] revealed Resident #80 required extensive assistance with bed mobility and personal hygiene, and was totally dependent upon staff for dressing, eating and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of the quarterly care plan undated revealed Resident #80 was at risk for falls. Further review revealed Resident #80's care plan was not updated with effective interventions after falls on 3/1/18, 4/20/18 and 6/19/18 nor after a fall with serious injury on 7/2/18. Medical record review of the clinical notes dated 7/2/18 revealed .returned from (hospital) .C1(cervical)-C2 Fx (Fracture) and Aspen (Rigid neck brace) collar placed around residents neck, collar is to stay in place for 3 months .laceration to forehead with stitches .will continue to monitor . Interview with MDS Coordinator #3 on 8/17/18 at 7:55 AM, in the MDS office, revealed the MDS coordinators updated the care plans quarterly with the MDS assessments. Continued interview revealed the care plans were updated all other times by the nurses on the floor. Interview with LPN #1 on 8/18/18 at 3:00 PM, on 2 South Hallway, revealed interventions were to be placed on the care plan and updated by the .care plan manager . Refer to F689 | 2020-09-01 |
| 33 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 677 | G | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide assistance with activities of daily living for dependent residents by failure to provide bathing assistance for 1 resident (#53), and failure to provide timely incontinence care and toileting for 2 residents (#80 and #89) of 52 residents sampled. This failure resulted in Harm for Resident #80 and Resident #89. The findings include: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly care plan updated on 5/30/18 revealed self-care deficit .Extensive assistance required with bathing .Scheduled shower days: Tuesday and Friday AM .2 Times Weekly Starting 06/23/2016 .Staff to ask (Resident #53) Every other day if she would like a bath .Active (Current) . Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Continued review revealed the resident required 2 person assistance with bed mobility and toileting and 1 person assistance with dressing, hygiene, and bathing. Medical record review of the Activities of Daily Living (ADL) Verification Worksheet revealed from 7/10/18 through 7/18/18, revealed Resident #53 received 1 shower. Interview with Resident #53 on 8/13/18 at 11:08 AM, in the resident's room, revealed the resident did not receive a shower .last week at all not Tuesday or Friday they told me they were short staffed .it has happened before .not enough of them . Continued interview revealed .I was supposed to get a shower twice a week . Interview with Certified Nursing Assistant (CNA) #3 on 8/15/18 at 9:25 AM, in the 2 South Dining room, revealed the facility did not always have enough help to take care of the residents. Further interview revealed there have been times residents have not received showers and missed a shower day that resulted in the residents receiving only 1 shower per week .Our Kiosk that we document in does not differentiate in partial showers, bed baths, showers or whatever it just says bathing and we mark that no matter what we do but that does not mean that a .shower is done .but it looks like it . Interview with Household CNA Coordinator #1 (a CNA also) on 8/15/18 at 9:40 AM, in the 2 south dining room revealed there are .call offs and have lost some employees and do not always have enough staff to take care of the residents about 2-3 days out of the week . Further interview revealed there had been times the residents had not received showers because of staffing . Interview with CNA #4 on 8/15/18 at 9:56 AM, in the 2 south dining room, confirmed .not always enough staff to meet the needs of the residents .it upsets me .we are understaffed, I can't do my job the way I would like . Continued interview revealed .It's that way almost every day just 2 of us . Interview with LPN #2 on 8/15/18 at 10:05 AM, in the 2 south den area, revealed there was not always enough staff to meet the needs of the residents .like today the person I was working with put her notice in so there is only 1 nurse, the weekends there are not enough CNA's, last Sunday there was only 1 nurse and 2 CNA's .there have been times the residents have not received a shower due to staffing . Interview with LPN #1 on 8/18/18 at 9:12 AM, on the 2 south hallway, confirmed there .is never enough staff .recently had a set back with a CNA getting fired, a nurse quit, a CNA quit .they haven't been replaced .I have reported to the Director of Nursing (DON) and the Administrator . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS 14 day assessment dated [DATE] revealed Resident #89 had an indwelling catheter and was frequently incontinent of bowel. Medical record review of the unscheduled MDS assessment dated [DATE] revealed the Resident # 89's BIMS score was 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was extensive 2 person assist for bed mobility, transfers, and toileting. Interview with Resident #89 on 8/14/18 at 9:47 AM in the resident's room, confirmed .They are real short on day shift. I have called out because I need the bed pan and they did not get to me for a while and I had an accident on myself. It made me feel shamed . Interview with the DON on 8/20/18 at 3:11 PM in the conference room, confirmed .she (Resident #89) was not treated with respect and dignity . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS dated [DATE] revealed the resident was moderately cognitively impaired. Continued review revealed Resident #80 required 1 person assist for bed mobility, locomotion on unit, eating, toileting, dressing and hygiene. Continued review revealed Resident #80 was always incontinent of urine and bowel and was not managed on a bowel and bladder incontinence program. Medical record review of the quarterly care plan, undated, revealed the resident was always incontinent .nursing to check every 2 hours and change if wet/soiled and clean skin with mild soap and water .apply moisture barrier . Continued review revealed Bowel Continence: incontinent of bowel movement .check for incontinence .every 2 hours .clean and dry skin if wet or soiled . Further review revealed a self-care deficit with extensive assistance required with bathing, hygiene, dressing and grooming with goal .will be odor free . Medical record review of the ADL (Activities of Daily Living) Verification Worksheet revealed Resident #80 was provided incontinence care on 8/13/18 at 12:54 AM with the next incontinence care documented on 8/13/18 at 6:40 PM at time lapse of 17 hours and 46 minutes. Observation of Resident #80 on 8/13/18 at 10:48 AM, in the 2 South dining room, revealed the resident with front of pants and around perineal area wet. Observation of Resident #80 on 8/13/18 at 11:59 AM, in the dining room, revealed the resident with front of pants and around perineal area wet and had a strong urine odor. Observation of Resident #80 on 8/13/18 at 4:03 PM, in the resident's room, revealed the resident sitting in a wheelchair in his room. Continued observation revealed Resident #80's pants and the bottom front of his shirt were wet and soiled with a brown and dark yellow ring at the bottom of the shirt and had a strong urine odor. Interview with LPN #1 on 8/13/18 at 4:06 PM, in the resident's room, confirmed the resident's pants and shirt were wet with urine and he was in need of incontinence care. Continued interview revealed the last time resident had been provided incontinence care or toileted was unknown. Further interview confirmed the resident had a strong odor of urine. Interview with the DON on 8/15/18 at 3:50 PM, in the conference room, confirmed a resident wet with urine and with a strong odor of urine, sitting in the dining room area, could be offensive to other residents and could result in feelings of embarrassment for the resident. | 2020-09-01 |
| 34 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 686 | G | 0 | 1 | Q9H011 | **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 prevent the development of a pressure ulcer for 1 resident (#80) wearing a medical device of 5 residents reviewed for pressure ulcers and failed to practice proper infection control prevention through hand hygiene during a dressing change for 1 resident (#119) of 2 persons observed for dressing changes of 52 residents sampled. The facility's failure resulted in the development of a pressure ulcer and Harm for Resident #80. The findings include: Review of the facility policy, Pressure Ulcers dated 5/1/11 revealed .To provide each resident the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care .All wounds, regardless of cause will be evaluated with documentation at each dressing change. A thorough wound evaluation will be completed at least weekly .Documentation will contain information regarding: Location and Staging .Size .Exudate .Pain .Wound bed .Description of wound edges .All pressure ulcers must be monitored daily .For pressure ulcers that do not have daily .dressing change ordered, the TAR (treatment record) should reflect daily monitoring .An interdisciplinary team will perform weekly wound rounds to observe and measure all pressure ulcers in the facility. Documentation of findings will be kept on the Weekly Pressure Ulcer Record .Skin/Wound Care Protocols .Relieve pressure in and out of bed . Review of the facility policy, Pressure Ulcer Prevention dated 6/2013 revealed .To assure that no pressure ulcers develop within the facility unless it is unavoidable . Review of the facility Skin Assessments/Checks Policy revised 7/24/18, revealed .A skin assessment will be conducted by the nurse on a weekly basis. Documentation will include any and all skin issues noted .Skin assessments will be done by nursing assistants on bath/shower days. Any skin issues noted will be reported to the resident's nurse . Review of the facility policy, Pressure Ulcer Treatment, revised 7/18, revealed .If a resident is noted to have a pressure ulcer the nurse in charge of the resident's care should be notified. The nurse should notify the Wound Nurse and Physician .Follow standing orders for pressure ulcers including writing the order as 'per treatment guidelines' .these guidelines have been approved by the Medical Director .The Wound Nurse will evaluate the initial treatment based off the standing orders on their next working day to determine if any changes need to be made based on the condition of the ulcer . Review of the facility policy, Infection Control: Handwashing dated 1/1/17 revealed .All personnel will follow the handwashing procedure to prevent the spread of infection and disease .Employees will perform appropriate handwashing procedures using antimicrobial or non-antimicrobial soap and water under the following conditions .Before, during and after performance of normal duties such as handling dressings .Whenever doubt of contamination .Using gloves does not replace handwashing/hand hygiene . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed the resident had moderate impaired cognitive skills for daily decision making. Continued review revealed the resident required assistance of 1 person for bed mobility, locomotion on unit, eating, toileting, dressing, hygiene, and 2 person assistance for transfers. Medical record review of the Clinical Note dated 7/2/18, at 10:19 AM, revealed the resident suffered a fall from the bed at approximately 9:10 AM, and was sent to the emergency room for evaluation. Medical record review of the Clinical Note dated 7/2/18 at 8:30 PM, revealed the resident returned from the emergency room at 8:10 PM, with the [DIAGNOSES REDACTED]. Continued review revealed the collar was to stay in place for 3 months then have a follow-up with x-rays to monitor progress. Continued review revealed the resident was also sent with a collar for bathing. Medical record review of the Weekly Skin Assessment Form dated 7/27/18 revealed .Open area to Rt. (right) Clavicle. Medical record review of the Clinical Note dated 7/28/18 at 8:24 AM, revealed on 7/27/18 at 9:21 PM, an open area described as a skin tear was discovered on the resident's right clavicle measuring 3 centimeters (cm) in length by 0.8 cm in width. Medical record review of the Physician's Order and progress notes dated 7/30/18 revealed .Consult wound care team for evaluation and treatment of [REDACTED]. Medical record review of the Clinical Note dated 8/2/18 at 7:29 AM, revealed the resident was evaluated by the Wound Nurse Practitioner (NP). Continued review revealed the wound to the resident's right clavicle measured 3.2 cm by 2.6 cm by 0.2 cm. Continued review revealed the NP described the wound as unstageable at this time and facility acquired pressure ulcer, medical device related injury. Medical record review of the Physician's Order and progress notes dated 8/2/18 revealed .refer to (neuro surgeon) for cervical fracture follow up .Please D/C (discontinue) Hard C-collar .Place patient in soft cervical collar .D/C current wound treatment .[MEDICATION NAME] Blue .R (right) cervical wound .change every 3 days and PRN (as needed) . Medical record review of the Clinical Note dated 8/7/18, revealed the wound to the right clavicle was evaluated by the NP and measured 2.3 cm by 1.1 cm. Review of the Care Plan undated, conducted on 8/14/18 revealed no documentation or update that included C1-C2 fractures, care and use of the cervical collar, pressure ulcer development and specific treatment or interventions. Observation of the resident on 8/14/18 at 5:17 PM, in the resident's room, revealed the resident received wound care to unstageable right clavicle wound provided by Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1. Continued observation revealed the soiled dressing to right clavicle was removed and contained a moderate amount of yellowish-brown drainage on the dressing, and the wound bed was covered with slough which indicated an unstageable wound. Interview with the Director of Nursing (DON) on 8/16/18 at 9:05 AM, in the conference room, confirmed the expectation was a daily skin assessment to be conducted on residents who wore a splint, or a Cervical Collar. Interview with Licensed Practical Nurse (LPN) #2 on 8/16/18 at 9:30 AM, on 2 South Hallway, revealed skin assessments were conducted by nursing staff weekly. Continued interview revealed the CNAs (Certified Nursing Assistant) reported skin issues that were observed during bathing or care. Further interview revealed residents who wore splints or cervical collars should have had skin checked weekly and when bathed. Interview with CNA #4 on 8/16/18 at 2:21 PM, in the 2 South living room area, revealed CNAs were not allowed to remove the C-Collar. Continued interview revealed the nurse changed the soft collar out with one used on bath days. Further interview revealed the C-collar had not been removed except for bath days. Interview with CNA Household Coordinator #1 on 8/16/18 at 2:23 PM, in the 2 South living area, revealed CNAs did not remove cervical collars. Continued interview revealed the nurse changed the cervical collar for shower days. Interview with CNA #3 on 8/16/18 at 2:42 PM, in the 2 South living room area, revealed the C-collars were exchanged for showers and that was the only time the C-collar was removed. Interview with the wound NP on 8/17/18 at 5:10 PM, in the conference room, revealed the wound to right clavicle was a preventable, avoidable, medical device induced pressure ulcer. Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation with the Wound Care Nurse on 8/15/18 at 8:14 AM, in Resident #119's room, revealed the Wound Care Nurse prepared for wound care for 2 pressure ulcers and 1 lesion: *Stage 2 pressure ulcer located on the right heel *Lesion on the left foot *Stage 2 pressure ulcer located on the L ischial Continued observation revealed the Wound Care Nurse washed her hands, applied clean gloves, removed sock from the right heel, applied wound cleanser and applied [MEDICATION NAME] to pressure ulcer. Continued observation revealed she reapplied sock to the right foot and removed sock from left and applied wound cleaner to the left foot lesion with her contaminated glove. Further observation revealed she placed her gloved contaminated fifth digit of her hand in triad cream and placed it on the left foot lesion. Continued observation revealed the Wound Care Nurse reapplied the resident's left sock and repositioned the resident's pants to reveal the left ischium pressure ulcer. Further observation revealed she removed the dressing with her contaminated gloved hands then removed the contaminated gloves. Continued observation revealed she applied clean gloves to her uncleaned hands. Further observation revealed she measured the left ischium pressure ulcer with her contaminated gloves, applied wound cleanser to the pressure ulcer, placed the [MEDICATION NAME] Blue directly on the wound, and applied a new dressing with unclean hands. Continued observation revealed she placed the contaminated items in the bag, removed her contaminated gloves and washed her hands. Interview with the Wound Care Nurse on 8/15/18 at 8:25 AM in the conference room, confirmed, .I failed to remove my gloves and wash hands during the dressing change .I applied treatment with dirty gloves . Interview with the Director of Nursing (DON) on 8/16/18 at 9:52 AM in the conference room confirmed .She failed to wash her hands and apply clean gloves during the dressing change. She (Wound Care Nurse) did not follow infection control practices and did not follow our policy . | 2020-09-01 |
| 35 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 689 | K | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, interview, facility investigation review, and observation, the facility failed to implement an effective fall prevention program for 7 residents (#119, #40, #39, #80, #28, #34, #47) of 7 residents reviewed for falls with injuries, of 40 residents in the facility with falls. The facility's failure to implement new interventions and have an effective falls prevention program resulted in injuries for 6 Residents (#119, #40, #80, #28, #34, and #47) and placed Residents (#119, #40, #39, #80, #28, #34, #47) in Immediate Jeopardy (a situation in which the provider's noncompliance 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 informed of the Immediate Jeopardy on 8/18/18 at 8:20 PM, in the conference room. The Immediate Jeopardy (IJ) was effective 11/10/17 and is ongoing. The facility was cited F689 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The findings include: Review of facility policy Falls-Clinical Protocol-Assessment and Recognition, last revised 9/12, revealed .5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observation of the events, etc. 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification- 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke. b. Often, factors in varying degrees contribute to a falling problem .Treatment/Management - 1.Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. 3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example, dizziness or musculoskeletal pain) has resolved. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. 5. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful . Review of facility policy, Accident and Incident Report-Resident, dated 1/1/17 revealed .When an accident or incident involving a resident occurs, any person witnessing the incident will call for appropriate assistance .To assure appropriate follow-through on all accidents and incidents. To study the cause of accident and incidents and to give guidance for corrective/preventive action .Do not move the resident until a licensed nurse evaluates the condition . Medical record review revealed resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #119's Brief Interview for Mental Status (BIMS) score was 0, indicating the resident had severe cognitive impairment. Continued review of the MDS revealed the resident was extensive 2 person assist for bed mobility, transfers, and toilet use and was frequently incontinent of urine. Review of facility documentation revealed Resident #119 had 9 falls between 7/9/17 to 7/10/18 and 2 falls resulted in traumatic injury. Medical record review of Resident #119's ongoing care plan revealed the resident was at risk for falls and interventions implemented included on 12/24/15: non-slick footwear that fits and assist with transfers as needed; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions; keep personal items within easy reach; bed to be in lowest position with wheels locked; call light within reach when in room; invite/escort to activities of choice; instruct/remind to call for assist with mobility/transfers; use of proper assistive device wheelchair/walker. On 1/8/16 a sensor alarm in chair was added; on 2/5/16 a bed sensor was added; on 4/15/16 floor mat due to resident transfers self to from wheel chair was added; on 5/9/16 posey grip in wheelchair due to increased falls was added; 10/14/16 toileting as needed and Call Before You Fall signs was added; and on 5/30/17 anti-tip bars and anti-lock brakes to wheelchair was added. Medical record review of a Clinical Notes Report dated 7/1/17 at 10:16 PM, revealed, .res (resident) alarm heard sounding at same time of a loud crash .res in bathroom, on the floor, wheelchair by sink. Brakes on wheelchair not on .no injuries .Will continue to monitor closely and respond to alarms . Interview with the DON on 8/17/18 at 10:25 AM, in the conference room, confirmed an investigation was not conducted for the fall on 7/1/17 in order to determine the cause of the fall and to implement interventions to prevent further falls. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #119 scored a 22 (high risk for potential falls). Review of a facility Incident/Accident Report dated 8/20/17 revealed on 8/20/17 at 5:00 PM the resident had a fall. Further review revealed .Resident observed lying in hallway in front of her w/c (wheelchair). Lying with face down and toward right side. Laceration to right forehead, scratch on right cheek .Additional comments and/or steps taken to prevent recurrence: Will ask PT (physical therapy) eval (evaluation) for cushion . Review of a Written Statement for the accident on 8/20/17 revealed, I just sat (Resident #119) back in her chair, she had been leaning forward. I sat down at kiosk by kitchen to chart my vitals. I also noticed before incident she was dragging rt (right) foot under chair. I told her several times from 3 - 4:30 pm to slow down and sit back in her chair so she wouldn't fall (Resident #119 had severe cognitive impairment). As I started charting .another CNA (Certified Nursing Assistant) said oh no, I turned to see (Resident #119) w/c rolling over her, she was on the floor, the w/c flipped . Review of a Written Statement for the accident on 8/20/17 revealed, This nurse was notified that resident had fallen out of her w/c in hallway. Observed lying on the floor in front of her w/c (wheelchair) .Was lying with face down on floor and toward her right side large amt (amount) of blood from laceration on right forehead . Medical record review of a physician's orders [REDACTED].#119 to the emergency room (ER) for evaluation. Medical record review of a Clinical Notes Report dated 8/20/17 at 11:13 PM, revealed, .Resident has stitches in right forehead . Review of the Interdisciplinary Team Review for the accident on 8/20/17, revealed, Interventions implemented was not completed and Probable Cause was leaning forward in w/c. Request eval for cushion . Interview with the Clinical Therapy Manager on 8/17/18 at 3:55 PM, in the therapy room, confirmed .She (Resident #119) was not evaluated for wheelchair seating and positioning after 8/20/17 .No recommendations were done, there was no eval . Medical record review of a Significant Change in Status MDS assessment dated [DATE] revealed the resident's BIMS was 0 and was occasionally incontinent of urine. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #119 scored a 23 (high risk for falls). Medical record review of a Clinical Notes Report dated 10/15/17 at 11:16 PM revealed, This nurse was informed that resident was sitting in the floor in the bathroom .Resident sitting beside commode trying to get self up. States that she slid off the commode after she went to the bathroom. No injuries found .Resident reminded by staff and family to please ask for assist when needing to go to the bathroom (Resident had severe cognitive impairment) . Review of an Incident/Accident Report dated 10/15/17 revealed the actual time of the fall was 5:15 PM. Review of the CNA's Written Statement revealed I was getting (another resident) up for supper. I heard (Resident #119) calling HELP ME. I found her on floor in .bathroom. She was trying to get in her w/c and slid into floor . Further review revealed, .steps taken to prevent recurrence: try to keep resident in sight of staff to help her go to BR (bathroom) . Review of the Interdisciplinary Team Review for the fall on 10/15/17 revealed Interventions implemented was to toilet the resident at least every 2 hours (an expected nursing intervention) and the Probable Cause was Toileting self et (and) fell . Medical record review of a Clinical Notes Report dated 11/10/17 at 8:53 AM revealed, 0805 (8:05 AM) Notified by CNA that chair alarm was activated and she entered room and observed resident sitting in the floor in the bathroom. Resident was attempting to pull herself up from a sitting position. CNA assisted resident into w/c and then notified this nurse. This nurse observed resident and noted to have deformity to right lower extremity . Further review revealed at 1:35 PM, .[DIAGNOSES REDACTED]. Review of the Incident/Accident Report for the accident on 11/10/17 revealed the steps taken to prevent recurrence was not completed. Continued review of a Written Statement by the CNA revealed The alarm was going off on the chair in (Resident #119) room and she was in the bathroom trying to get up hanging on the rail and on the floor and her right leg was around bottom of the toilet between the wall. She was hanging so help transfer her to the wheelchair and let the nurse know . Medical record review of ER (Emergency) Trauma Worksheet dated 11/10/17 revealed .unwitnessed fall .fell this morning out of her wheelchair while attempting to stand .Granddaughter states this happens quite frequently at patients nursing home and has resulted in several injuries in the past .Patient complains of right lower leg pain . Review of the Investigation Tool for the accident on 11/10/17 revealed for the Interdisciplinary Team Review, Interventions implemented was not completed and Probable Cause: Res transferring self. No safety awareness. Medical record review of the acute care Hospital Discharge Summary dated 11/14/17 revealed .Right tib-fib (tibia-fibula) fracture following a fall .suffered a fall at (facility) and sustained a right tib-fib fracture .cast was applied . Interview with Licensed Practical Nurse (LPN) #3 on 8/16/18 at 3:00 PM, in the 1 North nurses station, revealed .(on 11/10/17) CNA assisted her to the wheelchair .then came to get me .when I went in there observed a clear deformity to right lower leg .the CNA was not supposed to move her . Interview with the DON on 8/16/18 at 9:52 AM, in the conference room confirmed it did not appear an intervention to prevent falls was put in place after the fall on 11/10/17. Medical record review of a Clinical Notes Report dated 11/16/17 at 10:30 AM revealed, CNAs report that chair alarm was activated and staff went to investigate alarm and observed (Resident #119) sitting in the bathroom .This nurse entered room and observed resident sitting in the floor beside the toilet with both legs stretched out in front of her. No apparent injuries .Resident had an incontinence episode of stool and was assisted on toilet. Resident transferred to sunroom and seated in bean bag chair . Review of an Incident/Accident Report dated 11/16/17 revealed the steps taken to prevent recurrence: Res had just been toileted @ (at) 9:30 (fall occurred at 10:30). Will ask res more freq (frequently) if toilet needs. Bean bag utilized as well . Review of a CNA's Written Statement for the accident on 11/16/17 revealed, Chair alarm was going off .(Resident #119) was trying to get on the toilet alone . Review of the Interdisciplinary Team Review for the accident on 11/16/17 revealed, Interventions implemented: Toilet more freq. Utilize bean bag. Probable Cause: apparently attempting to toilet self. Medical record review of a Clinical Note Entry dated 11/19/17 at 12:45 PM revealed, .Observed resident sitting in the floor next to the bed with bilateral legs outstretched in front of her. W/C was also next to the bed and alarm had activated. When resident was asked what she was doing, she places her hands on her hand and states 'I don't know' .no apparent injuries .Daughter states that during a visit this week her mother told her she needed to go to the bathroom, and before she could get help, her mother was attempting to go to the bathroom unassisted . Review of a CNA's Written Statement for the accident on 11/19/17 revealed, Light was going off in (Resident #119) room and when I went in she was on the floor beside her bed. Review of the Incident/Accident Report for the accident on 11/19/17 revealed .steps taken to prevent recurrence .therapy picked her up . Review of the Interdisciplinary Team Review for the accident on 11/19/17 revealed no documentation a review was conducted, no interventions were implemented, and a probable cause was not indicated. Medical record review of Resident #119's ongoing care plan revealed an intervention on 11/24/17 of self-releasing safety belt in the wheelchair. Medical record review of a quarterly MDS assessment dated [DATE] revealed Resident #119's BIMS was 0 and the resident was frequently incontinent of urine. Medical record review of a Clinical Notes Report dated 4/13/18 at 2:36 PM revealed 1400 (2:00 PM) Called to sunroom by CN[NAME] CNA reports walking into dining room and observing resident laying in the floor in the sunroom. Reports that resident was previously sitting at the dining room table for meal. Upon assessment, observed resident laying on her left side in front of her w/c which was left in the sunroom during meal .Resident crying and yelling out in pain .resident does grab at her left hip and leg . Review of a Clinical Notes Report dated 4/13/18 at 11:42 PM revealed, .resident was admitted to (hospital) with a Lt. (left) femur fx. Medical record review of an acute care hospital Surgical Consultation Note dated 4/13/18 revealed .female who has profound dementia fell today injuring her left hip. X-rays in the emergency room reveal comminuted angulated intertrochanteric [MEDICAL CONDITION] hip . Review of the Incident/Accident Report for the accident on 4/13/18 revealed the .steps taken to prevent recurrence was not completed. Review of the Investigation Tool revealed under Devices .Ordered sensor, alarm in place it was written N/A (not applicable). Under Interventions, (indicating interventions that were to be in place at the time of the fall) was a self-releasing seat belt, mats, pressure sensor alarm, nonskid socks, low bed, and night light. Review of the Interdisciplinary Team Review for the accident on 4/13/18 revealed no documentation a review was conducted, no interventions were implemented, and a probable cause was not indicated. Medical record review of the acute care hospital Discharge Summary dated 4/16/18 revealed .Left proximal femur fracture postop (postoperative) 4/15 (4/15/18) ORIF (open reduction internal fixation) . Interview with LPN #3 on 8/16/18 at 3:08 PM, in the 1 north nurses station, revealed .(on 4/16/18) After lunch saw her sitting at one of the dining room tables .was in a regular chair .wheelchair was in the sunroom .was attempting to ambulate to her wheelchair .I assessed her .Complain of pain left hip area .Was grabbing and grimacing Left hip/leg area . Medical record review of Resident #119's ongoing care plan revealed an intervention on 4/19/18 of Lap Buddy (cushion placed across the lap and hooks under arms of wheel chair) while in wheel chair and on 4/21/18 sensor alarm to wheel chair (an intervention that was to be in place since 1/8/16). Medical record review of a Clinical Notes Report dated 4/19/18 at 6:00 PM revealed, Interdisciplinary Meeting held this day, in attendance: (3 family members), Administrator, Medical Director, DON, Therapy Manager, Clinical Mentor, and Social Worker. Resident family concerned regarding resident numerous falls .remain concerned with number of falls that have occurred. Family understands that resident has a dx (diagnosis) of Dementia, which is advancing. Resident has no safety awareness due to her cognitive deficits. Current interventions reviewed and will remain, with the addition of a lap buddy to apply to w/c, unfortunately the current armrests on resident w/c will not accommodate this lap buddy. Therapy to order new arm rests for w/c, then we will apply further Velcro to add another layer of protection and another step for resident to attempt to self transfer or remove these intervention devices. We will continue with current lap buddy until these new arm rests arrive. Hipsters provided to staff and instructed on use and to also leave resident in her w/c for meals . Review of an undated letter addressed to the family of Resident #119 and written by the facility Administrator revealed, .Thank you for taking time to meet regarding (Resident #119)'s care plan. More specifically, we discussed your concerns regarding the potential for (Resident #119) to suffer an injury by falling .it is important you clearly understand that (the nursing facility) cannot eliminate the potential for falls to occur .as we discussed, we will not have a staff member consistently within close proximity of (Resident #119), nor are we required to do so. Even with a staff member nearby, a resident still may accidentally fall. It is simply an unavoidable risk .you may consider hiring a private duty aide to remain with (Resident #119) . Medical record review of a Significant Change in Status MDS assessment dated [DATE] revealed Resident #119's BIMS was 0 and the resident was frequently incontinent of urine. Medical record review of a Clinical Notes Report dated 6/27/18 at 8:09 PM revealed, Residents bed sensor alarm sounded and noted that resident was partly off bed onto bedside matt. Bed was in lowest position and resident had legs and bottom on matt and upper torso on bed hanging onto side rails. Noted that resident had a skin tear on back and left arm . Review of an Incident/Accident Report dated 6/27/18 revealed .steps taken to prevent recurrence: Pool noodles . Review of the Interdisciplinary Team Review for the accident on 6/27/18 revealed, .Interventions implemented: Pool noodles. Probable Cause: Climbing out of bed, side rails are padded, has low air loss mattress w/ (with) sensor alarm, mats et low bed. Medical record review of a Clinical Notes Report dated 7/10/18 at 3:10 AM revealed, Pt (patient) alarm going off when CNA went to room, found pt half in bed and half out of bed. Head and upper body in bed and legs and feet on floor. Pt. has abrasion in middle of forehead . Review of an Incident/Accident Report dated 7/10/18 revealed .steps taken to prevent recurrence: Velcro noodles to mattress rail . Review of the Interdisciplinary Team Review for the accident on 7/10/18 revealed, Interventions implemented: Velcro noodle to mattress. Probable Cause: Unknown due to cognition. Res could not explain. Interview with Registered Nurse (RN) #2 on 8/15/18 at 7:03 AM, in the 1 north nurse's station, revealed .She (Resident #119) has fallen on numerous shifts .when up has to be in wheelchair and has a belt .she knows how to unhook .she is like a Houdini . Interview with the DON on 8/16/18 at 9:05 AM, in the conference room, confirmed . She (Resident #119) has had frequent falls. She continues to fall with all the interventions she has. We even told family they might want to consider hiring a 24 hour sitter. We have a few frequent fallers . Interview with CNA #16 on 8/16/18 at 2:42 PM, in the 1 north hallway, revealed .We don't have enough supervision for her (Resident #119) . Observation and interview with the Director of Nursing (DON) on 8/17/18 at 7:33 AM, in Resident #119's room, revealed the resident was in bed lying on her left side. Further observation revealed Velcro pads were hanging downward, on the outer upper end of the bed rails, and the pool noodles were up against the wall. Interview with the DON confirmed .the Velcro noodles are not attached to the bed correctly and the pool noodles are not in the resident's bed . Interview with Licensed Practical Nurse (LPN) House Mentor #1 on 8/17/18 at 8:10 AM, in the 1 North dining room, revealed .If she is sitting in a regular chair a staff member has to be with her. No intervention to address resident supervision .she continues to try to transfer herself and fall. She has no safety awareness .The lap buddy I just an extra measure to free herself. It is to slow her down. The lap buddy is working to certain extent. Gives us more time to get to her . Further interview confirmed no interventions were put in place to prevent further falls after Resident #119's fall on 11/10/17. Interview with House Mentor #1 on 8/18/18 at 9:25 AM, in the Mentor's office, confirmed staff were not documenting toileting. Further interview confirmed Resident #119 needed more frequent toileting than every 2 hours. The Mentor stated . All of us are responsible to make sure intervention is to be implemented . Further interview revealed when a fall occurred, .Nurse Fills out incident report .IDT (Interdisciplinary Team) comes up with new intervention . Further interview confirmed a root cause analysis was not done for the falls on 11/19/17 or 4/13/18 to determine the probable cause of the falls in order to implement interventions to prevent further falls. Further interview revealed, .(Resident #119) needs supervision within eye sight .She wanders all over unit . Further interview revealed the interventions implemented of toileting more frequently and toileting as needed were not different and not specific. Interview with the DON on 8/18/18 at 10:36 AM, in the conference room, revealed .I don't know what Velcro noodles would be exactly, maybe pool noodles . Interview with the DON on 8/18/18 at 12:39 PM, in the conference room, revealed .I've not seen a bean bag chair since I've been here .The lap buddy slows her down. We have recommended to family they do the 24 hour sitter .A lap buddy wouldn't prevent falls .You can't really prevent falls . Telephone interview with CNA #23 on 8/18/18 at 1:00 PM revealed the CNA had never seen any pool noodles with Velcro and did not know what Velcro noodles (intervention that was to be put in place after the fall on 7/10/18) were. Interview with CNA #5 on 8/18/18 at 8:59 PM, revealed the CNA did not know what Velcro pool noodles were. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of Resident #40's care plan dated 5/23/18 revealed the resident was at risk for falls due to weakness, history of falls, Dementia, and Hypertension. Continued review revealed interventions included wear non-slick footwear, instruct the resident on safety measures to reduce risk of falls, attempt to engage in Activities of Daily Living (ADL's) that improve strength, balance, and posture, and keep areas free of obstacles to reduce the risk of falls or injury. Medical record review of the Admission MDS dated [DATE], revealed Resident #40 had a BIMS score of 3, indicating the resident was severely cognitively impaired, and required extensive assistance of 1 for mobility, toileting, and transfers. Review of a facility Incident/Accident report dated 6/27/18, revealed Resident #40 was found on her knees in her room with 2 skin tears to the left wrist. Continued review revealed steps taken to prevent recurrence included .Call before you fall signs - visual cueing . Review of the Interdisciplinary Team Review for the accident on 6/27/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Medical record review of a Nursing Note dated 7/6/18, revealed .Ambulates w(with) walker w/one assist, however she frequently forgets to ask for assist and attempts to get out of chair and ambulate to/from room by herself. Frequent reminders given to call for assist. Gait is unequal and unsteady . Medical record review of a Nurses note dated 7/30/18, revealed Resident #40 was in her recliner, attempted to pick up a cup that had fallen on the floor, and slid out onto the floor. Further review revealed the resident had non slip socks on. Continued review revealed the resident was instructed to always use the call light. Review of a facility Incident/Accident report dated 7/30/18 revealed Resident #40 had a fall in her room with no injuries noted. Continued review revealed steps taken to prevent recurrence .Reinstructed & (and) demo (demonstrate) call light use . Review of the Interdisciplinary Team Review for the accident on 7/30/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Review of a falls assessment dated [DATE] revealed Resident #40 scored 11 (at risk for falls). Review of an Incident/Accident report dated 8/2/18 revealed Resident #40 was found lying on her back in her bathroom with her walker on top of her. Continued review revealed .Two knots were found on the back of her head with a laceration on one of them .It was determined to send her out for evaluation . Review revealed interventions in place at the time of the fall were mats and non-skid socks. Further review revealed steps taken to prevent recurrence .Reiterate use of call light .Removal of hosiery and use slipper socks . Review of CNA #15 Written Statement revealed, (CNA #14) and I were in (another resident's room) with another resident, and heard someone yelling. Ran out to see what happened next door. Went into (Resident #40) room and found her lying on bathroom floor . Review CNA #14 Written statement revealed, (CNA #15) & (and) I were in (another resident room) and heard some one yelling and went to check in each room & it was (Resident #40) laying in bathroom floor . Review of the Interdisciplinary Team Review for the accident on 8/2/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Further review revealed no signature from the Medical Director, Administrator or DON to indicate the fall was reviewed. Review of a falls assessment dated [DATE] revealed Resident #40 scored a 14 (at risk for falls). Medical record review revealed the resident was admitted to an acute care hospital on [DATE] for .Mechanical fall .Subdural hematoma .[MEDICAL CONDITION] .Patient was admitted after falling backwards in bathroom at (facility) . Medical record review of a Computed [NAME]ography (CT) of the Head radiology report dated 8/2/18 revealed the resident had an acute subdural hematoma (SDH). Medical record review of a Nursing Note dated 8/6/18 revealed .Resident arrived back from (named hospital) 8/6/18 .Family at bedside .daughter states she is alert at times and does not recognize her. She has severe bruising to back of head and neck, w/a (with a) small scab to back of L (left) side of head. Bruising to R (right) arm, R index finger swollen and red. Small skin tears to bilateral arms. L lower arm skin tear . Medical record review of Resident #40's care plan dated 8/6/18, revealed the resident was at risk for falls related to weakness, History of Falls, Dementia, [MEDICAL CONDITION] medication use and status [REDACTED]. Medical record review of a Nursing Note dated 8/12/18 revealed the nurse heard Resident #40 yelling out, the nurse entered the room, and found the resident lying in the corner of her room with her back against the wall. Further review revealed the resident was found to have a large bruise to the left hip and a skin tear to the right arm. Continued review of the note revealed earlier the same day, the resident was found standing in the resident's room, going to the bathroom, and other staff reported she gets up without calling for assistance. Further review revealed the resident's call light was in reach at the time of the fall and staff re-educated the resident on the use of the call light. Review of a facility Incident/Accident Report dated 8/12/18, revealed the resident was found in the corner of her room between the bed and the bathroom and the resident stated she slipped. Continued review revealed under steps taken to prevent recurrence there were no interventions implemented. Review of the Investigation Tool for the accident on 8/12/18 revealed, under the section Interventions, which indicated the interventions in place at the time of the fall, none of the interventions were marked, and handwritten in the section was Re-Educate. Review of the Interdisciplinary Team Review for the accident on 8/12/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Further review revealed no signature of the Medical Director, Administrator or DON to indicate they had reviewed the accident. Medical record review of a falls assessment dated [DATE] revealed the falls assessment was incomplete and no score was documented. Medical record review of a physician's orders [REDACTED].Please get floor mat that alarms @ nurses station & place beside bed . Interview with RN #3 and medical rec (TRUNCATED) | 2020-09-01 |
| 36 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 690 | D | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to provide catheter care for 1 resident (#89) of 4 residents reviewed with catheters, of 52 sampled residents. The findings include: Review of facility policy Catheter Care-Indwelling Catheter, dated 1/1/17, revealed .PURPOSE: to prevent infection and provide daily hygiene . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 Day Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status Score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance with 1 staff member for bed mobility and toileting and required total assistance with 2 staff members for transfers and bathing. Further review revealed the resident required a wheelchair for mobility and was assessed as having an indwelling catheter. Medical record review of admission orders [REDACTED].FC(Foley Catheter)(indwelling urinary catheter) .chg (change) monthly .cath (catheter) care . Medical record review of readmission orders [REDACTED]. Medical record review of a Clinical Nurse Note dated 8/11/18 revealed .catheter replaced with #18 (size) catheter with 20cc (cubic centimeter) balloon (balloon to hold catheter in place) . Medical record review of a Physician order [REDACTED].Urinary Catheter Care q (every) shift .Starting 8/18/18 .Insert indwelling catheter .Every One Month Starting 8/18/18 . Interview with Resident #89 on 8/18/18 at 11:45 AM, in the resident's room, revealed .my catheter was changed just the other day .that was the first time they (facility) changed it .the nurse said she had to change the catheter because I had it since (MONTH) .they don't do catheter care everyday .they only do it on Tuesday and Thursday when I have my bath . Interview with LPN Nurse Mentor #5 on 8/18/18 at 3:56 PM, in the nursing station, confirmed when the resident was admitted to the facility the physician order [REDACTED]. Interview with the Director of Nursing on 8/18/18 at 5:00 PM, in the conference room, confirmed the catheter was to be replaced monthly and catheter care was to be reordered when the resident returned to the facility. Continued interview confirmed catheter care was to be completed daily unless ordered otherwise. | 2020-09-01 |
| 37 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 692 | D | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation and interview, the facility failed to ensure interventions were implemented and monitored to prevent further weight loss for 2 residents (#34, #54) of 5 residents reviewed for nutrition, of 52 residents sampled. The findings include: Review of the Facility Weight Assessment and Intervention Policy revised 9/08 revealed 6 .threshold for significant unplanned weight and undesired loss will be based on the following criteria (where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100): a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe .Continued review revealed .Individualized care plans shall address .identified causes of weight loss .Goals and benchmarks for improvement .Time frames and parameters for monitoring and reassessment . Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 3 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Continued review revealed Resident #34 was independent with eating with assistance of set up only, and had no weight loss. Medical record review of the weight record from (MONTH) (YEAR) through (MONTH) (YEAR) revealed: 5/6/18 126.2 pounds 6/3/18 126 pounds 7/3/18 121.8 pounds 8/5/18 weight 111.2 pounds 8/12/18 weight 115.4 pounds Review of Nutrition Progress assessment dated [DATE] revealed Resident #34's current weight was 126 pounds, Nutrition [DIAGNOSES REDACTED].Intervention: Liberalization of diet, Evaluation .monitor weights and intake . Review of a clinical notes report dated 8/10/18 at 1:45 PM entered by Dietitian #2 revealed a significant weight loss of 8.7 percent, 10.6 pounds from 7/3/18 through 8/5/18. Medical record review of physician's orders [REDACTED].RD (Registered Dietician) recommendation -Weekly wts (weights) x (for) 4 weeks r/t (related to) 8.7% wt loss x 1 month, Refer to Psychiatry (Psych) d/t (due to) wt loss . Review of Physicians Order Sheet and Progress Notes dated 8/15/18 revealed .recommendation per RD: 1) Boost Plus (nutritional supplement drink) TID (3 times per day) between meals . Review of Resident #34's care plan dated 8/16/18 revealed .therapeutic diet as ordered CCD (consistent carbohydrate diet) regular diet. Therapeutic restriction of choice .provide ques and encouragement. Feed (Resident #34) remaining food items .monitor food intake at each meal .Boost three times a day between meals . Interview with LPN #5 in nurse's office in secure unit on 8/18/18 at 3:10 PM revealed the nutritional supplement Boost was documented as given on the Medication Administration Record [REDACTED]. Review on 8/18/18 at 3:10 PM of the Psychiatry referral book in the Nurses office revealed Resident #34 was referred to Psychiatry on 8/10/18. Continued review revealed no documentation the referral had been addressed by Psychiatry. Interview with the DON on 8/18/18 at 4:55 in the conference room confirmed Resident #34 had not been seen by Psychiatry since the referral date of 8/10/18, . should have been since Psych is in the building 2 times a week . Interview on 8/20/18 at 10:19 AM with Dietary Manager and Registered Dietician #1 in the conference room confirmed the facility failed to ensure interventions were implemented to prevent further weight loss. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed no behaviors, required 1 person assistance with hygiene, 2 person assistance with transfers, and dressing, and set up help for eating. Continued review revealed Resident #54 was on a mechanically altered diet, weighed 219 pounds, and had no oral or dental issues. Continued review revealed a BIMS Score of 14 indicating the resident was cognitively intact. Medical record review of the quarterly MDS dated [DATE] revealed no behaviors, required 1 person assistance with dressing and hygiene, 2 person assistance with transfers, and set up help for eating. Continued review revealed Resident #54 was on a mechanically altered diet, had a weight loss of 20 pounds from the previous MDS assessment, with a current weight of 199 pounds, and had no oral or dental issues. Medical record review of the quarterly care plan print date of 6/14/18 revealed .potential for weight loss .tremors of hands decrease his ability to self feed, dysphagia, swallowing difficulty .Staff to assist .when tremors are increased .Complete set-up and provide assistance with .eating . Continued review revealed at risk for Aspiration/Choking due to Dysphagia/Cough with intervention to .Assist .no straws .plate guard and weighted utensils with all meals . Further review revealed the facility failed to develop and implement an individualized care plan to address the identified weight loss of 20 ponds. Observation of Resident #54 on 8/13/18 at 10:06 AM, in the resident's room, revealed the resident was eating breakfast provided in a divided plate with no plate guard, had hand tremors and was noted to have food on clothing. Further observation revealed no weighted utensils in use. Observation of Resident #54 on 8/14/18 at 9:23 AM, in the resident's room, revealed breakfast was provided in a divided plate with no plate guard, and regular silverware. Continued observation revealed the resident had difficulty feeding self due to tremors of hands. Observation of Resident #54 on 8/15/18 at 8:35 AM, in the resident's room, revealed breakfast was served on a regular plate, with regular silverware and bowl. Interview with RD #1 on 8/15/18 at 2:50 PM, in the conference room, revealed RD #1 was unfamiliar with this resident and was not aware of the resident's weight loss or any interventions. Further interview revealed the RD was not able to determine the interventions that were previously initiated on the care plan and if the interventions of weighted utensils and plate guard were discontinued. Interview with MDS Coordinator #3 on 8/17/18 at 7:55 AM, in the MDS office, revealed the MDS Coordinators updated the care plans quarterly with the MDS assessments. Continued interview revealed the care plans were updated all other times by the nurses on the floor. Continued interview revealed no straws, and the plate guard were active on the care plan for Resident #54. Observation of Resident #54 on 8/18/18 at 9:20 AM, in the resident's room, revealed the resident had breakfast food pureed consistency, a regular plate and regular silverware. Continued observation revealed no plate guard or weighted utensils. Interview with LPN #1 on 8/18/18 at 10:15 AM, on the 2 South Hall way revealed the resident had a plate guard but it was discontinued. Continued interview revealed the resident used a divided plate with meals. Further interview, in the resident's room, confirmed resident did not have a plate guard, a divided plate or weighted utensils. Interview with LPN #1 on 8/18/18 at 3:00 PM, on 2 South Hall, revealed the interventions were to be placed on the care plan and updated by the .care plan manager . Continued interview revealed LPN #1was unaware of Resident #54's 20 pound weight loss or any weight loss interventions except a divided plate that had been used. Interview and observation with Resident #54 on 8/18/18 at 10:00 AM, in the resident's room, revealed the resident had never used weighted silverware and did not want to utilize. Continued interview revealed Resident #54 had used a plate guard when provided and it made eating easier. Continued observation revealed the resident had a regular plate without a plate guard. | 2020-09-01 |
| 38 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 697 | G | 0 | 1 | Q9H011 | **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 assess and monitor the effectiveness of an individualized Pain Management Program for 1 resident (#236) of 3 residents reviewed for pain of 52 sampled residents. The facility's failure to effectively control Resident #236's pain resulted in actual Harm to the resident. The findings include: Review of the facility policy, Pain Management, undated, revealed .Pain is always subjective; pain is whatever the person says it is .Fear of dependence, tolerance and addiction does not justify withholding opioids [MEDICATION NAME] in residents suffering with pain .Alert Communicative Resident .1. Resident identified with having pain will be asked degree of pain according to Numerical Pain Scale (0-10), with zero representing no pain and 10 representing the worst possible pain .4. Efficacy will be documented within one hour after administration of [MEDICATION NAME] .9. Physician will be notified of ineffective [MEDICATION NAME] .10. Physician will be notified immediately if pain suddenly becomes severe .18. Prevalent pain breakthrough should be reported to physician . Medical record review revealed Resident #236 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set assessment dated [DATE], revealed the resident had a score of 15 on the Brief Interview For Mental Status, indicating she was cognitively intact. Medical record review of a care plan, undated, revealed .Potential for altered level of comfort-chronic pain related to .recent pressure ulcer s/p (status [REDACTED].Interventions .Notify MD (Medical Doctor) of unusual complaints of pain . Medical record review of a Nurse Practitioner's (NP) note dated 8/2/18 revealed .Discussion with patient regarding pain management had requested an increase in pain meds due to wound. Education provided re (regarding) pain management and good stewardship of use. Discussed times of administration important to better manage pain related to wound . Neurological .Patient is awake, alert and oriented x 3 . Medical record review of a nurse's note dated 8/6/18 at 3:29 PM revealed .Resident had c/o (complaints of) pain unrelieved by PRN (as needed) medication .NP notified. New orders to continue pain medication and new order for [MEDICATION NAME] (medication to treat anxiety) PRN for anxiety . Medical record review of a Physicians Order dated 8/6/18 revealed [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]-narcotic pain medication) 10 milligrams (mg)-325 mg tablet PRN every 6 hours and [MEDICATION NAME] (medication to treat anxiety) 0.5 mg tablet PRN every 12 hours. Resident went to [MEDICAL TREATMENT] this AM .Resident did not tolerate dressing changes well . Medical record review of a nurse's note dated 8/6/18, revealed .Resident stated she did not need the [MEDICATION NAME] at this moment .Wound care done on L (left) hip this AM. Resident is now refusing to have wound care done on R (right) hip d/t (due to) pain, wound care nurse made aware. Will continue to monitor for further changes . Medical record review of a Wound Nurse note dated 8/6/18 revealed .Talked a long time for importance of changing drsgs (dressings) twice a day with reasoning .Right buttock wound was surgically had debridement done. Measured 12.8 x 9.8 .Left buttock wound measured 14 x 14 .There is another small wound noticed just below it measures 3 x 1.5 . Medical record review of a nurse's note dated 8/7/18 revealed .Resident complained of pain that is unrelieved by PRN pain medication . Wound care completed. Resident did not tolerate dressing changes well . Medical record review of a nurses note dated 8/8/18 at 4:06 PM revealed .Also discussed about the importance of accepting and managing the wound care as ordered .Ensured that pain management prior to the dressing change for the best outcome . Medical record review of a Physicians Order dated 8/9/18 revealed .medicate for pain prior dressing change . Medical record review of the Medication Administration Record [REDACTED]. Medical record review of a Nurse's Note for Resident #236 dated 8/13/18 at 1:50 PM revealed pain on a scale of 10 while dressings being changed . Interview with the Licensed Practical Nurse (LPN) #13 on 8/15/18 at 9:30 AM, on the 300 unit, confirmed the resident had complained of pain during dressing changes on 8/13/19 and 8/15/18 and had been given the medication prior to dressing change but did not report the unrelieved pain to the Physician. Interview with Certified Nursing Assistant (CNA) #23 on 8/15/18 at 9:40 AM, on the 300 hallway confirmed she had been in the resident's room during a dressing change and the Resident #236 .hollered out . when the dressing was changed and when the resident was repositioned. Observation and interview with Resident #236 on 8/15/18 at 9:55 AM, in the resident's room revealed the resident was awake and alert, resting in bed. Continued observation revealed mild facial grimacing noted with movement. Continued interview with the resident confirmed she received pain medication before the dressing change but still had severe pain during the dressing changes twice a day. Further interview confirmed she had reported the pain to the nurses and the Nurse Practitioner. Continued interview confirmed on a scale of 1 to 10 the pain is a 10, and that she has yelled out and asked the staff to stop during the dressing change. Further interview confirmed she just bears it .I don't think the pain medication is strong enough to control it . Continued interview confirmed she had refused to have dressing changes done due to the dressing changes being so painful. Interview with the Wound Nurse on 8/15/18 at 11:25 AM, in the conference room, confirmed the resident had experienced pain during dressing changes, and she required a lot of emotional support and encouragement to get through the treatment. Further interview confirmed she had not notified the Nurse Practitioner of Resident #236 having pain during the dressing changes. Continued interview confirmed .The dressing change cannot be pain free . Telephone interview with Registered Nurse (RN) #5 on 8/15/18 at 1:45 PM, confirmed the resident had extreme pain during dressing changes. Continued interview revealed she tried to give her the pain medication 20 minutes before dressing changes and she hollered out each time. Further interview revealed the nurse had not notified the Physician or Nurse Practitioner that she had pain. My thought processes were that she was being seen by the wound care team . Continued interview confirmed she asked the resident if it always hurt like this and the resident stated yes. Telephone interview with RN #3 on 8/15/18 at 2:00 PM, confirmed she had completed dressing changes on the resident and most times she has pain during the dressing changes. Further interview confirmed the nurse gave pain medication 30 minutes to an hour prior to the dressing change. Continued interview confirmed .I think it (wound) hurts because it is so deep . Further interview confirmed sometimes the resident will ask the staff to stop because of the pain and will refuse dressing changes at times. Continued interview revealed .I think the Doctor already knows about the pain. I didn't report it because it's the nurse's discretion to assess if the patient can tolerate the dressing change . Further interview confirmed pain is to be monitored every shift. Interview with the Nurse Practitioner #1 on 8/16/18 at 10:05 AM, in the conference room, confirmed she addressed the resident's complaints of pain with the resident when she was first admitted and did not want to increase the pain med at that time but discussed timing of the pain medication related to timing of the dressing changes. Continued interview confirmed she was not made aware by staff that the resident was experiencing extreme pain during the dressing changes. Interview with the Director of Nursing on 8/16/18 at 5:20 PM, in the conference room confirmed staff failed to monitor, manage and report unrelieved pain for Resident #236 and failed to follow the facility's pain management policy to use the numerical pain scale with a cognitively intact resident and reassess pain within 1 hour after administration of an [MEDICATION NAME](pain medication. | 2020-09-01 |
| 39 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 698 | D | 0 | 1 | Q9H011 | **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 assess and monitor a Central Venous Catheter (CVC) for 1 resident (#133) of 3 residents receiving [MEDICAL TREATMENT], of 52 sampled residents. The findings include: Review of the facility [MEDICAL TREATMENT] protocol, revised 5/2018 revealed .The [MEDICAL TREATMENT] organization will work with the Clinical Mentors in regards to proper care and treatment of [REDACTED]. Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident received [MEDICAL TREATMENT]. Continued review revealed the resident scored 5 on the Brief Interview For Mental Status, indicating severe cognitive impairment. Review of a Physicians Orders dated 7/24/18 revealed the resident receives [MEDICAL TREATMENT] 3 times per week. Medical record review of a care plan undated, revealed .Has [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) and is at risk for complications .Interventions .Monitor shunt site for any s/s (signs and symptoms) of infection, occlusion, etc . Medical record review of a [MEDICAL TREATMENT] Treatment Sheet print date 8/6/18 revealed current [MEDICAL TREATMENT] access of CVC catheter right chest. Medical record review of the Treatment Administration Record (TAR) dated 7/25/18-8/14/18, revealed no documentation the facility assessed the resident's catheter or dressing after [MEDICAL TREATMENT] treatment. Observation and interview with Resident #133 on 8/15/18 throughout the day revealed the resident had a CVC to the right upper chest for [MEDICAL TREATMENT] vascular access. Continued interview with the resident on 8/15/18 confirmed she was new to [MEDICAL TREATMENT] and didn't not know much about it. Interview with the Director of Nursing on 8/15/18 at 4:55 PM, in the conference room, confirmed there was no documentation the [MEDICAL TREATMENT] CVC had been monitored. Further interview confirmed it should be documented on the TAR. | 2020-09-01 |
| 40 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 725 | K | 0 | 1 | Q9H011 | Based on review of the facility's CMS-672 Resident Census and Conditions of Residents, review of the Matrix for Providers, review of the facility's Daily Census Report, review of facility staffing schedules, observation, medical record review, review of facility incident reports, and interview, the facility failed to maintain adequate staffing levels to ensure the supervision of residents to prevent repeated falls for 7 residents (#28, #34, #39, #40, #47, #80, #119) of 40 residents reviewed for falls in the facility, and to ensure residents were provided assistance with activities of daily living (ADLs) care for 3 residents (#53, #80, and #89) of 52 residents reviewed. The facility's failure to ensure adequate staffing levels resulted in Immediate Jeopardy (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) for 7 residents (#28, #34, #39, #40, #47 #80, #119) with serious injuries after falls. The facility's failure to provide assistance with toileting resulted in Harm to Residents #80 and #89. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 8/20/18 at 8:10 PM, in the conference room. The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility's CMS-672 Resident Census and Conditions of Residents signed by the Administrator on 8/13/18 revealed the facility had a census of 137 residents. Further review revealed 90 residents were occasionally or frequently incontinent of bladder; 80 residents were occasionally or frequently incontinent of bowel; 25 residents ambulated with assistance or assistive devices; 92 residents had dementia; 86 residents had behavioral healthcare needs; and 8 residents had pressure ulcers. Review of the Matrix for Providers completed on 8/13/18 revealed the facility had 40 residents who had experienced falls while in the facility, with 10 residents having an injury with a fall and 7 residents having a major injury as a result of a fall. Residents who had major injuries after a fall were Residents #119, #47, #28, #34, #39, #40, and #80. Review of the facility's Daily Census Report dated 8/13/18 for the Secured Unit revealed the unit had 31 residents and 2 empty beds. Review of the facility's staffing schedule for the Secured Unit for (MONTH) (YEAR) revealed the unit was to have 1 Licensed Practical Nurse (LPN) and 4-5 Certified Nursing Assistants (CNAs) working Monday through Friday day shift; 1 LPN and 3 CNAs working weekend day shift; 1 LPN and 3-4 CNAs working Monday through Friday evening shift; 1 LPN and 2 CNAs working weekend evening shift; either 1 LPN or 1 Registered Nurse (RN) and 2-3 CNAs working Monday through Friday night shift; and 1 LPN or RN and 2 CNAs working weekend night shift. Observation on Thursday 8/16/18 at 10:50 AM, in the Secured Unit dining room, revealed residents seated in chairs and wheelchairs. Continued observation revealed no CNA or nurses were in the line of sight of the residents in the dining room and sunroom. Further observations revealed all the residents' doors were open without a staff member in line of sight. Further observation revealed the Wound Care Nurse and Wound Nurse Practitioner were in one of the resident's rooms. Medical record review and review of facility incident reports revealed Resident #119 had 9 falls between 7/1/17 and 7/10/18, with 3 falls requiring transfer to the emergency room , and 2 falls resulting in fractures of the legs. Interview with CNA #16 on 8/16/18 at 2:42 PM, in the Secured Unit hallway, revealed .We don't have enough supervision for her (Resident #119) .If we do have enough staff they pull us . Interview with Household CNA Coordinator #4 on 8/16/18 at 2:47 PM, in the Secured Unit hallway, revealed .We always have staff, but (they are) pulled .When (they) get pulled, don't have enough staff .With 3 people just can't do it . Interview with CNA #5 on 8/18/18 at 8:59 AM, on the Secured Unit hallway, revealed .Right before supper we position them (residents) (in chairs) that is how we supervise .last 3 months before it was horrible . Observation on Saturday 8/18/18 at 9:10 AM, in the secured unit sunroom, revealed Resident #119 was seated in her wheelchair. Continued observation revealed no CNAs or nurses were in line of sight of the resident. Medical record review and review of facility incidents revealed Resident #47 had 10 falls between 4/9/18 and 6/13/18 with one fall requiring sutures for a laceration. Further review revealed the resident was not safe to ambulate independently. Observation on 8/18/18 at 10:30 AM, in the Secured Unit dining room, in front of the kitchen, revealed LPN #5 was at the medication cart between the dining room and the sunroom, preparing medications for a medication pass. Continued observation revealed 16 total residents were in the dining room, sitting area, and sunroom. Further observation revealed Resident #47 ambulated into the dining room, in front of the kitchen, pushing his wheelchair towards the sunroom. Further observation revealed LPN #5 began to yell out to the homemaker/cook staff member, who was located in the kitchen, to find a staff member to help assist the resident, who was observed to be unsteady on his feet. Further observation revealed the other CNAs were in resident rooms. Further observation revealed the homemaker staff member went out on the unit and tried to find a CNA to help with Resident #47. Continued observation revealed LPN #5 assisted the resident back into a wheelchair and continued to prepare medications for medication pass while the homemaker was locating a CNA to assist. Review of the facility's Daily Census Report dated 8/13/18 for 2 South revealed the unit had 31 residents and one empty bed. Review of the facility's staffing schedule for 2 South for (MONTH) (YEAR) revealed the unit was to have 1 nurse and 3 CNAs per shift Monday through Friday and 1 nurse and 2 CNAs per shift on the weekends. Interview with Resident #61, who lived on 2 South, on 8/13/18 at 10:31 AM, in the resident's room, revealed Resident #61 did not think there was always enough staff to provide baths. Continued interview confirmed .the girls (CNAs) will come in and say there are only 2 of us (CNAs) and we can't do your bath today . Further interview revealed .sometimes there is only 1 to 2 to take care of all of us (residents) .because they have to go to the kitchen to work sometimes . Interview with Resident #96, who lived on 2 South, on 8/13/18 at 10:39 AM, in the resident's room, revealed .(the facility) short staffed .staff have quit and they haven't replaced them .a lot of times there is just 1 or 2 (CNAs) on the floor . Interview with Resident #53, who lived on 2 South, on 8/13/18 at 11:08 AM, in the resident's room, revealed .didn't get a shower last week at all .not Tuesday or Friday they told me they were short staffed .it has happened .several times .not enough of them . Interview with CNA #3 on 8/15/18 at 9:25 AM, in the 2 South dining rooms, revealed the facility did not always have enough help to take care of the residents. Continued interview revealed there had been times when residents had not received showers. Interview with Household CNA Coordinator #1 on 8/15/18 at 9:40 AM, in the 2 South dining room, revealed there had been .call offs and have lost some employees and do not always have enough staff to take care of the residents about 2 to 3 days out of the week . Continued interview revealed .pulled to the kitchen sometimes 3 to 4 times a week . Further interview confirmed there had been times the residents had not received showers because of staffing. Interview with CNA #4 on 8/15/18 at 9:56 AM, in the 2 South dining room, revealed there was not always enough staff to meet the needs of the residents .it upset me .we are understaffed. I can't do my job the way I would like . Continued interview revealed .At least once a week we try to give a shower .there have been times on the weekends that we have not been able to get some residents up out of bed because there is not enough staff . Interview with LPN #2 on 8/15/18 at 10:05 AM, in the 2 South living room area, revealed there was not always enough staff to meet the needs of the residents. Continued interview confirmed .like today the person I was working with put her notice in so there is only 1 nurse. The weekends are not enough CNAs. Last Sunday there was only 1 nurse and 2 CNAs .there have been times the residents have not received a shower due to staffing . Review of the facility's staffing schedule for 1 South for (MONTH) (YEAR) revealed the unit was to have 1-2 nurses for each shift Monday through Friday; 3-4 CNAs on day shift, 2-3 CNAs on evening shift, and 2 CNAs on night shift Monday through Friday; 1 nurse each shift on weekends; and 2 CNAs on day and evening shift and 1 CNA on night shift on the weekends. Further review revealed there were no nurses scheduled for 7:00 AM - 3:00 PM shift on 8/18/18 and 8/19/18. Interview with Nurse Mentor #5 on 8/14/18 at 7:50 AM, in the 1 South nursing station, revealed .we need the help last night .I only have 1 nurse (LPN #13) working today . Review of the staffing schedule for 8/14/18 day shift on 1 South revealed the unit was supposed to be staffed with 2 nurses. Interview with LPN #13 on 8/14/18 at 8:25 AM, in the 1 South hallway, confirmed .I am the only nurse on the floor today .I have 30 patients today .it happens all the time being the only nurse on the floor . Interview with Resident #89, who lived on 1 South, on 8/14/18 at 9:47 AM in the resident's room, confirmed .They are real short on day shift. I have called out because I need the bed pan and they did not get to me for a while and I had an accident on myself. It made me feel shamed . Interview with RN #4 (night shift nurse on 1 South) on 8/17/18 at 6:35 AM revealed .I had 30 patients last night .I was the only nurse with 1 CNA . Review of the staffing schedule for 2 South for 8/16/17 11:00 PM - 7:00 AM shift revealed the unit was to be staffed with an RN and 2 CNAs. Interview with CNA #2 on 8/17/18 at 5:45 PM, on the 2 South hallway, revealed .just 2 of us working down here and I don't even know these patients .I work upstairs on the skilled .I was pulled from the 3rd floor and that left 1 CNA up there to take care of 17 or 18 patients . Review of the staffing schedules for 2 South and 3rd floor for the evening shift of 8/17/18 revealed 2 South was to have 2 CNAs and the 3rd Floor was to have 2 CNAs. Interview with LPN #1 on 8/18/18 at 9:12 AM, on the 2 South hallway, revealed .is never enough staff .recently had a setback with a CNA getting fired, a nurse quit, a CNA quit .they haven't been replaced .I have reported to the DON (Director of Nursing) and the Administrator . Interview with the DON on 8/20/18 at 5:30 PM, in the conference room, revealed the Nurse Mentors and Household CNA Coordinators schedule staff 6 weeks in advance and staffing is to be reviewed by each house daily. The DON stated staffing in the facility was consistent, unless a staff member needed to be pulled to another unit in the facility. Further interview revealed staffing was based upon census and acuity in each house and was determined by utilizing a computerized staffing calculator. Further interview revealed staff turnover was discussed in the leadership meetings every 2 weeks and CNA turnover was high, but nursing turnover was stable. Interview with the DON on 8/20/18 at 5:35 PM, in the conference room, revealed staff had reported to the DON there was not enough staff, but the DON stated staffing was adequate. The DON stated if someone was pulled to work on another unit or another role, then staff felt they didn't have enough adequate staff. Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff that are unfamiliar. Difficult to do training with mostly on the job training, and turnovers in leadership have not been helpful .Falls .We can't tie them up (restrain residents) . Telephone interview with the Chair of the Board on 8/20/18 at 3:47 PM, confirmed .the facility had staff turnover .turnover in these positions are critical . Refer to F-550, F-657, F-677, F-689, F-726, F-835, F-841, F-867, and F-947. | 2020-09-01 |
| 41 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 726 | K | 0 | 1 | Q9H011 | Based on review of the facility's Quality Assurance and Performance Improvement Plan, review of the facility's (YEAR) Assessment, and interview, the facility failed to implement a program to ensure nursing staff education and competency were completed The failure to ensure nursing staff were educated and competent placed 7 residents (#28, #34, #39, #40, #47, #80, and #119) in Immediate Jeopardy (IJ), 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 informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan, revised 2/27/18, revealed .The Quality Assurance (QA) Committee consists of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the Infection Preventionist .All associates including contracted staff are educated on the principles of QAPI .Associates will be trained on using QAPI process including participation on a Performance Improvement Project (PIP Team) .The QAPI program is sustained during transitions in leadership and staffing through all-associate education and involvement in the QAPI process . Facility associates and management have been trained on Root Cause Analysis .The QAPI program will be evaluated annually by the QAPI Steering Committee with input from the Leadership Team/Executive Leadership. This review will include whether goals were met, if standards of practice are being followed, any training needs will be identified and addressed . Review of the (YEAR) Facility Assessment revealed .Each job description identifies the required education .Additional competencies are determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed to care for the resident population .competencies are based on the care and services needed by the resident population .competencies are verified upon orientation, at least annually and as needed .The Staff Development Coordinator tracks and trends course completion history and performance trends, reporting those to the Administrator and Director of Nursing (DON) . Interview with the DON on 8/18/18 at 10:36 AM, in the conference room, and review of falls investigations and interventions put in place by staff to prevent further falls, revealed and intervention for Resident #119 included Velcro noodles to the bed. The DON stated .I don't know what Velcro noodles would be exactly, maybe pool noodles . Telephone interview with Registered Nurse (RN) #5 on 8/15/18 at 1:45 PM, confirmed Resident #236 had extreme pain during dressing changes. Continued interview revealed she tried to give her the pain medication 20 minutes before dressing changes and she hollered out each time. Further interview revealed the nurse had not notified the Physician or Nurse Practitioner that she had pain. My thought processes were that she was being seen by the wound care team . Telephone interview with RN #3 on 8/15/18 at 2:00 PM, confirmed she had completed dressing changes on Resident #236 and most times she had pain during the dressing changes. Further interview confirmed the nurse gave pain medication 30 minutes to an hour prior to the dressing change. Continued interview confirmed .I think it (wound) hurts because it is so deep . Further interview confirmed sometimes the resident will ask the staff to stop because of the pain and will refuse dressing changes at times. Continued interview revealed .I think the Doctor already knows about the pain. I didn't report it because it's the nurse's discretion to assess if the patient can tolerate the dressing change . Interview with the Staff Development Coordinator on 8/18/18 at 4:30 PM, in the conference room, revealed the nursing staff has an orientation period that begins with Human Resources (HR) onboarding. The nurses have HR videos they watch and Relias (computer-based training modules) they watch. Some modules are for all staff and some are specific to nursing. The Staff Development Coordinator conducts a diabetic lab with the nurses that lasts approximately 1/2 a day with competency checked on insulin administration. When the nurses have completed the videos, the Staff Development Coordinator sends them to their nursing unit with an orientation checkoff sheet and then the House Mentor is responsible for the nurse's training. The nurses are paired with a preceptor of the House Mentor's choosing. The Staff Development Coordinator only receives the orientation checkoff sheet from the Mentors when they are done and states she is not involved in decision making of when nurses are competent. Further interview revealed she did not recall any specific training on falls other than the computer based Relias training assigned during orientation and annually. When asked if falls was covered in that training, the Staff Development Coordinator stated that she thought she remembered something on falls, like what to do if you see water in the floor. Further interview revealed she was new to the position and stated she did not have an annual plan or monthly plan for education. The Staff Development Coordinator stated she was still trying to find where deficiencies in education were, where annual trainings were due and had not been done, and was developing education month to month if someone told her there was a need. The Staff Development Coordinator stated the monthly trainings she had developed since being in her role was on the evacuation policy in (MONTH) (YEAR), then they conducted mock evacuation drills in (MONTH) and (MONTH) (YEAR) and she was currently conducting one on one training with everyone on Personal Protective Equipment (PPE) and handwashing. Interview with the Director of Nursing (DON) on 8/18/18 at 7:13 PM, in the conference room, confirmed the facility staff were responsible for investigating falls. Falls were reported to the nurse on duty and the accident report was turned into the Clinical Mentor. The Clinical Mentor checked for completeness of the report and the nurse and Clinical Mentor discussed the interventions to put in place to prevent further falls. The DON stated the current facility practice was for the nurse Clinical Mentor to decide on a fall intervention and to put it in place immediately after an incident. The nurse was to do a fall risk assessment after every fall and it was put with the investigation packet. Any interventions put in place depended on interventions already in place. The DON stated the nurses knew what options were available and they used .nursing clinical judgement (used when deciding which intervention to put in place) .no education on falls .just their (staff) clinic experience . The DON stated the nurses did not do any root cause analysis at the time of the fall and the leadership was also not doing a root cause to determine the cause of the fall in order to implement interventions to prevent further falls. The DON stated they were aware the care plans were not updated, I don't know when the care plans (were updated) .the mentor in the house should be updating the care plans .I think that there is work to be done .doing weekly meetings we will be able to get more in depth and with dementia they (residents) forget they can't get up . Interview with the DON on 8/18/18 at 7:15 PM, in the conference room, revealed, .I am not familiar with long-term care, and she (Administrator) had taught me regarding (fall) interventions . Further interview with the DON revealed the DON was familiar with Resident #47 and stated as far as she was aware the resident had not had any further falls once he was admitted to the secured unit following his return to the facility after a psychiatric hospital stay (resident had 2 falls since his return). Refer to F-657, F-689, F-725, and F-947. | 2020-09-01 |
| 42 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 812 | E | 0 | 1 | Q9H011 | Based on facility policy review, observation and interview, the facility failed to maintain 2 of 13 resident refrigerators in a safe operating manner and failed to keep foods stored at an appropriate temperature, potentially affecting 29 residents on the Secure Unit and 33 residents on the 2 South hall. The findings include: Review of the facility policy Food Safety dated 1/2016 revealed .Refrigerators must maintain Temperature Controlled for Safety (TCS) foods at 41 (degrees) or below. Refrigeration and freezer thermometers must be accurate to at least +/- (plus or minus) 2 degrees. If temperatures are above 41 (degrees) for TCS foods, corrective actions must be implemented . Observation and interview with the Food Director on 8/13/18 at 12:20 PM, of the 2 South resident refrigerator revealed an internal thermometer at 44 degrees. Further observation revealed (1) 1/2 pint of reduced fat buttermilk with a temperature of 49 degrees. Interview with the Food Director confirmed the refrigerator was not at the appropriate temperature. Continued interview confirmed the following TSC foods stored in the refrigerator would be discarded: 12 cheese slices9-1/2 pints of chocolate milk 9- 1/2 pints of free milk 9-1/2 pints of chocolate milk 5- 1/2 pints of buttermilk 4-1/2/pints of 2% milk 2 cartons of peach yogurt 1 carton of strawberry yogurt 1 carton of cherry yogurt Observation and interview with the Food Director and Dietary Manager on 8/13/18 at 12:30 PM, of the 1 South resident refrigerator revealed an internal thermometer at 42 degrees. Further observation revealed (1) 1/2 pint of vitamin D milk and (1) 1/2 pint of chocolate milk with a temperature of 44 degrees and (1) 1/2 pint of 2% milk with a temperature of 47 degrees. Interview with the Food Director and Dietary Manager confirmed the refrigerator was not at an appropriate temperature. Continued interview confirmed the following TSC foods stored in the refrigerator would be discarded: 5- 1/2 pints of fat free milk 10- 1/2 pints of 2% milk 5- 1/2 pints of buttermilk 10 cheese slices 1 unopened package of approximately 30 cheese slices 1 unopened package of bologna slices 1 opened package of approximately 25 bologna slices 2 qts vanilla pudding and 3 qts chocolate pudding | 2020-09-01 |
| 43 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 835 | K | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of facility falls investigations, review of facility dailycensus and staffing, observation, and interview, the Administrator failed to ensure facility policy and procedures were implemented for falls; failed to ensure revision of care plans was completed with appropriate and individualized interventions to prevent falls; failed to prevent avoidable pressure ulcers; failed to ensure an effective falls program was implemented to prevent residents from having multiple falls and multiple injuries with falls; and failed to ensure adequate staffing to supervise residents who had falls and adequate staffing to provide activities of daily living care (ADL) care to residents. The Administrator's failure to ensure an effective falls program was implemented placed 7 residents (#28, #34, #39, #40, #47, #80, and #119) in Immediate Jeopardy (IJ), 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's failure to ensure residents were provided assistance with toileting resulted in Harm to Residents #80 and #89. The Administrator's failure to ensure residents received pain control resuled in Harm to Resident #236. The Administrator's failure to ensure residents did not develop pressure ulcers resulted in Harm to Resident #80. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F 689, F725, F 726, F 841, F 867 and F 947. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: During the annual Recertification survey conducted 8/13/18 - 8/20/18, review of clinical notes, accident reports, and fall investigations revealed Resident #119 had 9 falls between 7/1/17 - 7/10/18 and sustained 3 major injuries: a right tibia fracture, left femur fracture, and left [MEDICAL CONDITION]; Resident #28 had 2 falls between 2/15/18 - 6/7/18 and sustained 1 major injury: a [MEDICAL CONDITION] femur; Resident #34 had 2 falls between 2/25/18 - 7/14/18 and sustained 2 injuries: a left [MEDICAL CONDITION] and a laceration to the back of the head requiring staples; Resident #39 had 9 falls between 4/2018 - 8/2018; Resident #47 had 8 falls between 4/5/18 - 6/13/18 and sustained 1 injury: a right eye injury requiring sutures. Resident #40 had 4 falls between 4/2018 - 8/2018 and sustained 1 injury: a subdural hematoma (a collection of blood outside the brain); and Resident #80 had 5 falls between 1/27/18 - 7/2/18 and sustained 1 major injury: a Cervical 1 - Cervical 2 fracture. During the Recertification survey, review of wound reports, Wound Nurse Practitioner documentation, and interviews, revealed Resident #80 developed 1 avoidable unstageable wound to the right clavicle. Interview with the Administrator on 8/20/18 at 12:20 PM, in the conference room, revealed the Administrator led the Quality Assurance and Performance Improvement (QAPI) meeting. During the meeting they discussed how many falls during a month looking for trends and patterns. Falls were reviewed during the morning meeting. The Administrator stated .some things I was concerned about .some of the interventions were not appropriate .after doing it that month (review of falls in AM meeting) our teams were educated .educate as we go .if nursing staff used same intervention or inappropriate intervention we would educate the mentor at that time . Further interview confirmed the facility had not used root cause analysis during falls and a resident's historical falls was not being discussed. The facility conducted the first root cause analysis in July. Further interview revealed, .saw increase in falls .increase multiple resident falls .we knew fall rate increased . Further interview revealed, .have not discussed pressure ulcers in huddle .not sure if they're talking about them in therapy .we have not done it in morning meeting yet . Interview with the Consultant, who was the facility's previous Administrator from 3/18 - 6/18, on 8/20/18 at 1:47 PM, in the conference room, revealed the falls program included household huddles daily to find interventions. The previous Administrator stated he did not attend the meetings and did not have clinical experience and relied on the nurses for interventions. Further interview revealed that approximately the 3rd week of (MONTH) he became aware falls had increased. The previous Administrator called on the Minimum Data Set (MDS) nurse to assist in decreasing falls. The previous Administrator stated there was a falls task force with in the form of huddle meetings. The previous Administrator confirmed he had no involvement in the huddles or Interdisciplinary Team (Interdisciplinary Team) meetings. He stated MDS would facilitate those meetings and .informal monitoring to ensure meetings (huddles) being held with (MDS #1) were informal .nothing formal . Refer to Refer to F-550, F-657, F-677, F-686, F-689, F-697, F-725, F-726, F-867, F-947 | 2020-09-01 |
| 44 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 841 | K | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Medical Director Contract, review of the Advanced Practice Nurse (APN) Protocol, review of the Facility Assessment, medical record review, review of facility falls investigations, observation, and interview, the Medical Director failed to ensure identification, development, and implementation of appropriate plans of action and ensure the effective use of its resources to maintain the highest practicable well-being of all residents, failed to ensure performance improvement was implemented and monitored, failed to provide an individualized pain management plan to avoid pain and mental anguish, failed to ensure interventions were implemented for residents with repeated occurrences with falls which placed residents at risk of harm, failed to ensure revision of care plans were done with appropriate and individualized interventions to prevent falls, failed to prevent avoidable pressure ulcers, failed to ensure an appropriate falls intervention program was implemented to prevent residents from having multiple falls and injuries, and failed to ensure a facility assessment was performed and implemented. The Medical Director's failure placed 7 residents (#119, #28, #34, #39, #40, #47, #80) in Immediate Jeopardy (IJ), 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 informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F725, F 726, F 835, F 841, F 867 and F 967. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the Medical Director Contract revealed .4. Services to be performed by provider .Responsible for the overall coordination of medical care at the Facility. Coordination of care means Provider shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident care policies and providing oversight and supervision of medical services and medical care of residents .Evaluate and take appropriate steps to correct any problems associated with any possible inadequate care Provider identifies .Participate, upon request, in personnel evaluations and other quality monitoring programs established by the Facility including attendance at the Facility's Quality Assurance Committee meetings .Provider will deliver high quality services that .Promote standards of timeliness .enhance continuity of service to all Health Center residents .conform to federal and state regulations . Review of the Advanced Practice Nurse (APN) Protocol, undated, revealed .Requiring Authority .the (APN) will provide health care services under the general supervision of (Medical Director) .F. Interpret and analyze patient data to determine patient status, care management and treatment and effectiveness of interventions . Review of the Facility Assessment (YEAR), dated 6/2/18, revealed .Community Staff .The Medical Director oversees medical practice and provides guidance in the development of clinical policies and programs at our community .Currently, there is 1 Medical Doctor and 2 Nurse Practitioners who visit the community two to three times a week to see residents . During the annual Recertification survey conducted 8/13/18 - 8/20/18, review of clinical notes, accident reports, and fall investigations revealed Resident #119 had 9 falls between 7/1/17 - 7/10/18 and sustained 3 major injuries: a right tibia fracture, left femur fracture, and left [MEDICAL CONDITION]; Resident #28 had 2 falls between 2/15/18 - 6/7/18 and sustained 1 major injury: a [MEDICAL CONDITION] femur; Resident #34 had 2 falls between 2/25/18 - 7/14/18 and sustained 2 injuries: a left [MEDICAL CONDITION] and a laceration to the back of the head requiring staples; Resident #39 had 9 falls between 4/2018 - 8/2018; Resident #47 had 8 falls between 4/5/18 - 6/13/18 and sustained 1 injury: a right eye injury requiring sutures. Resident #40 had 4 falls between 4/2018 - 8/2018 and sustained 1 injury: a subdural hematoma; and Resident #80 had 5 falls between 1/27/18 - 7/2/18 and sustained 1 major injury: a Cervical 1 - Cervical 2 fracture. During the Recertification survey, review of wound reports, Wound Nurse Practitioner documentation, and interviews, revealed Resident #39 developed 3 avoidable wounds: 1 stage II on the right buttock, 1 stage III to left buttock, and an unstageable to the coccyx; Resident #80 developed 1 avoidable unstageable wound to the right clavicle; Resident #86 developed 1 avoidable stage IV wound to the right hip; and Resident #119 developed 2 avoidable wounds: 1 unstageable to the left ischium and 1 stage II to the right foot. Review of facility Quality Assurance and Process Improvement Meeting (QAPI) meeting minutes dated 8/29/17 - 7/24/18 revealed the Medical Director attended 11 out of 13 QAPI meetings. Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed she attended the QAPI meetings and falls were reviewed monthly in the meetings. Continued interview confirmed recurrent falls were reported to the Nurse Practitioners (NP) and any concerning issues went directly to the Medical Director. Further interview confirmed .I don't know how much detail is in QAPI meeting . Continued interview confirmed .involvement with pressure ulcers primarily supervisory. I use wound trained NP's and a wound Nurse . Further interview confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff that are unfamiliar. Difficult to do training with mostly on the job training, and turnovers in leadership have not been helpful .Falls .We can't tie them up . Continued interview confirmed when the Medical Director signed the Incident/Accident reports she was agreeing with the interventions put in place. The Medical Director stated .the reports are not always timely . Refer to F 550, F657, F 677, F 686, F 689, F 697, F 725, F 726, F 835, F 867, and F 947. | 2020-09-01 |
| 45 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 867 | K | 0 | 1 | Q9H011 | Based on review of the facility Quality Assurance and Performance Improvement Plan, Facility Assessment review, medical record review, observation, and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to have an effective, ongoing QAPI program to ensure an effective falls program was implemented to prevent repeated falls for residents, resulting in injuries after falls. The QAPI committee's failure to ensure an appropriate falls intervention program was implemented, failure to ensure care plans were revised after falls, failure to ensure sufficient staffing to supervise residents at risk for falls, and failure to ensure competent staff, resulted in residents having multiple falls and injuries, and placed 7 residents (#119, #28, #34, #39, #40, #47, and #80) of 40 residents in the facility who had falls, in Immediate Jeopardy (IJ), 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 informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F725, F 726, F 841, F 867 and F 967. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan, revised 2/27/18, revealed .Purpose .(QAPI) Program utilizes an on-going, data driven, pro-active approach to advance the quality of life and quality of care for the residents .Quality Assurance and Performance Improvement principles drive our decision making as we endeavor to produce positive outcomes .QAPI committee consists of representatives from various departments .Performance Improvement Projects (PIPs) will be implemented when an opportunity for improvement is identified. These PIPs may apply to processes or systems throughout the community .QAPI program is ongoing, comprehensive and addresses the services provided .data will be obtained from the following reports .Clinical reports - infection, medication error, pressure injuries, falls .The QAPI team will meet monthly, or more often as needed, to review findings and identify potential PIPs .The Nursing Home Administrator (NHA) and Board of Directors are responsible and accountable for the development, implementation and monitoring of the QAPI program .The Quality Assurance (QA) Committee consists of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the Infection Preventionist .The QA Committee meets at least quarterly to coordinate and evaluate the activities under the QAPI program .The QAPI Steering Committee, which includes the Medical Director as co-chair, meets monthly and is accountable for the continuous improvement in Quality of Life and Quality of Care .The QAPI Steering Committee collects data from QA sub committees (e.g., pain, falls, and weight loss) .All associates including contracted staff are educated on the principles of QAPI .Associates will be trained on using QAPI process including participation on a Performance Improvement Project (PIP Team) .The QAPI program is sustained during transitions in leadership and staffing through all-associate education and involvement in the QAPI process .PIPS .identify areas where gaps in performance may negatively affect resident .In prioritizing activities, the team will consider: high-risk to residents .high-volume or problem prone areas .health outcomes .resident safety .resident choice .At least annually a project that focuses on high risk or problem-prone areas will be addressed through the QAPI program including PIP development .The team will utilize root cause analysis to identify the cause of the problem and any contributing factors. Plan-Do-Study-Act PDSA will also be used .Our community uses a systematic approach to determining the root cause of an issue and any contributing factors. Facility associates and management have been trained on Root Cause Analysis .The QAPI program will be evaluated annually by the QAPI Steering Committee with input from the Leadership Team/Executive Leadership. This review will include whether goals were met, if standards of practice are being followed, any training needs will be identified and addressed . Review of Facility Assessment (YEAR), dated 6/2/18, revealed .Community Assessment and QAPI .Information from the Community Assessment will be incorporated into the Quality Assurance Performance Improvement (QAPI) process .The identification of residents will help to drive the activities of the QAPI process. The description of care, services and resources available at our community provides both areas for monitoring of processes and outcomes as well as information for investigation of root causes of adverse events and gaps in performance .Community Staff .Our community is overseen by a Board of Directors, an Executive Director and a licensed Nursing Home Administrator. The Medical Director oversees medical practice and provides guidance in the development of clinical policies and programs at our community .Currently, there is 1 Medical Doctor and 2 Nurse Practitioners who visit the community two to three times a week to see residents . Interview with the Director of Nursing (DON) on 8/18/18 at 7:13 PM, in the conference room, confirmed the facility staff were responsible for investigating falls. Falls were reported to the nurse on duty and the accident report was turned into the Clinical Mentor. The Clinical Mentor checked for completeness of the report and the nurse and Clinical Mentor discussed the interventions to put in place to prevent further falls. The DON stated she was not familiar with Long Term Care and had a background in acute care. The DON stated the facility had plans to reinstate a weekly fall meeting that the facility used to conduct before her arrival in (MONTH) of (YEAR). The DON was not sure when weekly fall meetings had stopped, but they had reviewed the falls and ensured care plans were updated. The DON stated the current facility practice was for the nurse Clinical Mentor to decide on a fall intervention and to put it in place immediately after an incident. The accident reports were filed and tracked by the Minimum Data Set (MDS) Coordinator in an excel spread sheet that was brought to QAPI. The nurse was to do a fall risk assessment after every fall and it was put with the investigation packet. Any interventions put in place depended on interventions already in place. The DON stated the nurses knew what options were available and they used .nursing clinical judgement (used when deciding which intervention to put in place) .no education on falls .just their (staff) clinic experience . The DON stated fall investigation reports were then brought to a leadership huddle with leadership staff, to the DON, to the Administrator, and to the Medical Director for signatures. The DON stated in the leadership huddles they just reviewed the investigation completed by the unit nurses and looked at what the nurses indicated was the probable cause, interventions nursing implemented, time of fall, and any patterns. The DON stated the nurses did not do any root cause analysis at the time of the fall and the leadership was also not doing a root cause to determine the cause of the fall in order to implement interventions to prevent further falls. The DON stated they were aware the care plans were not updated, I don't know when the care plans (were updated) .the mentor in the house should be updating the care plans .I think that there is work to be done .doing weekly meetings we will be able to get more in depth and with dementia they (residents) forget they can't get up . The facility started a PIP for falls in (MONTH) after there had been 3 falls with injury and the facility needed to re-evaluate falls. The DON then stated the facility started looking at fall interventions when the new Administrator arrived in June. Interview with the Administrator on 8/20/18 at 12:20 PM, in the conference room, confirmed she led the QAPI meeting and staff discussed how many falls during a month and any trends or patterns. QAPI looked at residents with multiple falls in a month but did not look back further. The Administrator stated they didn't go back and look at every fall back in (MONTH) or last year.we haven't gotten there yet . The Administrator started a PIP plan and they reviewed falls in the morning meeting. The Administrator stated .some things I was concerned about .some of the interventions were not appropriate .after doing it that month (review of falls in morning meeting), our teams were educated .educate as we go .if nursing staff used same intervention or inappropriate intervention we would educate the mentor at that time . The Administrator stated root cause analysis during falls and related to a history of falls was not being discussed and the first root cause analysis was conducted in July. The facility saw an increase in falls and increase in multiple resident falls, and they looked at one month of falls. The Administrator stated they knew the fall rate increased. The Administrator stated .as we are starting the PIP plan we would talk .about education .have not discussed pressure ulcers in huddle .not sure if they're talking about them in therapy .we have not done it in morning meeting yet . Interview with the Consultant, who was the previous Administrator from 3/18 - 6/18, on 8/20/18 at 1:47 PM, in the conference room, revealed he did not attend the falls meetings or huddles and stated he did not have clinical experience. He stated he relied on the nurses for implementation of interventions. Further interview revealed he became aware approximately the 3rd week of (MONTH) falls had increased and he .Called on MDS (Minimum Data Set nurse) . to address. He stated, .MDS would facilitate those meetings .informal monitoring to ensure meetings (huddles) being held with (MDS #1) were informal .nothing formal . Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed recurrent falls were reported to the Nurse Practitioners (NPs) and any concerning issues went directly to the Medical Director. Further interview confirmed .I don't know how much detail is in QAPI meeting . (Medical Director's) involvement with pressure ulcers primarily supervisory, I use wound trained NP's and a wound Nurse . Further interview confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff .and turnovers in leadership have not been helpful .Falls .We can't tie them up . Refer to F-550, F-657, F-677, F-686, F-689, F-697, F-725, F-726, F-835, F 841, and F-947. | 2020-09-01 |
| 46 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 947 | K | 0 | 1 | Q9H011 | Based on review of the facility's (YEAR) Assessment, review of the facility's computer based training documentation, and interview, the facility failed to implement a system to track nurse aide competency levels in order to ensure training was sufficient based on the resident population. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F657, F689, F725, F726, F841, F867 and F947. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the (YEAR) Facility Assessment revealed .Each job description identifies the required education .Additional competencies are determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed to care for the resident population. Certified nursing assistants may have additional required competencies .competencies are based on the care and services needed by the resident population .competencies are verified upon orientation, at least annually and as needed .The Staff Development Coordinator tracks and trends course completion history and performance trends, reporting those to the Administrator and Director of Nursing (DON) . Review of the facility's computer based training documentation revealed no tracking system in place to determine nurse aide competency after required annual training and in-service education, including understanding falls and skin checks. Interview with the Staff Development Coordinator on 8/18/18 at 4:30 PM, in the conference room, confirmed she was not involved in decision making of when nurse aides were competent and did not recall any specific training on falls other than the computer based Relias training assigned during orientation and annually. When asked if falls was covered in that training, the Staff Development Coordinator stated that she thought she remembered something on falls, like what to do if you see water in the floor. Further interview revealed she was new to the position and stated she did not have an annual plan or monthly plan for education. She was still trying to find out where deficiencies in education were and developing an education month to month if someone told her there was a need. Interview with the Staff Development Coordinator on 8/20/18 at 2:49 PM, in the conference room confirmed .(Nurse) Mentors check (computer based training) and HR (human resources) follows that .I just started .orientation begins with me .goes on to mentor .(mentors) pick a preceptor .(nurse mentors) evaluate in 1st 90 days and if not performing .mentors talk to DON (Director of Nursing) .(nurse mentors) keep in contact with HR for Relias (computer based training) .Excel (spreadsheet) is more for me to know who is with what mentor .what household they are (on) . Interview with the Staff Development Coordinator on 8/20/18 at 4:55 PM, in the conference room, confirmed the facility did not have a system in place to track and trend the competency levels of nurse aides. Refer to F-550, F-677, F-689, F-725 | 2020-09-01 |
| 47 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2019-08-28 | 695 | D | 0 | 1 | CV0B11 | **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 properly store and discard an outdated nebulizer (device used to administer medication in the form of a mist inhaled into the lungs) administration equipment (nebulizer tubing and mask) for 1 resident (#28) of 7 residents reviewed for nebulizer therapy. The findings include: Review of facility policy Administering Medication through Small Volume (Handheld) Nebulizer, revised 1/1/2017, revealed .Store equipment in plastic bag with the resident's name and date on it .Change equipment and tubing every 7 days . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum data set ((MDS) dated [DATE] revealed Resident #28 had a Brief Mental Status Interview (BIMS) score of 3, indicating severe cognitive impairment. Continued review revealed Resident #28 required limited assistance with bed mobility, transfers, personal hygiene, and dressing. Medical record review of the Physician's Recapitulation Orders dated 8/2019, revealed a nebulization solution was ordered as needed every 6 hours. Medical record review of the Medication Administration Record [REDACTED]. Observation of Resident #28 on 8/26/19 at 9:55 AM and 3:02 PM, and on 8/27/19 at 8:40 AM, in the resident's room, revealed the nebulizer at the bedside with the mask dated 3/28/19 and not stored in a plastic bag. Observation and interview with Licensed Practical Nurse (LPN) #1 on 8/26/19 at 3:35 PM, in the resident's room, confirmed the date on the nebulizer mask was 3/28/19 and the mask was not stored in a plastic bag. Further interview confirmed the nebulizer equipment had not been changed for 21 weeks. Interview with Director of Nursing (DON) on 8/26/19 at 3:47 PM, in the DON's office, confirmed the facility failed to follow their policy to properly store and discard outdated nebulizer equipment for Resident #28. | 2020-09-01 |
| 48 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2019-08-28 | 842 | D | 0 | 1 | CV0B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure Physician Orders for Scope of Treatment (POST) were completed for 3 residents (#87, #273, and #279) of 31 residents reviewed for advanced directives. The findings include: Review of the facility policy Health Care Decision Making-Advanced Directives - TN (Tennessee), revised 12/7/16, revealed The purpose of this policy and procedure is to ensure residents are informed of their rights to execute an Advanced Health Care Directive .It also provides guidelines for completion of a TN Physician Orders for Scope of Treatment (POST) form, and to facilitate the implementation of the resident's wishes so that they are carried out according to the terms of these documents and applicable law and regulation .Upon admission or as soon as possible thereafter, if the resident does not have Advance Health Care Directives, the Nurse, Nurse Practitioner, or MD (physician) will explain these documents to the resident or representative and provide forms for their review (Appointment of Health Care Agent form; POST form) .Residents wishing to create an Advance Care Plan may do so through completion of the POST form .A POST must contain: 1. Resident's name and signature .4. Physician's signature .Prior to signature, the Physician must discuss the POST form and contents with resident or the responsible party. Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #87's POST form, undated, revealed documentation the resident was Do Not Attempt Resuscitation (DNR) status with Limited Additional Interventions. Continued review revealed Resident #87 or an appropriate resident representative had not signed the form, indicating DNR was the resident's wishes. Medical record review revealed Resident #273 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #273's POST form, revealed the resident requested a Do Not Attempt Resuscitation status with Limited Additional Interventions. Continued review revealed the Physician had not signed or dated the form. Medical record review revealed Resident #279 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #279's POST form, undated, revealed documentation the resident was a Do Not Attempt Resuscitation status with Limited Additional Interventions. Continued review revealed Resident #279 or an appropriate resident representative had not signed the form, indicating DNR was the resident's wishes. Interview with the Director of Nursing on 8/28/19 at 1:28 PM, in the conference room, confirmed the facility .get (advanced directives) upon admission . and were to be signed by the physician and resident or resident representative. Continued interview confirmed the facility failed to ensure facility policy for Advance Directives was followed for Resident #87, #273, and #279. | 2020-09-01 |
| 49 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2017-05-24 | 242 | D | 0 | 1 | 2T0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to honor individual choices for daily schedules for 2 residents (#84, #211) of 21 residents interviewed. The findings included: Medical record review revealed Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #84 had a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate cognitive impairment. Review of the medication record completed on 5/23/2017 at 3:48 PM revealed Resident #84 had a blood pressure medication ordered with parameters to hold the medication based on the resident's current blood pressure. The medication is set for an 8:00 AM administration schedule. Resident #84 also had an order for [REDACTED]. Observation and interview with Resident #84 on 5/22/2017 at 1:26 PM, in the resident's room confirmed she had not been given the opportunity to choose the time she preferred to be awakened in the morning nor the type of bathing she received. They wake me up at 5 (AM) but I don't get breakfast till 9 (AM). I would like to get up at 7 (AM) .I go (to the shower) on Tuesday and Friday. I didn't choose those days. An interview was completed with Activity Assistant (AA) #1 on 5/23/2017 at 2:10 PM. AA #1 stated, On admission, we fill out an assessment .We don't ask about what time they want to get up in the morning. On 5/23/2017 at 2:55 PM, an interview was completed with Certified Nursing Assistant #1 (CNA). CNA #1 stated she was familiar with Resident #84. I come in at 6:30 (AM). She is usually sleeping then. I go in to get her vitals (blood pressure, temperature, pulse) about 7 (AM). They get done every day. I ask if she wants to get up and she usually gets started with her day at that time. Breakfast comes out about 7:45 AM. Sometimes she says she doesn't want to get up at 7. Observation on 5/24/2017 at 7:05 AM, revealed staff checking vital signs. Observation on 5/24/2017 at 7:50 AM, revealed the breakfast tray was delivered to Resident #84. On 5/24/2017 at 8:05 AM an interview was completed with LPN #1. LPN #1 stated the activities staff ask residents about bedtimes, but not morning wake up times, and LPN #1 was unable to find any documentation in the record indicating Resident #84's preferred time to get up in the mornings. On 5/24/2017 at 8:05 AM, a review of the CNA Point of Care data noted no information about the time Resident #84 preferred to get up in the mornings. Medical record review revealed Resident #211 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #211 had a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident was cognitively intact. On 5/22/2017 at 2:53 PM, an interview was completed with Resident #211. Resident #211 stated she was not able to choose the time she was awakened in the morning. They get me up about 8:30 (AM). I prefer 9:00 (AM) or later. On 5/23/2017 at 3:00 PM, an interview was completed with CNA #1 who stated she was familiar with Resident #211. (Resident #211) eats about 7:45 (AM). She likes to sleep in. She will say, I don't feel like it and I want to wait awhile. She gets vital signs each morning around 7:00 (AM) and she will usually say she doesn't want to get up; she wants to wait till after breakfast. Review of the medication record on 5/23/17 at 3:45 PM noted no medications that required vital sign parameters before administering the resident's prescribed medication. On 5/23/2017 at 4:09 PM, an interview was completed with LPN # 2 who stated she was familiar with Resident #211. We get everyone's vital signs every day. We would get Resident #211's vitals each shift. On day shift they would start getting vital signs at 7:00 AM. On 5/24/2017 at 7:48 AM, Resident #211's breakfast tray was noted delivered. On 5/24/2017 at 8:05 AM, a review of the Nursing Assistant Point of Care data noted no information about the time Resident #211 preferred to get up in the mornings. An interview was completed with LPN #1 on 5/24/2017 at 8:05 AM, who stated activities staff ask residents about bedtimes, but not morning wake up times, and that she couldn't find any documentation in the record indicating Resident #211's preferred time to get up in the mornings. | 2020-09-01 |
| 50 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2017-05-24 | 371 | D | 0 | 1 | 2T0S11 | Based on facility policy review, observation, and staff interviews, the facility failed to distribute meals in a sanitary manner and failed to disinfect the hands to prevent contamination during meal service on 1 of 3 dining areas observed. The findings included: Review of policy and procedure on Handwashing, dated 10/2014, revealed, .Hands should be washed before starting to work; after break time; after using the rest room; after touching hair, face, or body .after touching anything that might contaminate hands .Sanitizing gel may ONLY be used as an added measure after washing hands to minimize bacteria, but not in place of handwashing . Observation on 05/22/17 at 11:53 AM, during meal service near the 300 hall, revealed Certified Nurse's Assistant (CNA) #5 picked up an uncovered plate of multiple food items from the hot bar (serving line), and carried it to an adjacent dining area across the hallway. Observation of CNA #6 revealed the CNA picked up an uncovered plate of multiple food items and carried the tray across the hallway into another dining area. Continued observation revealed the Dietary Aide (DA) #1 was plating food, without wearing gloves, wiping his face and adjusting his glasses, then touching the plate surfaces with bare fingers and placing resident's food on the plates to be served to the residents. Continued observation revealed DA #1 failed to wash his hands or use hand sanitizer after touching his face or glasses. Observation on 05/24/17 at 7:50 AM, during the breakfast meal service observation near the 300 hall, revealed CNA #8 picked up an uncovered breakfast plate from the tray line, walked across the hallway to the dining room and served Resident #102. Continued observation revealed CNA #9 also picked up an uncovered breakfast plate, carried the plate of food across the hallway to the dining room, and served Resident #105. On 05/24/17 at 8:04 AM, interview with the Dietary Manager (DM) #1, confirmed when staff are walking trays into another room from the serving line, the plated food should be covered. When asked if gloves are required when touching food surfaces, she confirmed that they were. | 2020-09-01 |
| 51 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2018-07-25 | 641 | D | 0 | 1 | M4WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure an accurate Minimum Date Set (MDS) for one resident (#89) of 43 sampled residents. The findings include: Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day MDS dated [DATE] revealed .Section P .physical restraints .used in chair or out of bed .1 (indicating used less than daily) . Observation of the residents on 7/26/18 at 1:02 PM, in the resident's room, revealed resident alert and verbal sitting in wheelchair in room. Continued observation of the resident room revealed no restraint in place to resident or in resident room. Interview with the MDS coordinator on 7/25/18 at 8:50 AM, in the MDS office, confirmed the MDS dated [DATE] was not accurate and the resident had not used a physical restraint. | 2020-09-01 |
| 52 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2018-07-25 | 684 | D | 0 | 1 | M4WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the Lippincott Nursing Center, medical record review, facility documentation review, observation, and interview the facility failed to correctly administer medications for 1 resident (#335) of 6 residents reviewed for unnecessary medications. The findings include: Review of the undated facility policy Administering Medications revealed .3. Medications must be administered in accordance with the orders .4. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Method of identifying the resident checking photograph attached to the electronic medical record .5. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication .6. The following information must be check/verified for each resident prior to administering medications: [REDACTED]. Vital signs, if necessary . Review of the Lippincott Nursing Center 8 Rights of Medication Administration dated 5/27/11 revealed the 8 rights of medication administration included the right patient, right medication, right dose, right route, right time, right documentation, right reason, and right response. Medical record review revealed Resident #335 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making was modified independence indicating the resident had some difficulty in new situations only. Review of facility documentation dated 7/17/18 revealed Resident #335 received the medications of another resident during the 9:00 AM medication pass. Continued review revealed the medications were administered incorrectly to Resident #335 based on mistaken identity. Medical record review of Resident #335's Electronic Medication Administration Record [REDACTED]. Medical record review of a nurses' note dated 7/17/18 and timed 10:30 AM revealed the resident's blood pressure was 196/87; Heart rate was 60 beats per minute; respiratory rate was 18 breaths per minute and the Oxygen saturation (amount of oxygen in the blood) was 98% (percent). Continued review revealed the resident was alert and oriented. Medical record review of a Nurse Practitioner's note dated 7/17/18 revealed .Pt (patient) was given morning meds (medications) that were prescribed to another pt. He had not received his own meds at the time. Medications were reviewed. His own morning blood pressure medication was held due to medicines he received. Pt was seen approx (approximately) 2 hours after receiving medications. He was alert and oriented. No adverse affects have occurred at this time. Discussed with patinet (patient) and daughter that he may have some drowsiness. Vital signs checked per staff and were stable . Medical record review of a nurses' note dated 7/17/18 and timed 1:45 PM revealed the resident's blood pressure was 151/76 and the resident was alert and oriented. Medical record review of nurses' notes dated 7/17/18 from 1:54 PM through 2:30 PM revealed the resident complained of nausea with some .thin watery emesis . Continued review revealed the resident remained alert, oriented and had some complaints of dizziness and sleepiness. Medical record review of a nurses' note dated 7/17/18 and timed 3:00 PM, revealed the resident had no further emesis. Continued review revealed the resident reported he was feeling .a little better . and wanted to go to his doctor's appointment. Medical record review of a nurses' note dated 7/17/18 and timed 3:30 PM, revealed the resident was out of the facility for a doctor's appointment. Medical record review of a Provider Note dated 7/18/18 revealed .patient received wrong medications including [MEDICATION NAME] (medication for [MEDICAL CONDITION]), Requip (medication for restless leg syndrome), [MEDICATION NAME] (medication for depression), Vitamin D (calcium), Risaquad (medication to balance good bacteria in the digestive system), [MEDICATION NAME] (blood pressure medication), and [MEDICATION NAME] (blood pressure medication) . Observations of Resident #335 from 7/23/18 through 7/25/18 revealed the resident was participating in physical therapy and talking with other residents in the hallway. Interview with Resident #335 and the residents' daughter on 7/23/18 at 11:30 AM, in the resident's room revealed the resident had received another resident's medication on 7/17/18. The residents' daughter reported Resident #335 received 2 blood pressure medications, an antidepressant, medication for [MEDICAL CONDITION], and a vitamin in error. Interview with Nurse Practitioner (NP) #1 on 7/24/18 at 3:05 PM, in the Station 4 Chart Room confirmed Resident #335 received another resident's medications on 7/17/18. Further interview revealed the resident complained of nausea for a couple of hours and vomited 1 time. Continued interview revealed the resident's vital signs remained stable, all of the labs were normal and there were no adverse side effects. Interview with Resident #335 on 7/24/18 at 3:41 PM, in the resident's room revealed the resident had received the medications in the hallway as the resident was going to therapy. The resident reported he had gotten sleepy while in therapy, had nausea and vomiting, and was light headed. Interview with Licensed Practical Nurse (LPN) #1 on 7/24/18 at 3:41 PM, in the Infection Control Office revealed she thought Resident #335 came out of room [ROOM NUMBER]. LPN #1 confirmed she gave Resident #335 the medication for the resident occupying room [ROOM NUMBER]. Interview with the Director of Nursing on 7/24/18 at 4:27 PM, in the Station 4 Resident Care Coordinator's Office confirmed Resident #335 received the incorrect medication on 7/17/18 and confirmed the facility failed to follow the facility policy for medication administration. | 2020-09-01 |
| 53 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2019-06-05 | 728 | D | 1 | 1 | PCFO11 | > Based on review of the facility's Nurse Aide Training (NAT) program, review of work schedules and interview, the facility failed to ensure 2 of 24 (Nurse Aide (NA) #1 and NA #2) NAs were removed from the working schedule and not allowed to perform the duties of a Certified Nursing Assistant CNA after 120 days of taking the NAT program. The findings include: Review of the facility working schedule for the months of February, March, (MONTH) and (MONTH) 2019 revealed NA #1 and NA #2 worked as NA performing the duties of a CN[NAME] Interview with the Director of Nursing (DON) on 6/5/19 at 3:00 PM in the DON's office, the DON was asked if NA #1 and NA #2 had passed the CNA certification exam. The DON stated, No . Interview with the DON on 6/5/19 at 6:03 PM in the conference room, the DON was asked when NA #1 and NA # 2 completed the Nurse Aide Training program. The DON stated .they were in the August/September (2018) class. The DON was asked if NA #1 and NA #2 worked at the facility longer than 4 months without being certified. The DON stated, .yes .they worked up until 2 weeks ago . The DON was asked what duties NA #1 and NA #1 performed. The DON stated, .CNA duties . The DON confirmed the NAs should not have worked longer than 4 months without passing the CNA certification exam. | 2020-09-01 |
| 54 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2019-06-05 | 839 | D | 1 | 1 | PCFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on license review and interview, the facility failed to ensure professional staff were licensed in accordance with applicable State laws for 1 of 41 (Licensed Practical Nurse (LPN) #2) nurses reviewed. The findings include: Review of the facility Personnel Action Form for LPN #2 revealed an employment date of [DATE]. Review of the State of Tennessee Department of Health Division of Health Licensure and Regulation Division of Health Related Boards on [DATE] revealed LPN #2's license number had an expired status with an expiration date of [DATE]. Review of the Department Allocation Worksheet for the pay period for [DATE] revealed LPN #2 worked at he facility through [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 3:00 PM in the DON's office, the DON was asked if LPN #2 worked for the facility. The DON stated, .yes .she worked until the middle of (MONTH) (2019) .at that time we discovered her license was expired . The DON confirmed LPN #2 should not have worked on an expired license. The DON was asked who was responsible for license verification. The DON stated, .we are responsible . | 2020-09-01 |
| 55 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2019-06-05 | 880 | D | 0 | 1 | PCFO11 | **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 followed when 3 of 8 (Certified Nursing Assistant (CNA) #1, Physical Therapist Assistant (PTA) #1, and Licensed Practical Nurse (LPN) #1) staff members failed to perform appropriate hand hygiene during contact isolation for Resident #182 and wound care for Resident #181. The findings include: 1. The facility's HANDWASHING policy with a revision date of 4/23/18 documented, .Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of Standard Precautions .in the case of spore forming organisms such as[DIAGNOSES REDACTED]icile ([MEDICAL CONDITION]) .require soap and water with friction .PR[NAME]EDURE .Wash hands before and after contact with each patient .and before and after removal of gloves . 2. Medical record review revealed Resident #182 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff), [MEDICAL CONDITION] Stage 3, Traumatic Subdural Hemorrhage, Diabetes, [MEDICAL CONDITIONS], and Depression. The physician's orders [REDACTED].Strict Isolation-All services provided in room .for [MEDICAL CONDITION] . Observations in Resident #182's room on 6/3/19 at 12:19 PM revealed CNA #1 delivered ice to the resident, removed the gown and gloves, used hand sanitizer, and exited the room. Observations outside Resident #182's room on 6/4/19 at 8:15 AM revealed PTA #1 donned a gown, mask and gloves, and entered Resident #182's room. PTA #1 remained in the room for 37 minutes and exited the room at 8:52 AM without performing hand hygiene. Interview with PTA #1 on 6/4/19 at 8:52 AM outside Resident #182's room, PTA #1 was asked if she washed her hands before she came out of the room. PTA #1 stated, I don't like to use their bathroom . PTA #1 then used the hand sanitizing gel that was on the isolation kit outside the door, and then walked to the therapy gym. Interview with Registered Nurse (RN) #1 on 6/5/19 at 8:03 AM in the conference room, RN #1 was asked why Resident #182 was in isolation. RN #1 stated, [DIAGNOSES REDACTED]. RN #1 was asked what the staff were supposed to do when they entered and exited Resident #182's room. RN #1 stated, They hand wash .the hand gel stuff don't work with the [MEDICAL CONDITION]. They are supposed to wash hands with soap and water coming out of the room. Interview with the Director of Nursing (DON) on 6/5/19 at 8:42 AM in the conference room, the DON was asked if the staff should perform hand hygiene using hand sanitizing gel after they left Resident #182's room. The DON stated, It's not appropriate for the [MEDICAL CONDITION]. 3. Medical record review revealed Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Management notes dated 6/1/19 revealed Resident #181 had extensive [DIAGNOSES REDACTED] (a disease in which calcium accumulates in the small blood vessels of the fat and skin tissue) ulcers, 3 to the left upper arm, 3 to the right upper arm, 1 to the right thumb, 1 to the right hand, and 1 to the right wrist. Observations in Resident #181's room on 6/4/19 at 3:21 PM revealed the following: LPN #1 removed the soiled dressing from Resident #181's right upper arm, cleaned the posterior upper wounds with saline soaked gauze, and then used a cotton swab to apply [MEDICATION NAME] gel, using the same gloves. LPN #1 did not perform hand hygiene between cleaning the wound and applying the clean treatment. LPN #1 placed a saline soaked gauze on the wound to the anterior right upper arm, still wearing the same gloves. LPN #1 did not change gloves or wash her hands between different wounds. LPN #1 removed her gloves, and adjusted the thermostat on the wall. LPN #1 did not perform hand hygiene after removing the soiled gloves. LPN #1 cleaned the [MEDICATION NAME] gel from Resident #181's posterior upper arm wounds with saline soaked gauze, and applied [MEDICATION NAME] One (a dressing used for painful wound management that prevents the outer dressing from sticking to the wound bed) and [MEDICATION NAME] Extra (a moisture retention dressing) using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed her gloves, applied clean gloves, and removed the dressing from Resident #181's right lower arm. LPN #1 did not wash her hands between glove changes and between different wounds. LPN #1 cleaned the wounds to Resident #181's right posterior lower arm using saline soaked gauze and then applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, (abdominal pads (ABD) used for large wounds or wounds needing high absorbency), and conforming gauze dressings using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed the dressings from Resident #181's right wrist and hand, cleaned the wounds with saline soaked gauze, and applied [MEDICATION NAME] One dressing. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 changed her gloves without performing hand hygiene, and applied [MEDICATION NAME] Extra, ABD pads, and conforming gauze to Resident #181's right wrist. LPN #1 did not perform hand hygiene between glove changes. LPN #1 removed the dressing from Resident #181's left upper arm and changed her gloves without performing hand hygiene. LPN #1 cleaned the wounds to the left upper arm with saline soaked gauze, applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, and ABD pad dressings, and wrapped the right upper arm with gauze. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. Interview with the DON on 6/5/19 at 8:42 AM in the conference room, the DON was asked when staff should perform hand hygiene during wound care. The DON stated, In between clean and dirty, I want them to be washing their hands and changing their gloves. The DON was asked if they were supposed to wash their hands when they changed gloves. The DON stated, Yes. | 2020-09-01 |
| 56 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2017-07-19 | 157 | D | 0 | 1 | 788Z11 | **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 clinical complication for one resident (#168) of 3 residents reviewed for abuse. The findings included: Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident was rarely/never understood. Medical record review of a nurse note by Registered Nurse (RN) #1 dated 7/18/17 at 8:50 AM revealed did not find [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) to R (right) chest as documented. will ask on coming nurse to double-check and if none found, to place another patch. Interview with RN #1on 7/19/17 at 2:25 PM via telephone revealed she worked the 7PM to 7AM shift the night of 7/17/17 and cared for Resident #168. Further interview revealed she noticed the [MEDICATION NAME] was missing around 4 AM. Continued interview revealed RN #1 reported the missing [MEDICATION NAME] to Licensed Practical Nurse (LPN) #1 at shift change and asked her to get it replaced if it wasn't found. Interview with LPN #1 on 7/19/17 at 2:55 PM via telephone revealed she worked 7/18/17 from 7 AM to 7 PM and cared for Resident #168. Further interview revealed RN #1 told her at shift change the [MEDICATION NAME] was missing. Continued interview confirmed LPN #1 intended to notify the Physician of the missing [MEDICATION NAME] but failed to do so. | 2020-09-01 |
| 57 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2017-07-19 | 225 | D | 1 | 1 | 788Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to investigate injuries of unknown origin for 1 resident (#379) and failed to initiate an investigation in a timely manner for a missing pain patch for 1 resident (#168) of 35 residents reviewed in Stage II. The findings included: Review of facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property, and Exploitation, revised 11/28/16 revealed .abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .An injury should be classified as an injury of unknown source when both of the following conditions are met: (a) The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and (b) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property, or exploitation did or did not take place .The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident . Review of facility policy, Miscellaneous Special Situations, Discrepancies, Loss and or Diversion of Medications, dated 6/2016 revealed .All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed .Immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator, Director of Nursing (DON), Consultant Pharmacist and Director of Pharmacy are notified and an investigation conducted. The Director of Nursing leads the investigation .Appropriate agencies, required by state regulation will be notified . Medical record review revealed Resident #379 was admitted to the facility on [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #379 scored 15/15 on the Brief Interview for Mental Status, indicating she was alert and oriented. Continued review of the MDS revealed Resident #379 required extensive assistance of 2 people for transfers and toileting; extensive assistance of 1 person for dressing and bathing; assistance of 1 person for grooming; supervision for eating; and was frequently incontinent of bowel and bladder. Medical record review of nursing notes dated 10/28/16 revealed Resident #379 had bilateral upper extremity skin tears. Continued review of nursing notes dated 11/4/16 revealed the resident had multiple skin tears to bilateral upper extremities. Review of incident reports revealed none were completed for these injuries and no investigations were completed for multiple injuries of unknown origin Interview with the Director of Nursing (DON) on 7/19/17 at 4:30 PM in the conference room, confirmed there were no incident reports for the skin tears which occurred on 10/28/17 and 11/4/17. Continued interview with the DON confirmed there was no investigation into either injury of unknown origin. Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident is rarely/never understood. Medical record review of a nurse note dated 7/18/17 at 8:50 AM by Registered Nurse (RN) #1 revealed did not find [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) to R (right) chest as documented. will ask on coming nurse to double-check and if none found, to place another patch. Interview with RN #1 on 7/19/17 at 2:25 PM via telephone revealed she worked the 7PM to 7AM shift the night of 7/17/17 and cared for Resident #168. Further interview revealed she checked the placement of the [MEDICATION NAME] around 4 AM and could not find it. Continued interview revealed RN #1 reported the missing [MEDICATION NAME] to Licensed Practical Nurse (LPN) #1 at shift change and asked her to get it replaced if it wasn't found. Interview with RN #3, Unit Manager on 7/19/17 at 2:45 PM in the conference room, when asked her expectation of when staff should notify her of a missing [MEDICATION NAME] on a resident revealed she would expect to be notified immediately. Continued interview revealed she was notified of the missing [MEDICATION NAME] for Resident #168 at approximately 9 AM on this date by LPN #2. Interview with the DON on 7/19/17 at 4:38 PM in the conference room revealed she did not find out about the missing [MEDICATION NAME] until this morning, and an investigation had since been initiated. Continued interview revealed RN #1 did not report the missing [MEDICATION NAME] to the unit supervisor or the DON. Further interview revealed the incident had not been reported to the state agency. Continued interview with the DON confirmed RN #1 did not report the possible misappropriation of narcotic medication in a timely manner and the facility did not report to the State Agency in the required time period. | 2020-09-01 |
| 58 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2017-07-19 | 514 | D | 0 | 1 | 788Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately document on the Medication Administration Record [REDACTED]. The findings included: Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident is rarely/never understood. Medical record review of the MAR for (MONTH) (YEAR) revealed .CHECK - Patch placement every shift . (narcotic pain medication [MEDICATION NAME]). Continued review revealed documentation the patch was not found on the night shift on 7/17/17. Further review revealed documentation for patch placement on 7/18/17 as RT AC (right [MEDICATION NAME]). Interview with Licensed Practical Nurse (LPN) #1 on 7/19/17 at 2:55 PM via telephone when asked did the resident have a [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) in place on 7/18/17 stated she could not find it. Continued interview when asked about the documentation of checking the patch placement for the [MEDICATION NAME] on 7/18/17 stated I think I put it was on but I should have put not in place. Further interview revealed LPN #1 stated didn't document it right. Interview with the Director of Nursing on 7/19/17 at 4:38 PM in the conference room when asked about LPN #1's documentation regarding the [MEDICATION NAME] placement on the 7/18/17 day shift revealed it was incorrect. Continued interview with the DON confirmed the facility failed to accurately document the [MEDICATION NAME] placement on 7/18/17 day shift for Resident #168. | 2020-09-01 |
| 59 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2018-08-01 | 684 | D | 0 | 1 | D20911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to administer treatment and services to restore normal bowel function for 2 of 4 (Resident #229, and 230) residents reviewed for bowel incontinence. The findings include: 1. The facility's BM (bowel movement) Protocol policy documented, .Polyethylene [MEDICATION NAME] .17 grams by mouth as needed for constipation if no BM in 2 days .Mix in at least 4oz. (ounces) of water or juice in the morning of the 3rd day .[MEDICATION NAME] 10mg (milligram) suppository rectally as needed for constipation if no results from [MEDICATION NAME] by bedtime of the 3rd day .Fleet Enema rectally as needed for constipation if no results from [MEDICATION NAME] suppository, administer at bedtime on the 4th day .If no BM on the morning of the 5th day notify the physician . 2. Medical record review revealed Resident #229 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #229 on 7/30/18 at 5:26 PM, in her room, Resident #229 stated, .been here since Wednesday .haven't had a BM in a week . Review of the physician's orders [REDACTED].#229 was on the BM Protocol. Review of the Toileting .BM record revealed Resident #229 did not have a BM on 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, and 7/31/18. Review of the Med (medication) PRN (as needed) record dated 7/1/18 to 7/31/18 revealed Resident #229 did not receive Polyethylene [MEDICATION NAME] on 7/28/18 (the 3rd day) and did not receive the [MEDICATION NAME] rectal suppository on 7/29/18 (the 4th day) as ordered per the BM protocol. Interview with Registered Nurse (RN) #1 on 8/1/18 at 2:28 PM in the Minimum Data Set (MDS) office, RN #1 reviewed the Toileting .BM record for Resident #229, and confirmed that Resident #229 had not had a BM on 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, and 7/31/18. RN #1 reviewed the Med PRN record dated 7/1/18 to 7/31/18, and stated, She didn't get the medication . 3. Medical record review revealed Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#230 was on the BM Protocol. Review of the electronic Toileting .BM record revealed Resident #229 did not have a BM on 7/21/18, 7/22/18, and 7/23/18. Review of the Med PRN record dated 7/1/18 to 7/31/18 revealed Resident #230 did not receive the Polyethylene [MEDICATION NAME] on 7/23/18 (the 3rd day). 4. Interview with the the Nurse Practitioner on 8/1/18 at 11:27 AM in the conference room, the Nurse Practitioner was asked if she had been notified about Resident #229 and 230 not having BMs. the Nurse Practitioner stated, .I was not aware .The expectation is the nurses follow the bowel protocol . Interview with RN #1 on 8/1/18 at 2:38 PM in the MDS office, RN #1 reviewed the Toileting .BM record for Resident #230, and confirmed that Resident #229 had not had a BM on 7/21/18, 7/22/18, and 7/23/18. RN #1 stated, He should have gotten the Polyethylene [MEDICATION NAME] on that third day. Interview with the Director of Nursing (DON) on 8/1/18 at 3:01 PM in the conference room, the DON confirmed that Resident #229 and #230 should have received medication after no BM for 3 days, and stated that it was not appropriate for staff to not follow the bowel protocol. | 2020-09-01 |
| 60 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2018-08-01 | 695 | D | 0 | 1 | D20911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to maintain respiratory equipment in a sanitary manner for 2 of 2 (Resident #16 and 178) sampled residents reviewed for respiratory care. The findings include: 1. The facility's RESPIRATORY MANUAL .Aerosol Therapy policy last revised 7/14, documented, .Cautions .Nebulizer can become contaminated resulting in an infection . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] sulfate .1 ampul ([MEDICATION NAME]) nebulization every 2 hours As Needed SHORTNESS OF BREATH NEBULIZATION .Dx (Diagnosis) .[MEDICAL CONDITION] . The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .1 ampul nebulization 3 times per day NEBULIZATION .Dx .[MEDICAL CONDITION] . Observations in Resident #16's room on 7/30/18 at 5:38 PM revealed Resident #16 in bed, with a nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. There was no cover or clean barrier for the mouthpiece. Observations in Resident #16's room on 7/31/18 at 8:30 AM revealed Resident #16 in bed with the nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. The mouthpiece was on the floor. Observations in Resident #16's room on 7/31/18 at 5:09 PM revealed Resident #16 in bed, with a nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. There was no cover or clean barrier for the mouthpiece. Interview with Licensed Practical Nurse (LPN) #1 on 7/31/18 at 5:13 PM on the Grove wing, LPN #1 was asked how the nebulizer tubing, masks, and mouthpieces should be stored. LPN #1 stated, .In a little baggie beside the machine. LPN confirmed the mouthpiece was not on a barrier or covered. 3. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .1 ampul nebulization every 6 hours .NEBULIZATION .Dx .shortness of breath . Observations in Resident #178's room on 7/30/18 at 12:51 PM, and on 7/31/18 at 8:44 AM, 11:36 AM, and 4:56 PM, revealed Resident #178 in bed, with a nebulizer on the bedside table. The tubing and mask were attached and dated 7/25/18. The mask and tubing were uncovered without a barrier. Interview with LPN #1 in Resident #178's room on 7/31/18 at 5:14 PM, LPN #1 confirmed the nebulizer tubing and mask were not covered or placed on a clean barrier and stated, It needs to be covered. Interview with the Director of Nursing (DON) on 7/31/18 at 5:31 PM in the conference room, the DON was asked how the nebulizer masks, mouthpieces, and tubing should be stored. The DON stated, There's a bag they are supposed to be using. and further stated it was unacceptable for them to be out on the bedside table without a cover or a clean barrier. | 2020-09-01 |
| 61 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2018-08-01 | 698 | D | 0 | 1 | D20911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on worksheet review, medical record review, and interview, the facility failed to ensure there was communication between the facility and the [MEDICAL TREATMENT] clinic for 1 of 1 (Resident #3) sampled residents reviewed for [MEDICAL TREATMENT]. The findings include: The facility's [MEDICAL TREATMENT] Communication Worksheet documented, .ongoing assessment of the patient's condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] clinic .Center nurse complete On [MEDICAL TREATMENT] days Pre-[MEDICAL TREATMENT] section of the form prior to appointment .Send with patient to [MEDICAL TREATMENT] clinic .Request the [MEDICAL TREATMENT] clinic to complete the bottom portion of form .return it to the center with the patient . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICAL TREATMENT] every Tuesday, Thursday, Saturday (medication administration record) each [MEDICAL TREATMENT] 3 times per week (Tuesday, Thursday, Saturday) . The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment, and the resident received [MEDICAL TREATMENT] services. Review of the Care Plan dated 1/17/18 revealed [MEDICAL CONDITION] with [MEDICAL TREATMENT] three times a week. Review of the [MEDICAL TREATMENT] communication forms revealed documentation was not completed on the forms dated 7/17/18, 7/19/18, 7/21/18 and 7/30/18. Interview with the Director of Nursing (DON) on 8/1/18 at 5:09 PM in the conference room, the DON was asked how she expected the nurses to communicate with the [MEDICAL TREATMENT] center. The DON stated, The nurse fills out the pre [MEDICAL TREATMENT] form .it goes with the patient to [MEDICAL TREATMENT] clinic .the [MEDICAL TREATMENT] clinic completes form .the form comes back with the patient .it's scanned into the system . The DON was asked what she expected the nurses to do if the [MEDICAL TREATMENT] center did not send back the form. The DON stated, .I would think they should call the clinic to see if they can get information .keep me informed so I can know the patient is getting what they need . The facility was unable to provide documentation of communication between the [MEDICAL TREATMENT] center and the facility. | 2020-09-01 |
| 62 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2018-08-01 | 880 | D | 0 | 1 | D20911 | Based on policy review, observation, and interview, 2 of 2 (Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #1) staff failed to ensure infection control practices were maintained to prevent the potential spread of infection during wound care. The findings include: The facility's HANDWASHING policy, dated 10/1/08, documented, Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of Standard Precautions .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . Observations in Resident #230's room on 7/31/18 beginning at 11:10 AM, revealed CNA #1 assisting RN #2 with wound care. RN #2 cleaned a marker with a bleach wipe and changed her gloves without performing hand hygiene. CNA #1 touched the bed covers, adjusted the bed, and changed her gloves without performing hand hygiene. RN #1 touched the wound with her gloved left hand and changed her gloves without performing hand hygiene. After applying a foam dressing to the wound, RN #1 changed her gloves without performing hand hygiene. After assisting with positioning Resident #230 during wound care, CNA #1 changed her gloves without performing hand hygiene. Interview with the Director of Nursing (DON) on 8/1/18 at 5:58 PM, in the conference room, the DON was asked what nursing staff should do between removing used gloves and donning clean gloves. The DON stated, Perform hand hygiene. | 2020-09-01 |
| 63 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-03-28 | 607 | D | 1 | 0 | 8HII11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and staff interview, the facility failed to timely report an injury of unknown origin per policy to facility administration per facility policy; failed to implement facility policy related to training after an allegation of injury of unknown origin; and the facility administration failed to report the allegation of injury of unknown origin within 2 hours to the State Agency (SA) per facility policy. Failing to implement abuse policies had the potential for abuse events to reoccur and put all 176 residents residing in the facility at risk. Findings include: Review of the facility Abuse, Neglect and Misappropriation or Property, policy, revised 8/24/17, revealed the definition of an injury of unknown origin as: .means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown source, or suspicion of crime. Directly after assuring that the resident(s) involved in the allegation or abuse event is safe and secure, the alleged perpetrator has been removed from the resident care area, and any needed medical interventions for the resident have been requested/obtained, the charge nurse will inform the Facility Administrator (the abuse coordinator), Director of Nursing (DON), physician and family or resident's representative of the allegation of abuse or suspicion of crime. The facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of crime as defined in this policy, and, if so, he or she, or the DON, will notify State agencies according to State reporting procedures within two hours. The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegation of abuse, injuries of unknown source, exploitation, or suspicions of crime as defined in this account. The facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed Resident #10 with severe cognitive impairment and no behaviors. Resident #10 required extensive assist of 1 person for bed mobility, dressing, and eating, and was dependent with 1 person assist for transfers, toilet needs, and bathing. Medical record review of a nursing assessment, completed by Licensed Practical Nurse (LPN) #7, dated 12/29/17 at 1:00 AM, revealed Resident #10 complained of pain and the LPN assessed the resident with swelling and pain in the right arm. The assessment did not indicate if the Administrator, or the DON were notified. Medical record review of a radiology report for Resident #10, dated 12/30/17 and faxed at 7:14 AM, revealed an acute mildly displaced distal humerus fracture. Medical record review of a Nursing Progress Note, dated 12/30/17, written by LPN #7 revealed the night shift nurse reported an x-ray indicating a right arm fracture. The resident was transported to the emergency room at 10:15 AM. The DON and Administrator were contacted as well (first observation of pain and swelling was on 12/29/17 at 1:00 AM). Medical record review of the emergency room Progress Note, dated 12/30/17, revealed a right arm fracture that the physician documented .was not a result of abuse/neglect . Medical record review of a Nursing Progress Note, dated 12/31/17 at 12:08 AM, revealed the .resident returned from the hospital in no acute distress with a right arm splint and arm sling, family at bedside, and pain medication administered with good results . Review of the facility interventions related to the investigation included Abuse Education (MONTH) (YEAR), which included 5 questions related to when to report abuse, signs of abuse, factors increasing the risk of abuse, and common reasons for abuse. Nurses were required to sign they received a copy of the Signature Healthcare's Triage Process. Review of the sign-in sheets for the Abuse Education (YEAR), revealed 137 of 285 listed staff had signed to indicate the training was completed. Review of the facility Positioning Competency, revealed guidelines for assistance for a resident positioning in a bed and chair, and included areas to indicate completion, comments, employee signature, supervisor signature, and yes or no for successful completion. Review of the facility sign-off sheet included completed sign-off for all staff. Upon review of the individual competency sheets revealed multiple sheets were missing dates, evidence the competency was completed, and supervisor signatures. Interview with the DON on 3/28/18 at 1:00 PM in the Conference Room revealed when Certified Nurse Assistant (CNA) #9 came on shift at 11:00 PM the CNA discovered Resident #10 complaining of pain when being turned. CNA #9 reported the issue to LPN #7 and the resident was assessed with [REDACTED]. The Night Shift Supervisor/Registered Nurse (RN) #2 was notified and came to assess the resident. An x-ray was obtained with the results of a right arm fracture. Further interview confirmed the RN did not notify the DON or the Administrator per policy of the injury of unknown origin. Further interview confirmed the facility failed to report the injury of unknown origin to the SA within 2 hours as required and per policy. Interview with the Administrator on 3/28/18 at 1:35 PM in the Conference Room revealed he did not recall the time of notification of the incident. Further interview confirmed he called the DON on 12/30/17 after the x-ray results were received. Further interview revealed the facility began abuse training immediately on the day of discovery. When CNA #8 stated on 1/03/18 the injury might have occurred during positioning the facility felt the injury was caused by faulty positioning, and the facility began staff competencies for positioning. Since the emergency room physician did not think the injury was related to abuse/neglect the facility moved from an allegation of abuse to care competency. Further interview confirmed a delay in notification resulted in the facility not reporting the injury of unknown origin within 2 hours to the SA per facility policy. The Administrator confirmed the abuse training and positioning competencies for nursing were not completed by the facility after the incident. Interview with the DON on 3/28/18 at 2:00 PM in the Conference Room confirmed the abuse training of when to report abuse was not completed for all staff and the positioning competencies were not completed for all nursing staff at the time of the investigation. | 2020-09-01 |
| 64 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-03-28 | 609 | D | 1 | 0 | 8HII11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review,and staff interview, the facility failed to timely report an injury of unknown origin to the facility administration; and failed to notify the State Agency (SA) within 2 hours for 1 of 8 residents (Resident #10) reviewed for injury of unknown origin. Failing to report allegations of injury of unknown origin could increase the risk to all 176 residents residing in the facility. Findings include: Review of the undated facility Abuse, Neglect and Misappropriation or Property policy, revealed the definition of an injury of unknown origin as: .means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown source, or suspicion of crime .the charge nurse will inform the Facility Administrator (the abuse coordinator), Director of Nursing (DON) .of the allegation of abuse .The facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of crime as defined in this policy, and, if so, he or she, or the DON, will notify State agencies according to State reporting procedures within two hours . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #10 with severe cognitive impairment, no behaviors, and requiring extensive assist of 1 person for bed mobility, dressing, and eating. Resident #10 was dependent with 1 person assist for transfers, toilet needs, and bathing. Medical record review of a nursing assessment, completed by Licensed Practical Nurse (LPN) #7, dated 12/29/17 at 1:00 AM, revealed Resident #10 complained of pain and the LPN assessed the resident with swelling and pain in the right arm. The assessment did not indicate if the Administrator, or the DON were notified. Medical record review of a radiology report for Resident #10, dated 12/30/17 and faxed at 7:14 AM, revealed an acute mildly displaced distal humerus fracture. Medical record review of a Nursing Progress Note, dated 12/30/17, written by LPN #7 revealed the night shift nurse reported an x-ray indicating a right arm fracture. The resident was transported to the emergency room at 10:15 AM. The DON and Administrator were contacted as well (first observation of pain and swelling was on 12/29/17 at 1:00 AM). Review of the facility documentation report revealed the SA was notified on 12/30/17 at 1:35 PM, 36 1/2 hours after the event. Interview with the DON on 3/28/18 at 1:00 PM in the Conference Room revealed when CNA #9 came on duty at 11:00 PM Resident #10 complained of pain when being turned. CNA #9 reported the issue to LPN #7 and the resident was assessed with [REDACTED]. The Night Shift Supervisor/Registered Nurse (RN) #2 was notified and came to assess the resident. An x-ray was obtained with the results of a right arm fracture. Further interview confirmed the RN did not notify the DON or the Administrator per policy of the injury of unknown origin. Further interview confirmed the facility failed to report the injury of unknown origin to the SA within 2 hours as required and per policy. Interview with the Administrator on 3/28/18 at 1:35 PM in the Conference Room confirmed there was a delay in notification of the injury of unknown origin to administrative staff resulting in the facility's failure of not reporting the injury within two hours to the State Agency as required and per policy. | 2020-09-01 |
| 65 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-03-28 | 880 | D | 1 | 0 | 8HII11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record review, staff interview, and observation, the facility failed to ensure infection control measures related to the dressing change of a peripherally inserted intravenous catheter (PICC) for 1 of 3 residents (Resident #7) reviewed with PICC lines; and failed to properly utilize hand hygiene during medication administration for 1 of 4 residents (Resident #15) observed for medication administration. Failing to change PICC line dressings had the potential to affect eight residents identified with PICC lines; failing to use hand hygiene could increase the risk of infection, and had the potential to affect all 176 residents in the facility. Findings include: Review of facility Infusion Therapy Procedures dated 2011, was reviewed and revealed .PICC and Midline Catheter dressing changes must be completed at minimum every seven days. Change immediately if: loose, not occlusive, moisture accumulation, drainage, redness, or irritation. Initial dressings will be changed PRN (as needed) if saturated, and 24-48 hours post insertion of Midlines, PICC's . if there is gauze present under the dressing or drainage is noted . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was alert, oriented, and independent with all activities of daily living except assistance of 1 to be off the unit. Medical record review of the nursing admission assessment dated [DATE] revealed the resident was admitted with a right upper extremity PICC line. Medical record review of physician progress notes [REDACTED]. Medical record review of physician orders [REDACTED]. Medical record review of a Daily Skilled Nursing Note dated 12/08/17 revealed .central line dressing scheduled as per staff to be changed . Medical record review of Medication Administration Records, (MAR), dated 11/30/17 through 12/10/17 (11 days) revealed no evidence of a dressing change to the PICC line. Medical record review of Physician order [REDACTED].#7 revealed .discontinue PICC line and reinsert new Midline catheter . Review of a procedure form for Resident #7 dated 12/10/17 revealed .the patient PICC line was out 7 centimeters and the dressing was loose on three sides. A Midline catheter was inserted into the left upper arm with a dressing applied . Medical record review of Physician order [REDACTED]. Medical record review of the MAR for Resident #7 dated from 12/11/17 through 12/26/17 (17 days) revealed no evidence of a dressing change to the Midline catheter. Medical record review of the Comprehensive Care Plan dated 12/11/17, revealed the .resident as at risk for complications related to the use of IV (intravenous) fluids and /or medications with a right upper arm PICC line . Interventions included .apply and check IV site treatment/dressings as ordered . Interview with the Director of Nursing (DON) on 3/28/18 at 2:30 PM confirmed the resident was admitted with a PICC line. Further interview revealed the PICC line became misplaced and a new Midline catheter was placed to continue the antibiotic administration. The DON confirmed the facility failed to have documentation of a dressing change to the PICC line and Midline catheter every seven days as per the facility policy. Review of the facility Medication Administration General Guidelines dated 2007 revealed, .hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, [MEDICATION NAME], enteral, rectal, and vaginal medications. Hand are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of medication administration on 3/27/18 at 8:50 AM revealed Licensed Practical Nurse (LPN) #6 entering the isolation room for Resident #15. LPN #6 donned personal protective equipment (PPE) to include a mask, gown, and gloves. With the help of Rehab #2 the resident was repositioned to allow better access to the resident gastronomy tub ([DEVICE]). LPN #6 removed gloves, donned new gloves, and assessed the [DEVICE] for placement and residual tube feed, changed gloves and administered several medications per the [DEVICE]. LPN #6 then changed gloves and administered prescription eye drops in each eye. LPN #6 took off gloves and reached under the PPE gown and took a large bore needle from a uniform pocket, donned gloves and used the needle to puncture two fish oil capsules, and place the liquid from the capsules in a medication cup. After changing gloves, LPN #6 administered the fish oil through the [DEVICE], changed gloves and administered a subcutaneous injection into the resident's abdomen. After changing gloves, LPN #6 administered a second drop of the prescription eye drop to each of the resident's eyes. LPN #6 then removed the PPE and gloves, washed hands with soap and water before exiting the room. The hand washing prior to exit was the only time LPN #6 completed hand washing or hand hygiene for the entire medication administration. Interview with LPN #6 on 3/27/18 at 9:30 AM on the second-floor hallway confirmed hand hygiene, to include hand washing or alcohol rub, was not used during the medication administration with Resident #15. Further interview revealed LPN#6 was unsure of the facility policy for hand hygiene. Interview with the DON on 3/28/18 at 5:10 PM in the facility Conference Room revealed staff were expected to wash hands or use alcohol rub any time gloves were worn and removed, before and after injections, and before eye drops and [DEVICE] medications. Further interview confirmed nursing staff should not remove items from pockets while in an isolation room. | 2020-09-01 |
| 66 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 550 | D | 1 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based facility policy review, facility investigation review, medical record review, observation and interview, the facility failed to provide timely personal care to 1 resident (#83) of 161 residents observed. The findings include: Review of the facility policy, Resident Rights, revised 8/16/18 revealed .The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness and dignity . Review of the facility investigation dated 2/14/19 revealed Resident #83 had emesis (vomit) on his clothes and the Certified Nurse Aide (CNA) #8, failed to provide care such as changing the resident's clothes. Medical record review revealed Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #83 was totally dependent on 2 people for dressing and mobility. Observation on 4/2/19 and 4/3/19 at 8:39 AM and 8:56 AM, respectively, in Resident #83's room revealed resident in bed, clean no signs and no symptoms of distress noted. Continued observation revealed Resident #83 had just finished eating breakfast and was assisted by staff. Record review of the facility investigation interview with the Chaplain on 2/15/19 revealed the Chaplain was in the dining room on the 4th floor at 2:00 PM and observed Resident #83 had emesis on him. Continued review revealed the Chaplain reported the observation to CNA #8. Record review of the facility investigation interview with CNA #8 on 2/14/19 revealed Resident #83 had vomited approximately 2:15 PM. Continued review revealed CNA #8 took Resident #83 to the room to provide care at 3:20 PM. Interview with the Administrator on 4/3/19 at 3:17 PM in her office revealed Resident #83 had vomited after lunch and the meal schedule for lunch on the 4th floor was from 11:30 PM to 12:30 PM. Continued interview revealed CNA #8 had removed Resident #83 from the dining room and left him in his room still covered in emesis to go down stairs to get a cupcake. Continued interview revealed the lunch trays were not late and at 2:00 PM a valentine's party was going on downstairs. Continued interview confirmed .it really bothered me about the time . | 2020-09-01 |
| 67 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 641 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess 1 resident (#58) of 59 residents reviewed. The findings include: Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #58's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed the resident received insulin injections 7 of the 7 day look back period. Medical record review of Resident #58's Physician order [REDACTED]. Interview with Registered Nurse (RN) #1, responsible for the MDS, on 4/2/19 at 1:45 PM in his office confirmed Resident #58's MDS dated [DATE] was coded to reflect the resident received insulin injections for 7 of 7 days. Continued interview when asked to look at Resident #58's physicians orders, RN #1 confirmed the resident had no orders for insulin. Continued interview revealed It's my mistake, I miscoded the MDS. | 2020-09-01 |
| 68 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 695 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observation and interview, the facility failed to provide necessary care for 3 residents (#34,#95 and #573) of 28 residents receiving respiratory services. The findings include: Review of the facility policy, Departmental (Respiratory Therapy)- Prevention of Infection, revised 2011, revealed .Store the circuit (nebulizer mask) in plastic bag, marked with date and resident's name between uses . Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Orders Sheet dated 2/28/19 revealed .May administer 2 liters of O2 (oxygen) per nasal cannula for SOB (shortness of breath) . Continued review revealed .may oral suction with [MEDICATION NAME] (suction device) as needed . Observation on 4/1/19 at 10:24 AM in Resident #34's room revealed the [MEDICATION NAME] was undated and unbagged and was hanging on top of the humidifier canister. Medical record review revealed Resident #95 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data set ((MDS) dated [DATE] revealed Resident #95 required oxygen therapy. Observation on 4/1/19 at 10:05 AM in Resident #95's room revealed the unbagged and undated nasal cannula and nebulizer mask were stored on top of the humidifier attached to the wall O2. Observation and interview with the House Supervisor on 4/1/19 at 5:27 PM and 5:30 PM in Residents #34 and #95 room confirmed the [MEDICATION NAME], nebulizer and nasal cannula was unbagged, undated and were stored on top of the humidifier canister. Continued interview confirmed .I see it and will change it . Medical record review revealed Resident #573 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Orders dated 3/1/19 for Resident #573 revealed .[MEDICATION NAME] CONC (concentrate) 1.25 milligrams (MG) 0.5, 1 vial per nebulizer via mask 6 times a day, [DIAGNOSES REDACTED].[MEDICATION NAME] 0.5 MG/2 milliliters (ML) suspension, 1 vial per nebulizer twice a day [DIAGNOSES REDACTED]. Observation on 4/1/19 at 9:37 AM and 12:00 PM in Resident #573's room, revealed the nebulizer mask lying on the bedside table was not bagged or dated. Further observation on 4/1/19 at 2:27 PM in the resident's room revealed the unbagged and undated nebulizer mask was lying on the resident's bed. Interview with LPN #4 on 4/1/19 at 2:49 PM on 400 North Hall confirmed nebulizer masks are kept in bags when not in use. Interview with the Director of Nursing (DON) on 4/3/19 at 11:45 AM in the DON's office confirmed nebulizer masks were to be kept in a plastic bag when not in use. | 2020-09-01 |
| 69 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 741 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to answer a call light in a timely manner for 1 resident (#72) of 161 residents observed. The findings include: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] and 3/20/19 revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review revealed Resident #72 required total dependence by one person for eating. Observation on 4/1/19 at 2:16 PM on the 400 South Hall in room [ROOM NUMBER] revealed Resident #72's call light was activated at 2:16 PM and 2 staff, Licensed Practical Nurse (LPN) #3 and a Certified Nurse Aide (CNA) were on the hall. Continued observation revealed LPN #3 at the medication cart and the CNA using the Kiosk (computer on the wall). Continued observation revealed another CNA walked out of a resident room toward the two staff members, with the activated call light visible. One CNA stated .I already checked and changed 412B . Continued observation revealed a MDS Coordinator walked towards the staff talking and they all looked up and kept talking. Continued observation revealed Unit Manager #3 answered the call light at 2:32 PM. Interview with Unit Manger #3 on 4/1/19 at 2:36 PM on the 400 South Hall when asked what was expected from staff when call lights were activated stated, call lights were expected to be answered when activated. | 2020-09-01 |
| 70 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 761 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to dispose of expired medications in 2 of 4 medication storage rooms and on 2 of 6 medication carts. The findings include: Facility policy review, Medication Administration General Guidelines, dated 9/18, revealed .Check expiration date on package/container. No expired medication will be administered to a resident .Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date .The beyond use dating, which only lists month/year, falls to the last day of that month . Observation of the 200 hall medication storage room on 4/1/19 at 1:00 PM with Licensed Practical Nurse (LPN) #7 revealed the following: 2 multiple dose bottles of Zinc Sulfate (a vitamin/mineral supplement) 220 milligrams (mg),100 count, expired 2/19 and unopened; a multiple dose bottle of [MEDICATION NAME] (a B vitamin supplement) 500mg,100 count, expired 2/19 and unopened; 2 multiple dose bottles of Centravites liquid (a vitamin supplement) 236 milliliters (ml) expired 2/19 and unopened; 3 mutiple dose bottles of [MEDICATION NAME] (a stimulant laxative) 5 mg,100 count, expired 3/19 and unopened; and 4 multiple dose bottles of Senna (a laxative) Syrup 237 ml expired 3/19 and unopened. Interview with LPN #7 on 4/1/19 at 1:16 PM in the 200 hall medication storage room confirmed .that medications should not be used if expired and should be discarded if they are . Observation of the Riberio unit medication storage room on 4/2/19 at 3:00 PM with LPN #8 revealed the following: a multiple dose bottle of Vitamin B1,100 count, expired 3/19 and unopened; 1 tube of [MEDICATION NAME] cream 1% unopened and expired 2/19; and 1 tube of [MEDICATION NAME] cream 1% unopened and expired 9/18. Interview with LPN #8 on 4/2/19 at 3:15 PM in the Riberio medication storage room confirmed .all medications should be used before their expiration date or discarded in the sharps bin here (pointing in the medication room) . Observation of the 200 West medication cart on 4/2/19 at 5:14 PM with LPN #7 on the 200 West hallway revealed a multiple dose bottle of Vitamin B-12 100 mg,130 count, expired 6/26/18. Interview with LPN #7 on 4/2/19 at 5:30 PM on the 200 West hallway confirmed .all expired medications should not be on the cart, should not be used . Observation of the Riberio unit medication cart on 4/3/19 at 2:30 PM with LPN #9 in the Riberio unit medication storage room revealed the following: a multiple dose bottle of Elder Tonic 473 ml expired 12/18 and a multiple dose bottle of D3 (a vitamin supplement) 5000 International Units (IU),100 capsules, expired 2/19. Interview with LPN #9 on 4/3/19 at 2:40 PM in the Riberio unit medication storage room confirmed .that no medications on the cart should be expired . Interview with the Pharmacist on 4/3/19 at 8:00 PM on the telephone confirmed .she reviewed all medication carts and medication storage rooms monthly .she was there on 4/1/19 later in the day at around 5 PM .and she usually removes expired medications by using kitty litter, placing them in sharps boxes, or giving them to the unit manager for disposal .expired medications should not be on the medication carts or in the storage rooms . Interview with the Director of Nursing on 4/3/19 at 8:07 PM in her office confirmed .medication carts and medication storage rooms should not have expired medications .they should be removed and disposed of by taking them back to pharmacy .expired medications should not be used . | 2020-09-01 |
| 71 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 812 | F | 0 | 1 | PJC211 | Based on facility policy review, observation, interview, and review of the Dish Machine Temp (Temperature) Audit, the facility dietary department failed to operate the dish machine according to the manufacturer's recommendation in 1 of 4 observations; and the facility failed to maintain 2 of 4 ice machines and 2 of 3 microwaves in a sanitary manner in 3 of 4 nourishment rooms. The findings include: Review of the facility policy, Dishmachine Procedure, revised on 1/17/19, revealed .Recording of Dishmachine Temperature .Record temperatures every shift on Dishmachine Temperature Log . Observation on 4/1/19 at 9:46 AM in the dietary department dishroom, with the Dietary Manager present, revealed the dishmachine was in operation. Further observation of the posted manufacturer's recommendation revealed the minimum wash temperature was 160 degrees Fahrenheit (F) and the minimum final rinse sanitizing temperature was 180 degrees F. Further observation revealed resident meal trays, plate covers, and plate bases were being processed through the dishmachine with the final sanitizing rinse temperatures of 171, 168, 166, and 160 degrees F. Further observation revealed the resident trays, plate covers and bases were stored after they were removed from the dishmachine. Interview with the Dietary Manager in the dietary department dishroom on 4/1/19 at 10:00 AM when asked who was responsible to take the dishmachine temperatures when it was in operation, the Dietary Manager revealed .I take the temperatures once a week and chart it . When asked who takes and records temperatures the other times, the Dietary Manager revealed the .only temperatures taken and recorded are the ones I get once a week . When asked when was the last time the temperatures were taken, the Dietary Manager revealed .I forgot to do it last week so it was the week before . Further interview revealed the Dietary Manager was not aware the temperatures were to be taken for every operation cycle, morning meal, mid-day meal, evening meal, and any other operation. Review of the Dish Machine Temp Audit form revealed the wash temperature on 1/8/19 and on 3/21/19 was158 degrees F, and on 3/26/19 was 159 degrees F. Further review revealed the final rinse sanitizing temperature on 3/21/19 was 179 degrees F. Interview with Maintenance staff #1 on 4/1/19 at 10:00 AM in the dietary department dish room revealed .over the weekend the boiler broke down and the steam it generates operates the dishwasher and it might not have recovered yet . Interview with the Administrator on 4/2/19 at 12:22 PM in the conference room confirmed the facility policy was not followed related to the failure to document the dish machine temperatures every shift. Observation in the Birmingham building Nourishment Rooms on 4/2/19, with facility staff present, revealed the following: At 3:12 PM on the 4th floor with Licensed Practical Nurse (LPN) #6 present, revealed the interior of the ice machine had pink colored debris on the ice slide. Further observation revealed the interior of the microwave had a very heavy accumulation of multi-colored dried debris and food debris. Interview with LPN #6 in the 4th floor Nourishment Room on 4/2/19 at 3:12 PM confirmed the microwave interior had debris and the ice machine interior had pink color debris. At 3:16 PM on the 3rd floor, with Medical Record staff #1 present, revealed the interior of the microwave had an accumulation of dried food debris. Interview with Medical Record staff #1 in the 3rd floor Nourishment Room on 4/2/19 at 3:16 PM confirmed the microwave interior had debris. At 3:20 PM on the 2nd floor, with Unit Manager #4 present, revealed the interior of the ice machine had pink colored debris on the ice slide. Interview with Unit Manager #4 on 4/2/19 at 3:20 PM in the Nourishment Room confirmed the interior of the ice machine had pink debris. | 2020-09-01 |
| 72 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 842 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain an accurate and complete record for 1 resident (#58) of 59 residents reviewed related to the Physician Orders and the Tennessee Physician Orders for Scope of Treatment (POST) form. The findings include: Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #58's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired. Medical record review of Resident #58's Physician Order Sheet dated [DATE] revealed .Full Code (meaning a person will allow all interventions needed to get their heart started) . Medical record review of Resident #58's POST form dated [DATE] revealed .Do Not Attempt Resuscitation (DNR/no CPR) (Cardiopulmonary Resuscitation) (allow natural death) . Interview with Unit Manager #1 on [DATE] at 4:20 PM in the Birmingham dining room confirmed Resident #58's POST form and physician orders did not match. Continued interview revealed .the POST form is the most up to date and should match the orders, it should have been caught before now . Interview with the Director of Nursing on [DATE] at 8:39 AM in the 2nd floor Unit Manager's office confirmed .the POST forms and physician orders for residents have to match . | 2020-09-01 |
| 73 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 921 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide a sanitary environment for 1 resident (#152) of 33 residents reviewed receiving feeding per feeding pumps. The findings include: Medical record review revealed Resident #152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED].Promote (enteral formula) at 63ml/hr (milliliter per hour) for total of 1336 ml in 24 hours via PEG (percutaneous endoscopic gastrostomy)/pump . Observation on 4/1/19 at 10:43 AM, 2:30 PM and on 4/2/19 at 1:45 PM in Resident #152's room revealed the tube feeding pump, pole and floor with large amount of dried tan debris. Interview with Unit Manager #2 on 4/2/19 at 1:45 PM in Resident #152's room confirmed .that is obviously tube feeding on the pump, pole and floor . Interview with the Director of Nursing on 4/3/19 at 2:40 PM in her office confirmed tube feeding pumps and poles were to be clean. | 2020-09-01 |
| 74 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 176 | E | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to determine if it was clinically appropriate for 3 of 3 (Resident #99,146 and 178) sampled residents reviewed were assessed to self-administer medications or had an order to self administer medications. The findings included: 1. The facility's Medication Administration General Guidelines policy documented, .Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team .and in accordance with procedures for self-administration of medications . The facility's Medication Administration Nebulizers documented, .remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer . The facility's SELF-ADMINISTRATION BY RESIDENT policy documented, .Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe .The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process . 2. Medical record review revealed Resident #99 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #99's room, on 6/13/17 at 9:45 AM, revealed LPN #7 dispensed [MEDICATION NAME] medication into a nebulizer cup. increased the oxygen level to administer the treatment, put the nebulizer mask on Resident #99, left the room and went to another hall. There was no assessment or physician order [REDACTED]. 3. Medical record review revealed Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment, and required extensive to total staff assistance for all activities of daily living. The care plan dated 3/20/17 documented, .Behavior .Problem .6/5/17 .Socially inappropriate .Resists Care .False Claims against staff .yelling out for caregivers continuously .Delusions . There was no documentation for self administration of medications. The physician's orders [REDACTED].[MEDICATION NAME] 20% (PERCENT) VIAL .One vial via nebulization four times a day .[MEDICATION NAME] .1 VIAL PER NEBULIZER FOUR TIMES DAILY . A telephone physician's orders [REDACTED].Add Dx's (diagnosis) of [MEDICAL CONDITION] . There was no assessment or physician order [REDACTED]. Observations in Resident #146's room on 6/11/17 beginning at 10:20 AM, revealed Resident #146 lying in bed holding a nebulizer medication cup in his hand containing clear liquid that was disconnected from the nebulizer. The nebulizer mask was around Resident #146's neck, and the nebulizer was turned on. The resident was yelling out for help, and was not able to state his name. There was no staff member in the room. 4. Medical record review revealed Resident #178 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #178 was severely cognitively impaired per staff assessment, and was totally dependent on staff for ADLs. The care plan dated 8/23/16, and last revised on 5/11/17, revealed there was no documentation for self administration of medications. The physician's orders [REDACTED].[MEDICATION NAME]/[MEDICATION NAME] SULFATE .1 VIAL PER NEBULIZER EVERY 6 HOURS . Observations in Resident #178's room on 6/11/17 beginning at 10:16 AM, revealed Resident #178 lying in bed with a nebulizer treatment in progress with the mask strapped to the resident's face. There were no staff member in the room. There was no assessment or physician order [REDACTED]. Interview with the Director of Nursing (DON) on 6/14/17 at 10:20 AM, in the conference room, the DON was asked whether there were any residents in the facility that could self-administer medications. The DON stated, No. The DON was asked whether it was appropriate for the nurse to start a nebulizer breathing treatment on a resident and then leave the resident alone. The DON stated, Well, the nurse is supposed to keep a frequent check on the residents. | 2020-09-01 |
| 75 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 253 | E | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview the facility failed to maintain the residents' rooms, bathrooms, furniture, and equipment in a safe and sanitary fashion for 2 of 4 (Ribeiro and 4th floor Birmingham) nursing units affecting rooms 102, 103, 104, 111, 115, 118, 119, 124 of Ribeiro unit and 402, 413, 415, 427, 429, and 430 rooms of the 4th floor Birmingham unit. The findings included: 1. The facility's Work Orders policy documented, .Maintenance work orders shall be completed in order to establish a priority of maintenance service .Procedure 1. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director. 2. It shall be the responsibility of the department directors or any staff member identifying needed repairs to fill out and forward such work orders to the maintenance director. 3. A supply of work orders is maintained at each nurses' station 4. Work order requests should be placed in the appropriate file basket at the nurses' station. Work orders are picked up daily. Emergency requests will be given priority in making necessary repairs. The facility's Restroom Cleaning policy documented, .PURPOSE: To provide adequate guidelines for cleaning restrooms .The Environmental Services Department will clean restrooms on a daily basis, using the following procedures .X. Showers and Tubs: [NAME] Spray all surfaces with an approved germicidal detergent including walls, curtains, faucets, and shower head, Rinse completely. B. Use a brush to remove soap scrum, if necessary, and rinse . The facility's Daily Cleaning of Patient Room policy documented, .PURPOSE: To insure .proper Infection Control Policy and Procedures in the Environmental Services Department .All resident/patient rooms will be cleaned on a daily basis .Damp dust all horizontal surfaces including, but not limited to over-bed tables, beside tables, baseboard night-light, pictures on walls, top of headboard, top of foot board, telephones, chairs, ledges, light switches, televisions, walkers, I.V. (Intravenous) poles, Geri-chairs, clean, (sic) mirror, soap and towels dispensers, and cabinets with an approved germicidal detergent. Work clockwise around the room .VIII. Clean bathroom according to procedure . 2 Observation of the Ribeiro secured nursing unit , on [DATE] beginning at 2:45 PM thru 3:45 PM, revealed: a. Room 102: A window sill was missing Formica and had missing baseboards A walker was held together with yellow tape that was peeling away from the metal bars. b. Room 103: Shower tiles had unknown black substance in the caulking c. Room 104: Window sill missing Formica d. Room 111: Baseboards missing e. Room 115: Baseboards missing f. Room 118: The lock on the clothes closet was broken which prevented the door from closing securely. g. Room 119 B: There were missing wood pieces which prevented the drawers from closing securely and the foot board on the A bed (near the door) was not securely attached to the bed frame which made it shaky and unstable. h. Room 124: Walls in the bathroom in room 124 were scuffed and in need of cleaning, repair and/or paint. Observation of the 4 th floor Birmingham nursing unit on [DATE] beginning at 4:00 PM thru 4:45 PM, revealed: a. Room 402: Window blinds were torn, bent, and not hanging straight which inhibited the blinds from closing completely, the shower tiles had large blotches of a black substance that resembled mold or mildew, the dresser was broken and in need of repair, and some of the base boards in the bathroom were missing. b. Room 413: Dresser drawer in room 413 was missing the knobs on the 3 top drawers. c. Room 415: The faucet in the sink was leaking and had a continuous line of dripping water. d. Room 427: Bed pan in room 427 was smeared with unknown brown substance and hanging in the bathroom on a metal rack. e. Room 429: A wall, located just outside room 429 was punched in which allowed a large gap between the wall and the base board. f. Room 430: Dresser was broken and the drawers could not close securely. Interview with Licensed Practical Nurse (LPN) # 2 on 4th floor Birmingham on [DATE] at 4:20 PM, LPN # 2 stated, everyone's responsibility to ensure that each resident's room and equipment was cleaned and maintained in a safe and sanitary fashion . Interview with the Facilities Management Director on [DATE] at 4:30 PM confirmed that he was responsible for maintaining each resident's equipment in a safe fashion. The Facilities Management Director stated when staff identified a piece of equipment or furnishings that were in need of repair, they were to complete a work order to ensure that it could be remedied timely. Interview with the facilities Management Director further stated that he had not received any work orders related to these concerns. The Management Director was asked what the procedure was for repairing furnishings and equipment. The Management Director, .if staff do not complete a work order, I would not be aware of the broken equipment and furnishings. Interview with the Environmental Services Supervisor, on [DATE] at 4:45 PM, the Environmental Services Director was asked whose responsibility it was to maintain the cleanliness of the resident's rooms. The Environmental Services Director stated, it was his department's responsibility to clean the residents' equipment and furnishings and his staff must have missed those concerns . Interview with the Administrator, on [DATE] at 10:30 AM, in the Administrator's office confirmed that it was the facility's policy to complete work orders for equipment and furnishings in need of repair. The Administrator stated, .it was our policy to clean and maintain the residents' rooms on a daily basis .the facility staff failed to follow the policies and procedures relative to maintaining the residents' equipment and furnishings and cleaning of the resident's rooms and their belongings on a daily basis . | 2020-09-01 |
| 76 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 279 | D | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to revise the care plan for side rails and bed alarm for 3 of 23 (Resident #25, 54, and 62) residents reviewed of the 43 resident 's included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed he had a severe cognitive deficit. Review of physician orders [REDACTED]. Review of the fall plan of care with an initiation date of 7/15/16 revealed the resident was identified as at risk for injury. The fall plan of care and the activities of daily living plan of care did not include the use of the side rails as ordered by the resident's physician. Observations in Resident #25's room on 6/11/17 at 2:48 PM, revealed Resident #25 lying in bed with bilateral full side rails in the raised position. Licensed Practical Nurse (LPN) #2 verified Resident #25 was only supposed to have the full side rail on the left side of the bed to assist with positioning and he was capable of sitting up on the side of the bed on his own. On 6/14/17 at 12:10 PM, LPN #1 verified the plan of care did not include the use of the side rail. 2. Medical record review revealed Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #54's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #54 had severe cognitive deficits. The Fall Risk Evaluation dated 4/10/17 had a score of 12 indicating the resident was at risk for falls (a score of 10 or higher indicated the resident is at risk.) Review of the physician's orders [REDACTED].#54 had an order for [REDACTED].>The plan of care for falls dated 8/16/16 indicated that the resident was at risk for falls as determined by a score of 18 on the 7/19/16 fall risk screen. The goal was for the resident to not sustain a fall related injury by utilizing fall precautions through the next review date of 7/11/17. The plan of care did not address the use of the physician ordered bed alarm. On 6/14/17 at 12:30 PM, LPN #1 verified the plan of care did not include the use of the physician ordered bed alarm. 3. Medical record review revealed Resident #62 was last admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's last quarterly MDS assessment dated [DATE] indicated the Resident #62 had severe cognitive deficits. The current fall plan of care listed bilateral side rails as enabler's but did not include the type of side rails (namely full, half or quarter side rails). Resident #62 was observed in bed with bilateral full side rails up on both sides of the bed on 6/11/17 at 4:20 PM; on 6/12/17 at 3:39 PM and 3:53 PM; on 6/13/17 at 7:40 AM, 8:41 AM, and at 1:39 PM; and on 6/14/17 at 9:36 AM. During the observation on 6/12/17 at 3:39 PM, LPN #4 verified the resident always used full side rails when the resident was in bed. Interview with LPN #1 on 6/14/17 at 12:20 PM, LPN #1 stated Resident #62 was not cognitively capable of using the side rails as enabler's and stated the bilateral full side rails were put into place at the request of the resident's family. | 2020-09-01 |
| 77 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 309 | D | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure proper positioning for dining for 1 of 1 (Resident #44) sampled residents reviewed for positioning during dining. The findings included: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment, no behaviors, and required extensive to total staff assistance for activities of daily living. Observations in the Birmingham 4th floor dining room on 6/11/17 at 5:57 PM, and 6/13/17 at 12:51 PM, revealed Resident #44 was seated at the table for a meal in a low scoot chair. Resident #44's tray was on the table in front of him, and he had to reach up to the table due to poor positioning. Interview with Licensed Practical Nurse (LPN) #6 on 6/13/17 at 12:55 PM, in the 4th floor dining room, LPN #6 was asked whether it would be better for Resident #44 if he was positioned a bit higher during meals. LPN #6 stated, .it (the scoot chair) could be lifted up . LPN #6 was asked whether she thought it looked too high for the dining table. LPN #6 stated, I do . Interview with Occupational Therapist (OT) #1 on 6/13/17 at 1:05 PM, at the 4th floor nurses' station, OT #1 was asked whether the chair was too low for the table. OT #1 stated, Yes . | 2020-09-01 |
| 78 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 323 | E | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure fall interventions were in place to prevent potential falls, to ensure the correct side rail type was in place for the resident and failed to assess residents for the use of the side rails for .and have the manufacturer's information for the side rails available prior to using the full side rails for 3 of 5 (Resident #25, 54, and 62) sampled residents of the 43 residents included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his annual Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. The assessment was coded to indicate he had long and short-term memory problems, was inattentive and had an altered level of consciousness. According to the assessment he required extensive assistance with bed mobility, transfers, locomotion on the unit and was totally dependent on staff. Review of a BIMS assessment dated [DATE] revealed he had a BIMS score of 0 indicating he was severely cognitively impaired. Review of current physician orders revealed he had an order for [REDACTED]. The order had and an original order date of 11/27/15 and did not specify the type of side rail to be used. Review of the Evaluation for use of Side Rails dated 06/07/17 and signed by Licensed Practical Nurse (LPN) #2 was marked side rails not indicated at this time and the use of the side rail and risk of entrapment related to the use of the side rail was not assessed. Review of the resident's current fall plan of care with an initiation date of 7/15/16 revealed the resident was identified as at risk for injury due to having the [DIAGNOSES REDACTED].osteoporosis . The fall plan of care and the activities of daily living plan of care did not include the use of the side rail. Observations in Resident #25's room on 6/11/17 at 2:48 PM, revealed Resident #25 lying in bed with bilateral full side rails in the raised position. The bed was at a regular height (not low). LPN #2 verified Resident #25 was supposed to have the full side rail on the left of the bed raised to assist him with positioning. LPN #2 lowered the full side rail on the right side of the bed. Interview with LPN #2 on 6/11/17 at 2:50 PM, in Resident #25's room, LPN #2 stated, .when both side rails were up they restrained the resident from sitting up on the side of the bed . Interview with LPN #1 on 6/14/17 at 12:10 PM, verified the MDS assessment dated [DATE] was not accurate as it was coded to indicate side rails were not used .and the Evaluation for the use of the Side Rails dated 6/7/17 was not accurate as it was marked side rails not indicated at this time. LPN #2 verified the plan of care did not include the use of the side rail and there was no assessment related to the resident's risk of entrapment and verified the assessment did not include other appropriate alternatives to the use of the side rail. 2. Medical record review revealed Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #54's quarterly MDS assessment dated [DATE] revealed Resident #54 had severe cognitive deficits, and required extensive assistance for bed mobility. Review of the physician's order sheets dated 5/30/17 documented orders for a bed alarm for fall prevention and bilateral safety mats next to bed. The physician's orders did not include an order for [REDACTED]. The current plan of care for falls dated of 8/16/16 documented the resident was at risk for falls as determined by a score of 18 on the 7/19/16 fall risk screen. The goal was for the resident to not sustain a fall related injury by utilizing fall precautions through the next review date of 7/11/17. The interventions included the use of quarter side rails as enabler's and right and left fall mats. The plan of care did not include the use of the physician ordered bed alarm. The most current Fall Risk Evaluation dated 4/10/17 had a score of 12 indicating the resident was at risk for falls (a score of 10 or higher indicates the resident is at risk). According to the evaluation the resident was at risk due to behavioral symptoms, being incontinent, using side rails, not able to balance without physical assistance, and the use of antipsychotic medication. Review of the most current Evaluation for Use of Side Rails form dated 4/10/17 assessed the resident as using right and left upper half side rails to assist in turning from side to side and to provide a sense of security. The evaluation did not include an assessment for the least restrictive or other alternatives to the use of the side rails. Review of a Physician's follow-up progress note dated 3/15/17 revealed the physician wrote the resident was restless. The physician's note documented the resident's behaviors were discussed with nursing. The physician wrote fall precautions in place-has a low bed/bed alarm. The progress note did not include the use of the side rails. The Facilities Management Department Work Request dated 5/25/17 documented the bed was to be replaced due to the bed control not working. The invoice documented the bed was replaced on 5/26/17. Interview with LPN #2 revealed, .when the maintenance department replaced the low bed with quarter side rails they replaced it with a regular bed with full side rails . Observation in Resident #54's room on 6/11/17 at 2:34 PM, Resident #54 was observed in bed and the bed was not in the low position and full unpadded side rails were raised. No bed alarm was present on the bed. Observations in Resident #54's room on 6/11/17 at 4:00 PM, Resident #54 was in bed with bilateral unpadded full side rails in place, the bed not in the low position and no bed alarm was in place. LPN #2 verified the observation. After looking at the plan of care, she verified the resident should have quarter side rails in place and not full side rails. Observations in Resident #54's room on 6/11/17 at 4:55 PM, Resident #54 was in a low bed with quarter side rails but there was no bed alarm in place. Observations in Resident #54's room on 6/12/17 at 7:37 AM, 6/12/17 at 2:04 PM, 6/12/17 at 3:22 PM, and 6/13/17 at 7:41 AM revealed the resident in a low bed with quarter upper bilateral side rails, and no bed alarm in place. On 6/13/17 at 7:44 AM, LPN # 2 verified the resident did not have the fall mat on the floor on the right side of the bed. On 6/13/17 at 7:58 AM, LPN #12 was informed of the resident not having the fall mat on the floor on the right side of the bed. After checking the physician's order, she went into the room obtained the fall mat form the corner of the room and placed the mat on the floor on the right side of the bed. On 6/12/17 at 3:22 pm, LPN #4 verified the resident did not have a bed alarm in place and further stated she was not sure if the resident was supposed to have a bed alarm in place . On 6/14/17 at 12:30 PM, LPN #1 verified the plan of care did not include the use of the physician ordered bed alarm. She verified the resident was supposed to have bilateral quarter side rails, a low bed, a bed alarm, and bilateral safety mats on the floor when he was in bed. She also verified the resident had no assessment for the least restrictive device or an alternative to the use of the bed rails. 3. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's last quarterly MDS assessment dated [DATE] indicated the Resident #62 had severe cognitive deficits. The current fall plan of care listed bilateral side rails as enablers but did not include the type of side rails (i.e. full, half or quarter side rails). Review of the Evaluation for use of Side Rails dated 5/12/17 revealed the assessment was coded side rails not indicated at this time. The assessment did not include an evaluation of the side rails or of her risk of entrapment and did not include an assessment of appropriate alternate interventions. Interview with LPN #1 on 6/14/17 at 12:20 PM, LPN #1 stated, .the resident was not mentally capable of requesting the use of the side rails and it was the resident's family who requested them . She also verified the Evaluation for use of Side Rails dated 5/12/17 was inaccurate as documented side rails not indicated at this time and bilateral full side rails were in use at the time the assessment/evaluation was completed. She verified the assessment lacked an assessment for risk of entrapment and other appropriate interventions. Interview with the Administrator on 6/13/17 at 8:41 AM, the Administrator and Director of Nursing verified Resident #25 was in bed with bilateral full side rails up on the bed. Certified Nursing Assistant #5 stated the resident always has full side rails up on both sides of the bed. | 2020-09-01 |
| 79 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 371 | F | 0 | 1 | PJSZ11 | Based on Hazard Analysis Critical Control Points (HACCP) Sanitation Manual Fifth Edition, observation and interview, the facility failed to ensure outdated and undated foods were stored in the nourishment refrigerators located on two of four (Birmingham 3rd and 4th floor ) nourishment rooms and failed to ensure the dishwasher rinse temperatures were maintained in accordance with manufacturer's specifications for 2 of 2 (6/13/17 and 6/14/17) days of observation. This had the potential to affect 171 of 187 residents in the facility. The findings included: 1. Review of the HACCP Sanitation Manual Fifth Edition page 63 revealed that .the final rinse temperature should be less than 194 degrees F (Fahrenheit). If the final (sanitizing cycle) rinse temperature is too high, the water is atomized and thus is inadequate for sanitizing . 2. Observation in the Birmingham 4th floor nourishment room on 6/11/17 at 12:20 PM, revealed there was no thermometer in the freezer, and the refrigerator in the nourishment room on the fourth floor contained one open pudding that did not have an opened date and a container of grape juice with a use by date of 6/10/17. Interview with the Licensed Practical Nurse (LPN) #2 on 6/11/17 at 12:24 PM in the Birmingham 4th floor nourishment room verified this observation. 3. Observation in the Birmingham 3rd floor nourishment room on 6/11/17 at 12:25 PM, revealed 2 containers of chocolate milk with a use by date of 5/29/17 and three containers of 2% milk with the use by dates of 6/10/17 in the refrigerator. Interview with LPN #3 on 6/11/17 at 12:30 PM in the Birmingham 3rd floor nourishment room verified the observation. 4. Review of the rinse temperature log for (MONTH) (YEAR) documented temperatures of 200 degrees F was recorded three times a day on all 13 days in (MONTH) (YEAR). Review of the dishwashers specifications revealed the dishwasher was not to exceed 194 degrees F. at the manifold. Observations in the kitchen on 6/13/17 at 2:18 PM, revealed the final rinse temperature of the high temperature dishwasher was 208 degrees F. Interview with the Food Service Director on 6/14/17 at 8:30 AM, the Food Service Director confirmed the dishwasher rinse temperature consistently ran over 200 degrees or greater and that a (Named Dishwasher Company) specialist checked the dishwasher and determined the gauges were inaccurate and ordered parts to repair the machine. | 2020-09-01 |
| 80 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 441 | E | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to ensure practices were followed to prevent the potential spread of infection when 1 of 1 (Licensed Practical Nurse #7) nurses observed during medication administration failed to clean nebulizer equipment after use and to clean the stethoscope between residents, and when laundry staff failed to ensure the hand-washing sink and the floors were clean in 1 of 1 laundry areas. The findings included: 1. The facility's Medication Administration Nebulizer (Updraft) policy documented, .Rinse and disinfect the nebulizer equipment . 2. Observations in Resident #99's room on 6/13/14 at 9:45 AM, revealed LPN #7 entered the room, auscultated Resident # 99's chest with a stethoscope, placed the stethoscope around her neck, and exited the room. LPN #7 went into another resident's room (Resident #160) to administer medications via a percutaneous endoscopic gastrostomy (PEG) tube, removed the stethoscope from around her neck and checked placement of the PEG tube by putting the stethoscope to the resident's abdomen, then placed stethoscope back around her neck. LPN #7 returned to Resident #99's room, turned the breathing treatment of [REDACTED]. LPN #7 then placed the stethoscope around her neck. LPN #7 did not clean the stethoscope between residents, and did not clean the nebulizer equipment after use. Interview with the Director of Nursing (DON) on 06/14/17 at 1:04 PM, in the nurse's conference room, the DON confirmed that nebulizer equipment and stethoscopes should be cleaned after each use. The facility's Care of Equipment/Laundry Department documented, .All equipment used by the Laundry Department must be maintained in a daily/regular basis . 3. The facility's Cleaning/Laundry Department policy documented, .In order to maintain the cleanliness of the laundry room, provide a clean, fresh environment for the residents, visitors and staff and to reduce the potential for infection, the following procedures are taken by the laundry staff .Use creme cleanser and green pad to scrub sink and wipe dry with a clean rag . 4. Observations in the laundry room on 6/14/17 at 9:41 PM, revealed a white 2-compartment sink covered in dirty brown/gray build-up. There was a large area of standing water on the floor in front of the dryers. Interview with Laundry Staff Member #1 on 6/14/17 at 9:45 PM, in the laundry room, Laundry Staff Member #1 was asked about the water on the floor. Laundry Staff Member #1 stated, We have been walking in water for over a year in here .we have told them about it . Laundry Staff Member #1 was asked what the dirty sink was used for. Laundry Staff Member #1 stated, Hand washing . Laundry Staff Member #1 was asked how often they cleaned the sink. Laundry Staff Member #1 stated, As often as we can. Interview with the Director of Environmental Services (DES) on 6/14/17 at 2:49 PM, the DES was asked about the water on the floor in the laundry area. The DES stated, I have reported it, and was told nothing could be done about it .may be the drain or one of the pipes in that area. The DES was asked how often he expected laundry staff to clean the hand washing sink. The DES stated, Daily. The DES was asked whether it was acceptable for the hand washing sink to be covered with the dirty build-up. The DES stated, No . | 2020-09-01 |
| 81 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 520 | E | 0 | 1 | PJSZ11 | Based on medical record review, observation, and interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to have an effective ongoing quality program that identified, developed, implemented, and monitored appropriate plans of action to correct issues. The findings included: 1. The QAA Committee failed to ensure that each resident received an accurate assessment to reflect the resident's current status. The deficient practice of F 278 is a repeat deficient practice for failure to accurately assess residents. The facility was cited F 278 on the recertification survey on 8/2012, 3/2015, and 4/7/16. 2. The QAA Committee failed to ensure a comprehensive care plan was developed for a resident that reflected the resident's current status. The facility was cited F 279 on the recertification survey for failure to develop care plans that reflected the resident's current status on 8/2012, and 4/7/16. 3. The QAA Committee failed to ensure resident's environment remained as free from accident hazards as possible and is a repeat deficient practice for this,. The facility was cited F 323 on the recertification survey on 8/2012, and 3/2015. 4. The QAA Committee failed to ensure proper sanitation and food handling practices in the kitchen and is a repeat deficient practice for failure to ensure proper sanitation and food handling practices in the kitchen. The facility was cited F 371 on the recertification surveys 8/2012, 12/2013, and 4/7/16. 5. The QAA Committee failed to develop an effective Infection Control Program that provided safe and sanitary environment, and prevent the potential development and transmission of disease and infection. The facility was cited F 441 on the recertification survey on 12/2013, 3/2015, and 5/6/16. Interview with the Administrator on 6/14/17 in the Administrator's office, the Administrator was asked if the QAA Committee had identified care plans as a quality concern. The Administrator stated, .I don't know that there has been anything that we have recently had to place a plan in place. I understand that we were tagged last year on following the interventions and updating and following the care plans . The Administrator was asked if the QA Committee ever identified any issues with side rails. The Administrator stated, .From what I found out this week our care plans don't match the consent, the MD (Medical Doctor) orders don't match the correct side rails that we have on the beds. I'm totally shocked by the side rails that you have found. Families have been adamant that we would get sued if their loved one got hurt in the side rails. Side rails have been an issue. We report on the number of side rails and restraints in QA . The Administrator was asked if the QA Committee identified issues with the environment and accident hazards. The Administrator stated, .I was not aware that the rounding forms and work orders were not kept. The Stand up meeting minutes has a place to put environmental concerns. He (Maintenance Director) will be inserviced. I am responsible for knowing what goes on in the building . The Administrator was asked if Infection control issues are reviewed during the QAA Committee meeting. The Administrator stated, .we have QA'd infection control . | 2020-09-01 |
| 82 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-05 | 580 | D | 1 | 0 | FKIB11 | **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 condition for 1 of 5 residents (Resident #1) reviewed. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician ordered ventilator settings for Resident #1 revealed: Mode- SIMV (synchronized intermittent mechanical vent), and Rate- 12 (minimum number of respirations per minute). Continued medical record review of a Respiratory care flow sheet revealed on 6/6/18 at 3:35 AM, 7:34 AM, 10:53 AM, 3:13 PM, and 7:00 PM the ventilator mode for Resident #1 was documented as being SIMV and the Set rate was 12. Continued review revealed at 3:13 PM the total respiratory rate had elevated to 21, and then to 28 at 7:00 PM which indicated Resident #1 was tachypnic (increased respirations). Continued review revealed at 11:05 PM on 6/6/18 Registered Respiratory Therapist (RRT) #1 changed Resident #1's ventilator mode to Assist Control which was an increase in ventilator support and also changed the respiratory set rate to 18. Continued review of the medical record revealed no documented notification to the Physician of Resident #1's change in condition. Interview with Director of Respiratory Services on 7/3/18 at 9:10 AM in the conference room confirmed Resident #1 had a change in condition on 6/6/18 which required an increase in ventilator support and RRT #1 failed to notify the Physician of the change in the resident's condition. Telephone interview with RRT #1 on 7/3/18 at 1:50 PM revealed on 6/6/18 Resident #1 trended tachypnic and he followed the respiratory algorithm to adjust the ventilator settings without first notifying the Physician of the change in the resident's condition. | 2020-09-01 |
| 83 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-05 | 684 | D | 1 | 0 | FKIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to administer antibiotic medication per physician order and per facility policy for 1 of 3 residents (Resident #3) reviewed receiving antibiotic medication. Findings include: Review of the facility policy, Medication Administration, dated 5/16, revealed .Procedures .Medication Administrations .Medications are administered with written orders of the prescriber . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders for antibiotic medication revealed the following: 1. On 6/6/18 [MEDICATION NAME] 500 milligrams (mg) every 12 hours for 7 days for [DIAGNOSES REDACTED]. 2. On 6/12/18 [MEDICATION NAME] ([MEDICATION NAME]/Clavulanic Acid) 875 mg by mouth three times daily for 7 days for [DIAGNOSES REDACTED]. 3. On 6/19/18 [MEDICATION NAME] 3.375 gram infuse intravenously every 6 hours for 10 days for [DIAGNOSES REDACTED]. Medical record review of the 6/2018 Medication Administration Record [REDACTED] 1. [MEDICATION NAME] was administered for 12 of 14 doses ordered from 6/7/18 at 12:01 AM through 6/12/18 at Noon. The facility failed to administer 2 of the 14 ordered doses. 2. [MEDICATION NAME] was administered for 19 of the 21 doses ordered from 6/12/18 at 8:00 PM through 6/18/18 at 8:00 PM. The facility failed to administer 2 of the 21 ordered doses. 3. [MEDICATION NAME] was administered for 36 of 40 doses ordered from 6/20/18 at 12:01 AM through 6/28/18 at 6:00 PM. The facility failed to administer 4 of the 40 ordered doses. Interview with the Unit B2 Manager on 7/3/18 at 10:50 AM in his office, after reviewing the 6/2018 antibiotic orders and the MAR for Resident #3, confirmed the facility failed to administer the antibiotics as ordered for [MEDICATION NAME], and [MEDICATION NAME]. Interview with the Director of Nursing on 7/3/18 at 11:18 AM in her office, after reviewing the 6/2018 antibiotic orders and the MAR for Resident #3, confirmed the facility failed to administer the antibiotics as ordered for [MEDICATION NAME], and [MEDICATION NAME]. Further interview confirmed the facility failed to follow the facility Medication Administration policy and failed to administer antibiotics per the physician orders. | 2020-09-01 |
| 84 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 550 | D | 0 | 1 | 565T11 | Based on observation and interview, the facility failed to serve meals to residents seated at the same table during 3 separate observations of the mid day meal. Findings include: Observation of the mid day meal on 7/23/18 from 11:40 AM-12:42 PM in the B3 dining room revealed 3 residents were seated at a table. 1 resident had a meal tray and the other 2 residents were not served a meal tray until 21 minutes later. Continued observation revealed 4 other residents were seated at a table and a Certified Nurse Assistant (CNA) #3 was assisting 1 resident while the other residents sat at the table. Continued observation revealed the last resident seated at the table was served his meal tray 1 hour after the 1st resident seated at the table was served. Interview with CNA #3 on 7/23/18 at 12:43 PM in the B3 dining room stated there were 3 carts delivered to the unit and not all of the trays came to the dining room residents at the same time. Further interview confirmed the last residents meal tray was on the 3rd cart and the resident had to wait to be served his meal until after the other 3 residents had received their meal. Observation of the mid day meal on 7/24/18 from 11:40 AM-12:20 PM in the B3 dining room revealed the 1st meal cart was delivered at 11:43 AM. 4 residents were seated at a table and 1 resident was served her meal tray while the other 3 residents were not served. Continued observation revealed the 2nd meal cart was delivered at 12:08 PM and the 2nd resident at the table was served his tray while the other 2 residents were dozing in their wheelchairs. Further observation revealed the 3rd meal cart was delivered at 12:22 PM and the other 2 residents received their trays. Interview with the Director of Nursing (DON) on 7/24/18 at 4:17 PM in the hall by the conference room was notified of the mid day meal dining observations on 7/23/18 and 7/24/18, and the concerns with all diners seated at a table together and not served their meal trays at the same time. The DON was asked if she was aware of the concern and stated, I didn't realize it was a concern to that extent. Interview with the Administrator on 7/25/18 at 7:15 AM in the conference room stated, I think we need to ask the resident if it's OK that others are eating, or take them for a walk or something. That would take care of the dignity thing. Is that right? The Administrator was asked if he knew what the Regulations said and stated, All diners at the table are to be served at the same time. That's the answer. Further interview confirmed cognitively impaired residents may not understand why others are eating and they are not. The Administrator confirmed the facility failed to serve all residents seated at the table at the same time. Observation on 7/23/18 in the R1 dining room during the mid- day meal a at pproximately 11:40 AM revealed the lunch trays were passed. Further observation revealed Resident #111 was seated at the table with 3 residents. Further observation revealed CNA #6 was assisting another resident while Resident #111 waited at the table to be assisted. Further observation revealed Resident #111 was assisted with his meal at 12:20 PM. Interview with CNA #6 on 7/23/18 at 12:40 PM in the R1 dining room revealed 4 CNA staff were assisting with dining. Further interview revealed the dining carts were not organized to the way the residents were seated. Therefore some residents got served first while others waited to be served. Interview with the DON on 7/25/18 at 5:25 PM in her office revealed staff should serve the group at the same time. Further interview confirmed we should have staff accommodating patients as they are seated at the table. | 2020-09-01 |
| 85 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 558 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to keep a bathroom call light in reach for 1 of 18 bathrooms ( room [ROOM NUMBER]) observed on the R1 unit. Findings include: Observation on 7/23/18 at 3:47 PM in the bathroom in room [ROOM NUMBER] revealed the call light on the right side wall was tied to the bar of the metal shelf connected to the wall. Observation and interview with Licensed Practical Nurse (LPN) #3 also known as the Unit Manager on 7/23/18 at 3:50 PM in the bathroom in room [ROOM NUMBER] confirmed the facility failed to have a call light in reach. Further interview revealed I don't know why it is like that. Interview with the Director of Nursing on 7/25/18 at 4:55 PM in conference room revealed she expected the bathroom call light to be accessible to all residents. | 2020-09-01 |
| 86 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 584 | D | 0 | 1 | 565T11 | Based on observation and interview the facility failed to maintain clean and sanitary resident equipment for 1 of 24 sampled residents (Resident #117) reviewed. Findings include: Observation of Resident #117 on 7/23/18 at 10:48 AM in the B3 day room revealed he was seated in a wheelchair. Continued observation revealed the left side of the wheelchair had rusted areas on the lower metal bar. Continued observation revealed the wheelchair frame was dusty, dirty, and had white spotted debris over the metal frame, foot rest and handles. Observation on 7/23/18 at 11:47 AM in Resident #117's room revealed the resident had dried debris and dirt on the upper side rails. Continued observation revealed there were light blue pads attached to the side rails by Velcro tabs and had black marks and spotted brown and yellow debris on them. Observation on 7/24/18 at 9:10 AM in Resident #117's room revealed the side rails and light blue pads remained unchanged from the observation the day before. Continued observation revealed the resident's wheelchair was stored in the bathroom and the rust, dirt, and white spotted debris was still present. Observation and interview of Resident #117's bed and wheelchair on 7/24/18 at 11:30 AM with Housekeeper #3 in the resident's room revealed dried debris on the side rails, dirty blue padding to the upper side rails and the wheelchair in the bathroom with rusted areas, and it was dirty with debris and white spots on the metal frame, foot rest and handles. Interview with Housekeeper #3 when asked when resident wheelchairs were cleaned stated, I'm not sure. The Housekeeper was asked when resident beds were cleaned and stated, Everyday. Continued interview with the Housekeeper when asked when resident padding was cleaned stated, They should be wiped down every day but if the resident is in the bed, it's kind of hard. The Housekeeper was shown Resident #117's wheelchair in the bathroom and stated, It don't look too good. It could use a rag or two. It needs to be wiped down. The Housekeeper was asked again how often resident wheelchairs were cleaned and stated, We took the wheelchairs down and hosed them down and wiped them up. When asked when that was, the Housekeeper stated, It's been quite a while. (MONTH) or (MONTH) of last year. The Housekeeper confirmed the side rails, blue pads and wheelchair should have been cleaned with a disinfectant. Interview with the Housekeeping Director on 7/24/18 at 12:12 PM in Resident #117's room when asked how often deep cleaning was performed on residents wheelchairs stated, Everywhere else it's always been the 3rd shift (Certified Nurse Aides) that are supposed to clean the wheelchairs. It's not happening here. Continued interview revealed the Housekeeping Director stated, We pressure washed every wheelchair last (MONTH) and as needed and when a resident is discharged . The Housekeeping Director was shown the dirty blue side rail pads (Housekeeper #3) had already cleaned the dried debris on the side rail) and the resident's wheelchair in the bathroom and stated, It definitely needs to be cleaned. The beds are cleaned on a daily basis and dusted underneath. We deep clean them every month, as needed and upon discharge. The pads should be cleaned daily or change them out. I do audits on rooms but beds are not included on it. I'm going to add it now though. Stated, I'm going to get with the maintenance man and see if we can get the rust off of here and clean this wheelchair up. The Housekeeping Director confirmed the facility failed to maintain Resident #117's equipment in a clean and sanitary manner. | 2020-09-01 |
| 87 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 604 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed failed to obtain a physician's order, failed to assess, failed to obtain a consent, failed to monitor and failed to re-evaluate the need for restraints for 1 of 23 (Resident #117) residents reviewed; failed to obtain a medical diagnosis, failed to monitor, and failed to re-evaluate the need for a restraint for 1 of 23 (Resident #111) residents reviewed. Findings include: Review of facility policy Use of Restraints undated, revealed, .Restraints only may be used .after consideration, evaluation, and the use of all other viable alternatives. All residents have the right to be free from restraint .PHYSICAL RESTRAINTS: are defined as any manual method, or physical .device, .or equipment attached or adjacent to the resident's body that an individual cannot remove easily and which restricts the resident's freedom of movement or normal access to his/her body . Medical record review revealed Resident #117 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. He was totally dependent for bed mobility and transfers with assistance of 2 or more people required. He was totally dependent for dressing, eating, toileting, personal hygiene and bathing with assistance of 1 person. The resident did not stand or ambulate and was unsteady with surface to surface transfers. He had bilateral impairments to upper and lower extremities. He used a wheelchair for mobility with assistance from 1 person. The resident did not use any physical restraints. Observation of Resident #117 on 7/23/18 10:48 AM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. There was a Velcro release belt to his upper chest and a regular seat belt latched across his lap. Both belts were secured by a metal clasp attached to the wheelchair. Resident #117 was asked if he could release the chest belt and stated, No ma'am. Observation of Resident #117 on 7/23/18 at 12:20 PM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. The Velcro release belt was intact to his upper chest and the seatbelt was latched across his lap. Continued observation revealed the resident was moving his right arm up from his lap above his head and was moving his head forward and backward repeatedly causing the wheelchair to bounce slightly. Medical record review of Resident #117's electronic medical record revealed no physician's orders for a restraint or positioning device. Medical record review of recapitulation Physician's Orders for (MONTH) (YEAR) revealed no orders for a restraint or positioning device. Medical record review revealed no restraint assessment, no restraint consent, no monitoring of a restraint and no re-evaluation of the restraint. There was no documentation that a lesser alternative to a restraint had been attempted prior to the use of the tilted wheelchair and belts. Interview with Licensed Practical Nurse (LPN) #2 and Unit Manager on B3 on 7/25/18 at 10:45 AM in his office was provided Resident #117's chart and asked where the documentation was regarding the resident's restraints and stated, They're not restraints, they use them for positioning. Those belts are for positioning and they don't prevent him from doing anything he can do without the belt. Continued interview with LPN #2 when asked why use the belts at all and stated, They are for positioning. We were told by MDS and care plan committee they weren't restraints due to his [DIAGNOSES REDACTED]. upright in the wheelchair he will flop over. (Demonstrated leaning forward over his knees). He has [DIAGNOSES REDACTED] in his legs sometimes and they go straight out, so he has the lap belt or he would slide right out of the chair. When asked where the assessment for the restraints, and documentation of their release every 2 hours, medical diagnosis, consent, and documentation of the least restrictive restraints previously used on the resident he stated, There is not any documentation for any of that, because we didn't do it, we used the chair with those belts for positioning. Interview with the MDS Coordinator on 7/25/18 at 11:58 AM in LPN #2's office with LPN #2 present stated, We were using the chair with the belts for positioning to prevent falls. When asked if the resident had had a fall LPN #2 stated,He has not. Continued interview revealed the MDS Coordinator stated, If he can't stand up then its not a restraint. Assistant Director of Nursing (ADON) #2 entered the office at 12:05 PM and all 3 staff were asked if other residents with a [DIAGNOSES REDACTED].? The staff stated they were not sure. The staff was asked if the resident could voluntarily move his head backward and forward was the chest belt preventing him from moving voluntarily and ADON #2 and LPN #2 both said Yes. The staff was asked if the resident was receiving his highest practicable well being by being restrained by tilting him back, and having a chest and lap belt if he could only move his right arm a little bit and his head? The ADON and the LPN agreed the chest belt did prevent Resident #117 from moving freely. Further interview revealed when asked if a wheelchair with a chest and lap belt was the best and least restrictive alternative for Resident #117, LPN #2 stated, It's definitely not the best chair for him. I referred him to therapy a year ago for a different chair and positioning but nothing changed. The ADON stated, The chair is not appropriate. LPN #2 stated, He is supposed to be up in the chair 3 times a week for 3 hours max (maximum) because his skin is so fragile. ADON#2, the MDS Coordinator and LPN #2 confirmed there was no physician's order or any documentation in the resident's medical record indicating the tilted wheelchair, chest belt and lap belt were to be used for positioning for Resident #117. Interview with the Occupational Therapist (OT) on 7/25/18 at 12:55 PM in the Physical Therapy Department confirmed Resident #117 was last seen by therapy on 3/29/17 per request of the nursing staff. Continued interview revealed the resident was evaluated for contracture management only. The OT was asked if they re-evaluate resident equipment like specialized wheelchairs every so often after the resident has used it for a while and stated No, we're not allowed to. We have to wait for a referral from nursing. If they need to be re-evaluated, nursing sends the request on an orange request form with the specific things they are concerned about. Continued interview revealed the OT was asked when they recommend a specific wheelchair with chest and lap belt restraints, did the physician have to approve it first, and the OT stated, We write the order for what we think is best for the resident and the physician comes behind us and signs off on it. When the OT was asked if that order was supposed to be on the active order sheet if the resident is still using it he stated, Yes, it should be in the chart. Further interview revealed when the OT was asked if he could check the electronic record to determine when and how long Resident #117 had the wheelchair and restraints, the OT looked in the computer and stated, No, I can't tell how long he's had it. When (named corporation) took over the facility in (YEAR) we didn't have access to the previous electronic records. Continued interview revealed the OT was asked if there were other residents in the facility with a [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 7/25/18 at 3:50 PM in her office confirmed the facility failed to obtain a physician's [DIAGNOSES REDACTED].#117; failed to assess the resident for the use of restraints and/or positioning; failed to obtain a consent for restraints; failed to document the release of the restraints; failed to evaluate the ongoing use of restraints, and failed to document the least restrictive alternative for restraints for the resident. Continued interview with the DON confirmed there was no documentation in Resident #117's medical record regarding the use of a chest belt or lap belt for positioning purposes. Findings include: Medical record review revealed Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the Cognitive Skills for Daily Decision Making score 3 indicating severe impairment. Medical record review of the Quarterly MDS dated [DATE], Quarterly MDS dated [DATE] and Annual MDS dated [DATE] revealed .Section P. - Used in chair or out of bed Trunk restraint 1(Used less than daily) . Medical record review of the physician orders dated 1/6/16 revealed .Seat belt with alarm when up in wheelchair. Check Placement of seat belt with alarm every 30 minutes and release every 2 hours for toileting and repositioning. DX (diagnosis): Safety ; Frequency 0600 (6 AM),0800 (8 AM),1600 (4 PM). Medical record review of the Medication Administration Record [REDACTED].Seat belt with alarm when up in wheelchair. Check Placement of seat belt with alarm every 30 minutes and release every 2 hours for toileting and repositioning. DX (diagnosis): Safety ; Frequency 0600 (6 AM),0800 (8 AM) ,1600 (4 PM). Observation of Resident #111 on 7/23/18 at 12:20 PM in R1 dining room revealed the seat belt attached to the wheelchair and buckled around his waist. Interview with LPN #4 on 7/25/18 at 8:31 AM in the hallway near the residents room revealed the seat belt was used to prevent the resident from sliding out of his wheelchair onto the floor. Further interview confirmed LPN #4 failed to adjust his seat belt as ordered. Interview with the Nurse Practitioner on 7/25/18 at 8:40 AM at the R1 nurse station revealed if Resident #111 was in his wheelchair during the day he must have seat belt for safety. Further interview revealed the reason for the seat belt is for safety. It gives him freedom but keeps him safe. Interview with LPN #3 on 7/25/18 at 1:23 PM at the nurse station Further interview confirmed no documentaion was found for the placement and release of the safety belt. Interview with the Director of Nursing on 7/25/18 at 2:15 PM in her office revealed confirmed that there is no medical [DIAGNOSES REDACTED]. Further interview revealed there was no place for the CNA's to document on the MAR. Telephone interview with the Medical Director on 7/25/18 at 2:53 PM revealed he did not confirm the medical [DIAGNOSES REDACTED]. | 2020-09-01 |
| 88 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 609 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation and interview the facility failed to report an allegation of abuse to the state agency within the required 2-hour time frame for 3 of 6 sampled residents in 1 of 3 allegations of abuse (Resident #118, Resident #71, and Resident #151) reviewed. Findings include: Review of facility policy Abuse, Neglect & Misappropriation or Property reviewed 11/6/17 revealed, .The Facility Administration is the Facility's designated Abuse Coordinator and any questions regarding the interpretation or implementation of the policy should be referred back to him or her .an alleged violation involving abuse .are reported immediately, but no later than 2 hours after the allegation is made . Medical record review revealed Resident #118 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 for Resident #118 indicating moderate cognitive impairment. Continued review revealed behaviors exhibited of verbal symptoms toward others. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS dated [DATE] revealed a BIMS score of 99 for Resident #71 indicating severe cognitive impairment. Continued review revealed no moods or behaviors were exhibited. Medical record review revealed Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a 5-day admission MDS dated [DATE] revealed a BIMS score of 15 for Resident #151 indicating no cognitive impairment. Continued review revealed no moods or behaviors were exhibited. Review of a facility investigation involving Resident #118, Resident #71 and Resident #151 on 7/15/18 at 5:30 PM revealed an allegation of resident to resident abuse. Continued review revealed the facility reported the allegation of abuse on 7/16/18 at 7:43 PM. Interview with the Director of Nursing (DON) on 7/25/18 at 12:10 PM in the DON's office confirmed the facility failed to report the allegation of abuse for Resident #118, Resident #71, and Resident #151 to the state agency within the required 2-hour time frame. | 2020-09-01 |
| 89 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 641 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to accurately assess the use of restraints for 1 of 2 sampled residents (Resident #117) reviewed. Findings include: Medical record review revealed resident #117 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. He was totally dependent for bed mobility and transfers with assistance of 2 or more people required. He was totally dependent for dressing, eating, toileting, personal hygiene and bathing with assistance of 1 person. The resident did not stand or ambulate and was unsteady with surface to surface transfers. He had bilateral impairments to upper and lower extremities. He used a wheelchair for mobility with assistance from 1 person. The resident did not use any physical restraints. Observation of Resident #117 on 7/23/18 10:48 AM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. There was a Velcro release belt to his upper chest and a regular seat belt latched across his lap. Both belts were secured by a metal clasp attached to the wheelchair. Resident #117 was asked if he could release the chest belt and stated, No ma'am. Observation of Resident #117 on 7/23/18 at 12:20 PM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. The Velcro release belt was intact to his upper chest and the seatbelt was latched across his lap. Continued observation revealed the resident was moving his right arm up from his lap above his head and was moving his head forward and backward repeatedly causing the wheelchair to bounce slightly. Interview with the MDS Coordinator on 7/25/18 at 11:58 AM in the Unit Manager's office on the 3rd floor was asked why the use of a restraint was not captured on the Quarterly MDS for Resident #117 and stated, because we were using the chair with the belts for positioning to prevent falls not as a restraint. Continued interview confirmed there was no documentation in the resident's medical record the restraints were used for positioning purposes. The facility failed to accurately assess the use of restraints for Resident #117. | 2020-09-01 |
| 90 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 656 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop a comprehensive care plan for positioning and restraints for 1 of 23 sampled residents (Resident #117) reviewed. Findings include: Medical record review revealed Resident #117 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. Continued review revealed the resident did not use any physical restraints. Observation of Resident #117 on 7/23/18 10:48 AM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. There was a Velcro release belt to his upper chest and a regular seat belt latched across his lap. Both belts were secured by a metal clasp attached to the wheelchair. Resident #117 was asked if he could release the chest belt and stated, No ma'am. Observation of Resident #117 on 7/23/18 at 12:20 PM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. The Velcro release belt was intact to his upper chest and the seatbelt was latched across his lap. Continued observation revealed the resident was moving his right arm up from his lap above his head and was moving his head forward and backward repeatedly causing the wheelchair to bounce slightly. Medical record review of the comprehensive care plan for Resident #117 revised 5/26/18 revealed no identified concern related to restraints or positioning, and no related interventions. Interview with Licensed Practical Nurse (LPN) #2, Unit Manager, on 7/25/18 at 10:45 AM in his office was provided Resident #117's chart and asked where the documentation was regarding the resident's restraints and stated, They're not restraints, they use them for positioning. The LPN was asked to review the resident's care plan for positioning and/or restraints and interventions and stated, There is no restraint care plan because those belts were for positioning. Continued interview when the LPN was asked about care of the resident related to the chest belt, lap belt and tilted back wheelchair he stated, There should be a positioning care plan for all of that. Interview with the MDS Coordinator on 7/25/18 at 11:58 AM in the Unit Manager's office on the 3rd floor confirmed there was no positioning care plan for Resident #117, because we were using the chair with the belts for positioning to prevent falls. Interview with the Director of Nursing (DON) on 7/25/18 at 3:50 PM in her office confirmed the facility failed to create a positioning care plan with specific interventions for Resident #117, and failed to create a restraint care plan for the resident. | 2020-09-01 |
| 91 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 677 | E | 0 | 1 | 565T11 | Based on observation and interview, the facility failed to timely assist 5 of 7 dependent diners in the B3 dining room during 2 observations of the mid-day meal. Findings include: Observation of the mid-day meal in the B3 dining room on 7/23/18 from 11:40 AM-12:42 PM revealed 4 dependent diners were seated at the same table. 1 resident at the table was served a tray at 11:42 AM and was assisted by a Certified Nurse Aide (CNA). The other 3 dependent diners at the table did not receive a meal tray. Continued observation revealed 2 dependent diners at the table were served a meal tray at 12:01 PM and assisted by 2 CNAs. Further observation revealed the 4th dependent diner was served his meal tray at 12:40 PM and assisted by a CN[NAME] Interview with CNA #3 on 7/23/18 at 12:43 PM in the B3 dining room confirmed there were 3 residents the dining room that required cueing and 6 residents were dependent diners and required total assistance with eating. Continued interview confirmed there were 2 CNAs in the dining room available to assist the residents and 3 CNAs were passing trays on the halls at that time. CNA #3 confirmed 1 dependent diner waited 1 hour before she could assist him with his meal. Observation of the mid-day meal in the B3 dining on 7/24/18 from 11:40 AM-12:20 PM revealed 3 dependent diners and 1 resident requiring cueing were seated at a table. Another dependent diner was seated in a Geri Chair by the table. Continued observation revealed the resident in the Geri Chair and 1 resident seated at the table were served their meal at 11:43 AM and assisted by CNA #4 and CNA #5. Continued observation revealed CNA #3 served the resident that required cueing his meal at 12:08 PM and assisted with set up and cutting his food. CNA #4 sat next to him and cued him while the other 2 dependent diners dozed in their wheelchairs. Continued observation revealed the remaining 2 dependent diners were served their meals at 12:22 PM and assisted by CNA #4 and CNA #5. Interview with the Director of Nursing (DON) on 7/24/18 at 4:17 PM in the hall by the conference room was notified of the dining observations on 7/23/18 and 7/24/18 and the concerns of dependent diners having to wait for assistance before they could eat their meal. The DON was asked if she realized this was a concern and stated, I didn't realize it was a concern to that extent. Interview with the Administrator on 7/25/18 at 7:15 AM in the conference room confirmed the facility failed to assist dependent diners timely. | 2020-09-01 |
| 92 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 800 | F | 0 | 1 | 565T11 | Based on observation and interview, the facility failed to serve pureed food at the appropriate consistency to 22 of 22 residents receiving pureed textured food. Findings include: Observation on 7/23/18 at 11:40 AM in the dietary department, with the Dietary Manager present, revealed the resident mid-day meal tray service was in progress. Further observation revealed the pureed textured beef, potatoes, and cauliflower all pooled together in the plate. Interview with the Dietary Manager on 7/23/18 at 11:40 AM in the dietary department confirmed the facility failed to serve pureed textured food at an appropriate consistency and appetizing manner. | 2020-09-01 |
| 93 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 812 | F | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility dietary department failed to maintain refrigeration temperature at or less than 41 degrees Fahrenheit (F); failed to maintain dietary equipment in a sanitary manner; failed to thaw meat appropriately; failed to have facial hair covered during food preparation; and failed to remove expired or outdated food in 3 of 6 observations in the dietary department. Findings include: Observation on [DATE] at 8:20 AM, with the Dietary Manager present, revealed the walk-in refrigerator for produce internal temperature was 50 degrees F and a 4 inch pan of slaw was in storage on the shelf. Further observation on [DATE] at 10:20 AM revealed the walk-in refrigerator for produce was 50 degrees F and a 4 inch pan of slaw was stored on the shelf. Observation of the Dietary Manager obtaining the slaw temperature revealed 47.5 degrees F. Further observation on [DATE] at 3:50 PM revealed the walk-in refrigerator for produce was 50 degrees F and no slaw was stored in the refrigerator. Interview with the Dietary Manager on [DATE] at 8:20 AM, 10:20 AM and 3:50 PM in the walk-in refrigerator for produce in the dietary department confirmed the internal temperature was 50 degrees F and the slaw was 47.5 degrees F. Further interview confirmed the facility failed to maintain the refrigeration unit and the food in the unit at or less than 41 degrees F. Observation on [DATE] at 8:20 AM and at 3:50 PM, with the Dietary Manager present, revealed the walk-in refrigerator for dairy and the walk-in refrigerator for produce compressor unit grates, blades and ceiling area had hanging black accumulation of debris present, therefore could contaminate any exposed foods. Interview with the Dietary Manager at 8:20 AM and at 3:50 PM confirmed the compressor grates, blades and ceiling area had debris present in the walk-in refrigerators for dairy and produce. Observation on [DATE] at 10:20 AM, with the Dietary Manager present, revealed 4 sealed vacuum packed chopped ham cubes were under running water in a sink. Further observation revealed the running water was in contact with 1 of the 4 packs. Further observation revealed 1 sealed vacuum packed chopped ham cubes was in a pan of water stored on the counter of the sink with the running water. Interview with the Dietary Manager on [DATE] at 10:20 AM in the dietary department confirmed the dietary staff failed to properly thaw meat under running water. Observation on [DATE] at 3:45 PM, with the Dietary Manager and Registered Dietitian (RD) present, revealed a male dietary staff member with facial hair and no hair covering in place was opening a bag of lettuce and pouring the lettuce into a serving container. Interview with the Dietary Manager on [DATE] at 3:45 PM in the dietary department confirmed the dietary department failed to ensure staff with facial hair wore facial covering to protect the food from contamination. Observation on [DATE] at 3:50 PM, with the RD present, revealed the interior of the ice machine had ice in contact with the bottom of the ice slide. Further observation revealed the bottom of the ice slide had pink colored residue touching the ice. Interview with the RD on [DATE] at 3:50 PM in the dietary department confirmed the facility failed to maintain the ice machine in a sanitary manner. Observation on [DATE] at 9:20 AM with the Dietary Manager present, revealed the emergency food supply was located in a separate storage area of the facility. Review of the emergency food revealed 3 cases of 41.25 pounds (lbs.) each of Corn Beef Hash and 3 cases of 39.75 lbs. of Beef Stew with the facility receiving date of [DATE]. Further review revealed nine 30 lb cases of non-fat powered milk with the pack date of [DATE] and one 30 lb case with the pack date of [DATE]. Interview with the Dietary Manager on [DATE] at 9:20 AM in the emergency food storage area confirmed the facility failed to dispose of expired food. Observation on [DATE] at 9:45 AM in the dietary department, with the Dietary Manager present, revealed the can openers in the vegetable preparation area and the cook preparation area had black sticky debris accumulated on the blade, slot, and base of the equipment. Interview with the Dietary Manager on [DATE] at 9:45 AM in the dietary department confirmed the facility failed to maintain the can openers in a sanitary manner. | 2020-09-01 |
| 94 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 880 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 23 residents (Resident #87 and Resident #1) reviewed related to dating of oxygen tubing for Resident #87 and Resident #1, and dating of humidified water canister for Resident #1, and storage and dating of a [MEDICATION NAME] (suctioning instrument) for Resident #1. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Medical record review of the physician's orders [REDACTED].oxygen at 5 liter / per minute via mask. As needed. Dx (diagnosis) lethargic, low blood pressure .3/16/18 Treatment/Procedure suction with [MEDICATION NAME] PRN (as needed) for increased secretions . Observation on 7/23/18 at 10:27 AM in Resident #1's room revealed the [MEDICATION NAME] connected to tubing hanging on the wall uncovered and undated. Further observation revealed nasal cannula uncovered and undated. Further observation revealed humdified water canister connected to oxygen port on wall dated 5/16/18. Interview and observation with Licensed Practical Nurse (LPN) #3 also known as the Unit Manager on 7/23/18 at 3:39 PM in Resident #1's room confirmed the the [MEDICATION NAME] with tubing and nasal cannula was uncovered and undated. Further observation and interview revealed the date on the humidified water canister was 5/16/18. Interview with LPN #3 on 7/25/18 at 1:23 PM at the nurse station confirmed the tubing was suppose to be dated and changed weekly by the nurses. Further interview confirmed the facility failed to date, and cover the respiratory equipment and replace the humidified water canister. Medical record review for Resident #87 revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #87's Annual MDS dated [DATE] revealed the facility assessed the resident to have a BIMS score of 14 which indicated the resident was cognitively intact. Further review of the MDS section O revealed the resident was receiving oxygen therapy. Review of the (MONTH) (YEAR) physician's orders [REDACTED].change oxygen tubing weekly every Wednesday night . Review of the (MONTH) (YEAR) medication administration record (MAR) for Resident #87 revealed .change oxygen tubing weekly every Wednesday night . Observation of Resident #87 on 7/23/18 at 10:55 AM and 3:43 PM, and on 7/24/18 at 8:16 AM in the resident's room revealed the resident's oxygen tubing was not dated. Interview with RN #1 on 7/24/18 at 8:24 AM in Resident #87's room confirmed the oxygen tubing was not dated. RN #1 picked up the oxygen tubing and stated the tubing and canisters are changed and dated at the same time, there's usually a piece of tape on the tubing with a date on it but I don't see one on his. Further interview confirmed oxygen tubing was to be changed and dated every 7 days. Interview with the Assistant Director of Nursing (ADON) #1 on 7/24/18 at 8:30 AM in the 400 hall confirmed oxygen tubing and canisters were to be changed and dated weekly. Interview with the Director of Nursing (DON) on 7/25/18 at 8:45 AM in the conference room confirmed oxygen tubing should be dated. The DON stated there was no policy for dating oxygen tubing, it's documented on the MAR every Wednesday and the oxygen tubing should be dated. | 2020-09-01 |
| 95 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 908 | E | 0 | 1 | 565T11 | Based on observation and interview, the facility failed to maintain equipment in the dietary department in a safe operating condition. Findings include: Observation on 7/23/18 at 10:20 AM, with the Dietary Manager (DM) present, in the dietary department revealed 17 of 17 tray delivery carts had a build-up of calcium on the interior and the tray rungs. Further observation revealed 16 of the 17 tray delivery cart interiors had rust present. Further observation revealed the interior of the dish machine had a heavy accumulation of calcium. Further observation of all the insulated plate dome lids and insulated heated plate bases interior and exterior had heavy accumulation of calcium. The calcium deposits on the insulated heated base could interfere with the base heating process and therefore could fail to maintain the food temperatures. The calcium deposits on the insulated dome lid and base could prevent a good seal to maintain the food temperature. Interview with the Dietary Manager on 7/23/18 at 10:20 AM in the dietary department confirmed the facility failed to maintain the tray delivery carts to prevent calcium build-up and to prevent rusting. Further interview confirmed the facility failed to maintain the interior of the dish machine from building up calcium. Further interview confirmed the insulated dome lids and bases had an accumulation of calcium present. Interview with the Maintenance Director on 7/23/18 at 10:50 AM in the dietary department confirmed the dietary department water left calcium deposits inside the dish machine. Further interview revealed the dish machine .is old and breaks down frequently .and needs the conveyor belt replaced . Further interview confirmed calcium deposits were present on the resident insulated plate dome lid and base making them .look unattractive . | 2020-09-01 |
| 96 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 224 | J | 1 | 0 | ONHF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, and interview, the facility failed 2 of 8 residents reviewed for neglect (#1, #2). The facility staff failed to provide services in a manner to prevent neglect resulting in physical harm to two residents who were aggressive and resistive during care being provided. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #1 and #2. F-224 is Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .6. In cases of alleged resident abuse, the Director of Nursing or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are incapable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 required extensive assistance of 1 staff for hygiene, and Activities of Daily Living (ADL). Continued review of the MDS revealed Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Further review of the MDS revealed Resident #1 had not exhibited any behaviors. Medical record review of General Emergency Department Discharge Instructions dated 6/24/17 revealed Resident #1 had a [MEDICAL CONDITION] (long bone of the upper arm) and was given a splint to use. Resident #1 was also written a prescription for [MEDICATION NAME] 5/325 milligrams (mg) (pain medication). Review of a Witness Statement taken by the Administrator on 6/24/17 at 1:15 PM, from NA (Nurse Assistant #1) revealed 2 NAs were assisting Resident #1 with perineal care. Continued review revealed, .NA (#1) said NA (#2) got a towel trying to clean her and (Resident #1) started swinging (and) flailing arms not making contact .NA (#2) stepped back and stated don't be hitting me .Then grabbed patient's arms (and) held (them) down on (the) bed with the towel in the other hand trying to clean her .Grabbed (her) arm too hard (and the) arm snapped .Looked like bone was going to come through (resident's) arm. Force held arm down and bone popped .Patient screamed said you broke my arm. I commented (NA #2) you broke her arm . Review of a Witness Statement dated 6/24/17 written by NA #2 revealed, .I attempted to provide morning perineal care for (Resident #1) but she wouldn't let me clean her because she was swinging her arms .I went to get the assistance of (NA #1) but the resident was still swinging her arms so hard, she almost hit my face because I was standing at the head of the bed so she can't (could not) hit me but she was swinging so hard that I proceed (ed) to hold her hand when I heard a crack . Review of a Witness Statement dated 6/24/17 written by NA #1 revealed, .(NA #2) came to get her for assistance with the Resident (#1) morning perineal care .(Resident) started swinging her arm and trying to hit staff .don't hit me, then grabbed (the) resident's arm and held it down, I heard her bone crack . Review of a Witness Statement dated 6/24/17 written by Licensed Practical Nurse #3 (LPN) revealed, .(NA #2) came and asked her to come to Resident (#1's) room quickly .She said NA (#2) had broken Resident (#1's) arm .(LPN #3) asked (NA #2) how she know (knew) she had broken her arm and (NA #2) stated the resident was swinging her arms and she put her arm up to block it and she heard it crack .(LPN #3) looked at Resident (#1's) arm and could tell it was broken . Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property dated 6/28/17 revealed Resident #1 suffered a distal humerus fracture due to physical contact with a Nurse Aide #2 (NA) #2. Continued review revealed the .resident was displaying agitation while staff were attempting to provide personal care .Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. Further review of the Resident Investigative Tool revealed .resident was displaying agitation while providing care .She became restless and began swinging her arm at the Nursing Assistant (NA #2) .(NA #2) redirected the resident by placing residents hand down by her side .Due to her [DIAGNOSES REDACTED].This allegation was not substantiated because there was no willful intent to harm the resident. The Assistant Administrator went on to write the facility .educated all clinical staff to step away from residents when they become agitated during care. Interview with NA #1 on 9/26/17 at 9:30 AM in the conference room revealed Resident (#1) could be very feisty and did not like to be changed during perineal care. NA #1 stated Resident #1 would become aggressive at times, trying to hit or kick staff .when the resident became agitated she would reapproach, go get help from another NA or let the nurse know she could not complete personal care for the resident. Continued interview with NA (#1) revealed .on 6/24/17 (NA #2) came to get her to help provide perineal care for (Resident #1) because she was agitated and had bowel movement (BM) all over her .the resident had BM on her hands and was swinging her arms around in agitation, but she was not involved in the actual perineal care but was trying to talk to the resident and calm her down .she suggested to (NA #2) they take a break and reapproach the resident but (NA #2) continued doing care .(NA #2) blocked the resident from touching her face and held her arm down on the bed when she heard a loud popping sound .told the other (NA #2) that she broke the resident's arm and to go get the nurse .she worked with (NA #2) for a long time and did not think she intentionally hurt the resident . Further interview with NA #1 revealed NA #2 had a we're going to do it now, want to get your work done type of attitude. Interview with NA #2 on 9/26/17 at 10:00 AM, in the conference room revealed she had worked with Resident #1 for many years and Resident #1 had dementia but would be more agreeable to care if you gave her coffee. NA #2 stated on 6/24/17 .she attempted to provide perineal care for Resident #1 but she became agitated and she went to get help from (NA #1) who came into the resident's room to assist her .the resident was swinging her arms and had BM on her hands when she swung her arm towards her (NA #2's) face .reacted and it all happened so quickly but she blocked her arm and put the resident's arm down by her side when they heard a crack. Interview with Licensed Practical Nurse #1 (LPN) on 9/26/17 at 11:20 AM in the 300 Hall manager's office revealed LPN #1 served as the Unit Manager for the 300 Hall and stated Resident (#1) .was a confused, pleasant lady who, at times, was resistive to perineal care and showers. Continued interview with LPN #1 revealed Resident #1 did not have any specific triggers and that it varied from day to day whether the resident would become agitated or aggressive during personal care. Regarding the incident on 6/24/17 LPN #1 indicated he would expect staff to always back away and reapproach a resident who was resisting care and having combative behaviors. He indicated he would expect staff to back away from residents before it came to the point where they had to put their hands on them. He stated, we have a lot of psych (mental disorder) and dementia training. Interview with the Behavior Health Manager (BHM) on 9/26/17 at 2:30 PM in the conference room revealed she would expect staff to respect residents' rights without neglecting them. Continued interview revealed if a resident exhibited aggressive behaviors during care she would expect them to step away and not expect staff to physically touch the resident to intervene unless a resident was falling or about to hurt themselves. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room, revealed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17. Continued interview confirmed she was suspended and an investigation was completed. He confirmed the NAs knew they should have handled the situation differently by stepping back, letting the resident calm down and reapproaching. Interview with LPN #3 by phone on 9/26/17 at 4:10 PM revealed on .6/24/17 she was notified by (NA #2) she had broken (Resident #1's) arm during personal care. LPN #3 said she assessed the resident and called the Unit Manager. Continued interview revealed Resident #1 could be resistive to care, very fragile and if the resident was swinging her arms around she would expect the NA to step back, let her calm down, reapproach and get a nurse if needed. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and stated if a resident had combative behaviors during care she expected the staff to call the charge nurse and not force the resident to do anything. She further confirmed in Resident #1's case a fracture can happen very easily and if (NA #2) had not touched her, her arm would not have (been) broken. Continued interview confirmed if the resident was resisting that much (NA #2) could have stopped care completely. The Medical Director confirmed NA #2 did not use common sense while providing care with Resident #1 and her actions could cause [MEDICAL CONDITIONS] type symptoms. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed Resident #2 scored a 4 out of 15 on the BIMS which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed the resident had not exhibited any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17 indicated Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use included .provide non-confrontational environment for care . and .reapproach resident later, when she becomes agitated . Medical record review of a Weekly Skin assessment dated [DATE], revealed Resident #2 had reddened intact skin on her sacrum. Continued review revealed no other skin issues were noted on the assessment. Medical record review of a Daily Skilled Nurses Note dated 6/29/17 at 11:50 PM revealed Resident #2 refused all her nighttime medications. Continued review revealed the note did not indicate Resident #2 had any aggressive behaviors or that LPN #4 had any contact with the resident during her shift. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/, revealed Resident #2 made an allegation of abuse against LPN #4 on 6/30/17 stating .LPN (#4) came into her room to get her to take 7 pills and she refused because she had her own Dr.(doctor) and reported the nurse cut her arms to pieces with her claws . Continued review of the tool revealed Resident #2 had a history of [REDACTED]. Further review revealed Resident #2 had episode slapping meds (medications) out of (the) nurse hands .Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and the resident bruises easily. Review of a Witness Statement dated 6/30/17, written by NA #3 indicated Resident #2 called the NA between 9:00 AM and 10:00 AM and stated, look what she did to me while showing her both of her arms. Review of a Witness Statement dated 6/30/17, written by LPN #2 who served as the Unit Manager for the 200 Hall revealed a NA came to her and reported, someone was rough. LPN #3 took Resident #2 to her room to complete a skin assessment and interview. Resident #2 stated to LPN #3 on 6/29/17, a nurse came into her room and try (tried) to get her to take 7 pills and that she refused because she had her own Dr. (doctor) and then stated the nurse cut her arms to pieces with her claws trying to get her to take meds. Review of a Witness Statement dated 6/30/17, written by LPN #4 revealed went in to give her the meds and she slapped the meds off my hand stating she didn't want it. I then held her hands and scooped up the crushed meds off her bed. Review of the C.N.[NAME] (Certified Nursing Assistant) Skin Care Alert form dated 6/30/17, completed by LPN #2 revealed Resident #2 had 4 areas on her left arm and hand and 3 areas on her right arm and hand with the following written in multiple discolorations. Medical record review of Resident #2's Care Plan dated 6/30/17, revealed Resident #2 had bruises on her bilateral forearms and top of hands Review of one of the staff interviews dated 6/30/17, written by LPN #4 with the questions Did you notice any bruising on her legs? revealed the response, her arms was what I noticed (bruises/dark spots). Review of the facility handwritten notes provided by the Assistant Administrator revealed on 6/30/17 at 2:00 PM an allegation of abuse was reported regarding Resident #2. Continued review revealed Resident #2 stated that .nurse came in last night to give medication, but she refused it. The nurse allegedly cut her arms with her claws. She didn't take her medication but then stated that she did take her medicine because it was the only way that she could stop what the nurse was doing. States she tried to call for help .does have bruising to bilateral forearms/discolorations/dark spots? The Assistant Administrator took a statement from Resident #2 that stated .she grabbed her arms when she refused her meds .Felt like she was cutting her arms with a knife .she was in bed and trying to fight her off and she finally left the room .she tried to call for help .Described the nurse as having black frizzy hair with some red .she (nurse) tried to give her 9 pills but she wasn't going to take them .she didn't tell anyone during the night because they cut her communication off. Continued review revealed the notes also describe information taken from the Psych Services provider revealed APN (#1) (Advanced Practice Nurse) reported the resident told her nurse came in and gave her 7 pills and told her that the Dr. had ordered them .the resident slapped them away and grabbed her with her claws and she tried to call for help .she grabbed and twisted her arms. Medical record review of a Social Service Note dated 6/30/17 at 5:41 PM revealed the Social Service Worker #1 (SSW) spoke with the resident as she was eating in the unit dayroom and noticed bruises on the resident's arm and asked the resident what happened. (Resident #2) began the story of how she refused medications but the nurse made her take them anyway. SSW #1 asked the resident why she did not want to take her medications and the resident responded she only takes medications from her doctor whom she trusts. Medical record review of a Behavioral Medicine/Progress Note dated 6/30/17, written by APN #1 revealed during an interview Resident #2 appeared to acknowledge her confusion as she struggled to find words and organize her thoughts. APN #1 wrote Resident #2 said last PM she had gone to her room for the evening .The black lady that checks on me came in to give me 7 pills and I refused to take them swatting her hand away .She grabbed my arm and twisted it .She pointed to open areas and said those were her claws .she struggled staying awake to watch the black lady that kept checking on her .As above, pt (patient) struggled very hard to express her words, was confused At times, appeared to want to become tearful .The last thing she told this provider was if it can happen to me then it can happen to someone else . Review of a facility Coaching & (and) Counseling session form dated 6/30/17, revealed LPN #4 was counseled regarding failure to complete proper paperwork regarding medication administration. Review of the Working Schedule for LPN #4 revealed she worked on 6/30/17 clocking in at 6:35 PM and out at 7:22 AM. LPN #4 worked on B2 which was the 200 Hall with Resident #2. Interview with LPN #2 on 9/27/17 at 8:40 AM in the Manager's office who served as the Unit Manager for the 200 Hall revealed on 6/30/17, Resident #2 had discolorations on her arms but not bruises. She stated they were purple in color but they were not bruises and she did not discuss the incident with LPN #4 who was accused of abuse by the resident. She further stated NA #4 came to her and told her Resident #2 said someone grabbed her arms. LPN #2 said she did the skin assessment and interviewed the resident and passed the information on to the administrative staff. Interview with the Assistant Administrator on 9/27/17 at 8:50 AM in the conference room, revealed she interviewed LPN #4 and she stated Resident #2 smacked the medications out of her hand. Continued interview revealed the Assistant Administrator questioned LPN #4 about her statement and she stated LPN #4 told her she put the resident's hand down in her lap and reassured her. Further interview confirmed the Assistant Administrator did not interview NA #4 who Resident #2 told first about the incident. Further interview with the Assistant Administrator revealed the resident always had discolorations and age spots on her skin. Interview with the Assistant Director of Nursing #1 (ADON) on 9/27/17 at 9:05 AM in the Manager's office, revealed she sat in on the interview between the Assistant Administrator and LPN #4. Interview revealed ADON #1 confirmed LPN #4 stated in the interview she held Resident #2's hands in her hand while she picked up the medication. Continued interview revealed ADON #1 stated when she reviewed the skin assessment and it said multiple discolorations on her arms she would think bruising, a purplish color, maybe age spots, may be old but I would need more detail. She further stated since the skin assessment from 6/29/17 and 6/30/17 do not match, it would make her want to investigate further. Further interview with ADON #1 confirmed LPN #4 could have done something differently so she would not have had physical contact with the resident. She confirmed LPN #4 could have stayed in the room but backed away from the resident so she would calm down or pulled the call light so someone would come and help her. Continued interview confirmed LPN #4 did not have to physically intervene with the resident and if Resident #2 had discoloration on her arms all the time, she would expect to see it reflected in the skin assessments. Interview by telephone with LPN #4 on 9/27/17 at 1:30 PM, revealed on 6/30/17 she went into Resident #2's room to give her medication. Continued interview revealed the resident slapped the medications out of her hand and was swinging her arms trying to hit her. Further interview revealed LPN #4 stated she held the resident's hands with one hand and picked up the medication with her other hand. Interview with LPN #4 revealed the resident always had discolorations on her hands and arms and she did not use any physical force on Resident #2. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview revealed the Medical Director confirmed the bruises on Resident #2's arms were not documented beforehand so they were not old bruises, they were new ones. Interview with APN #1 on 9/28/17 at 1:10 PM in the conference room, confirmed after reading her documentation from 6/30/17 on Resident #2, she (resident) was clearly distraught about something that had happened. APN #1 stated she communicated this information to the Assistant Administrator and the DON (Director of Nursing) that day. Interview with the DON on 9/28/17 at 2:10 PM in the conference room revealed the DON was not employed with the facility in (MONTH) (YEAR) and stated if residents have combative behaviors she expects staff to always stop what they are doing, ensure the residents are safe and call for help, reapproach and let the nurse know. Continued interview confirmed if the staff are unable to complete care or give medication then they should document it. Further interview confirmed staff should not have unnecessary physical contact with residents. | 2020-09-01 |
| 97 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 225 | J | 1 | 0 | ONHF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to conduct a thorough investigation for 1 of 4 residents reviewed for abuse. After receiving an allegation of abuse from Resident #2 the facility failed to suspend the accused employee who then worked with the resident on the same night. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #2. F-225 is Substandard Quality of Care The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .allegation of abuse as a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred or plausibly might have occurred .neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .if the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated Investigation Guidelines .The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegations of abuse .injuries of unknown origin source .exploitation .or suspicious crime .6. In cases of alleged resident abuse, the Director of Nursing (DON) or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are incapable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. The MDS revealed no documentation of Resident #2 exhibiting any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17, revealed Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use provide non-confrontational environment for care and reapproach resident later, when she becomes agitated. Medical record review of Resident #2's Care Plan dated 6/30/17, revealed Resident #2 had bruises on her bilateral forearms and tops of hands and was initiated after the allegation of abuse was made on 6/30/17. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/ revealed Resident #2 made an allegation of abuse against Licensed Pratical Nurse #4 (LPN) on 6/30/17. Resident #2 reported LPN #4 came into her room to get her to take 7 pills and she refused because she had her own Dr. (Doctor) She reported the nurse cut her arms to pieces with her claws. Continued review of the Investigative Tool revealed Resident #2 had a history of [REDACTED]. The report indicated Resident #2 had episode slapping meds out of nurse('s) hands. Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and that the resident bruises easily. Review of a Witness Statement dated 6/30/17 written by LPN #4 revealed she went in to give her the meds and she slapped the meds off my hand stating she didn't want it. So, I held her hands and scooped up the crushed med off her bed. Review of the investigative documentation provided by the facility for their self-reported abuse allegation against LPN #4 on 6/30/17 revealed the administrative staff interviewed 2 residents regarding their care. Five staff members were interviewed regarding Resident #2 and her behavior on the day of the incident. LPN #4 who was the staff member named in the allegation was not suspended during the investigation per facility protocol and returned to work the same day, working the same assignment area where the resident (who had verbalized fear of the same incident happening again) resides. Review of a Coaching & (and) Counseling Session form dated 6/30/17 revealed LPN #4 was counseled regarding failure to complete proper paperwork regarding medication administration. Review of the Working Schedule for LPN #4 revealed she worked on 6/30/17 clocking in at 6:35 PM and out at 7:22 AM. LPN #4 worked the night shift on B2 which was the 200 Hall with Resident #2 the same day she made an allegation of abuse. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation and interviewed other staff regarding LPN #4. Continued interview with the Administrator confirmed he believed the investigation was complete and did not suspend LPN #4. Interview with the Administrator revealed it was more likely the skin assessment prior to the incident was inaccurate because the night shift nurse who completed it may not have seen the resident. Further interview confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. Interview on 9/27/17 at 1:30 PM by telephone with LPN #4 confirmed she was not suspended after the allegation of abuse by Resident #2 and did not receive any education regarding residents with dementia or combative behaviors. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview with the Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new bruises and if a resident described an incident or person as abusive, it needed to be investigated. Further interview with the Medical Director confirmed the facility failed to follow all the steps of the investigative process including suspending the accused nurse. Interview with the Assistant Administrator on 9/28/17 at 1:30 PM in the conference room, confirmed the investigation was completed on 6/30/17 and she cleared LPN #4 to come back to work that night. Continued interview confirmed she did not know if the Investigative Tool needed to be filled out and dated with the date the investigation was completed so she did not document any interview with LPN #4 during the investigation and she did not document findings from the investigation where she cleared her to work that night. Interview with the DON on 9/28/17 at 2:10 PM, in the conference room confirmed staff should not have unnecessary physical contact with residents and if staff were described in the allegation they should be suspended for the course of the investigation. Continued interview confirmed the DON stated if staff were accused of abuse and the allegation was unsubstantiated, then staff should still receive education and training regarding the issue. Refer to F-224 J | 2020-09-01 |
| 98 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 226 | J | 1 | 0 | ONHF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation and interview, the facility failed to implement their abuse policy related to the proper identification, training and investigation of abuse/neglect. The facility failed to operationalize its abuse policy after an allegation of abuse against a resident (#2) by a Licensed Practical Nurse (LPN) #4 was reported. This failure resulted in the potential for continued abuse against residents with whom LPN #4 continued caring for as part of her work assignment. This failure resulted in an Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #1 and #2. The facility further failed to properly identify neglect regarding Resident #1 as related to not substantiating abuse after Nurse Aide #2 (NA) intervened during resistive care of a resident by using physical force. The facility failed to ensure residents were free from abuse/neglect as per their abuse policy for 2 of 8 residents reviewed (#1, #2). F-226 is Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .non-accidental or not reasonably related to the appropriate provision of ordered care and services .allegation of abuse as a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred or plausibly might have occurred .neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .if the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated .Investigation Guidelines .6. In cases of alleged resident abuse, the Director of Nursing (DON) or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are incapable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents. Medical record review for Resident #1 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 required extensive assistance of 1 staff for hygiene and scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident as severely cognitively impaired. Review of the Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property form dated 6/28/17 indicated Resident #1 suffered a distal humerus (upper arm bone) fracture on 6/24/17 because of physical contact with a Nurse Aide #2 (NA). The tool indicated the resident was displaying agitation while staff were attempting to provide care. Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. The Investigative Tool indicated the resident was displaying agitation while providing care. She became restless and began swinging her arm at the (NA #2). The NA (#2) redirected the resident by placing the resident's hand down by her side. Due to her [DIAGNOSES REDACTED]. Continued review revealed the incident was not deemed as neglect by the facility. Further review of the Investigative Tool revealed the facility determined Resident #1's combative behavior, her [DIAGNOSES REDACTED]. Continued review of the Investigative Tool revealed the Assistant Administrator documented educated all clinical staff to step away from residents when they become agitated during care. Review of the facility investigation provided by the facility for their self-reported abuse allegation against NA #2 on 6/24/17 revealed the administrative staff did not substantiate the allegation of abuse/neglect. Continued review revealed the facility did not substantiate neglect, even though NA #2 intervened with physical force acting against the facility's policy and procedure for abuse/neglect while providing personal care for Resident #1 where she exhibited aggressive and resistive behaviors toward personal care offered which caused an acute physical injury to occur. Interviews by the surveyor with the two NAs involved in the incident, the Nurse on duty, the Unit Manager and Administrator indicated the events happened in accordance with the Investigative Report filled out by the Assistant Administrator. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room revealed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17. He stated she (NA #2) was suspended and an investigation was completed. Continued interview with the Administrator revealed the facility did not determine neglect had occurred during the incident. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed the Medical Director reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and stated if a resident had combative behaviors during care she expected the staff to call the Charge Nurse and not force the resident to do anything. Continued interview with the Medical Director confirmed in Resident #1's case a fracture can happen very easily and if NA #2 had not touched her, her arm would not have been fractured. Further interview confirmed if the resident was resisting that much she could have stopped care completely and NA #2 did not use common sense while providing care for Resident #1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] indicated Resident #2 scored a 4 out of 15 on the BIMS which indicated the resident was severely cognitively impaired. The MDS did not indicate Resident #2 exhibited any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17 indicated Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use included provide non-confrontational environment for care and reapproach resident later, when she becomes agitated. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/ indicated Resident #2 made an allegation of abuse against LPN #4 on 6/30/17. Resident #2 reported LPN #4 came into her room to get her to take 7 pills and she refused because she had her own Dr. (doctor). She reported the nurse cut her arms to pieces with her claws. Review of the Resident Investigative Tool revealed Resident #2 had a history of [REDACTED]. Continued review revealed the report indicated Resident #2 had episode (of) slapping meds out of nurse('s) hands. Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and that the resident bruises easily. Review of the investigative documentation provided by the facility for their self-reported abuse allegation against LPN #4 on 6/30/17 revealed the administrative staff interviewed 2 residents regarding their care. Five staff members were interviewed regarding Resident #2 and her behavior on the day of the incident. LPN #4 who was the staff member named in the allegation was not suspended during the investigation per facility protocol and returned to work the same day, working the same assignment area where the resident (who had verbalized fear of the same incident happening again) resides. There was no documentation LPN #4 and other staff were provided education or training after the incident. Medical record review of Resident #2's Care Plan dated 6/30/17 indicated Resident #2 had bruises on her bilateral forearms and tops of hands. This Care Plan was initiated after the allegation of abuse was made on 6/30/17. Interview with Nurse Aide (#3) on 9/28/17 at 8:05 AM in an empty resident room on the 200 Hall, confirmed NA #3 did not receive any training or education that she could recall after she reported the incident on 6/30/17 regarding alleged abuse towards Resident #2. Interviews with 6 staff members by the facility revealed Resident #2 described her interaction with LPN #4 similarly. Interviews revealed the resident reported she refused to take medications from LPN #4 and slapped the medications from her hand and reported the Nurse touched her hands and arms. Resident #2 referred to LPN #4 as cutting her arms to pieces with her claws in multiple accounts to different staff members. According to LPN #4's statement and the investigation by the Administrative staff, LPN #4 did have unnecessary physical contact with Resident #2. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation, however he could not confirm the staff received any further education or training regarding this issue. Continued interview with the Administrator confirmed they should have also interviewed other staff and additional residents regarding LPN #4 according to the facility policy. He confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview with the Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new and if a resident described an incident or person as abusive, it needed to be investigated. Further interview confirmed the facility should have followed all the steps of the investigative process including suspending the accused nurse. Interview with the DON on 9/28/17 at 2:10 PM in the conference room revealed the DON was not employed with the facility in (MONTH) (YEAR) and stated if residents have combative behaviors she expects staff to always stop what they are doing, ensure the residents are safe and call for help, reapproach and let the nurse know. Continued interview confirmed if the staff are unable to complete care or give medication then they should document it. Further interview confirmed staff should not have unnecessary physical contact with residents. Refer to F-224 J, F-225 J | 2020-09-01 |
| 99 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 279 | J | 1 | 0 | ONHF11 | **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 develop a comprehensive care plan for 2 residents (#1, #8) of 8 residents reviewed. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #1. The findings included: Review of facility policy, Care Plans-Comprehensive, dated 9/21/16 revealed .The nurse/Interdisciplinary Team develops and maintains a comprehensive Care Plan for each resident that identifies the highest level of functioning the resident may be expected to attain .Each resident's comprehensive Care Plan is designed to .Incorporate identified problem areas .Incorporate risk factors associated with identified problems .Aid in preventing or reducing declines in the resident's functional status and/or functional levels .Care Plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers .Care Plans are revised as information about the resident and the resident's condition change .The nurse/Interdisciplinary Team is responsible for the review and updating of Care Plans. The Care Plan should reflect the current status of the resident and be updated with changes in the residents status .When the resident has been readmitted to the facility from a hospital stay . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 required extensive assistance of 1 staff for hygiene, and scored a 3 of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Further review of the MDS revealed Resident #1 had not exhibited any behaviors. Medical record review of Resident #1's Care Plan dated 6/6/17 revealed no individualized interventions for agitation, aggressiveness or combative behaviors during perineal care. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property dated 6/28/17 revealed Resident #1 suffered a distal humerus (long bone of the upper arm) fracture on 6/24/17 due to physical contact with a Nurse Aide (NA) #2. Continued review revealed the .resident was displaying agitation while staff were attempting to provide personal care and .Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. Further review of the Resident Investigative Tool revealed .resident was displaying agitation while providing care .She became restless and began swinging her arm at Nurse Aide (NA #2) .The NA redirected the resident by placing residents hand down by her side .Due to her [DIAGNOSES REDACTED]. Interview with NA #1 on 9/26/17 at 9:30 AM in the conference room revealed Resident #1 could be very feisty, did not like to be changed during perineal care, and would become aggressive at times, trying to hit or kick staff. Continued interview with NA #1 revealed Resident #1 has had these behaviors for a long time and usually if the staff offered her black coffee she would calm down and comply with care. Further interview revealed when the resident became agitated the NA would reapproach, go get help from another NA or let the nurse know she could not complete care on the resident. Interview with NA #2 on 9/26/17 at 10:00 AM in the conference room revealed she had worked with Resident #1 for many years. Further interview revealed Resident #1 had Dementia and could be combative with care at times but would be more agreeable to care if you gave her coffee. Interview with License Practical Nurse #1 (LPN) on 9/26/17 at 11:20 AM in the 300-hall manager's office, revealed the LPN served as the Unit Manager for the 300 hall. Further interview revealed Resident #1 was a confused, pleasant lady who, at times, was resistive to perineal care and showers. Further interview revealed Resident #1 did not have any specific triggers and that it varied from day to day whether the resident would become agitated or aggressive during care. Further interview with LPN #1 revealed he was unsure if there was a Care Plan in place for Resident #1's behaviors and staff knew to offer the resident black coffee as a way of calming her down when she became agitated. Interview with the Behavior Health Manager (BHM) on 9/26/17 at 2:30 PM in the conference room revealed she did not have a Behavior Health Plan in place for Resident #1 and did not recall a time when staff approached her for suggestions or education for that particular resident. Further interview revealed the BHM was unsure if there was a Care Plan in place for Resident #1's behaviors. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room revealed there should have been a Care Plan in place to address Resident #1's combative behaviors during care and the individualized interventions the staff used when the resident displayed combative behaviors. Telephone interview with LPN #3 on 9/26/17 at 4:10 PM revealed Resident #1 could be resistive to care and was very fragile. Further interview revealed the NAs knew how to get the resident to calm down and would offer her coffee at times. Further interview revealed the LPN was unsure if there was a Care Plan in place for Resident #1's behaviors. Interview with the Medical Director on 9/28/17 at 11:05 PM in the conference room, revealed the nursing staff should ensure Care Plans were in place for the resident's problems. Further interview revealed Resident #1's combative behaviors should be care planned and interventions documented. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/14/17 with [DIAGNOSES REDACTED]. Medical record review of Progress Notes revealed Resident #8 was sent for a Psychiatric Evaluation on 6/26/17 after an incident with Resident #4 and returned to the facility on [DATE]. Review of a Discharge Summary dated 7/12/17 revealed .The medication mgmt. (management) for this patient was aimed towards minimizing disruptive behavior both verbal and physical at her facility, however, given her chronic and persistent mental illness, periods of agitation or bizarre behavior are likely to continue to occur, and will require consistent behavioral supervision . Continued review of the Progress Notes revealed Resident #8 received another Psychiatric Evaluation from 7/17/17 until 8/14/17. Review of a Discharge Summary Psychiatry dated 8/14/17 revealed the admission was due to .behavioral issues continued to manifest themselves because of her problematic behavior after her last discharge . Continued review of Progress Notes revealed Resident #8 continued to exhibit behaviors after the second Psychiatric Evaluation. Medical record review of the Care Plan dated 8/14/17 failed to reflect the incident between Resident #8 and Resident #4. Continued review revealed the Care Plan also failed to contain information about Resident #8's behaviors. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) of 3, indicating she was severely cognitively impaired. Further review revealed the resident exhibited wandering behaviors 4-6 days of the review period. Medical record review of the Care Plan dated 8/14/17 revealed the Care Plan was not updated after the MDS dated [DATE] addressed wandering behaviors. Interview with the Behavioral Health Manger (BHM) on 9/26/17 at 2:35 PM in the conference room revealed Resident #8 does have behaviors that include wandering, going into other residents' rooms, spitting, and the resident required constant redirection. Further interview confirmed Resident #8 was sent for a Psychiatric Evaluation on 6/26/17 after the incident with Resident #4 and sent for a Psychiatric Evaluation again after continued behaviors following the readmission on 7/12/17. Interview with Social Services Worker #2 (SSW) on 9/26/17 at 4:05 PM in the conference room revealed SSW #2 was the assigned SSW for the unit where Resident #8 resides. Further interview confirmed Resident #8 had behaviors that included agitation, invasion of personal space of others and aggressive behaviors at times. Further interview revealed Resident #8 went for the second Psychiatric Evaluation and received electroconvulsive therapy and medication changes. Interview with the Administrator on 9/26/17 at 2:30 PM in the conference room revealed Resident #8 received a second Psychiatric Evaluation due to the facility's concern of the resident being a threat to herself and others. Further interview confirmed the facility failed to update Resident #8's Care Plan after the resident-to-resident incident with Resident #4 and after both psychiatric evaluations. Refer to F-224 J, F-225 J, F-226 J | 2020-09-01 |
| 100 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 490 | J | 1 | 0 | ONHF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy and procedure, medical record review, observation, and interview, the Administrator failed to administer the facility in an effective manner, utilizing all its resources including the proper investigation process per the abuse/neglect policy and procedure and training and education on how to handle aggressive resident interactions during care provided, resulting in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for resident (#1, #2) of 8 residents reviewed. The findings of the abbreviated and partial extended survey found Immediate Jeopardy with Substandard Quality of Care at 483.13 (Resident Behaviors and Facility Practice). Resident #1 and Resident #2 were free from neglect. A Nurse Aide #2 (NA) and Licensed Practical Nurse #4 (LPN) physically intervened when the residents resisted care and had aggressive behaviors resulting in bodily injury and psychological trauma to the residents. Components of the facility's abuse/neglect prevention programs were not immediately implemented, including identification of the neglect, thorough investigation as well as prevention of further potential neglect by LPN #4 (Refer to F224, F225, and F226). The Administrator's failure to protect Resident #1 and Resident #2 from abuse/neglect, as well as ensure the staff were competent and trained in working with residents with combative behaviors has caused or is likely to cause acute injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 9/27/17, and determined to exist on 6/24/17. The facility's Administrator was informed of the Immediate Jeopardy on 9/27/17 at 2:30 PM in the Administrator's office. The findings included: 1. F224 - The Administrator failed to provide services necessary to avoid physical harm or mental anguish for Resident #1 and Resident #2. Resident #1 suffered a fractured arm after NA #2 intervened with physical force during perineal care being provided. Resident #2 potentially suffered from mental anguish and bruising due to LPN #4 intervening using physical force by holding her hands or arms while the resident was being aggressive and resistive to medication administration. 2. F225 - The Administrator failed to conduct a thorough investigation for the incident regarding Resident #2. Allegedly, LPN #4 held the resident's hands or arms while the resident was exhibiting aggressive and resistive behaviors during medication administration. The facility did not suspend the LPN during the investigation, and did not interview residents or staff about their interactions with the LPN. 3. F226 - The Administrator of the facility failed to ensure their abuse/neglect policy was implemented related to identification of abuse/neglect, investigation of abuse/neglect and training and education offered. The Administrator failed to ensure a thorough investigation was conducted for an allegation of physical abuse by Resident #2. The Administrator, who served as the Abuse Coordinator, did not recognize the staff members who had used physically forced interventions with Resident #1 and Resident #2 failed to provide the necessary services to prevent physical harm or mental anguish, and did not provide education or training to staff after the incident on how to handle residents with aggressive and resistive resident behaviors. 4. F279 - The Administrator failed to ensure a comprehensive Care Plan for Resident #1 was incorporated and identified problem areas, for Resident #1 and #2, and ensured Care Plans are revised to reflect the current status and/or functional level of the resident to include resident behaviors with appropriate interventions for staff to act appropriately. Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 defined neglect as .failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute .allegations of abuse .injuries of unknown source .exploitation .or .suspicious crime .The Facility Administrator may delegate some or all of the investigation to the Director of Nursing, Medical Director, or other subject matter experts as appropriate but the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation and to draw conclusions regarding the nature of the incident .Under the heading .Investigation Guidelines .6. In cases of alleged resident abuse, the Director of Nursing or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are capable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room, confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation; however, the Administrator did not state if the staff received education or training on this issue. Continued interview confirmed they should have also interviewed other residents and staff regarding LPN #4 according to their policy. Further interview confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. The Administrator confirmed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17 and she was suspended and an investigation was completed. The Administrator confirmed the NAs knew they should have handled the situation differently by stepping back, letting the resident calm down and reapproaching. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. The Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new bruises and if a resident described an incident or person as abusive, it needed to be investigated. Continued interview with the Medical Director confirmed the facility should have followed all the steps of the investigative process including suspending the accused nurse. The Medical Director confirmed she reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and if a resident had aggressive/combative behaviors during care she expected the staff to call the Charge Nurse and not force the resident to do anything. She confirmed in Resident #1's case a fracture can happen very easily and if NA #2 had not touched her, her arm would not have been broken and if the resident was resisting that much she should have stopped care completely. The Medical Director confirmed NA #2 did not use common sense while providing care with Resident #1 and her actions could cause [MEDICAL CONDITION] (Post Traumatice Stress Disorder) type symptoms. | 2020-09-01 |
| 101 | NHC HEALTHCARE, MILAN | 445069 | 8017 DOGWOOD LANE P O BOX A | MILAN | TN | 38358 | 2019-08-01 | 610 | D | 0 | 1 | 6GVS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 2 (Resident #84) abuse incidents reviewed. The findings include: The facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy revised 12/11/17 documented, .INTERNAL INVESTIGATION POLICY .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident .The investigation is conducted immediately under the following circumstances .When it is identified that an alleged incident may have occurred .When there is a question as to whether to conduct an investigation, it is best to do so . Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #84 on 7/29/19 at 9:05 AM, in her room, Resident #84 stated, .I was left wet all night. They (staff) didn't do anything. She (Certified Nursing Assistant (CNA)) said I shouldn't be lying about her. The next night they (staff) got on to her (CNA). The third night she (CNA) kissed me in the mouth and said she (CNA) loved me. Resident #84 was asked if she knew the CNA's name. Resident #84 stated, (Named CNA #1). She works midnights . Review of an untitled facility timeline presented by the Assistant Director of Nursing (ADON) on 7/29/19 regarding an incident with Resident #84 documented, .7/18/19 .(Named Resident #84) reported the CNA from 11p (pm)-7am shift had not change her (Resident #84) properly. Patient (Resident #84) states that at approximately 2-3 am she (Resident #84) put her call light on because she (Resident #84) was wet and needed to be changed. Patient (Resident #84) stated (Named CNA #1) answered her call light. Only changed her (Resident #84) under pad and brief but did not change her wet bottom sheet .7/22/19---I (ADON) received a call from (Named Resident #84's daughter) .She (Named Resident #84's daughter) stated that her mother (Resident #84) had told her (Named Resident #84's daughter) about the incident of being wet and stated that .when (Named CNA #1) made her first round on 11-7 shift that she (CNA #1) asked (Resident #84) why she (Resident #84) lied on her (Resident #84) and said she (CNA #1) did not change her (Resident #84) appropriately .I (ADON) spoke with (Named Resident #84) who did state all of the above documented that occurred. She (Resident #84) also reported, that (Named CNA #1) cared for her (Resident #84) last night .stated when she (CNA #1) came in to check her (Resident #84), she (CNA #1) leaned over and kissed her (Resident #84) on the lips and stated 'I (CNA #1) still love you (Resident # 84)'. (Named Resident #84) stated that made her feel uncomfortable .and 'I (Resident #84) don't know why this has happened .I (Resident #84) did not lie on her (CNA #1)' .7/23/19 .(Named CNA #1) states she did change (Named Resident #84) properly. When I (ADON) questioned about her (CNA #1) accusing (Named Resident #84) of lying, she (CNA #1) stated, 'Yes, I did ask her why she (Resident #84) lied on me (CNA #1)' .Also questioned (CNA #1) about the kissing (Named Resident #84) on the lips. (Named CNA #1) stated, 'I (CNA #1) would never kiss my patients on the lips, but I do hug and kiss them on the cheek every night I work . The ADON confirmed that she had written this timeline and signed the document. Interview with Resident #84 on 7/31/19 at 8:32 AM, in her room, Resident #84 was asked if CNA #1 often kissed her on the cheek. Resident #84 stated, She kissed me on the mouth. Resident #84 was asked again if CNA #1 sometimes kissed her on the cheek. Resident #84 stated, No. Interview with CNA #1 on 7/30/19 at 7:35 AM, in the Conference Room, CNA #1 was asked what happened with Resident #84. CNA #1 stated, I went in the room and asked the patient, I'm trying to think what I said .asked patient why she (Resident #84) said I didn't change her and .why she (Resident #84) said I didn't change the bottom sheet. CNA #1 was asked if she kissed Resident #84. CNA #1 stated, On the cheek. CNA #1 was asked if she asked Resident #84 if she lied on her. CNA #1 stated, I don't recollect. Interview with the ADON on 7/30/19 at 1:46 PM, in the Conference Room, the ADON was asked about the incident with CNA #1 and Resident #84. The ADON stated, (Named Resident #84) said she (CNA #1) leaned down and hugged her (Resident #84) and kissed her on the lips and she (Resident #84) did not feel comfortable with that .Tuesday morning I came in and talked to her (CNA #1) about her (CNA #1 stating Resident #84) lying on her. She (CNA #1) admitted that she had said that .I then talked about the kiss .(CNA #1) said she .hug them and kiss them (residents) on the cheek . The ADON was asked when she typed up the untitled timeline. The ADON stated, .I completed it yesterday when you asked for it . The ADON was asked if any other residents were asked about CNA #1. The ADON stated, I did not. The ADON was asked if any staff were questioned about CNA #1. The ADON stated, I did not question any staff. The ADON was asked if Resident #84 had ever accused staff falsely. The ADON stated, Not that I'm aware of . The ADON was asked according to their policy, what should be done when there is an allegation of neglect or abuse. The ADON stated, An investigation should be conducted immediately. Interview with the Director of Nursing (DON) on 7/30/19 at 2:59 PM, in the Conference Room, the DON was asked if an investigation had been done about the incidents with Resident #84. The DON confirmed there was no investigation. | 2020-09-01 |