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 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 240 | K | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, medical record review, resident family interviews and staff interviews, it was determined that the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. Specifically, several residents are forced to live in bed in their rooms for three to four days each week due to the lack of a sufficient number of Geri-chairs and/or other assistive devices needed to accommodate them when out of bed. The facility implements a rotating schedule which allows on average, two residents to be out of bed in Geri Cairs on alternating days. Those residents who are gotten out of bed most frequently are those described by staff as physically most active or most cognitively intact. In effect, these residents are confined in their rooms in bed for a significant portion of every week. This is a quality of life issue with the potential to affect the resident's physical, emotional, and psycho-social well-being. The findings are: 1. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident is alert and cognitively intact. She has a history of uncontrolled blood glucose levels and a history of falls, with severe injury sustained in her room on 7/11/10 while attempting to self toilet. Observations conducted by the survey team reveal that this resident was left socially isolated and without adequate assistance from staff for 3 of 5 survey days. During a tour of Unit B conducted on 8/19/10, at 9:30 A.M. this resident was observed in her room, alone and in bed. At 10:45 A.M., the resident was observed to still remain in bed. At Approximately, 12:10 P.M., after completing the tour and while walking along the corridor of unit B in the direction of the Nursing station, the surveyor heard resident #1 calling for help. The resident was calling in a loud voice, help!, Help!, will somebody please help me. The surveyor observed that there were no staff present on the unit to hear or respond to the resident's call for help. As the surveyor entered the resident's room, the resident was observed to still be in bed. The resident stated Oh thank you, I really needed somebody to come help me. Thank you. I can't eat, I need help and I need to go to the bathroom first. I've been calling and calling and no one comes. It's like this every day. They just leave me here. I can't ever get anyone to help me. When asked why she was still in bed and not having lunch in the dining room with the other residents, she responded , no one came to get me up. Sometimes they do but not every day. The surveyor found a nurse on Unit A to assist the resident. On 8/20/10, at 10:20 a.m., Resident #1 was observed again in her room in bed. The resident was alone. On 08/20/10 at approximately 5 PM, upon approaching the resident ' s room, the surveyor heard resident #1 calling for help. On entering the resident ' s room, the surveyor observed the resident was sitting in bed, the side rails up, with a tray table across the bed. The following items were on the tray: a container of milk, a vegetable dish, a cup of juice, an 8oz cup of hot coffee, bread, and approximately 3 large stuffed Ravioli pasta shells. The resident was attempting to feed herself; she appeared to be struggling to cut the Ravioli. She was experiencing difficulty getting the food from the plate to her mouth which resulted in it spilling on her lap and on the bed. The resident shared with the surveyor, that it is difficult for her to get help from the staff and when asked about the meals, the resident stated The food usually tastes good but it was hard today. She went on to say, It is a good thing you were here today, otherwise I would not get to eat; I would still be fighting with it. The surveyor noted that after the food was cut into pieces, placed in the spoon for the resident , and the resident was cued that the food was on the spoon, she was able to continue to feed herself. An interview was conducted with a staff nurse (Registered Nurse) assigned to resident #1 immediately following this observation. The nurse was asked why the resident was receiving her dinner in her room, and she replied that she was not sure why. When she was asked to describe the resident ' s ADL needs specifically related to eating; she stated the CNA has to set-up her tray . When the nurse was asked, does resident #1 need assistance with cutting her food setting up she acknowledged that she should have the food cut for her. A review of the Registered Dietician's initial nutritional assessment notes found in the resident's medical record and dated 07/22/10 reveals that the resident requires Partial assist; type- set up, monitor- may need to be fed . Appears more confused, not getting out of bed much yet History of uncontrolled blood sugar. The Resident 's blood glucose levels are directly affected by her oral intake. Her Diabetic status has an impact on her overall quality of life. She requires close monitoring and facilitation of adequate food consumption. The resident's recent fall while attempting to self toilet resulted in a [MEDICAL CONDITION] which has affected her ability to ambulate and has affected her overall quality of life. 0n 8/24/10, after the survey team brought to the facility's attention the lack of monitoring, social interaction and assistance given to this resident , The resident was observed to have been taken out of her room and placed with the larger resident population. It was also noted that she was receiving assistance during meals as needed. Resident #2 is a [AGE] year old female diagnosed with [REDACTED]. The resident was admitted to the facility 0n 6/15/09. Minimum Data Set (MDS) assessments dated 6/15/09 and 6/15/10 indicate the resident is severely cognitively impaired and requires extensive assistance for bed mobility, transfers and ADLs. The resident is tube fed. Weights recorded on Nutritional Assessments indicate the resident's weight fluctuates between 76-84 lbs. Monthly Nursing Summaries from 9/2009 through 6/2010 describe the resident as alert and well-adjusted, has intact hearing and visual acuity, but does not speak, and does not attend activities on a daily, weekly, or monthly basis. The resident resides in a two-person shared room . Although her roommate is verbally responsive and physically active, she was not observed on any survey day to interact with resident #2, and according to Nursing staff, prefers to be left alone. Comprehensive Care Plans 6/15/09-5/17/10 identifies a problem list for resident #2 that includes: 1. allergies [REDACTED]. Geri -chair 3. Hypertension 4. Inability to make needs known 5. Potential for alteration in nutrition 6. Potential for alteration in respiratory status 7. Skin break down 8. Social Isolation Care Plan interventions include: 1. Requires Geri-chair to be out of bed. 2. Provide opportunities for Socialization daily: a) Out of room b) Take to lounge for socialization c) Involve in activities A Risk Predictor for Skin Breakdown Assessment form categorizes the resident as at high risk with a score of 10. The resident currently has multiple pressure sores including a Stage 3 at the right hip, Stage 3 at the left hip, a Sacral ulcer, Stage 3, and toe wounds. The initial nursing admission assessment for 6/15/09 documents only stage 2 pressure sores at the buttocks, left shoulder and earlobes. Rehabilitation Screening Forms dated 7/13/09, 9/14/09, and 7/1/10 indicate the resident is non-weight bearing and requires a wheelchair for mobility and transfers. Recommendations for other adaptive devices include a Geri-chair. An initial recreation assessment documented on Activity Progress Notes dated 6/15/09 reads R.T. (Recreational Therapist) met with this [AGE] year-old female in her room during P.M. hours. Pt. was in bed in an upright position, looking around the room; is unresponsive, disoriented x3, requires maximum assistance for ADL care, and with attending activities. Being that pt. is unresponsive and disoriented x3 to time, place and person, sensory stimulating activity would benefit her the most. Soft music, touch therapy, aroma therapy would benefit her the most .RT will also try to get her up in a Geri-chair 2-3 x weekly. A recreational Services Treatment Plan dated 9/21/09 documents in the questionnaire section that the resident is unable to speak . The rest of the assessment including a section identifying possible barriers to leisure programs is blank. No interventions are recommended for Physical Therapy, Occupational therapy or Speech therapy. Documentation on Activity Assessments for 9/28/09 -6/17/10 indicate the resident has psychosocial needs for sensory stimulation, is unresponsive to one to one programming, responsive to one to one visits, and prefers to be out of room. The resident is said to enjoy small groups, enjoys visits with family and friends, but is unable to make needs known. She is described as dependent on others for wheelchair support and requires assistance to attend activities. . Social Services documents on a Social Services Quarterly Summary on 9/23/09 that the resident appears to hear, but with variable response. A recent Nursing Readmission assessment dated [DATE] documents the resident does not ambulate and does not respond verbally, only at times when her daughter and grandson visits. A Review of Nursing Notes, Monthly Summaries, CNA documents including the Resident's Turn and position logs as well as interviews with staff revealed that from 6/7/10 until 8/25/10 the resident spent a total of 68 days confined in bed. In June 2010, the resident was maintained in bed for of 19 of 30 days. From 6/7/10 until 6/14/10 , the resident was left in for bed 7 consecutive days; from 6/16/10, until 6/25/10 she was left in bed for 9 days and from 6/27/10 through 6/30/10, left in bed for 3 days. Nursing and CNA documentation for July, 2010 reveals that the resident was left in bed for 26 of 31 days and spent 23 days in bed in August 2010. The resident was closely observed by the surveyor throughout the survey from 8/19/10 through 8/25/10. These observations revealed that the resident makes direct eye contact, is able to look around her environment, is responsive to tactile stimuli, responsive to painful stimuli, and cries when emotionally painful subjects like her mother, daughter and grandson are discussed. The resident was observed to spend all day on each survey day ( 4 of 5 days) in bed. Staff interactions with the resident were limited to providing AM. and P.M. care, medication administration, and wound care. The resident was not observed to be in daily activities programs or other resident social activities. The resident was not observed to have visitors. The resident's roommate was observed to not attempt to interact with the resident in any way. Interviews were conducted with CNA and Nursing staff responsible for care of this resident on both day and evening shifts, were conducted with housekeeping staff responsible for cleaning the resident's room and with the resident's family by telephone contact. On 8/19/10 during the initial facility tour, resident #2 was identified by a staff nurse as one of eight residents who do not get out of bed very much. According to the nurse, We don't have enough Geri.-chairs to get everyone up at the same time. On 8/19/10 during interview with a CNA at 10:30 a.m. regarding the resident's in bed status, the CNA explained that the resident had to stay in bed because we don't have a chair to put her in. We had some more, but they broke, we had three but now we only have two. the other one we can't use because the back drops down and the residents would get hurt. A second CNA interviewed at 11:30 a.m. told the surveyor that the resident spends most days in bed. She used to be up more, but not now. She needs a chair and we don't have one for her. At 4:00 P.M. on 8/20/10, an interview was conducted with a CNA working the evening shift and caring for resident #2. This CNA stated She hasn't been out of bed in a long time. We don't have enough chairs for her. We need new Geri-Chairs, the other ones broke. They (the residents) have to take turns to get up On 8/19/10, the Director of Nursing (DON) was interviewed at 1:00 P.M. and when asked about the facility's supply of Geri- Chairs, stated There aren't enough for everyone who needs one. We have to use a rotating schedule. We keep a schedule of who is supposed to get up every day. They have to take turns. If one gets up today, then we get another resident up tomorrow. There are eight residents that we have to rotate and we only have three chairs. The DON continued explaining the administrator knows about it, and was supposed to order some more Geri-chairs but I don't know what happened, I keep asking about them. We did have more but they all broke. In response to questions about the length of time the facility has been without an adequate number of these Chairs, the DON stated for about two months. When asked about the potential for the residents currently observed in bed to be put in wheelchairs, the DON admitted that some residents might be able to use a wheel chair, but I'm not sure we even have enough of those. We don't have one that could accommodate Ms. _____. ( Resident #2) At the conclusion of this interview, the surveyors requested a copy of the Ger Chair Schedule; the DON replied, I'll see if I can find it. It should be here somewhere. Several minutes later, the DON informed the surveyor, I can't find it but I can make you one. At 3:45 P.M., the surveyor was given a document titled Geri Chair Schedule. Seven resident names were listed on this document. Resident #2 was not listed on the schedule. The seven residents listed on the schedule were observed at various times throughout each day on 8/19/10, 8/20/10, and 8/23/10. Each resident was observed to remain in bed for the entire day, on all three days. A Housekeeping staff responsible for cleaning resident #2's room was interviewed on 8/20/10 at 1:15 P.M. stated no she doesn't get up. I see her in the bed every day. I don't think they have enough chairs, the chairs are broken There are other residents too, who can't get out of bed. There is one char in the shower room but it's broken. A telephone interview was conducted with the resident's mother on 8/23/10. During this interview the Mother explained that resident #2 used to be outgoing, loved being outside, loved going to the beach because she loved the water and she likes being with people. I think she recognizes me when I visit her. The Mother admitted that she has never seen the resident out of her room or out of bed during her visitations. No, I've never seen her out of the room. Everytime I come she's in the bed. Interviews were held with the Administrator on 8/23/10 regarding residents who were forced to stay in bed. The Administrator informed the surveyor that she was aware of the shortage of Geri-chairs and had told the CEO that new ones needed to be ordered. She said she would order some. I don' t know why she didn't. The Survey team met with the Administrator , Chief Executive Officer and Director of Nursing Services on 8/23/10 to discuss the team's observations of resident isolation, the inadequate supply of Geri-Chairs or other Assistive device needed for residents to be gotten out of bed, and the lack of recreational, Social interaction or other activity needed to prevent Physical and psychological harm to these residents. On 8/24/10, the following day, upon entering the facility, the survey team observed that with the exception of one of the residents listed on the Rotating Geri-chair log, all residents had been gotten out of bed including resident #2. On 8/24/10, the CEO informed the team that a new supply of six Geri-Chairs were ordered for immediate delivery | 2017-01-01 |
| 2 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 281 | D | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Medication adminisrration Records and Physician orders, it was determined that the facility does not assure that medication orders are transcribed in an accurate manner to ensure the appropriate doseage of medications to reisidents: The Findings are: Following obeservation of a Medication Pass conducted on 8/20/10, When the surveyor reviewed Physician order [REDACTED]. 1. An physician's orders [REDACTED].M , However, it was transcribed on the Medication Administration record as 2 units of [MEDICATION NAME] subcutaneously in the P.M. According to interivews conducted with the Director of Nursing on 8/20/10, the medication was not given to the resident erroneously because the transcription error was discovered and corrected prior to administration to the resident. The Incident Report of the transcription error dated 6/10/10, reads, the error was discovered and corrected prior to administration to the patient. The Incident report specifies that the nurse making the incorrect documentation was notified and informed of her error and teaching re-inforced regarding the need to double check all medication prescriptions. 2. A resident was prescribed [MEDICATION NAME] 2mg on 7/9/10 by the Physician, however the medication order was transcribed as [MEDICATION NAME] 20mg. on the Medication administration record. During an interview conducted with the Director of Nursing on 8/20/10 regarding this error in transcription the surveyor was informed that the medication was not given as erroneously transcribed, but was discovered by a nurse prior to administering medications. An incident report dated 6/10/10, 7:A.M., written by the nurse finindg the transcription error and which documents this occurence reads: Medication [MEDICATION NAME] transcribed incorrectly on MARS. I found this on 6/10/20 at 7:30 A.M. [MEDICATION NAME] was ordered as 2mg, transcribed 20mg ; Corrected MAR immediately. Error was reviewed with Ms._______ (nurse) and the importance of double checking all medications transcribed was re-inforced. Interviews were held with the Director of Nursing regarding both transcription errors. The Nurse responsible for writing the errors was not available for interview, however, according to the Director of Nursing Neither incorrect dose was given, the Nurse who came after was reviewing the physician orders [REDACTED]. He knows the residents and what medications they get very well, so he re-wrote the correct doseages. | 2017-01-01 |
| 3 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 309 | G | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of resident medical records and facility policy and procedures, it was determined that the facility failed to ensure that each resident received the necessary care and services to manage pain. The facility does not have a formal system in place for pain management. This was evident for 2 of 10 residents who were observed to not receive medication for pain prior to , during , or immediately following wound care. The Findings are: 1. Resident #1 is a [AGE] year old female with [DIAGNOSES REDACTED]. The resident had a fall on 7/11/10 which resulted in a right [MEDICAL CONDITION] and a Total Hip Replacement (Hemiarthroplasty). The resident has a history [MEDICAL CONDITION] the soles of her feet. Although [MEDICAL CONDITION] healed, the resident's nursing documentation indicates the resident continues to experience tenderness at the burn sites. On 08/23/2010 @ approximately 2:20 p.m., a dressing change of the residents right heel was observed. The nurse performing the dressing change, was observed to check the doctor's order, sanitize her hands and then gathered supplies. As the old dressing was being removed, the resident groaned audibly. She was heard to groan twice. The Nurse (RN) performing the dressing change, did not pause or stop the procedure. She did, however, acknowledge the resident's painful response by saying to her I am sorry honey and continued with the wound care. She did not stop to assess the severity of the resident's pain and she did not offer the resident pain medication. When the surveyor asked the RN if the resident had received pain medication prior to the dressing change she replied, I am not entirely sure she if she has pain medication ordered. An interview was conducted immediately following the dressing change with this nurse. The nurse was asked why she did not stop, assess or offer the resident pain medication when the resident clearly was experiencing pain. She replied, She only does that when you are messing with her foot. The nurse was asked under what conditions would she give the resident pain medication. She answered, I would give it, if she asked for it. Review of the Physician orders [REDACTED]. 1. Tylenol 650 mg Q4HR PRN for pain or Temp 100 PO, 2. [MEDICATION NAME] 5/500 mg Q4HR PRN PO. The facility's Policy and Procedure for Treatment and Dressing Changes includes instructions to : Ask if the resident would like pain medication prior to treatment Review of a Wound Care Protocol revealed that the procedural Instructions only address Stage III Decubitus. The last sentence in those instructions for a Stage III Decubitus reads: Medicate for pain relief if indicated prior to treatment 2. An LPN was Observed to prepare for and perform a Stage 3 Sacral wound treatment on 8/24/10 at 3:40 P.M. A CNA ( Certified Nursing Assistant) was in attendance at the resident's bedside. In preparation, the nurse removed a roll of tape from the treatment cart, cut several strips of tape from the roll and stuck the cut strips to the residents bedside table. The nurse was then observed to take a blue Chux pad, handed to her by the CNA assisting with the treatment, removed a used pair of scissors from the wound treatment cart and used this scissor to cut the Chux in half. One half of the Chux was placed onto the resident's bedside table. The nurse then proceeded to the resident's bathroom to wash her hands. After donning gloves, the nurse removed a bottle of Normal Saline from the top of the treatment cart, opened the cap of the Normal Saline bottle, and placed the bottle onto the Chux draped bedside table. Several sterile guaze pads (4x4's) were placed onto the Chux . The nurse poured Normal Saline onto the guaze, removed a box of gloves from the treatment cart, and placed the box onto the Chux draped table. A clear plastic bag, taken from the treatment cart , was taped onto the resident's bedrail. The nurse was observed to then remove her gloves and proceed to the bathroom to wash her hands. After returning to the resident's bedside, the assisting CNA and the nurse re- positioned the resident, and the nurse removed the resident's Attends brief. Fecal matter was observed on the Attends brief. The soiled Attends brief was placed into the plastic bag hanging on the residents bedrail. Old dressings, saturated with purulent drainage, were removed from the wound site and discarded into the clear plastic bag taped to the resident's bed. The nurse stopped the treatment , cleansed the resident's buttocks and entered the residents's bathroom where she was observed to wash her hands for 8 seconds. Upon returning to the resident, the nurse put on a new pair of gloves, poured Normal Saline onto the Chux draping the bedside table, picked up a previously Normal Saline soaked guaze and began to use to the guaze ( in a patting motion) to soak up the Normal Saline just poured onto the Chux. The nurse proceeded to use this guaze to cleanse the sacral wound. This procedure was repeated six times. Following this cleansing method, the nurse was observed to pick up a previously soaked Normal Saline guaze, dip it into the pool of Normal Saline previously poured onto the Chux pad and to use this guaze to pack the wound site. She was observed to cover the site with a dry guaze taken from the Chux pad. After applying tape to the site, the nurse removed her gloves and then entered the resident' bathroom to wash her hands. She was observed to wash hands for 6 seconds. The CNA, who was not wearing gloves, disposed of the clear plastic bag which contained the old dressings, and soiled Attends brief. During these dressing changes, the resident was observed to frequently blink her eyes rapidly, particularly during the sacral wound treatment, and to become very diaphoretic. When the nurse was asked if she thought the resident was experiencing pain, The nurse replied, no, I don't think she's in pain. When asked if the resident had been medicated for pain prior to wound care, the nurse responded, no, I do her dressings all the time and I never had to medicate her before. A review of the resident's medical record conducted after the wound care observation revealed Nursing and Social Worker documentation indicating that the resident elicits response to painful stimuli. A Nursing Note dated 6/7/10, reads She does not respond to verbal commands, but she does respond to painful stimuli by making sounds. Social Services documents on a Social Services Quarterly Summary 12/16/09, Patient is non-verbal and not responsive though there are facial expressions that indicates pain and discomfort. Upon review, Physician order [REDACTED]. The Medication Administration Record [REDACTED]. When this concern was communicated to the Director of Nursing Services on 8/2410, an order for [REDACTED].> | 2017-01-01 |
| 4 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 311 | D | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations , resident and staff interviews and review of the the resident's medical record, it was determined that the facility failed to ensure that a resident receives appropriate treatment and services to maintain or improve her abilities to achieve and maintain the resident's highest practicable outcome. The Findings are: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/20/10 at approximately 5 PM, upon approaching the resident ' s room, the surveyor heard resident #1 calling for help. On entering the resident ' s room, the surveyor observed the resident was sitting in bed, the side rails were up, and a bedside table was positioned across the bed. A food tray was on this table . The following items were on the food tray: a container of milk, a vegetable dish, juice, 8oz cup of hot coffee, bread, and approximately 3 large stuffed Ravioli pasta shells. The resident was attempting to feed herself. she was struggling to cut the Ravioli. She was experiencing difficulty getting the food from the plate to her mouth which resulted in it spilling on her lap and on the bed. An interview with the resident was conducted at the time of this observation. The resident shared with the surveyor, that it is difficult for her to get help from the staff. When asked about the meals at the facility, she replied, The food usually tastes good but it was hard today. She stated, It is a good thing you were here today, otherwise I would not get to eat; I would still be fighting with it. The surveyor noted that after the pasta was cut into pieces and placed in the spoon for the resident , and the resident was cued that the food was on the spoon, she was able to pick up the spoon and to feed herself. At the time of this observation the resident appeared to have a very good appetite and ate approximately 80% of her meal. An interview was conducted with a staff nurse (Registered Nurse) assigned to resident #1 immediately following this observation. The nurse was asked why the resident was receiving her dinner in her room, and she replied that she was not sure why but the resident is known for wanting to stay in her room. When she was asked to describe the resident ' s ADL needs specifically related to eating; she stated the CNA has to set-up her tray. When the nurse was asked, if resident #1 needed assistance with cutting her food, she acknowledged that she should have the food cut for her . Resident #1 has a history of uncontrolled blood sugars. Her blood glucose levels are directly affected by her oral intake. The facilitation of adequate food consumption in significant for this resident. Her Diabetic status has an impact on her overall quality of health. A Registered Dietician's initial nutritional assessment notes dated 07/22/10 in the Eating Ability section reads: Partial assist type- set up, monitor, may need to be fed . On the same document in the Summarize Nutritional Findings section, the following statement is included: Appears more confused, not getting out of bed much yet. The summary documents: History of uncontrolled blood sugar. 0n 8/24/10, after the survey team brought to the facility's attention, the observed lack of monitoring and assistance given to the resident during meals, it was observed that resident #1 was taken out of her room for lunch and placed with the larger resident population. It was also noted that she was receiving assistance with meals as needed. The facility failed to ensure that resident #1 was provided with needed assistance in order to promote independence with self feeding. | 2017-01-01 |
| 5 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 323 | L | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, and staff interviews, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible, and each resident receives adequate supervision and assistive devices to prevent accidents . This finding incorporates both environmental and quality of care practice. The environmental finding has the potential to place all residents in the facility at risk and constitutes Immediate Jeopardy. The Findings are: 1. The facility is a 40 bed SNF/NF facility built on a mountain top. One wing of the facility lacks a safe means of egress for evacuating residents in an emergency. The exit doors leading from this wing open onto a steeply sloped incline with a narrow cemented walkway which runs alongside the mountain cliff. The walkway does not have protective rails or barriers of any kind. Any resident wandering in this area who has an unsteady gait or makes a misstep is at risk of falling off the mountain cliff. This walkway is easily accessed from two other exit doors. Additionally, the facility has a number of residents who were identified as wanderers. Several residents were observed to wander outside of the building unattended by staff on various days of the survey from 8/19 through 8/25/10. One resident was observed taking a walk unattended on 8/20/10, at approximately 2:00P.M., and one resident was observed to sit outside of one of the exit doors unattended at various times throughout the day on all survey days. Meetings were held with the Facility owner, the Chief executive Officer, the Administrator and Director of Nursing Services on 8/19/10 at 12:35P.M. to discuss the Immediate Jeopardy findings. The Owner immediately arranged to correct this problem. On 8/20/10 at 11:00A.M. a construction company was observed on site preparing the grounds for construction. The construction includes the following: 1. Construction of a safety concreted ramp leading from the exit doors to the walkway. 2. Expansion of the walkway. 3. A safety Barrier along the walkway. 2. Based on interviews and review of medical records, it was determined that the facility failed to appropriately supervise one of ten sampled residents who sustained a fall and resultant hip fracture which required surgical intervention and pain management. This deficient practice is evidenced by the following: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. As a result, the resident required a Right Hip Hemiarthroplasty ( total right hip replacement). The Minimum Data Set Assessment for mobility and transfer reveals that the resident requires supervision and personal assistance for transfers and ambulation. The resident's April 2010 Fall Risk Assessment identified her as a high risk for falls with a score of 13. According to the instructions on the Falls Risk form, a total score of 10 or above represents a high risk. A review of the facility ' s report of this Incident revealed that on 5/10/10 at 3:15 P.M., this resident fell out of her wheel chair in the lounge. The Incident report documents there were no witnesses to the incident. The report also reveals that no follow-up investigation of the incident was planned, the resident's next of Kin was not notified, and no visible injury sustained. The resident's Care Plan for falls specified that fall assessments should be done quarterly and PRN. There was no evidence of re-assessment of the resident or revision to the care plan following this incident. The CNA Care Plan for the resident also did not reflect any revisions. A second incident report dated 7/11/10 at 6:30 PM, documents that the resident was found on the floor of the bathroom in her room. Section D of the Incident Report, records: The resident was at high risk for falls. She was admitted with burns to her feet and was unable to ambulate for several months. Once her feet were healed, she wanted to ambulate, but she was very weak and required a walker with assist of one. Interviews conducted on 8/20/10, 8/23/10, and 8/24/10, with the Activities Director, Dietician, CNA's, and Nurses from various shifts, confirmed that staff were aware of this resident's risk factors and need for assistance with transfers, ambulation and toileting. Three of the staff members noted that these requirements are the same as when she was a new admission. In an interview with the surveyor on 8/24/10 at 1:20 PM, the Director of Nursing (DON) acknowledged that a falls risk re-assessment should have been done after the May 2010 incident, as well as revisions to the care plan prior to the second fall on 7/11/10. When the resident's care plan was reviewed on 08/24/10 , no new interventions for fall prevention had been added. The facility ' s Policy and Procedures on Fall Prevention, Revision date April 23 2010, reads under section #2 as follows: ? Assign resident to be monitored frequently to prevent falls. ? Apply bed and chair alarms to alert staff when resident is moving. The curriculum used as a part of the facility's mandatory in-service training on fall prevention (given quarterly) provides the following instructions: Interventions for fall prevention ? Never leave at risk residents unattended ? Wander guards on wrist or ankle ? Bed alarms when resident is getting out of bed. There was no evidence that these interventions were implemented for resident #1 on admission, or after the May 2010 fall, nor after the 07/11/10 fall when the resident sustained [REDACTED]. | 2017-01-01 |
| 6 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 431 | D | 0 | 1 | MZE911 | Based on observations and staff interviews conducted during a Direct Survey it was determined that the facility did not ensure safe and secure storage of narcotics and emergency drugs, including the appropriate disposition, of drugs. This had the potential to affect all residents on both nursing units. Findings include: On 08/19/10 during the tour of the medication room, in the presence of the Director of Nursing (DON), the facility 's emergency box was noted to be unlocked, but was checked as locked on the medication log. When asked about this discrepancy, the DON stated It is my fault; the box is usually checked at the start of the shift by the day nurse. I saw the check mark made by the nurse at the lock not present column but I crossed it out. She did not give an explanation for why she had done this. A review of the contents of the emergency box revealed discrepancies between what the box contained and what ws transcribed on the log sheet . The following discrepancies were observed for the following medications: [REDACTED] 1. Glucagon Injection: the Emergency Medication log lists 7 but only 4 were in the box. 2. Phenergan Suppository: the Emergency medication log listed 6, but none were in the box. 3. Benadryl 25 mgs PO tabs: a bottle of 10 tablets was in the box, but not listed on log. 4. Epinephrine: the Emergency medication log listed 3 but only 1 was in the box. During an on-the-spot interview, the DON acknowledged that the count and content of the box should reconcile. On 8/19/10 at 3:15 p.m., a review of the narcotics record revealed that the narcotic medication count did not reconcile. The findings included: 1. The balance listed on the record for Ativan 2mg/cc Intramuscular was 1.75cc , the actual balance was 9.75cc. The narcotic sheet did not have an amount entered in the area designated as amount received from pharmacy. During an on-the -spot interview, the nurse was asked to explain the discrepancy related to the Ativan , she replied I believe that the individual signing out the Ativan mistook the 2mg/1cc and thought the vial was 2cc. 2. A bottle of Morphine Sulfate Elixir 20 mg/ml: a bottle with a 118.5 cc was observed in the narcotics cabinet and was accounted for on the narcotic log; however, the nurse informed the surveyor that this resident was no longer in the facility and, in fact, had been gone since 08/13/10. She stated that she was unsure why the bottle was still in the cabinet and acknowledged that this medication should have been returned to the pharmacy or disposed of. | 2017-01-01 |
| 7 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 441 | L | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations of the facility environment, observation of nursing practices including blood glucose monitoring practices, medication administration procedures, storage of biologicals, storage of patient care equipment and products, wound care treatments, as well as information revealed in resident and staff interviews, and facility policies and procedures, it was determined that the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The findings are pervasive and systemic and have the potential to affect all residents on many levels and constitutes Immediate Jeopardy. The Findings are: 1. During the general tour conducted of the facility on 8/19/10 the following was observed: a) A storage room, identified by nursing as the clean utility room contained several metal shelves. An old, dirty mattress was on the floor and propped against one of these shelves. According to the nurse accompanying the surveyor on tour, We sometimes have used that mattress for patients in the past. I don't know why it's in here or when it was last used. Several plastic expandable air mattresses were observed on the top shelf rack. One half of this shelf was labled Dirty Mattresses, the other half contained several mattresses which the nurse identified as clean. Another shelf contained several packages of adult Attends briefs. Two of the packages were opened and exposed to air, 10 individual briefs were not enclosed in packaging, but lay directly on the shelf. Dust was visible on this shelf. A large torn, plastic bag containing air mattresses was also observed on this shelf. A layer of dust was visible on the plastic bag. The mattresses were identified by the nurse as clean air mattresses. b) The medication room contained a refrigerator identified as the medication refrigerator. When inspected, the refrigerator thermometer showed a measurement of 60 degrees Farenheit. The contents of this refrigerator included three 10 cc vials of Insulin, [MEDICATION NAME] 100u/ML, [MEDICATION NAME] 70/30 100 Units/ml. and Insulin [MEDICATION NAME] R. Each of these vials were opened and according to the RN in attendance, were currently being used for medication administration. An uncovered bowl of applesauce, which according to the nurse, is generally used for medication administration was observed on a shelf of the refrigerator c) A dirty, 16 ounce plastic alcohol bottle containing a green colored liquid which the nurse described as the solution the nursing staff uses to cleanse the glucose monitors was observed on the counter of a cabinet. The label on the bottle was dirty. The label was dated 3/30/10. d) 3 large (lb.) red plastic jars containing Protein Whey powder were observed on a counter. In front of these were 3 smaller plastic bottles, (approximately 1000 cc containers) , with dirty labels containing protein whey powder. According to the nurse and dietician interviewed immediately following this observation, The protein whey is is received by the facility in the large containers and the nurses fill the smaller bottles with the Protein Whey powder each morning. Both the nurse and Dietitician admitted that there was no specific procedure for sanitizing the smaller plastic Bolles before they are filled or re-filled. 2. A Registered Nurse was observed administering medications on 8/20/10. During this observation the nurse was observed to not sanitize her hands either by handwashing or by use of a [MEDICATION NAME] gel sanitizer before and after each resident dose. The nurse was observed to drop a vial of medication onto the floor, to pick up the medication vial From the floor and to place the vial back into the medication cart. She was not observed to sanitize the vial before replacing it on the cart. She was not observed to wash her hands after picking up the vial from the floor, nor was she observed to wash or sanitize her hands before giving the next medication dose. 3. Two nurses, an LPN and an RN were observed performing the narcotic count on 8/20/10, at 3:45 P.M. The nurse (LPN) counting the medications was observed to spill several tablets of a medication onto the medication cart, pick up the spilled tablets with her bare hands and to put those tablets back into the medication vial. 4. During the tour of the medication room conducted on 8/19/2010, the Director of Nursing (DON) reported to the surveyor that one Glucometer, one container of test strips, and one lancet Pen device is used to test the blood glucose level of all the diabetic residents in the facility. The Ultra One Touch bottle, which was in a tray with the Glucometer, had a red blood smeared stain on it. The Director of Nursing (DON), identified a 16 oz dirty, white plastic bottle, (which upon observation looked like a used Rubbing Alcohol bottle), as the container used to hold the disinfectant solution that is used to clean the blood glucose testing equipment. Written in black on the bottle was Disinfectant Cleaner , there was no other labeling on the bottle. The date on the bottle, also written in black, read 3/30/10. When the Director of Nursing (DON) was asked, who prepares this solution? She replied, it is prepared by the Maintenance Director. 5. On August 19, 2010 at 4:20 p.m., a Registered Nurse (RN) was observed performing a fingerstick on resident #1. The nurse brought a plastic tray that contained a sharps container, Insulin syringes, the glucometer, lancet pen, 2x2 uncovered white gauzes, 2x2 alcohol pads, and a specimen container that had a clear green liquid with a yellow paper label affixed to it that read disinfectant cleaner. During the procedure, the nurse was observed to remove a test strip from a blood smeard container and to use the strip for blood sampling of the resident. 6. On August 19 2010, between 4:50 p.m. and 5:15 p.m., immediately following resident #1's blood glucose testing, the Registered Nurse (RN) was observed to carry the same equipment into resident #5's room and perform his blood glucose test. 7. During an interview conducted on the morning of the 8/23/10 with the facility ' s Maintenance Director, the Maintenance Director acknowledged that he prepares the solution used by the nursing staff to clean the glucose monitoring equipment. When asked how he prepares the solution? He stated I usually mix half and half: Half solution of DC Forward, a Disinfectant/Bactericidal liquid, and half water, then I pour it into the small 16 oz bottle for the nurses. He continued by stating, that the same solution is used for cleaning/disinfecting wheelchairs, the glucose monitor, tables and emesis basins. He stated that the decision as to whether the ? and ? proportion is used depends on the size of the equipment; if the area is large, then 3 quarts water to 1 quart solution is used. This method of cleaning equipment contradicts the manufacturer ' s instructions for the use of the cleaning solution, and does not ensure proper sanitization or disinfection. 8. On 8/23/10 at 1:30 p.m, an observation was made of an RN staff nurse conducting a fingerstick. She was observed to check the doctor ' s orders, gather the shared glucose monitoring equipment, wash her hands, and put on gloves. She was observed to wipe the exterior of the glucometer and the opening to the lancet Pen device using gauze that had been immersed into a green liquid, inside of a specimen container. After obtaining the blood glucose level of the resident, she disposed of the lancet in a Sharps container and threw away the test strip. After washing her hands, she returned the equipment to the tray and carried it back to the Medication room. During an on-the-spot interview, she was asked how long had she been using the single glucometer and lancing pen for more than one resident? She stated that she has been working at the facility for 2 years and for the past 2 years it was always done in the same way. When she was asked, how long has she been sanitizing the equipment using this method? She stated that this method of sanitizing has been used at the facility for about 1 year. She stated that the mixture is done by the Maintenance Director, and provided to them approximately 2 -3 times per week. When asked specifically about what type of container is used, she acknowledged that the 16 oz Alcohol bottle was used until the recent change to the specimen container. 9. During an interview conducted on the afternoon of the 8/24/10 in the resident ' s library, with one of the In-service Instructor ' s , the in-serviice instructor acknowledged that no specific inservice training had been given nursing staff related to sanitizing or disinfecting the glucose testing equipment (glucometer and Pen). The facility ' s policy and procedure on Glucometer Cleaning, with revision date of 3/29/2010 reads: Procedure for Cleaning: 1. Clean exterior surface of monitor and pen, after each patient with damp gauze and a facility approved disinfectant 2. Glucometer must be turned off before cleaning 3. Do not use solvents These instructions are inconsistent with the manufacturer ' s recommendations which are as follows: OneTouch Ultra 2: Blood Glucose Monitoring System The manufacturer ' s directions for cleaning the meter, OneTouch UltraSoft Blood Sampler and One touch UltraClear Cap: To clean these items, wipe them with a soft cloth dampened with water and mild detergent. - Do not use alcohol or other solvent to clean the meter. - Do not immerse the OneTouch UltraSoft Blood Sampler in any liquid. - To disinfect these items, prepare a solution of one part household bleach to ten parts water. 10. Glucose Monitoring practices of an LPN obtaining blood samples for four residents was observed on 8/20/10 at 11:40 A.M. During these performances , the following was observed: a) After obtaining a blood sample and measurement reading, the nurse was observed to place an uncleaned pen device onto the resident's unprotected bedside table , observed to pour a disinfectant solution used to cleanse the monitor onto a 4x4 guaze from a urine specimen cup, and to use this guaze to swab both the lancet pen device and the face of the monitor. b) After obtaining a blood sample the nurse was observed to obtain a disinfectant solution from a urine specimen cup, poured a small amount onto a 4x4 guaze and used this guaze to swab the pen device and glucose monitor. c) The nurse obtained a lancet from the vial containing lancets. While attempting to insert the lancet into the lancet pen device, The nurse dropped the unprotected lancet onto the the resident's bed, picked up the lancet, inserted it into the pen and punctured the resident's finger; a disinfectant solution, used to cleanse the monitor, was poured onto a 4x4 guaze pad from a urine specimen cup. d) The nurse was observed to enter the resident's room, wash hands, and to don gloves. The nurse placed a monitoring strip into the glucose monitor. The monitor fell into a plastic supply tray. After retrieving the monitor with the stirp still attached, the nurse was observed to pick up the lancet puncture device. The puncture device did not have a protective cap. The nurse attemepted to put the lancet into the puncture device but dropped the lancet onto the resident's legs. She was observed to pick up the lancet. insert it into the lancet pen and proceeded to perform the puncture. e) An LPN was Observed to prepare for and perform a Stage 3 Sacral wound treatment on 8/24/10 at 3:40 P.M. A CNA ( Certified Nursing Assistant) was in attendance at the resident's bedside. In preparation, the nurse removed a roll of tape from the treatment cart, cut several strips of tape from the roll and stuck the cut strips to the resident's bedside table. The nurse was then observed to take a Chux pad was from the CNA assisting with the treatment, and obtained a used pair of scissors from the wound treatment cart to cut the Chux in half. One half of the Chux was placed onto the resident's bedside table. Following these steps, the nurse proceeded to the resident's bathroom to wash her hands. After donning gloves, the nurse removed a bottle of Normal Saline from the top of the treatment cart, opened the Normal Saline and placed the bottle onto the Chux draped bedside table. Several sterile guaze (4x4's) were added to the Chux pad. The nurse poured Normal Saline onto the guaze, removed a box of gloves from the treatment cart, and placed the box onto the Chux draped table. A clear plastic bag taken from the treatment cart , was taped onto the resident's bedrail. The nurse was observed to remove her gloves and proceeded to the bathroom to wash her hands. After returning to the resident's bedside, the assisting CNA and the nurse re- positioned the resident, and the nurse removed the resident's Attends brief. Fecal matter was observed on the Attends brief. The soiled Attends brief was placed into the plastic bag hanging on the residents bedrail. Old dressings, saturated with purulent drainage, were removed from the wound site and discarded into the clear plastic bag taped to the resident's bed. The nurse stopped the treatment , cleansed the resident's buttocks and entered the residents's bathroom where she was observed to wash her hands for 8 seconds. Upon returning to the resident, the nurse put on a new pair of gloves, poured Normal Saline onto the Chux draping the bedside table, picked up a previously Normal Saline soaked guaze and began to use to the guaze ( in a patting motion) to soak up the Normal Saline just poured onto the Chux. The nurse proceeded to use this guaze to cleanse the sacral wound. This procedure was repeated six times. Following this cleansing method, the nurese was observed to pick up a previously soaked Normal Saline guaze, dip it into the pool of Normal Saline previously poured onto the Chux pad and to use this guaze to pack the wound site. She was observed to cover the site with a dry guaze taken from the Chux pad. After taping the site, the nurse removed her gloves and then entered the resident' bathroom to wash her hands. She was observed to wash hands for 6 seconds. The CNA, who was not wearing gloves, disposed of the clear plastic bag which contained the old dressings, and soiled Attends brief. During this procedure, the nurse was not observed to wash hands effectively, was not observed to maintain aseptic technique when preparing the field, was not observed to maintain asepsis when cleansing the wound site or with packing of the wound, did not change gloves and wash her hands after cleaning the site and before the application of new dressings and the CNA was not observed to glove when handling contaminated items. Additionally, the nurse was not observed to sanitize the used scissors before replacing it to the wound cart. The treatment cart was identified as the cart containing all supplies used with all residents requiring wound care. On 08/23/2010 @ approximately 2:20 p.m., the dressing change of resident #1's right heel was observed. The nurse conducting the dressing change was observed to check the doctor ' s order prior to starting, sanitized her hands and then gathered the supplies for the dressing change. As the old dressing was being removed, the resident groaned audibly two times. The Registered Nurse (RN) performing the dressing change did not stop the procedure. She did, however, acknowledge the resident ' s pain by saying to her I ' m sorry honey and continued with the wound care. She did not assess the severity of the resident ' s pain and no pain medication was offered. When the surveyor asked the RN if the resident had received pain medication prior to the dressing change she replied, I am not entirely sure she has pain medication ordered. After removing the soiled dressing, the nurse removed her gloves, donned clean gloves, cleansed the right heel with a gauze soaked with normal saline, and then covered the wound with 4x4 gauze. She placed the resident ' s heel on the bed, and removed her gloves. She then, stepped out of the room into the corridor and went to the treatment cart where she removed a roll of kerlix gauze. She re-entered the resident ' s room, donned clean gloves and wrapped the resident ' s heel with the kerlix. The nurse placed the soiled dressing and the gauzed used to clean the wound in the resident ' s garbage untagged. The nurse did not wash or sanitize her hands after cleansing the resident ' s wound, before or after going to treatment cart for the additional supplies, or before securing the dressing. An interview was conducted immediately following the dressing change. The nurse was asked why she did not stop, assess or offer the resident pain medication when the resident clearly was experiencing pain? She replied, She only does that when you are messing with her foot. The nurse was asked when she would offer a resident pain medication. She answered, I would give it, if she asked for it. Review of the Physician orders [REDACTED]. 1. Tylenol 650 mg P.O. Q4HR PRN for pain or Temp 100. 2. [MEDICATION NAME] 5/500 mg P.O. Q4HR PRN Review of the facility ' s Policy and Procedures on Treatment/Dressing Changes reads: Ask if the resident would like pain medication prior to treatment The facility ' s Policy and Procedure on Wound Care Protocol reveals that there are instructions for providing pain medication for residents with Stage III Decubitus only . These instructions indicate the nurse is to : Medicate for pain relief if indicated prior to treatment A review of the facility's new hire personnel health records revealed that 6 of 10 health records lacked evidence of current screening for [DIAGNOSES REDACTED] (Mantoux/ PPD testing). i) On 8/23/10 between 12:45 p.m. and 1:10 p.m. an interview was held with the Administrator and the Director of Nursing. During this interview both acknowledged that it is the facility's practice and expectation that each staff has evidence of an initial PPD prior to hire and an annual PPD update or evidence of [DIAGNOSES REDACTED] testing and outcome. On 8/24/10 during an interview conducted with the Health Records Executive Assistant, the assistant acknowledged that 6 of 10 health records for new personnel were missing pre-employment evidence of [DIAGNOSES REDACTED] screening and test results. She stated that it is her responsibility for maintaining the accuracy of these files. When asked why the health records were missing the appropriate evidence of screening for [DIAGNOSES REDACTED]. She replied, I failed to follow up with some of the employee health records, but It is my understanding from an RN (Registered Nurse) in charge, and as a matter of fact, from more than one RN, that PPDs (Mantoux) are valid for two years. She also stated that today, however, I became aware that this practice may be controversial amongst the nurses. CDC recommendations for preventing M. [DIAGNOSES REDACTED] transmission in health care settings includes: Testing done at pre-placement, annually, after exposure to a person with infectious [DIAGNOSES REDACTED], for symptoms suggestive of TB, or upon request of the employee. Identification of infected individuals is essential for the control of [DIAGNOSES REDACTED] within the healthcare environment. Screening is to be done on an annual basis in order to (1) identify converters who are at risk for developing disease and (2) monitor the effectiveness of the institutional TB control program. Guidelines for Preventing the Transmission of [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]in Health-Care Settings, 2005 MMWR 2005; 54 (No. RR-17, 1-141) h) On all survey days 8/19/10 through 8/25/10, roaches were observed crawling along corridor floors on both unit A and Unit B, were observed crawling on the walls of the corridors of both units, were seen in resident rooms, were observed crawling along the Nursing stations and were seen crawling on a medication cart and the Medication administration Record during a medication pass observation. Six of six residents confirmed this pest problem during a group meeting held on 8/20/10 at 10:30 A.M. | 2017-01-01 |
| 8 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 469 | E | 0 | 1 | MZE911 | Based upon observations conducted on 8/19/10, 8/20/10, 8/23/10, 8/24/10 and 8/25/10 of the facility environment including hallways, resident rooms, dining rooms and care equipment, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. The findings are: On all survey days 8/19/10 through 8/25/10, roaches were observed crawling along corridor floors on both unit A and Unit B, were observed crawling on the walls of the corridors of both units, were seen in resident rooms, were observed crawling along the Nursig stations and were seen crawling on a medication cart and the Medication administration Record during a medication pass observation. Additionally, 5 of 6 residents confirmed this pest problem during a group meeting held on 8/20/10 at 10:30 A.M. During an interview held with the Maintenance Director on 8/19/2010 regarding the roach sitings, the Director acknowledged the problem of roaches and explained that the facility uses the services of a Pest control company which comes into the facility to exterminate different areas of the building each month and sometimes more frequently. Maybe the insecticide they use isn't effective or maybe we need to try another company. On 8/19/2010 at 5:330 P.M., the Maintenance Director provided the Survey team with a proposed contract for pest control services obtained from a new company. | 2017-01-01 |
| 9 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 490 | L | 0 | 1 | MZE911 | Based upon the extent of non-compliance with Federal Regulations identified during the Re-Certification Survey conducted from 8/19/2010 through 8/25/2010 it was determined that the facility is not administered in a manner that enbles it to use its resources effectively and efficiently to attain or maintain the highest physical, mental and psychosocial well-being of each resident. The Findings are: Refer to: F240 F309 F311 F323 F431 F441 F469 NFPA 101 Life Safety Code Standards K038: J K050: D K062: D | 2017-01-01 |
| 10 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 226 | G | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility complaints and investigations, and resident and staff interviews, it was determined that the facility failed to protect 1 of 14 residents (Resident #7) from physical abuse inflicted by staff and that caused the resident to sustain an injury. The findings are: Resident #7 is a [AGE] year old female diagnosed with [REDACTED]. Nursing Monthly Summary Assessments dated 7/1/2013, 8/1/2013 and 9/1/2013 indicate the resident is alert but confused, speaks incoherently, and requires assistance with transfers. The resident is non-ambulatory and uses a wheelchair. A complaint investigation dated 8/28/2013 identifies the resident as a victim of physical abuse. During review of the resident's medical record a nursing note documented on Clinical Notes dated 8/22/2013 at 5:30 P.M. were observed to read: I was made aware of a small cut to the resident's forehead. The area was cleaned ad a bandage applied; Incident report written. A second entry written for 1-3:00 A.M., reads: Met resident in bed asleep .bandage to forehead, slight swelling noted. A review of an Incident Report dated 8/22 /2013 reveals the resident sustained [REDACTED]. The incident report provides the following description of occurrence: A fight between two employees; Resident # 7 was found with a small cut to the forehead. Area was cleaned and antibiotics applied and covered with a bandage. An investigative Report dated 8/28/2013 summarizes the incident as follows: On August 22, 2013, it was reported that there was an altercation between a CNA and a housekeeper which started as a result of a resident's family member asking to have some fruit placed in the refrigerator. According to witnesses of the incident, the CNA questioned whether or not the fruit was labeled. The housekeeper said yes, they were, and felt that the CNA was harassing her. According to the LPN Charge nurse, she overheard the housekeeper asking the CNA to excuse (move away from) behind the nursing station in order for her to sweep and mop. The CNA was asked three times and refused to move until the nurse intervened and ordered her to move. The CNA left from behind the nurse's station and the housekeeper proceeded to sweep. At the same time the phone rang and the housekeeper answered it. The CNA told her not to answer the phone again and proceeded to pull the phone away from the housekeeper. In the altercation of the phone incident, a resident was physically hurt. She received a blow to the forehead which left a red mark and a small amount of swelling. The resident was immediately removed from the scene while the two staff members continued to fight. Further investigation with the evening shift revealed that both employees were arguing before the fight occurred. During an interview with the facility ' s administrator conducted 9/12/2013 at 1:15 P.M., the administrator stated that she made a thorough investigation of the incident and both parties admitted that they were fighting which is against the facility ' s policy. The fighting occurred in front of residents and Resident #7 was hurt. The administrator also stated that it is the Nursing Home's policy that fighting in the work place will not be tolerated and if a resident is hurt in the process of employees fighting, it will be considered physical abuse of that resident. The administrator stated both employees admitted to hitting the resident with the phone during the fight which caused swelling and a red mark to the Resident's forehead. The administrator also stated that she has had problems with these two employees in the past. The Housekeeping Director was interviewed on 9/12/2013 at approximately 3:00 P.M. and reported during the interview that the housekeeper involved in the fight was a problem and had been a problem for a long time. He stated the employee was difficult to manage, would not follow orders, and did whatever she wanted. He further stated that the she (the housekeeper) has been involved in a previous incident of verbal fighting that occurred with another staff member right outside of resident rooms. He stated the housekeeper was screaming out derogatory words and everyone including the residents could hear her. She thinks she can do whatever she wants because she's worked here for so long. During the resident Group Meeting held 9/10/2013, when residents were asked about incidence of abuse, one resident in the group, Resident #14 reported that about three weeks ago, he observed a fight between two of the staff that occurred at the nurse's station. An individual interview was held with Resident #14 on 9/12/2013 at 10:30 A.M. The resident reported that during the fight he witnessed between the two staff members about three weeks ago, a resident who was sitting in a wheelchair near the nurse's station was hurt when she was hit in the head with the telephone. The resident stated the staff was fighting over the telephone. He said he was not the only one to witness the incident. Everyone saw it. Personnel files of the CNA and Housekeeper were reviewed on 9/12/2013. Each file revealed a history of multiple incidents of violent verbal behavior. Disciplinary Notices that were found in the CNA's file indicate the CNA was counseled for verbal abuse and use of profanity in front of residents on several occasions from 5/10/07 through 4/28/12. On 5/14/07, the CNA was counseled and received a Letter of Warning for an act of insubordination and abusive behavior directed at a Charge Nurse occurring at the Nurses' station 5/10/07. On 11/23/09, she was counseled for verbal abuse and harassment of other employees /coworkers. On 1/27/10, she was counseled for Job and resident abandonment and on 5/31/11 she was counseled for becoming irate and verbally assaulting the Administrator during a staff meeting. A warning notice, documented by the Director of Nurses, reveals that on on 5/31/11, the CNA was on sick leave. She was, however, in the facility and decided to attend the monthly staff meeting. During the course of the discussion, she became very irate and began a verbal assault on the Administrator. I immediately informed her that her behavior was unacceptable and disrespectful to the Administrator as well as all others in attendance and would not be tolerated. She was asked to cease the behavior, but instead, her behavior escalated and her tirade of negative remarks continued. This resulted in disruption of the staff meeting. She was then asked to leave the meeting and the facility but did not do so until she was finished with her verbal assault. I have spoken with the CNA on several occasions regarding her inappropriate behaviors - specifically outbursts that have incited the staff. She has been asked to discuss any matters which she is not in agreement with instead of making negative comments or engaging in loud outbursts in the presence of everyone. In spite of this, she continues to do so. A disciplinary action notice dated 3/14/2012 documented by the Director of Nursing reveals that on 3/8/12, outside the door of a resident 's room, and within hearing distance of residents, the CNA and another housekeeper verbally abused each other with derogatory terms. Letters warning of suspension and /or termination are documented in this employee file for each incident since the initial episode that occurred in 2007. There was no evidence found in the CNA's file to indicate that either of these interventions was implemented. A Review of the Housekeeper's personnel record reveals that she was initially hired as a cook in 1998 was terminated in 1999 for insubordination and serving residents improperly cooked food (raw food), was rehired as a laundry attendant and subsequently transferred to housekeeping. She has received the following Disciplinary Action Notices since her date of hire and prior to the violent physical incident that occurred on 8/22/2013: On 2/22/1999 she was counseled for insubordination and unsafe food preparation. Documentation on a Performance Improvement Disciplinary Action Plan dated 4/8/99 indicates that on 3/26/1999 and 3/28/1999 the employee committed various food handling infractions which presented a health risk to residents. The problems have been continuous as documented on 2/22/99 and 3/23-3/24/2099. Ongoing counseling has been provided to the employee since 1/25/99. On 4/13/1999, the employee received a Personnel Action Termination Notice indicating she is not appropriate for Dietary Services. On 5/22/2001, the employee was counseled for improperly cleaning resident rooms. On 1/9/2002 the employee received a verbal warning for insubordination when she refused to participate in an investigation of resident abuse and neglect. 3/7/2002, a Suspension Notice was given the employee for insubordination when she refused to participate in an investigation of misappropriation of resident's property. 1/13/2010, the Housekeeper was counseled for a violent verbal outburst occurring within the vicinity of resident rooms. A description of this incident is reported by a witness on a document titled Afternoon Disturbance and reads Yesterday, while completing some work on the computer in the MDS room, I heard some loud noise coming from outside. I ignored it for a few minutes until the yelling was getting louder and louder, and at this time heading toward the B Wing where the residents reside. I took a glance outside and saw the Housekeeper loudly cursing and repeatedly saying ya'll please leave me alone. I then addressed her and asked her to lower her tone. The noise down the hallway was definitely disturbing the residents. At that point she asked me to mind my business and leave her alone. I then told her that whatever issue she has, it doesn ' t need to affect those who reside here. Again, she got louder and I resorted to closing the MDS door. Other staff members were asking her to lower her voice, but she just kept getting louder. On 11/30/2010, a Verbal Warning was given for time fraud. ON 12/8/2010, a Written Warning and counseling was given for insubordination and the use of disrespectful language when speaking to her supervisor. On 1/12/2011, the employee received a written warning for an incident of Violent Verbal outbursts that occurred in the presence of residents and was directed at a supervisor. This incident was witnessed by five co-workers who documented the following observations: Witness #1: I was standing at the nurse ' s area when I heard the Housekeeper screaming at the top of her voice, leave me alone! Witness #2: I was in the Nurses ' area when the housekeeper was yelling and making a lot of noise. Ms. ? (Nursing Supervisor) told her to quiet down and she made a remark to her Don't tell me Nothing. She was walking toward the B-Wing and Ms. (Nursing Supervisor) told her to cool down and she made another remark to her saying leave me alone! Witness #3: I was standing at the Nurse's station when I heard the Housekeeper Screaming at the top of her voice, leave me alone. Leave me alone! Witness #4: I found this behavior to be very disruptive and in the presence of residents. I think this needs to be addressed. On 2/8/2011, a Written Warning was given for verbal violence and insubordination by refusing to obey her supervisor directives, engaging in loud arguing with the supervisor and causing a disturbance to residents. The Housekeeper received another Verbal Warning 4/14/2011 for insubordination and refusing to follow her supervisor's orders. This incident was witnessed by two co-workers who documented the following on Witness Statements dated 2/8/2011: Statement#1: On Tuesday, February 8, 2011 at around 2:25 P.M., I was in room A07 (a resident ' s room) cleaning and removing trash from the room when I heard loud arguing on the floor. I came outside the room and I heard the Housekeeper saying to her Supervisor, leave me alone. Don ' t tell me what to do. You don't have anything better to do? Just leave me alone! The Supervisor asked her to please calm down with the loud noise on the floor. She continued to tell him to leave her alone, don't tell me what to do. He repeatedly asked her to stop making noise in the building and she continued in her loud voice, so he walked away. Statement #2: I heard the Housekeeper on the floor saying to leave her alone and she was so loud on the floor. She has no respect for her boss. The Housekeeper received another verbal Warming 4/14/11 for insubordination and refusing to follow her supervisor ' s order. 3/29/2012, a Written Warning was given for verbal abuse directed at another employee, and for using inappropriate language in the resident ' s lounge in the presence of residents. 4/28/2012 the employee was cited for verbal abuse directed at a co-worker and use of profanity in the presence of residents, and on 8/29/2012, a Written Warning was received for violent verbal outbursts and blatant refusal to obey a supervisor ' s orders. In spite of these multiple incidents, the housekeeper remained employed by the facility. The facility ' s Policy for Abuse Prevention includes specific conduct violations that warn its staff of immediate termination. The first violation listed on this Code of Conduct is any verbal or physical abuse to any resident or fell ow employee. This policy was not implemented. In spite of the evidence contained in both employees ' personnel files, they were allowed to continue working until resident # 7 was harmed on 8/22/2013. As a result, the facility was unable to maintain a violence-free workplace, did not protect residents from exposure to violence, and failed to protect one resident from an injury caused by the violent actions of two of its staff. The facility failed to operationalize its Abuse Prevention program. | 2017-01-01 |
| 11 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 241 | D | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview and record review, it was determined that the facility failed to maintain residents appearance in a manner that promotes their dignity. The findings are: Resident # 9 is a [AGE] year-old male diagnosed with [REDACTED]. Care Plans for Dementia, documented 7/2013, indicate the resident is Aphasic, cognitively impaired, hearing impaired and requires total care for all ADLs. On 9/9/2013, at 9:40 A.M., the resident was observed during the initial unit tour lying supine in bed. The door to the resident ' s room was open, his bedside curtain was not drawn, and the resident was uncovered. A bed sheet was hanging off of the foot of the bed and the resident ' s lower body was exposed. The resident was observed to wear a hospital type gown that was pulled up to his torso and he was wearing an adult diaper. The resident ' s feet were exposed and revealed extremely elongated, mycotic toenails. The resident's fingernails were also extremely elongated and mycotic. An interview was held immediately with the nurse accompanying the surveyor who stated the staff needs to check this resident more frequently to make sure he stays covered because he ' s very restless, he pulls his covers off a lot and he should not be exposed. When the nurse was asked about the condition of the resident's finger and toenails, she explained the cutting of residents' fingernails is the responsibility of the Nursing Director and the Doctor is responsible for cutting everyone's toenails. I don't know why they were not done. They should be cut every three months. On 9/9/2013 at 10:00 A.M., during the interview conducted with the Director of Nursing to discuss resident #9 ' s care, the Nursing Director explained the facility maintains a monthly list of residents who require fingernail and toenail cutting. Residents are scheduled each month, and after the list is completed, it is signed off by the doctor and by the charge nurse or by me to indicate the residents nails were cut. The doctor cuts all of the resident's toenails and I cut the fingernails. I'm sure that resident (#9) had his nails cut about three months ago. I can check the list, but I know he's on the list for the Doctor for this month. The fingernail/toenail cutting schedules for the past six months were requested but were not immediately available for review. When presented, they were observed to not have been signed off by either the physician or a nurse to indicate each resident on the list had been groomed. Resident #9 was listed on the monthly schedules for November, 2012, February 2013, May 2013, and August 2013. On 9/9/2013 at approximately 5:00 P.M. the Director of nursing informed the surveyor that she had just attempted to cut resident #9's fingernails, but they were too thick and required a larger toenail cutter than the one size available in the facility. The DON stated she would have to find a larger size. During the Quality of life Assessment Interview held with residents on 9/10/2013 at 10:30 A.M., 5 of the 5 residents in attendance complained of having to wait for as long as 6 months before their finger and toenails were cut. The Attending Physician, responsible for grooming resident toenails was interviewed 9/11/2013 at approximately 11:00 A.M. and reported to the surveyor that he came in to cut Resident #9 ' s toenails but was unable to do so in the usual manner because the toenails were too mycotic and a special instrument was required. Cross refer F-312 | 2017-01-01 |
| 12 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 244 | E | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, it was determined that the facility failed to actively respond to a grievance regarding delayed meals presented by the residents at a resident council meeting. This was identified during a group meeting for 5 of 5 alert and oriented residents from 2 of 2 nursing units. This deficient practice was evidenced by the following: In preparation for the Quality of Life Assessment Group Interview the resident council minutes were reviewed from January 2013 through July 2013 and revealed that the issue of a long wait time for meals distribution was discussed in May and June. A review of the facility's Resident Council Concern Sheet used to follow-up on grievances did not reveal that the facility had responded to the resident ' s complaint of late meal delivery for either May or June of 2013. Resident Grievance files dated 03/20/2013 contain a complaint that indicates Food trays come to the unit, but there is a long wait/lag time before the trays are distributed and then the food is cold. There were no attached comments to indicate that the facility had responded to this grievance. During a group meeting conducted on 09/10/13 at 10:30 a.m., when asked Do you receive your breakfast, lunch and dinner on time? Four of five residents stated most of the time it's late. When asked how long beyond the scheduled time do the meals arrive? Four of the five residents attending stated, at least 30 minutes from the scheduled meal time. They all concurred that this practice occurs for all three meals. One of the residents told the surveyor, I am a Diabetic and take Insulin so this is not good for me (referring to the late meal distribution). The surveyor reviewed the record of this resident (resident #1), which revealed that the resident is an Insulin Dependent Diabetic. It further revealed that this resident was recently re-admitted to the facility on [DATE] following an acute hospitalization stay and is documented to have experienced a significant weight loss. During an interview conducted on 9/10/13 at approximately 12:15 PM with the Registered Dietitian (RD) it was revealed that the Kitchen serves both the Adolescent facility and the Nursing Home. When asked directly about the complaint of a long wait/lag time for meal distribution, the Registered Dietician stated the residents get the food late because the kids come first because they have to go to school. When interviewed on the afternoon of 09/11/13 regarding the Adolescents being fed before the Nursing home residents, the Administrator stated she was unaware that this was occurring and that the Adult resident should always be fed first. The Medical Director was interviewed 09/12/13 and stated he was not aware that the Adolescent facility was being served meals before the Nursing residents. This should never occur, these are separate facilities and the Nursing Home residents should always receive their meals first. | 2017-01-01 |
| 13 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 250 | E | 0 | 1 | IBTI11 | Based on observation, interview and record review, it was determined that the facility failed to provide effective medically-related social services to assist residents to maintain their highest practicable physical, medical and psychosocial well-being. The findings are: A group meeting was held with alert and oriented residents on 9/10/2013 at 10:30 A.M. 5 of the 5 residents in attendance stated in response to questions about the social worker, that they did not know the name of the social worker employed by the facility. 4 residents stated they had never met or been visited by a social worker, and 4 of the 5 residents complained they had never received assistance from a social worker to resolve any social service needs. Each resident in the Group stated, whenever they needed help with a problem, they consulted the Activities Director. Resident #12 complained of requiring assistance with his immigration status. The resident stated he did not receive any money from any source because he was having problems with renewal of his green card. The resident stated, as a result, he has not had any money, not even one dollar of his own, to put into his pocket for the past three years. The resident stated he has requested help with this problem, but no one has helped him. One resident in the group, Resident # 13, complained of not receiving any money from any source for the past two years. The resident stated he had spoken to nursing staff about this problem and it still was not resolved. This resident stated he had not met with a social worker to discuss this issue. He stated he did not know there was a Social Worker in the facility. Resident #13 also complained of the lack of response to his request for discharge from the facility. The resident explained he needed to return to his home to help care for his ill brother. He stated that although he had shared this concern with staff, he had not received assistance from anyone to facilitate his discharge. The resident stated he has not been seen by a Social Worker to discuss his concerns. The medical record of each of the above residents, #12 and # 13 were reviewed on 9/10/13. There was no evidence found in each of these records to indicate a Social worker had responded to their individual concerns. During a meeting with the Director of Nursing on 9/10/13 at 12:15 P.M., when the Surveyors requested to meet with the facility ' s Social Worker, the Director of Nursing stated the Social Worker was not on site. The Nursing Director stated the Social Worker would not be available to meet with the survey team until Wednesday evening when he was scheduled to come to the facility. A telephone interview was held with the Social Worker on 9/10/15 at 2: 00 P.M. During this interview the Social Worker confirmed that he worked for the facility Monday, Wednesday and Thursday evenings. He explained that he was employed full-time at another agency and made time to see residents at the nursing home on those three evenings a week. He stated he has been employed part-time by the facility for several years. During this telephone contact, the Social Worker was interviewed regarding Resident #12 ' s Immigration Green Card concern. The Social Worker informed the surveyor that he was assisting the resident with this problem. When asked about the lack of Social Worker documentation in the resident's chart, the Social Worker explained there was no evidence of his involvement documented in the resident's chart at the Nursing Home because he has the information in a file in his office at his other place of work. The Social Worker was interviewed regarding Resident #13's financial concern and he stated he wasn't sure if the resident was eligible for any funding. The Social Worker offered no explanation for the lack of documentation in the Resident's chart to indicate he had addressed this concern. The Social Worker acknowledged that he was aware of Resident #13's request for discharge and stated that an effort was made 3 or four months ago to send him to his family, but no one was willing to take responsibility. The Social Worker could offer no explanation for the lack of documentation in either the Social Work progress notes or Interdisciplinary notes to indicate He had attempted to address this problem. During an individual interview held with Resident #5 on 9/11/20 13 at 6:00 P.M., the resident discussed her discharge plans with the surveyor. The resident stated she was a bit concerned about returning home without help as she lived alone. The resident stated a member of her family was helping her to make arrangements to return home. The resident stated she was not aware that the facility had a social worker and had never received a visit from a Social Worker to discuss her discharge plans or concerns. The resident stated, but, I would like to speak with one as soon as possible. A telephone interview was conducted with the resident ' s family on 9/12/13 at 11:30 A.M. This family member stated she was making arrangements for the resident to return home as quickly as possible as that is her desire. She stated the resident was due for discharge in a few days and would be returning to her own home where she lives alone. The family member said the resident will need some assistance during the day due to her developing confusion, and she was not sure who could provide that service. She stated she had never seen a Social Worker during her visits to the facility, had not received a telephone call from the Social Worker, and had not received help from the Social Worker to assist her with the resident ' s discharge plan. The resident's medical record was reviewed 9/11/13 and was found to not contain evidence of the Social Worker ' s involvement with this resident's discharge. During an interview with the Director of Nursing Services to investigate resident complaints, the DON explained that the Social Worker comes to the facility part-time in the evenings because he has a full-time job during the day. She stated the Social Worker set his own hours and was scheduled to work on Monday, Wednesday and Thursday evenings from about 6 P.M until 9 P.M. The DON acknowledged that most of the residents began to prepare for bed at around 6 to 7 P.M., after finishing their dinner meal. An interview to discuss resident concerns was held with the Administrator on 9/11/2013 at 1:45 P.M. The Administrator explained that it was difficult for the facility to find qualified Social Workers. She stated the social Worker employed by the facility does come in for a few hours in the evenings. The Administrator stated the Social Worker does make sure the residents Medicaid certifications were completed and did sign off on the MDS. The Administrator did acknowledge that most residents began to prepare for bed around 6:30 P.M. following completion of the evening meal. On Wednesday 9/11/13, although the Survey team remained in the facility until 7:30 P.M., the Social Worker did not appear on site as scheduled. At least one resident, Resident#5 awaited his arrival. The Director of Nursing confirmed on 9/12/2013, the next morning that the Social Worker did not come to the facility at all during the previous evening. | 2017-01-01 |
| 14 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 312 | D | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficient practice was noted for one of 14 sampled residents. The findings are: Resident # 9 is a [AGE] year-old male diagnosed with [REDACTED]. Care Plans for Dementia, documented 7/2013, indicate the resident is Aphasic, cognitively impaired, hearing impaired and requires total care for all ADLs. On 9/9/2013, at 9:40 A.M., the resident was observed during the initial unit tour lying supine in bed. The door to the resident ' s room was open, his bedside curtain was not drawn, and the resident was uncovered. A bed sheet was hanging off of the foot of the bed and the resident ' s lower body was exposed. The resident was observed to wear a hospital type gown that was pulled up to his torso and he was wearing an adult diaper. The resident's feet were exposed and revealed extremely elongated, mycotic toenails. The resident's fingernails were also extremely elongated and mycotic. An interview was held immediately with the nurse accompanying the surveyor who stated the staff needs to check this resident more frequently to make sure he stays covered because he's very restless, he pulls his covers off a lot and he should not be exposed. When the nurse was asked about the condition of the resident's finger and toenails, she explained the cutting of residents fingernails is the responsibility of the Nursing Director and the Doctor is responsible for cutting everyone's toenails. I don't know why they were not done. They should be cut every three months. On 9/9/2013 at 10:00 A.M., during the interview conducted with the Director of Nursing to discuss resident #9 ' s care, the Nursing Director explained the facility maintains a monthly a list of residents who require fingernail and toenail cutting. Residents are scheduled each month, and after the list is completed, it is signed off by the doctor and by the charge nurse or by me. The doctor cuts all of the resident's toenails and I cut the fingernails. The Director of Nurses stated I' m sure that resident (#9) had his nails cut about three months ago. I can check the list, but I know he's on the list for the Doctor for this month. Copies of the fingernail/toenail cutting schedule for the past six months were not immediately available when requested, and when produced, were observed to not have been signed by either the physician or a nurse to indicate each resident on the list had been groomed. Resident #9 was listed on the monthly schedules for November, 2012, February 2013, May 2013, and August 2013. On 9/9/2013 at approximately 5:00 P.M. the Director of nursing informed the surveyor that she had just attempted to cut resident #9's fingernails, but they were too thick and required a larger toenail cutter than the one size available in the facility. The DON stated she would have to find a larger size. A quality of life Assessment Interview was held with residents on 9/10/2013 at 10:30 A.M. 5 of the 5 residents in attendance complained of having to wait for as long as 6 months before their finger and toenails were cut. The Attending Physician, responsible for grooming resident toenails was interviewed 9/11/2013 at approximately 11:00 A.M. and reported to the surveyor that he came in to cut Resident #9s toenails but was unable to do so in the usual manner because the toenails were too mycotic and a special instrument was required. Cross refer F-241 | 2017-01-01 |
| 15 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 314 | G | 0 | 1 | IBTI11 | Based on observation, interview and record review, it was determined that the facility failed to ensure that a resident without pressure sores, received the necessary care and services to prevent the development of a pressure sore. This was found true for one of 14 residents reviewed. The findings are: During the initial tour, conducted 9/9/2013 at approximately 9:40 P.M. on Unit A, Resident # 9 was observed lying in bed in a supine position. The resident was uncovered, and his feet were exposed. The resident was observed to wear heel pressure relieving booties on both feet. The bootie on his right foot was partially off, not covering the right heel, and the Velcro straps of the bootie were pulled tightly around the anterior longitudinal arch of the resident's foot. The bootie straps were observed to cover an open wound. The nurse accompanying the surveyor was immediately interviewed and stated she thinks the wound developed from the pressure of the bootie straps being pulled too tightly over the resident's foot. The Nurse stated the wound began to develop about three weeks ago. A CNA, identified as a consistent care giver for Resident # 9 was interviewed 9/9/2013 at 9:55 a.m. in the hallway outside of the Resident ' s room. In response to questions about the development of the resident's wound, The CNA stated, the straps on the booties caused the sore because they were being pulled too tight. An interview was held with the Director of Nursing {DON} immediately following the initial tour. The DON described the residents wound as a pressure sore that developed over time and caused by the straps of the bootie being pulled too tightly across the resident's foot. The DON stated they were not treating the wound because there was no drainage. She stated she had not yet in-serviced her staff on the proper application of heel booties to prevent pressure sores from developing, but would do so right away. The DON stated she would have the doctor evaluate the wound to determine what treatment is necessary. | 2017-01-01 |
| 16 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 325 | D | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to effectively monitor a resident's nutritional status in the presence of unplanned weight changes. This deficient practice was identified in 1 of 10 residents (Resident #1) reviewed for nutritional concerns. This was evidenced by the following: The resident's [DIAGNOSES REDACTED]. The Clinical records, identified the resident as alert and oriented x 3, and able to make needs known. Resident Assessment Instrument (RAI), dated 8/13/31, indicated the resident's weight as 143 pounds (lbs.) and had experienced no significant weight gain or loss. Review of the physician's orders [REDACTED]. In the Initial Nutritional Assessment, dated 8/6/13, the Registered Dietician documented the resident's weight as 143 lbs., requires partial assist with tray set-up, could feed self, and consuming 75% of meals; weight gain may be due to decrease activity since foot/leg problems. No significant nutritional risk. A review of the resident's monthly weights recorded in the unit's weight book indicates the following: Resident #1's weight was 143 pounds (lbs.) on 08/06/13. On 8/26/13, the resident's weight was recorded as 126 lbs., indicating a 17 lb. weight loss in 20 days. A re-weigh performed on 8/27/13, listed the weight as 126 lbs. There was no documented evidence that the physician was informed of the weight variance of 17 lbs. between 8/6/13 and 8/27/13. The Registered Dietician documented the resident's weight on a Dietary Progress Note dated 9/6/2013 as 125 lbs. and documented that the resident experienced a significant weight loss of 10 lbs. in a 30 day period, and 15 lbs. in a period of 180 days. Although the Registered Dietitian (RD) identified the resident's weight loss as unplanned, there was no documented evidence that the RD evaluated for factors contributing to the resident's weight loss. During an interview conducted on the afternoon of 9/11/13, the Registered Dietitian (RD) acknowledged that the resident experienced a 17 lbs. weight loss. She stated that on 08/27/13, the resident was changed from monthly weights to weekly weights. She further stated that after a discussion with the resident on 09/06/2013, she added Cocoa to the resident's diet. During a Quality of Life Assessment Resident Interview on 09/11/2013 at 6:30 PM resident #1 was asked about whether snacks are provided and she stated they don't give me a sandwich at night, I am a Diabetic and I am not the only one who ' s not receiving a snack at night. There was no documentation in the medical record that any member of the Interdisciplinary Care Team had identified, investigated, or appropriately addressed the resident's weight loss, or identified whether or not the resident's prescribed diet was adequate. This review reveals that the facility's staff waited 2 weeks before addressing the resident's significant weight loss. | 2017-01-01 |