of F281 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F281 is cited
0.0% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D4100.0%
E—
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F281 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F281 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
K · Immediate jeopardy, patternNovember 21, 2017
Based on interview and record review, the facility failed to provide or arrnage services that meet professional standards for 1 of 27 residents (resident #21) whose care was reviewed for Code Status in that:
LVN C, LVN E and RN D failed to assess, document interventions and initiate Cardiopulmonary Resuscitation (CPR) for Resident #21 who was unresponsive, pulseless and a full code status.
This failure resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. …
Based on observation, interview, and record review, the facility failed to provide care and service in accordance with acceptable professional standards of quality for one of three sampled residents (Resident A) when:
1. For Resident A, the facility failed to ensure assessment and monitoring was provided for Resident A according to his plan of care when Resident A complained of a sore penis on September 22, 2017, and perineal site discomfort on October 3, 2017.
2. For Resident A, the facility failed to ensure Resident A received urinary catheter (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care in accordance with the facility policy and procedure and professional standards to include the use of a leg strap to prevent… …
D · No harm, potential for more than minimal, isolatedApril 11, 2018
Based on interview and medical record review, the facility provided oxygen therapy for 1 of 3 sampled residents (Resident 2) without a physician's order. This failure placed the resident at risk for inconsistent care that could have contributed to Resident 2's respiratory decline.
Findings:
Resident 2 was admitted for therapy following an accident resulting in a fracture. Resident 2 also had [MEDICAL CONDITION] fibrosis, a lung disease which caused scarring in the lungs leading to serious breathing problems.
During a review of Resident 2's clinical records, no order for oxygen was found. …
B · No harm, potential for minimal, patternNovember 15, 2017
Based on record review and interview, it was determined that the facility failed to provide parameters for PRN (as needed) pain medications for 8 resident in a standard survey sample of 24 residents. (Resident identifiers are #2, #6, #8, #9, #11, #12, #17, and #19.)
Findings Include:
Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009.
Pages 699
Prescriber must document the diagnosis, condition, or need for use for each medication ordered
Page 708 The prescriber often gives specific instructions about when to administer a medication
Resident #2
Review of the Medication Administration Record [REDACTED]
[MEDICATION NAME] Tablet 400 mg (milligrams). …
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