of F282 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F282 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 F282 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F282 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.
J · Immediate jeopardy, isolatedDecember 15, 2017
Based on interview, record review, and review of the Resident Instrument Assessment (RAI) Manual 3.0, it was determined the facility failed to implement the care plan for one (1) of one (1) sampled residents (Resident #1).
The facility care planned for staff to monitor Resident #1 for tailgating visitors while they were in the building and to use an audible monitoring system to alert staff of exit seeking behaviors. However, on 11/13/17, Resident #1 exited the building behind a visitor without staff's knowledge and without the alarm system sounding. …
Based on record review and interviews, the facility failed to ensure that each resident's care plan was followed 1 of 8 sampled residents reviewed for falls. Resident #3 care plan was not followed which resulted in an Anterior Shoulder dislocation on 9/23/17. The facility's investigation revealed that one Certified Nursing Aide (CNA) transferred the resident using a stand lift while the care plan indicated the resident was to be transfer with 2 staff members when a lift was used. …
D · No harm, potential for more than minimal, isolatedSeptember 28, 2018
Based on interview and record review, the facility failed to ensure that a physician's order was followed related to the dose of a pain medication (amount of the medication to be given) for one of four sampled resident (1).
This failure had the potential for Resident 1 to receive too much or too little of the ordered dosage.
Findings:
Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].
A review of Resident 1's medical record indicated a physician's order, dated, 2/01/16: [MEDICATION NAME] sulfate (a very strong pain medication that can cause breathing to slow down) 20 mg (milligrams)/ml (milliliters) sol (solution): give 0.25 ml (5 mg) by mouth q (every) 4 hours prn (as needed) for mild pain; give 0.5 ml (10 mg) q 6 hours prn for moderate pain & give 0.75 ml (15… …
B · No harm, potential for minimal, patternNovember 8, 2017
Based on interview and review of medical record, the facility failed to update the comprehensive care plan of 1 resident in a survey sampled of 20 residents. (Resident identifier is #4.)
Findings include:
Review on 11/7/17 of Resident #4's medical record revealed that there was no care plan in place which addressed Resident #4's stage two pressure sore on their right buttock. Review of Resident #4's nurses' notes revealed Resident #4 had developed this pressure sore on 10/30/17.
Interview with Staff C (Assistant Director of Nurses) review the above finding and Staff C acknowledged adding this pressure sore to Resident #4's comprehensive care plan on 11/7/17 after it had been brought to the attention of facility staff.
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