Every finding on record at Eamc Lanier Nursing Home

Based on document review, interviews and review of the facility's policy, the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly. This had the potential to affect the care and services for each of the 65 residents in the facility. Findings include: Review of a facility policy titled, Quality Assurance Performance Improvement for EAMC (Eastern Alabama Medical Center) Long Term Care, dated March 2017 indicated, .Procedure.The QAPI committee meets at least quarterly . Review of a facility document titled, Quality Assurance Performance Improvement Plan, dated November 2020 indicated, .The QAA committee will meet quarterly and as needed. Review of facility documents titled EAMC-[NAME] Nursing Home Quality Assessment & Assurance Committee Microsoft TEAMS Meeting, dated 10/20/20, 01/20/21, and 04/28/21 indicated the dates when the QAA committee members met. There was no evidence to show the QAA committee members met in July 2021 which would indicate the committee members did not meet quarterly. During an interview on 08/19/21 at 12:15 PM, Employee Identification (EI #3, the Quality Assurance (QA) nurse and EI #1, the Administrator stated that the past QA meetings have not been done face to face. EI #1 stated the QAPI team met across a secured electronic network. During an interview on 08/19/21 at 12:24 PM, EI #1 stated they had to cancel the QAPI meeting for July 2021 since the Medical Director was out of town and the facility had to reschedule the meeting in August 2021. EI #1 stated the quarterly QAPI meeting was scheduled on 08/18/21 but had to be rescheduled to 09/01/21 due to the current recertification survey. EI #1 confirmed it was four months since the last QAPI meeting was held. EI #1 stated the Medical Director has an assistant Medical Director who could have attended but did not attend.

Based on observation, interview, and record review, the facility failed to ensure a licensed staff member did not write on a dressing that Resident Identifier (RI) #67 was wearing during the wound care observation on 3/21/19. This affected RI #67, one of two sampled residents observed during wound care. Findings Include: RI #67 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #67's most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/06/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The MDS also revealed RI #67 had one Stage 2 Pressure Ulcer (PU), one Stage 3 PU and two Stage 4 PU's. On 3/21/19 at 9:18 AM, Employee Identifier (EI) #2, Registered Nurse (RN), and another RN were observed performing wound care for RI #67. During the provision of wound care, EI #2 was observed to write the date, time and her initials on a dressing after she applied it to RI #67's right and left foot. On 3/21/19 at 1:16 PM, an interview was conducted with EI #2. During the interview, EI #2 stated there would be a potential for a dignity concern if treatments (dressings) were dated and initialed while the resident was wearing them. When asked what could have been done differently, EI #2 stated the treatments (dressings) could be initialed prior to putting it on the resident.

Based on observation, interview, record review and a facility policy titled, Privacy/Promoting Dignity, the facility failed to ensure privacy was provided for Resident Identifier (RI) #67 during wound treatment, when other staff entered the resident's room and RI #67's privacy curtain was not pulled. This affected RI #67, one of two sampled residents observed during wound care. Findings Include: A review of a facility policy titled, Privacy/Promoting Dignity with a revised date of 8/17, revealed: .1. EAMC staff will knock on a patient's door prior to entering room, listen for response, and then enter patient's room respectfully .3. Prior to providing any care and/or treatments a staff member will .provide privacy for patient . RI #67 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #67's most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/06/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The MDS also revealed RI #67 had one Stage 2 Pressure Ulcer (PU), one Stage 3 PU and two Stage 4 PU's. On 3/21/19 at 9:18 AM, Employee Identifier (EI) #2, Registered Nurse, (RN), and another RN were observed performing wound care for RI #67. EI #2 pulled the privacy curtain of RI #67's roommate, but did not pull RI #67's privacy curtain. EI #2 was providing wound care when EI #3, Licensed Practical Nurse (LPN), and a Certified Nursing Assistant (CNA) entered RI #67's room. EI #3 and the CNA knocked on the door prior to entering. EI #2 explained that resident care was being performed, but EI #3 and the CNA entered and explained they were going to provide care for RI #67's roommate. As they walked to the other side of the room, RI #67's scapula (upper back) was exposed during the wound care. RI #67's privacy curtain was not pulled. On 3/21/19 at 1:16 PM, an interview was conducted with EI #2. When asked what the facility policy was for privacy during care, EI #2 stated if the resident was not in a private room, pull the curtain. When asked why she would want to pull the curtain on the side of the room she was working, EI #2 stated in case someone was coming in and out of the room. EI #2 stated when staff heard a knock at the door and patient care was announced, staff should request permission to come in. EI #2 stated they (EI #3 and the CNA) should have paused and waited for permission after patient care was announced. When EI #2 was asked if they paused and waited, she stated she remembered them knocking, her saying resident care and they came on in. When asked how should the curtain have been pulled to provide privacy, EI #2 said it should have been for the entire length of the room. On 3/21/19 at 3:32 PM, an interview was conducted with EI #3. When EI #3 was asked what was the facility policy for resident privacy during patient care, she said they knock on the door and if no one said anything they walk in. EI #3 said if someone said patient care, she would announce herself and if they were providing care, their curtain would be pulled on their side and they (her and other staff) would do care on their side. When EI #3 was asked if she was granted permission to come in after patient care was announced, she said she looked in and said she needed to take care of her patient, and no one said anything so she proceeded to the patient's side of the room where the curtain was already pulled. When asked what should have been done differently in that room, EI #3 said since they were working with the A bed, the A bed privacy curtain should have been pulled.

Based on observation, interview, and record review, the facility failed to ensure wound care was provided for Resident Identifier (RI) # 67, a resident with multiple pressure ulcers, in a manner to prevent infection. Licensed staff failed to wash her hands after picking up tape dropped on the floor, and then proceeded to prepare supplies for the wound treatments, and failed to wash hands during treatment, before applying product to a wound. Further, licensed staff failed to clean the scissors before and during RI #67's treatments. These failures affected RI #67, one of two residents observed for wound care. Findings include: RI #67 was admitted to the facility on [DATE]. RI #67's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 2/06/19 documented RI #67 had severely impaired daily decision making skills. This assessment also indicated RI #67 had one Stage 2 pressure ulcer, one Stage 3 pressure ulcer, and two Stage 4 pressure ulcers at the time of the assessment. Progress Notes, dated 2/13/19, documented RI #67 had pressure ulcers on the right foot, involving the great toe, and on the left foot, involving the first and second toes. On 3/21/19 at 9:18 AM, Employee Identifier (EI) #2, the Wound Nurse, was observed performing wound care for RI #67. EI #5, Registered Nurse/Director of Nursing, assisted. While performing set-up for the treatments, EI #2 dropped a roll of tape on the floor. She then picked the tape up and used it to tape a bag down onto the overbed table as her barrier. EI #2 then put the tape on top of the treatment cart. Without washing her hands or performing any hand hygiene, EI #2 prepared supplies prior to beginning the treatments. EI #2 removed multiple items, including [MEDICATION NAME] Ag (silver), gauze, wound cleaner, rolled gauze, tape, medication cups, measuring strips, and Venelex ointment, from the treatment cart and placed them on the table for the treatment. EI #2 then reached into her jacket pocket and removed a pair of scissors and also placed those on her supply barrier. After the supplies were prepared, EI #2 washed her hands and forearms, placed gloves onto the barrier, gloved her hands, opened two rolls of gauze, and opened treatment supplies. Prior to beginning the treatment, RI #67's right heel pillow was removed. Without cleaning them, EI #2 used the scissors from her pocket to cut a bandage loose from the resident's right foot. Both EI #2 and #5 removed the bandage. The bandage was noted with minimal to moderate serosanguinous drainage. They then washed their hands and forearms, and measured the wound. After measuring, EI #2 and EI #5 again washed hands and put on gloves, and EI #2 began cleaning the wound to RI #67's right great toe with gauze and wound cleaner. EI #2 then measured the [MEDICATION NAME] Ag with a measuring strip and used the scissors to cut it. The scissors had not been cleaned. EI #2 used a tongue blade to apply Venelex ointment to the right toe. A second and third tongue blade were also used to apply Venelex to the remaining toes on the right foot. EI #2 then used her gloved hands to massage the ointment into RI #67's foot. Then, using the same gloves, EI #2 placed the [MEDICATION NAME] Ag onto the wound opening and applied rolled gauze. EI #2 did not remove gloves and wash hands until she dated the dressing. EI #2 then began the treatment to RI #67's outer left great toe. Using her right hand (just washed and gloved), EI #2 touched the feeding tube pump and bed control, repositioned the resident and removed the left heel boot and dressing from the left foot. EI #2 cleaned RI #67's wound with gauze and wound cleaner, and then performed measurements. EI #2 then washed hands and moved on to another wound, also located on the left foot. EI #2 said both areas would be dressed at the same time. EI #2 cut the [MEDICATION NAME] Ag with the previously used scissors, applied Venelex ointment with a tongue blade, in the same manner as the right foot, and massaged the ointment into the foot using her gloved hands. She then applied the [MEDICATION NAME] Ag and wrapped RI #67's foot in gauze. EI #2 did not wash hands until she was done applying the gauze dressing. EI #5 was observed cleaning the scissors after these treatments were completed. EI #2 and #5 then continued on to complete RI #67's last treatment for [REDACTED]. On 3/21/19 at 1:16 PM EI #2, Wound Nurse, was interviewed. EI #2 said she used the tape dropped on the floor to tape down the trash bag onto the table (used as a barrier). When asked what happens when you pick up an item off the floor, EI #2 said it should be disposed of because the floor is a dirty surface. EI #2 further stated your hands would be considered dirty as well, after picking an item up off the floor. EI # 2 then went on to say that if you prepared supplies using contaminated hands, they would be considered dirty, too. EI #2 said it was important to use clean supplies and have a clean barrier during wound treatments for infection control purposes. EI #2 was then asked about the policy regarding the use of scissors during wound care. EI #2 said the scissors should be cleaned after finishing the wound care. EI #2 said the scissors were in her pocket because she brought them from her office, and she forgot to clean them before using them. After reviewing the steps taken during the wound care observation, EI #2 agreed she had used contaminated scissors during the treatment. When asked what should be done between treatments of different wounds, EI #2 said wash hands. EI #2 was then asked why she used gloved hands to massage the Venelex into RI #67's feet, then apply [MEDICATION NAME] wearing those same gloves. EI #2 said she should not have done that; she should have washed her hands and put on clean gloves. When asked what harm could occur in not washing hands and changing gloves, EI #2 said infection.

Based on observation, interview, record review and review of the facility policy titled, Enteral (to deliver nutrition directly to the stomach) Feeding Via (by way of) Gastrostomy Tube, the facility failed to ensure Resident Identifier (RI) #67's head of bed (HOB) was elevated at all times or the tube feeding pump was turned off, while wound care was provided. RI #67's tube feeding pump was running for 27 minutes with the HOB down during wound care on 3/21/19. This affected RI #67, one of two sampled residents who received tube feeding. Findings Include: A review of a facility policy titled, Enteral Feeding Via Gastrostomy Tube with a review date of 8/17, revealed: .Procedure: .3. The head of the bed must be elevated at least 30-45 degrees at all times if tube feeding is continuous . RI #67 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #67's most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/06/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The MDS also revealed RI #67 had a feeding tube. A review of RI #67's (MONTH) 2019 PHYSICIAN'S ORDERS revealed: .HEAD OF BED TO BE ELEVATED AT ALL TIMES ASPIRATION PRECAUTIONS .PERIACTIVE 40CC/HR (CUBIC CENTIMETER/HOUR) X (TIMES) 22HRS . On 3/21/19 at 9:18 AM, Employee Identifier (EI) #2, Registered Nurse (RN), and another RN were observed performing wound care for RI #67. During the provision of wound care, RI #67's tube feeding was infusing. At 10:57 AM, RI #67's HOB was observed to be down while the tube feeding pump was on. RI #67's HOB remained down with the tube feeding pump on from 10:57 AM to 11:24 AM, a total of 27 minutes. On 3/21/19 at 1:16 PM, an interview was conducted with EI #2. When asked what the facility protocol was for tube feeding when care was provided to a resident, EI #2 stated to put the tube feeding on hold for 30 minutes. When asked why RI #67's tube feeding pump was running from 10:57 AM to 11:24 AM with the HOB down flat, EI #2 said she did not realize it was running. EI #2 stated there was risk for aspiration when RI #67's tube feeding pump was running while the HOB was down flat. EI #2 stated she should have turned the tube feeding pump off completely.

Based on observation, record review, interview and a facility policy titled, Hand Hygiene for Long Term Care, the facility failed to ensure a licensed staff member: a. did not place her bare fingers in a medicine cup prior to administering the medication to Resident Identifier (RI) #6, b. did not place the keys to the medication cart on top of the medication cart after they were dropped on the floor, c. washed her hands after picking up the medication cart keys off of the floor and prior to proceeding to prepare medication for RI #15 and d. did not pull the privacy curtain with her bare hands, then fail to wash her hands before administering medication to RI #15. These deficient practices affected RI #6 and RI #15, two of nine residents observed during medication administration. Findings Include: A review of the facility policy titled, Hand Hygiene for Long Term Care with a revised date of 08/17, revealed: .Indications for Hand Hygiene: .After: .having contact with inanimate objects near a patient . RI #6 was was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #15 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. On 03/21/19 at 7:15 AM, Employee Identifier (EI) #1 was observed during the medication administration of RI #6. EI #1 prepared RI #6's medication and handed RI #6 the medication cup with her bare right thumb and right middle finger touching the rim of the medication cup. EI #1's bare right index finger was on the inside of the medication cup. On 03/21/19 at 7:40 AM, EI #1 dropped the keys to the medication cart on the floor. EI #1 picked the keys up and placed them on top of the medication cart. EI #1 proceeded to prepare medication for RI #15 without washing her hands. EI #1 entered RI #15's room and washed her hands in the resident's bathroom. EI #1 then pulled the privacy curtain with her bare hands and administered medication to RI #15 without washing her hands. On 03/21/19 at 1:21 PM, an interview was conducted with EI #1. During the interview, EI #1 stated her fingers should not be placed inside of the medication cup. When asked what should have been done after she dropped the keys on the floor before proceeding to prepare medications, EI #1 stated she should have used hand sanitizer. During the interview, EI #1 stated she should not have placed the keys on top of the medication cart after they had been on the floor. EI #1 stated she should have washed her hands after she pulled the privacy curtain in RI #15's room. When asked about the potential for harm during the medication administration, EI #1 stated, cross contamination.

Based on observations, interviews, and review of the 2013 Food Code and the facility document titled: Record of Dishmachine Temperatures, the facility failed to ensure: 1) preparation equipment, dishes and utensils were effectively sanitized to destroy potential food borne organisms; 2) the tea urn spigot was thoroughly cleaned every 24 hours; 3) wiping clothes were stored in a sanitizing solution when not in use; and 4) staff prevented potential cross-contamination by not storing a blue scoop on top of the powder for thickening liquids. These deficient practices had the potential to affect all 88 residents who received meal trays from dining services. Findings include: 1) A review of the Food Code, U.S.(United States) Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: . 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) .in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), . (C/Centigrade, F/Fahrenheit) On 3/21/2018 at 9:45 AM, an observation was made of the operation of the dishmachine. The gauge for the rinse temperature exceeded the standard of 194 degrees F. The gauge read 210 degrees F. The (MONTH) (YEAR) log titled, Record of Dishmachine Temperatures revealed a total of 61 recorded temperature opportunities: Breakfast: eight documented rinse temperatures exceeded 194 degrees F and numerous data reached 210 degrees F. Lunch: rinse temperatures exceeded 194 degrees F ten times; Supper: rinse temperatures exceeded 194 degrees F a total of eight times; On 3/21/2018 at 9:50 AM, the Registered Dietitian (RD), Employee Identifier (EI) #1, said they had problems with the booster heater. EI #1 explained the facility did not have a booster heater. 2) Regulation 4-602.11 of the 2013 FOOD CODE, specifies: . (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (E) (2) At least every 24 hours for iced tea dispensers . On 3/21/2018 at 12:00 PM, one of two large empty tea urns was observed. The ServSafe Supervisor, EI #2, was asked to disassemble the faucet. The inside plunger was observed to have a solid brown build-up on the plunger. EI #2 was asked, is it clean, and was it being cleaned every 24 hours? EI #2 responded, No. 3) The 2013 Food Code revealed: .3-304.14 Wiping Cloths, Use Limitation . (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified . On 3/21/2018 at 10:10 AM, a wiping cloth was observed, not in use, near the blender. The cloth was wet and a ladle with food debris was resting on top of the cloth. The Dietitian (RD), EI #1, was asked what was the potential risk. EI #1 explained it was a potential for cross-contamination. On 3/21/2018 at 11:45 AM, a second wiping cloth was observed, not in use and on top of the preparation counter near the chopping machine. The cloth felt wet to touch. 4) On 3/21/2018 at 11:32 AM, a can of Thick n Easy was located on a counter top. Inside the can was a blue measuring scoop. The multi-use scoop was stored atop the powder. On 3/21/2018 at approximately 12:00 PM, the EI #1, the RD, was asked about the risk for the scoop stored in the can. The RD stated that she had never thought of the risk.

Based on record review and interviews, the facility failed to ensure individualized care plans were developed with measurable goals and approaches for: 1. RI (Resident Identifier) #95's refusals of care, use of an antipsychotic medication, and behaviors of yelling and combativeness. 2. RI #78's use of an antipsychotic medication related to a [DIAGNOSES REDACTED]. This affected two of 19 sampled residents for whom care plans were reviewed. Findings included: 1.) RI #95 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #95's most recent quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date of 2/22/2018 documented a BIMS (Brief Interview for Mental Status) score of 8 which indicated moderate cognitive impairment. A review of RI #95's physician orders [REDACTED]. 3/5/18 3:35 pm (1) Start [MEDICATION NAME] 0.5 mg (milligrams) Q (every) AM. DX (diagnosis): Dementia (with) agitation . A review of RI #95's nurses notes revealed the following entries related to behaviors: . 2/12/18 1400 (2:00 PM) Resident refused to let writer retake . BP (blood pressure) . Resident very combative . . 2/17/18 0900 (9:00 AM) Resident refused to get out of bed. Resident refused to take medicine. . 3/3/18 1740 (5:40 PM) . Resident began to panic and become very anxious . began crying . .3/5/18 1530 (3:30 PM) New orders for [MEDICATION NAME] 0.5 mg Q AM (0.5 milligrams every morning). . 3/16/18 1300 (1:00 PM) . resident spit morning pills on the floor . . 3/17/18 0645 (6:45 AM) Resident noted to be hollering/yelling @ (at) residents. Noted to have bumped into a few residents. Was able to redirect but started back hollering @ residents. . 3/18/18 0500 (5:00 AM) . similar behaviors (hollering/yelling @ residents/staff.) . RI #95's care plans were reviewed and there was not an individualized plan of care with approaches/interventions for the types of behavior identified in the nurses notes or for the use of the antipsychotic medication [MEDICATION NAME]. On 3/22/18 at 10:45 AM, EI #6 RN (Registered Nurse) was asked what behaviors were documented for RI #95. EI #6 said, she would have to look but she knew RI #95 had been combative at times and previously hard to direct at times. EI #6 said, RI #95 was placed on [MEDICATION NAME] 0.5 Q AM for dementia with agitation, running into others with the wheel-chair, and yelling at staff and residents. On 3/22/18 10:54 AM, EI #7 LBSW (Licensed Bachelor of Social Work) was asked what care plan was put in place for RI #95's behaviors and use of [MEDICATION NAME]. EI #7 said, she would have to add one. EI #7 was asked why RI #95 did not have an individualized plan of care to address behavior of panic or anxiety with approaches for RI #95. EI #7 replied, maybe it had not been reported well and RI #95 needed a care plan for that. 2.) RI #78 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of RI #78's most recent quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date of 2/8/2018 revealed a BIMS (Brief Interview for Mental Status) score of three which indicated severe cognitive impairment. A review of RI #78's (MONTH) (YEAR) physician orders [REDACTED]. A review of RI #78's care plans revealed there was not a plan of care in place to address behaviors, agitation, or the use of [MEDICATION NAME]. On 3/22/18 at 4:54 PM, EI (Employee Identifier) #7 LBSW (Licensed Bachelor of Social Work) was asked why RI #78 was on [MEDICATION NAME]. EI #7 said, for behavior of being combative, fighting, and calling out. When asked where RI #78's behavior care plan was, EI #7 said, there may not have been one. On 3/22/18 at 8:13 PM, EI #7 was again interviewed and was asked, why should residents have care plans to address dementia and behaviors. EI #7 replied, so staff can effectively respond to behaviors and care for residents with dementia. On 3/22/18 at 9:01 PM, EI #5 MDS Coordinator was asked, if residents should have care plans to address the use of antipsychotics. EI #5 said, yes.

Based on observation, interview, resident record review, and review of the facility policy Care of Residents with Behavioral and Emotional Problems the Facility failed to ensure RI (Resident Identifier) #95 did not receive antipsychotic medications without first attempting non-pharmacological interventions to address emotional needs and behaviors. This affected one of five residents sampled for receiving antipsychotic medications. Findings include: A review of the facility policy titled Care of Residents with Behavioral and Emotional Problems with a revised date of 9/1/1998 revealed the following: . PURPOSE: To ensure that residents' behavioral and emotional problems are managed as much as possible with non-chemical interventions. POLICY: . 2. The LBSW (Licensed Bachelor of Social Work) . is responsible for overseeing the . Behavioral Management Program. RI #95 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #95's most recent quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date of 2/22/2018 documented a BIMS (Brief Interview for Mental Status) score of 8 which indicated moderate cognitive impairment. RI #95's (MONTH) (YEAR) physician orders documented an order dated 3/5/2018 for [MEDICATION NAME] 0.5 milligrams to be administered daily for Dementia with Agitation. RI #95's care plans were reviewed and there was not an individualized plan of care with approaches/interventions for behavior or for the use of the antipsychotic medication [MEDICATION NAME]. On 3/21/2017 at 5:12 PM, RI #95 was observed near the nurses station, anxious and upset. The staff tried to redirect RI #95. On 3/22/18 at 10:45 AM EI #6 RN (Registered Nurse) was asked what behaviors RI #95 had exhibited. EI #6 said, she would have to look but she knew RI #95 had been combative at times and previously hard to direct at times. EI #6 said, RI #95 was placed on [MEDICATION NAME] 0.5 milligrams daily for Dementia with Agitation. On 3/22/18 at 10:54 AM EI #7 LBSW (Licensed Bachelor of Social Work), stated she was responsible for reviewing and monitoring behaviors prior to the use of antipsychotic medications. EI #7 said staff should notify her of any new or worsening behaviors exhibited by residents by utilizing a new behavior sheet. However, EI #7 said she did not have a behavior sheet for RI #95. EI #7 was asked what should have been done before RI #95 was placed on [MEDICATION NAME]. EI #7 said, they should have attempted different interventions prior to placing RI #95 on [MEDICATION NAME]; the nurse just notified the doctor of behaviors and medication was ordered.

Based on observation, record review, interview, and review of the facility's policy titled Section: SANITATION AND INFECTION CONTROL . Subject: ICE HANDLING, the facility failed to ensure the interior of the ice machine was free of an accumulation of black substance. This had the potential to affect all residents receiving meals from the dietary department. Findings include: Review of the facility's policy titled Section: SANITATION AND INFECTION CONTROL . Subject: ICE HANDLING, revised 04/2013, revealed the following: . PROCEDURES: . Inside of ice storage bins are emptied and cleaned on a bi-monthly basis . The facility provided a PM (Preventive Maintenance) Schedule Detail for the ice machine, dated 02/01/2017 at 10:12 a.m., that documented the following: . Bi Monthly P.M. for Ice Machine . Instructions: . 7 . make sure of residue has been removed from internal unit parts and flushed completely. This document indicated the last completion date for the preventive maintenance was 11/29/2016, and was due for the maintenance scheduled for 01/10/2017. On 01/31/2017 at 10:30 a.m., the ice machine was noted with a black/brown discoloration along the top of the plastic shield inside the unit. Employee Identifier (EI) #6, the Registered Dietitian (RD), was asked to wipe the area with a cloth. After wiping the interior of the ice machine, EI #4 stated, It's mildew. Brown discoloration was noted on the cloth. EI #6 confirmed the ice in the ice machine was used for beverages. During an interview with EI #6, the RD, on 02/01/2017 at 1:58 p.m., EI #6 stated per the policy the ice machine should be cleaned every other month. She said it should be cleaned as needed as well. When asked where this was documented, EI #6 stated it was scheduled to be done on 01/10/2017 but had not been completed yet. She stated the black discoloration noted inside the ice machine created the potential for contamination.

Based on observation, interview, and review of the facility policy titled SUBJECT: Dietary Department Maintenance ., the facility failed to ensure the walk-in freezer was maintained to avoid an accumulation of ice behind the fans/coil and along the ceiling. This had the potential to affect all residents receiving meals from the kitchen. Findings include: Review of the facility policy titled SUBJECT: Dietary Department Maintenance ., reviewed 06/2016, revealed the following: I. POLICY To provide guidelines and procedures for maintaining equipment in Dietary. II. PROCEDURE 1. A maintenance tech from Building Services will conduct a regular visual inspection of all major equipment. Particular attention should be paid to the following equipment: a. Walk-in freezer . 2. Dietary staff should contact Building Services as soon as possible upon noticing a problem with any equipment . During the initial tour of the kitchen on 01/30/2017 beginning at 8:03 p.m., the facility's walk-in freezer was observed with approximately a half inch of ice along the ceiling, extending out from the corner. Large amounts of ice were noted behind and under the fans at the back of the freezer. Multiple stalactites of ice were observed hanging from the back of the fan unit that were greater than four to five inches long and greater than two inches in diameter. During an interview with Employee Identifier (EI) #6, the Registered Dietitian, on 02/01/2017 at 1:58 p.m., EI #6 stated a large amount of ice build-up in the walk-in freezer could make it harder for the freezer to work. She verified she had seen the ice accumulation and said it probably took a couple weeks to reach that point. When asked why it had not been addressed prior to the survey, EI #6 said it happens so often they did not think anything of it.

Based on observations, interviews and record review, the facility failed to ensure: 1) licensed staff washed their hands prior to applying gloves during medication preparation and administration for Resident Identifier (RI) #11, 13, 18 and 19; and 2) licensed staff applied gloves prior to the administration of a subcutaneous injection to RI #12. This affected RI #11, 13, 18 and 19, four of seven residents observed during medication administration; and RI #12, one of two residents observed for subcutaneous injections and four of five nurses observed during medication preparation and administration. Findings include: 1) A facility policy titled, Handwashing with a revised date of 06/16 documented: .PURPOSE: To provide guidelines for the proper handwashing to prevent the spread of infection. PROCEDURE: .2. Between and after all physical contact with resident . 6. Before preparing or handling medications .10. After removing gloves . A.) RI #11 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #11's Physician orders [REDACTED]. On 01/31/2017 at 09:46 a.m., the surveyor observed Employee Identifier (EI) #1, an LPN (Licensed Practical Nurse) preparing RI #11's medications. EI #1 sanitized her hands, crushed the tablets and placed them in pudding, then put on her gloves to open the capsules. EI #1 removed her gloves and sanitized her hands. EI #1 did not wash her hands prior to putting the gloves on. On 01/31/2017 at 09:50 a.m., the surveyor interviewed EI #1 about the medication observation for RI #11. EI #1 stated hands should be washed before putting on gloves and after removing gloves. When asked why it was important to wash hands prior to gloving, EI #1 stated, So, you don't cross contaminate. B.) RI #13 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #13's February 2017 physician's orders [REDACTED]. On 02/01/2017 at 11:30 a.m., the surveyor observed EI #2, an LPN prepare to administer the insulin and [MEDICATION NAME]. EI #2 took the medications to RI #13's room, administered the [MEDICATION NAME] orally, pulled the privacy curtain, then put on her gloves. EI #2 did not wash her hands prior to putting her gloves on. On 02/01/2017 at 11:35 a.m., the surveyor interviewed EI #2 about the medication administration for RI #13. EI #2 stated she should have washed her hands before putting on her gloves due to the potential for contamination and spreading germs from one resident to another. C.) RI #18 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #18's physician's orders [REDACTED]. On 01/31/2017 at 5:42 p.m., the surveyor observed EI #3, a Registered Nurse (RN) prepare and administer the [MEDICATION NAME] sodium by gastrostomy tube to RI #18. EI #3 checked the dosage, got a medication cup, placed the tablet into the cup then put on gloves. She then crushed the medication and removed her gloves. EI #3 went to RI #18's room, then washed her hands. EI #3 did not wash her hands before putting on her gloves or directly after removing her gloves. On 01/31/2017 at 6:05 p.m., the surveyor interviewed EI #3 about the medication observation for RI #18. When asked what should be done prior to putting on her gloves, EI #3 stated hands should be washed or sanitized to prevent the spread of germs. D.) A facility document dated August 1998 titled, Glucose Screen, documented: .Infection Control Policy Guidelines Because of the hazardous nature of handling blood products, it is recommended that disposable gloves be used when collecting specimens, performing test procedures and cleaning blood glucose meter equipment. Gloves are to be removed and hands washed thoroughly with soap and water after completing the test procedure and prior to handling equipment not related to the procedure. RI #19 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#19's physician's orders [REDACTED]. On 02/01/2017 at 11:10 a.m, the surveyor observed EI #4, an LPN preparing to check RI #19's glucose level. EI #4 sanitized her hands and gathered the equipment needed, placed a barrier on RI #19's over the bed table. EI #4 then put on her gloves, cleaned the glucometer and removed her gloves. EI #4 then went to get the glucometer strips, came back and put on gloves, cleaned the strip bottle and removed her gloves. EI #4 washed her hands, performed the blood glucose check, removed her gloves, put on another pair of gloves and began to clean the glucometer. EI #4 did not wash her hands before putting on her gloves, or after removing her gloves. On 02/01/2017 at 11:15 a.m., the surveyor interviewed EI #4 about the performance of RI #19's blood glucose level check. EI #4 stated hands should be washed before putting on gloves and after removing gloves. When asked when she had washed her hands, EI #4 stated when she had entered the room, before touching the resident and after she got through. EI #4 stated that hands were to be washed to prevent the spread of infection and maintain cleanliness. On 02/02/2017 at 08:20 a.m., the surveyor interviewed EI #5, the Director of Nursing/Interim Infection Control Nurse about the medication observations. EI #5 stated that hands should be washed or sanitized prior to putting on gloves as well as after removing gloves. EI #5 stated it was important to wash hands before putting on gloves and after removing gloves to prevent the spread of infection. EI #5 also stated hands should be washed prior to gloving and after removing gloves when cleaning the glucometer to prevent cross contamination. 2) Potter and Perry's, FUNDAMENTALS OF NURSING, Eighth edition, copyright 2013, Chapter 31 - Medication Administration, pages 627 to 630 documented: .IMPLEMENTATION 1 Perform hand hygiene .7 Apply clean gloves . 9 Select appropriate injection site .21 Remove gloves and perform hand hygiene . RI #12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#12's February 2017 physician's orders [REDACTED]. On 01/31/2017 at 11:01 a.m., the surveyor observed EI #1 check RI #12's blood sugar level. The result was 257. EI #1 then prepared the [MEDICATION NAME]for administration to RI #12. EI # 1 drew up the insulin, went to RI #12's room, knocked and entered the room. EI #1 (without putting on gloves) administered the insulin injection subcutaneously to RI #12. After completing the injection, EI #1 stated, I forgot to put on my gloves. On 01/31/2017 at 11:10 a.m., the surveyor interviewed EI #1 about RI #12's insulin injection. EI #1 was asked what should be done when administering injections. She stated to wash hands and put on gloves. EI #1 stated she had not worn gloves while administering the insulin to RI #12. EI #1 further stated it was important to wear gloves due to the potential for cross contamination and infection. On 02/02/2017 at 08:20 a.m., the surveyor interviewed EI #5, the Director of Nursing/Interim Infection Control Nurse. EI #5 stated gloves were to be worn during the administration of injections because the nurse would have physical contact with the resident which requires gloves. EI #5 further stated it was important to wear gloves to prevent the spread of infection.

Based on observation, record review, interviews, and review of the Operating Instructions for the facility's wheelchair tie-down system, the facility failed to ensure Resident Identifier (RI) #10's wheelchair was forward facing and tie-down straps were secured properly during transport on the facility bus on 12/16/2016. This affected RI #10, one of three wheel-chair bound residents reviewed for proper transport. Findings include: On 01/11/2017, the State Agency received an anonymous complaint that RI #10's wheelchair turned over while being transported from the nursing facility to the hospital on [DATE]. The complainant alleged RI #10 hit his/her head when the vehicle hit a bump and the wheelchair rolled back. Review of the undated User Instructions for the facility's wheelchair tie-down system revealed the following: A. SECURE WHEELCHAIR 1. Place wheelchair facing forward . 3. Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-down straps are fixed at approximately 45 degrees . ! WARNINGS: * Systems should only be used with forward facing wheelchairs *Wheelchair Securement Systems should be used as shown in these instructions . RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Significant Change Minimum Data Set Assessment, with an Assessment Reference Date of 09/30/2016, indicated RI #10 utilized a wheelchair for mobility and required extensive to total assistance from staff for locomotion. RI #10's NURSE'S NOTES for 12/16/2016 at 11:30 a.m. documented RI #10 was dressed and ready to transport to a local outpatient center for a surgical procedure. The note also indicated RI #10 was . Transferred by w/c (wheelchair) to van. Social Services and CNA (Certified Nursing Assistant)/ Activities to transfer resident . RI #10's Surgical Documentation, dated 12/16/2016, documented the following: . General Information . Neurologic: . fall out of wheelchair during transport from nursing home to hospital. CT (Computerized Tomography) head done after arrival to preop was negative for intracranial hemorrhage . RI #10's son was interviewed on 01/31/2017 at 3:04 p.m RI #10's son stated he was at the hospital on [DATE] when the bus arrived. He said he was informed there was an incident on the bus on the way from the facility. He also said the staff had RI #10's wheelchair facing the side of the bus, instead of the front, and said he noted RI #10 had what appeared to be a blood blister on the back of the head. Employee Identifier (EI) #7, CNA/ Activities Assistant, was interviewed on 01/31/2017 at 4:15 p.m EI #7 explained on 12/16/2016 she, RI #10, and another employee (EI #8) were the only people on the bus. EI #7 said she was the one to strap RI #10 in and confirmed RI #10 was facing the aisle. EI #7 said she then drove the bus while EI #8 sat in the back with the resident. EI #7 said after they left the facility, they had to stop for gas; when pulling out of the gas station, RI #10's chair tilted back and he/she bumped his/her head. EI #8, Social Services Designee, was the other employee present on the bus on 12/16/2016. During an interview with EI #8 on 01/31/2017 at 4:50 p.m., EI #8 confirmed EI #7 had secured RI #10 in the wheelchair. EI #8 explained when they pulled out of the gas station, RI #10's wheelchair rolled back and RI #10 hit his/her head. On 02/01/2017 at 10:43 a.m., EI #7, CNA/Activities Assistant, demonstrated how she secured RI #10's wheelchair on 12/16/2016. EI #9, the Administrator, was in the wheelchair throughout the demonstration. EI #7 showed how she had RI #10's wheelchair positioned so the resident was facing the side of the bus, instead of the front. When demonstrating how she secured the tie-down straps, it was noted the back strap on the resident's right side was running under the rear wheel of the wheelchair and was not at a 45 degree angle. EI #9, the Administrator, acknowledged the strap anchors were still in the same position they were in on 12/16/2016 and said the only difference was they currently had self-tightening straps. The older straps had to be manually tightened. The anchors were positioned in a rectangle, measured by the the Administrator as two feet by four feet. When asked how they had determined if EI #7 had properly secured RI #10's wheelchair, EI #9 said staff reported one of the hooks (on the tie-down straps) came loose. EI #9 was unable to provide documentation that staff were trained on the tie-down system that was in place on 12/16/2016, but said the last training was over five years prior. EI #9 said the Operating Instructions for their newer system would also apply to the system in place at the time of RI #10's incident. EI #9 said RI #10's wheelchair was not forward facing, but should have been according to the instructions. When asked if it would be possible to properly secure the wheelchair if it was facing the side, EI #9 said it would hook, but since it was two feet verses four feet, it would be half the distance. When discussing the requirement that the straps be positioned at a 45 degree angle, EI #9 said the back straps were not positioned properly, and described them as being at angles of 75 to 80 degrees. EI #9 said it was possible this incident could have been avoided if RI #10's wheel chair had been forward facing and the straps secured at the correct angles. The surveyor determined current facility compliance by review and verification of the facility's Action Plan as outlined in general terms below: Action Items: - Implement plan for no wheelchair bound patient transfers until proper equipment available (12/20/2016) - Purchase new wheelchair restraint system (12/20/2016) - Educate and implement a checklist for transporters (staff educated on new checklist 01/12/2017) - Educate all transporting staff on new wheelchair restraint system once installed (all staff responsible for transporting residents educated by 01/12/2017) Documentation of these action items was reviewed. It was determined the new system was installed and staff responsible for transports were educated on use of the system and the new check-list for transports by 01/12/2017. The facility also maintained an ongoing monitoring log for all wheelchair transports via the facility bus.

Based on record reviews and interviews, the facility failed to ensure: 1) Resident Identifier (RI) #4 received timely medical treatment after a fall with complaints of pain. On Saturday, 3/12/2016, RI #4 sustained a fall to the left side. The following morning RI #4 began complaining of pain in the left thigh area and refused to move the left leg. According staff who cared for RI #4, the resident did not get out of bed which was very abnormal because he/she was normally up most of the day. The nursing staff documented that RI #4's pain medications were ineffective. After RI #4 began complaining of pain, nursing staff failed to conduct thorough nursing assessments, or contact the physician. The nursing staff further failed to implement the facility's standing orders to send RI #4 to the emergency room (ER) for evaluation and treatment. An x-ray was not ordered until the following Monday, 3/14/16, at 7:30 AM, two days after the fall. The x-ray revealed RI#4 sustained a left [MEDICAL CONDITION] requiring surgical repair. This deficient practice placed RI #4 in immediate jeopardy as it was likely to cause serious injury, harm, or death. On 06/24/2016 at 12:37 PM, the Administrator and Director of Nursing were notified of the Immediate Jeopardy in the area of Quality of Care at F309. The Immediate Jeopardy began on 03/12/2016 and continued until the facility implemented immediate corrective actions on 06/24/2016. 2) The facility further failed to ensure their bowel protocol was implemented when RI #2, a resident at risk for constipation, did not have a bowel movement from 03/09/2016 to 03/18/2016, nine consecutive days, resulting in the digital removal of a large, hard, clay-like fecal impaction on 03/19/2016. These failures affected RI #4, one of five residents sampled for falls with fractures, and RI #2, one of four residents reviewed for bowel management concerns. Findings include: 1) Review of the facility's Fall Management policy, dated 08/30/2005, revealed the following: . PROCEDURE: . 13. A licensed nurse will assess the resident after a fall to include the following: a. Vital Signs including a B/P (blood pressure) Sitting and Standing if possible. b. Description of the Incident c. Range of Motion d. Pupils e. Bruising f. Swelling g. Pain h. Level of Cognition i. Level of Consciousness j. Other Injuries k. Need for actions such as X-rays or transfer. 14. The nurse will document the assessment findings on the nurses notes to include the following: a. Assessment b. Dr. notified including the name, time, method notified, and new orders . d. Actions taken. e. Follow-up documentation. 15. The nurse will monitor the resident for 72 hours after a fall for the following: a. Swelling b. Pain c. Limited movement or limited range of motion . h. Abnormal symptoms . This policy also included a table outlining EMERGENCY situations versus NON-EMERGENCY situations. Hip pain following a fall was classified as an EMERGENCY situation. The facility's policy titled Resident's Condition Change Reporting, reviewed 08/31/2005, indicated the physician should be notified immediately when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention. Review of the facility's Standing Orders, signed 07/30/2014, revealed a standing order for the following: . 34. In case of emergency, if unable to contact the attending physician on call- send resident to the Emergency Department and notify the attending physician ASAP (as soon as possible) . RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. RI #4's 12/10/2015 Quarterly Minimum Data Set Assessment indicated RI #4 was cognitively intact and had occasional pain that did not interfere with sleep or limit daily activities. The facility's document titled INVESTIGATION FOLLOW-UP indicated RI #4 sustained a fall on 03/12/2016 at 8:30 PM. The resident was found on the floor on his/her left side at the foot of the bed. Redness was noted to RI #4's left side; however, RI #4 voiced no complaints of pain at that time. Review of RI #4's Nurse's Notes indicated Employee Identifier (EI) #3, Registered Nurse (RN) Supervisor, assessed RI #4 the following morning on 03/13/2016 at 10:20 AM, due to complaints of soreness and pain to the left thigh area. EI #3 documented RI #4 refused to move his/her left leg. EI #3 further failed to include the level of pain, amount of swelling, and if any bruising was noted. Also, there was no documentation the physician was notified. On 03/13/2016 at 11:30 AM, EI #5, Licensed Practical Nurse (LPN), also documented RI #4 complained of soreness to the left thigh area. EI #5 faxed a notification to RI #4's physician at this time; however, it was a weekend and the physician's office was closed. There was no documentation of a verbal/phone or immediate notification to the physician on call. The 03/13/2016, the 11PM-7PM (night) nurse documented on 03/14/2016, RI #4 complained of left hip pain since the fall and PRN (as needed) pain medications brought little relief and that RI #4 slept on and off throughout the night. There was no documentation of a nursing assessment to include pain level or any further interventions to relieve RI #4's pain, nor was the physician notified. Review of RI #4's March 2016 MEDICATION RECORD revealed routine pain medications, [MEDICATION NAME] (pain medication) and [MEDICATION NAME] [MEDICATION]), were given twice a day. In addition to the routine medications, RI #4 also received PRN [MEDICATION NAME] and Tylenol on 03/14/2016. During an interview on 06/23/2016 at 5:33 PM, EI #4, the Director of Nursing, explained how she responded to RI #4's call light on Monday morning, 03/14/2016. RI #4 was still complaining of left leg pain. EI #4 obtained an order for [REDACTED]. Review of RI #4's Physican's order revealed an order for [REDACTED]. The x-ray report, with a completion date of 03/14/2016 at 5:13 PM, documented the following results: . Reason for Procedure(s): FALL PAIN . IMPRESSION: I. Acute left intertrochanteric (hip) fracture . EI #7, LPN, documented in RI #4's Nurses Notes on 03/14/2016 at 5:30 PM, the physician was notified of RI #4's x-ray results and gave orders to send RI #4 to the emergency room for evaluation. RI #4's was admitted to the hospital on [DATE]. The hospital's History and Physical Reports documented the following: . HISTORY OF PRESENT ILLNESS The patient is a 91- year-old . who lives in a nursing home, who fell on Saturday night . The patient was noted to have a shortened and externally rotated left lower extremity . diagnosed with [REDACTED]. anticipated surgical management . EXTREMITIES: Left hip has some swelling, but all compartments are soft. No lacerations or abrasions. However, it does appear the left lower extremity is shortened . During an interview on 06/23/2016 at 9:05 AM, RI #4's sponsor state the resident fell on a Saturday night. When she arrived at the facility on Sunday, she was informed an x-ray would be done the following day. RI #4's sponsor said RI #4 complained of pain on Sunday and did not get out of bed. The sponsor called RI #4 at 4:30 PM on Monday to see if the x-ray had been done. RI #4 informed the sponsor that the x-ray had not been done. RI #4's sponsor explained the facility staff gave multiple explanations for the delay, including an incorrect order and miscommunication between the nursing home and the x-ray department. The sponsor said she was very upset that RI #4's hip was broken on a Saturday and the facility did not find out until Monday. According to RI #4's sponsor, the nurse told her staff were not putting RI #4 on a bed pan because they did not want to hurt the resident. Instead, they were letting RI #4 urinate on him/her self. An LPN further explained to the sponsor that RI #4 was not placed on a bed pan in case there was an injury, so staff would not make the injury worse. Interviews were conducted with the Certified Nursing Assistants (CNAs) who cared for RI #4 from the time of the fall on 03/12/2016 through 03/14/2016, EI #s 8, 9, and 10: EI #8 was interviewed on 06/24/2016 at 8:30 AM. EI #8 worked 3:00 PM until 11:00 PM on 03/12/2016. EI #8 said she was working when RI #4 fell and recalled RI #4 voiced no complaints of pain during her shift on 03/12/2016. EI #8 said she was also working at the time RI #4 was sent to theER on [DATE]. She said RI #4 was in a lot of pain at that time and was crying. EI #8 had never seen RI #4 like that before. EI #9 was interviewed on 06/24/2016 at 8:48 AM. EI #9 worked day shift on 03/13/2016, the day after RI #4's fall. EI #9 said RI #4 was in pain as evidenced by facial grimacing and that the resident stayed in bed all that day. EI #9 remarked that it was very abnormal for RI #4 to stay in bed because he/she was normally up most of the day. EI #9 was asked if she reported RI #4's pain to the nurse and she said yes. EI #9 said the resident reported informed her that the nurse had provided pain medications that were partially effective. EI #9 said after RI #4 received the pain medication, the resident was not grimacing as much, but kept complaining of leg pain. EI #10 was interviewed on 06/24/2016 at 9:15 AM. EI #10 worked 3:00 PM to 11:00 PM on 03/12/2016 and also worked the night shift through 7:00 AM on 03/13/2016. According to EI #10, initially RI #4 did not complain of any pain, but RI #4 was sore and by the next day it was much worse. EI #10 also worked 3:00 PM to 11:00 PM on 03/13/2016. She said RI #4 was complaining frequently of thigh and hip pain on that shift. EI #10 said RI #4 did not get out of the bed from the time he/she was placed into bed following the fall until sent out on Monday 03/14/2016. EI #10 said if RI #4 stayed in bed, staff knew something was wrong. EI #10 was working when RI #4 was transferred to the hospital on the 14 th. When EI #10 helped move RI #4 to the stretcher for transfer, he/she was crying and kept saying he/she was hurting. EI #10 thought by the 14th, RI #4's pain had worsened to the point the resident could not take it anymore. During an interview on 06/23/2016 at 3:05 PM, EI #5, the LPN present at the time of RI #4's fall on 03/12/2016, stated she assessed RI #4 after the fall. She said RI #4 voiced no complaints of pain at that time. When asked if she contacted RI #4's physician, EI #5 admitted she had not called the doctor, but told the oncoming nurse. EI #5 said because it was the weekend, she could not contact the physician since their office was closed. EI #5 explained how an RN Supervisor, EI #3, assessed RI #4 the following morning. EI #5 said she should have contacted RI #4's physician immediately in case of an injury. EI #5 said not contacting the doctor after a fall could delay orders or treatments, and the resident could have serious injury. EI #5 was asked how RI #4 was affected from 03/12/2016 to 03/14/2016 without physician notification or an x-ray. EI #5 said RI #4's treatment was hindered, and he/she could have received needed treatment faster. EI #5 was aware the facility had standing orders and stated when RI #4 began complaining of pain, staff could have sent the resident to the ER. EI #3, the RN Supervisor that assessed RI #4 on 03/13/2016, was interviewed on 06/23/2016 at 4:38 PM. EI #3 said when she came to work she received a report that RI #4 was complaining of some hip pain. EI #3 was asked about the 03/13/2016 nurses note she documented that RI #4 had an x-ray ordered for the following Monday (03/14/2016). EI #3 stated she did not know why the x-ray was ordered for Monday and admitted she did not check to see if it was actually ordered. EI #3 added that a lot of times on the weekends things are put off until Monday. EI #3 admitted when she checked on RI #4, she did not do a full assessment and only asked the resident what happened. When asked if RI #4's physician was notified, EI #3 said the physician should have already been notified at the time of the incident. EI #3 could not explain why RI #4 was not sent to the ER or why the x-ray was delayed until Monday. According to EI #3, if staff could not reach the doctor, the facility had standing orders to send the resident to the ER. When asked how not contacting RI #4's physician had affected the resident, EI #3 said she imagined RI #4 needed some relief (pain). A follow-up interview was conducted with EI #3 on 06/23/2016 at 4:10 PM. EI #3 was asked why she had not contacted the physician or implemented the standing order to send RI #4 to the ER. EI #3 answered because she thought staff already had it covered with an x-ray scheduled for Monday. EI #6, LPN, was interviewed on 06/23/2016 at 4:52 PM. EI #6 said she worked the night of 03/13/2016 through the morning of 03/14/2016. When asked if she contacted RI #4's physician when pain meds were not effective, EI #6 said she did not because often during the night, staff wait until the next morning to make contact with the doctor. EI #6 acknowledged the facility did have standing orders to send residents to the ER. EI #6 explained she should have sent RI #4 to the ER since it was in the resident's best interest because of the pain issues and history of the fall. EI #6 further explained had the doctor been notified or the resident sent out, RI #4 could have received some pain relief and received treatment sooner. When asked what signs and symptoms of pain RI #4 demonstrated, EI #6 felt RI #4's pain may have interfered with the resident's sleep that night. EI #6 did not know why RI #4 had to wait until the Monday after the fall for treatment. EI #6 stated she obviously should have called the doctor or sent RI #4 to the ER since it was in the same building as the nursing home. A follow-up interview was conducted with EI #6 on 06/24/2016 at 9:12 AM. EI #6 was asked how she assessed RI #4 when she documented pain medications as ineffective. EI #6 did not recall. When asked if she had checked RI #4's leg lengths, EI #6 did not recall checking RI #4's leg lengths. EI #6 said an assessment would have been documented in the Nurses Notes. EI #6 admitted she should have conducted an assessment due to RI #4's complaints of pain after a fall, but knew the x-ray was scheduled for Monday. When asked what her assessment should have consisted of, EI #6 stated a physical assessment and a pain assessment. EI #6 said even though she thought the x-ray was scheduled for Monday, she should have intervened and sent RI #4 out due to complaints of pain and ineffective medications. EI #11 worked 03/14/2016. During an interview on 06/24/2016 at 9:45 AM, EI #11 said the night nurse gave her a report her that RI #4 complained of pain throughout the night and that medications did not help. EI #11 said when RI #4 was moved around, the pain level was higher. EI #11 added, when staff were preparing to transport RI #4 to the ER, he/she was crying out in pain. EI #7, LPN, was interviewed on 06/24/2016 at 9:50 AM. EI #7 was working on 03/14/2016 and was working at the time RI #4 was transferred to the hospital. EI #7 explained if a resident falls over the weekend, the nurse should complete an assessment. If any injury is noted or the resident complains of pain, the physician should be notified or the resident should be sent to the ER per their standing order. Following a fall, EI #7 said the resident should be assessed every shift for 72 hours. She further stated if a resident starts complaining of pain, medication should be given and the physician notified. If the pain is not relieved by medications, the resident should immediately be sent to the ER. During an interview on 06/23/2016 at 5:33 PM, EI #4, the Director of Nursing (DON), was asked what staff should do when a resident falls on the weekend. The DON explained, first the resident should be assessed by the LPN, and if an RN is present, the RN should also complete an assessment. If an RN is not present, the RN should complete an assessment the following morning. EI #4 said after RI #4's fall on 03/12/2016, he/she initially had no complaints of pain. EI #4 then reviewed the Nurses Note dated 03/13/2016 at 10:20 AM (written by EI #3). EI #4 said EI #3 should have contacted the physician or implemented standing orders to send the resident to the ER. EI #4 said RI #4's x-ray was not ordered until Monday morning, the 14th, when she answered the resident's call light. EI #4 reviewed the 03/14/2016 11:00 PM to 7:00 AM Nurses Note (written by EI #6) and stated staff should have sent RI #4 to the ER. EI #4 said since the nursing home is in the same building, they should have utilized the ER. EI #4 admitted there was a delay in RI #4's treatment, from the date of the fall on 03/12/2016 until the following Monday (03/14/2016) when the MD was notified, an x-ray was obtained and the resident was sent to the ER. A follow-up interview was conducted with EI #4, DON, on 06/24/2016 at 12:04 PM. EI #4 was asked why the x-ray order written on 03/14/2016 at 7:30 AM was not completed until 03/14/2016 at 5:13 PM, nine hours and forty-three minutes later. EI #4 explained the x-ray was delayed because the unit receptionist put the order in as an ultrasound instead of an x-ray. EI #4 was then asked what she expected the nursing staff to do during the 72 hour monitoring period following a fall. EI #4 stated sometimes after a fall a resident may be fine, then later begin having pain. During the 72 hour timeframe nursing staff should be checking for pain, swelling, any bruising, any abnormalities, and any range of motion limitations. She added that the physician should be notified of the findings and the assessment should be documented. EI #4 reviewed RI #4's Nurses Notes from 03/12-03/14/2016 and could not determine if the assessments were completed. EI #4 said assessments were important to determine if there are any abnormalities or changes following an incident/fall. This deficiency was cited as a result of Complaint/Report # AL 495. ************************************ Allegation of Compliance (AOC) F309 On 06/24/2016 at 7:20 PM, the Administrator, Administrator in Training, Director of Nursing, and Staff Development Nurse were notified the AOC had been accepted. The AOC documented the following: EAMC-Lanier Nursing Home AOC for F-Tag 309 An inservice will be held for all RN and LPN staff on June 24, 2016 on 4:00pm. All attending staff will be educated on the following topics: · When and how to give a complete, detailed head to toe assessment including Orientation, Vitals, and Physical Status, among others (see attached assessment). · The proper procedure for making sure the appropriate parties are aware of any Resident Falls: The Residents' Physician, On-Call Physician (if Residents' Physician is unable to be immediately contacted), The Residents' Sponsor, Oncoming Nurse and CNA, and Support staff. · Utilize Standing Order stating, In case of emergency, if unable to contact the attending physician on call- send resident to the Emergency Department and notify attending physician ASAP. · The correct procedure in ensuring that the Medications given are appropriately and effectively combating the Residents' pain: If pain is not controlled (exhibited by verbal or facial grimacing and/or utilization of Pain Assessment tool) with current medication regimen, immediately contact Primary Care Physician. · Prior to first shift worked with EAMC-Lanier Nursing Home, all hired Licensed Practical Nurses and Registered Nurses to be ensured to be thoroughly knowledgeable on all of the aforementioned processes. Staff will review all Residents' falls and falls with injuries within the last thirty (30) days previous to June 24, 2016 to ensure accurate assessments was documented. Any negative findings (Lack of MD/Sponsor Notification, Vital Signs, Medication effectiveness, and/or Radiology orders) will be corrected immediately. All findings along with audit documentation will be communicated to the Survey Team on 6/24/2016. Policies that these changes impact were reviewed on 6/24/2016 and revisions were made to reflect these changes. ****************************************** After receiving an acceptable AOC on 06/24/2016 at 5:07 PM, various LPNs and RNs were interviewed regarding the education they received, including situation specific questions related to falls. The facility conducted a 30 day audit of all falls. They provided documentation on any needed corrective actions identified during their audit and copies of all physician notifications of falls within the past 30 days. Policies and Procedures were also reviewed and revised as needed and copies provided. This information was reviewed and the Administrator, Administrator in Training, Director of Nursing, and Staff Development Nurse were notified on 06/24/2016 at 7:20 PM, the Immediate Jeopardy was relieved. 2) RI #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #2's current care plans dated 09/10/2015 indicated RI #2 was at risk for constipation with a goal of BM (bowel movement) every three days. Review of RI #2's physician's orders [REDACTED]. Review of RI #2's March 2016 MAR (Medication Administration Record) revealed MOM was listed on the MAR, but was never given and then, discontinued on 3/10/2016. Review of RI #2's ADL (Activities of Daily Living) Record from 03/01/2016 to 03/31/2016, revealed that RI #2 was OOF (Out of the Facility) from 03/02/2016 until readmission on 03/09/2016. The BM section for 03/10/2016 on the 7-3 and 3-11 shifts and 03/13/2016 on 3-11 shift were blank. The BM sections for all other shifts and days from 03/09/2016 until 03/18/2016 on 11-7 shift documented RI #2 had no BMs. On 03/18/2016 on the 11-7 shift a small BM was documented. On 03/19/2016 an extra-large BM was documented. Employee Identifier (EI) #24, Licensed Practical Nurse (LPN), was interviewed on 06/22/2016 at 6:05 PM. She explained the facility's BM Protocol where 11-7 shift nurse compiled a Laxative List for residents who have not had a BM in 3 days. The 3-11 shift nurses were responsible for providing a laxative to these residents. She stated when a resident had not had a bowel movement in three days, nursing staff should first check for an impaction. If no impaction was noted, a laxative should be provided. EI #24 said staff should then monitor the resident for BMs and if no BM in 24 hours, the physician should be notified. Review of the facility's Laxative Lists for 03/09/2016 to 03/19/2016 revealed RI #2 was placed on the list on 03/12/2016 only. This entry listed RI #2's name and the date of the last BM as 03/09/2016, with the notation unable to swallow. A line had been drawn through the entry that was signed by EI #5, a Licensed Practical Nurse (LPN). On 06/22/2016 at 3:30 PM, EI #5, the LPN who signed the Laxative List for 03/12/2016, was interviewed. EI #5 stated that the facility had a BM protocol which was compiled by the 11-7 shift nurse for residents who have not had a BM in three days. She also acknowledged that she was the nurse who had documented on the Laxative List that RI #2 was unable to swallow. When asked what should have been done for RI #2 when he/she was unable to swallow the laxative, EI #5 stated she should have tried to get RI #2 something else or should have called the doctor. EI #5 also stated that RI #2 should have been on the Laxative List every day until RI #2 had a bowel movement. When asked what the potential for harm was in not having bowel movements, EI # 5 explained how the resident could begin vomiting and have a bowel obstruction. On 06/24/2016 at 11:52 AM, the surveyor interviewed EI #4, the Director of Nursing (DON). The DON confirmed that the facility's BM protocol directed the 11-7 shift nurse to place any resident who did not have a BM for 3 days on the Laxative List and the 3-11 (second shift) nurse to give the laxative. After reviewing RI #2's ADL Record for the BM history, EI # 4 stated that the only BMs RI #2 had from 03/09/2016 to 03/19/2016 were documented on 3/18/2016 as a small BM and 3/19/2016 as a very large BM. EI #4 reviewed the Laxative List for 03/12/2016 and stated that RI #2 should have been assessed, bowel sounds should have been assessed, and RI #2 should have been placed on the Laxative List. When asked what should have been done for RI #2 when the documentation reflected there was no BM from 03/09/2016 to 03/18/2016, EI #4 stated the doctor should have been notified and given a detailed notification. EI #4 stated that it was important to document BMs and place residents on the Laxative List to make sure residents are having BMs in a timely manner and to prevent residents from becoming nauseated and having obstructions. Review of RI #2's Nursing Observations/Notes from 03/09/2016 to 03/19/2016 revealed on 03/19/2016 on the 7 PM to 7 AM shift at approximately 4:00 AM, a CNA (Certified Nursing Assistant) reported that RI #2 had projectile vomiting of brown liquid. The note further documented RI #2's respirations were greater than 40 per minute and bowel sounds were barely audible. Hospice was notified. There was no indication the physician was notified prior to 03/19/2016 nor was there any evidence facility nursing staff checked RI #2 for an impaction. Review of the Hospice Nurses Notes for 03/19/2016, documented RI #2 had vomited and was very uncomfortable. RI #2's breathing was very rapid and the resident was moaning. RI #2 was checked for an impaction and a very hard clay like fecal impaction was removed by digital manipulation and an enema was given. On 06/23/2016 at 2:15 PM, the surveyor interviewed the Hospice Nurse who had taken care of RI #2 during March 2016. The Hospice Nurse confirmed that on 03/19/2016, a large fecal impaction had been removed from RI #2 and the resident had been given an enema. On 06/22/2016 at 3:08 PM, the surveyor interviewed EI #19, the Medical Director/ RI #4's primary physician. The surveyor reviewed RI #2's MAR, ADL Record, and physician's orders [REDACTED]. The Medical Director (EI #19) stated that he usually preferred a resident to have a BM every 24 to 48 hours. EI #19 further stated he had had many conversations with staff concerning RI #2, but did not recall any conversations about RI #2's bowel movements. When EI #19 was asked what could have been done for RI #2 when it was documented that he/she did not have a BM from 03/09/2016 to 03/18/2016 and was disimpacted on 03/19/2016, he stated they could have checked for an impaction sooner or could have given a [MEDICATION NAME] suppository.

Based on observations, interviews and record reviews, the facility failed to ensure: 1) paint was not peeling or scraped off the walls in the hallways and resident common areas; 2) wallpaper was not peeling off the walls in residents' rooms and residents' common areas; and 3) paint was not scraped/scuffed off the entrance doors and doorframes going into residents' rooms. These concerns were noted on two of two floors of the facility and had the potential to affect all 90 residents residing in the facility. Findings Include: The facility's policy and procedure titled, GENERAL OVERVIEW OF PROGRAM with a revised date of 07/31/2012 documented: . General Information The Engineering Department's objective is to provide a professional management program for Lanier Health Services that is designed to promote the facility in the public eye . Cosmetic Maintenance First impressions are important. People judge a book by its cover. Therefore, it is important that we get an immediate impact on the appearance of each building under the Engineering Department's care. Policing of . wall paper repairing, painting walls . is included. Our goal is to improve public perception, so that visitors, patients, and employees are pleased by the appearance of all facilities. On 06/21/16 beginning at at 12:35 PM, during the initial tour, the following observations were made on the first floor: The hallway consisting of Room Locator (RL) #s 1 through 7 was noted to to have multiple horizontal scratches and chipped paint extending half way up the walls. This was also noted on all doors and door frames. The Hallway containing RL #s 8 through 16 were noted with scratches and scrapes on doors. RL #17's door was covered in scratch marks and scrapes. RL #18's doorframe was covered in scratches and was missing paint on the lower half. On 06/21/2016 at 12:45 PM additional observations were made of the first floor: In the main lobby of the facility the base board was taped with blue tape. Between the bathrooms, the wall paper and base board was peeling off the wall. The baseboard on the left was missing, on the corner behind the two recliners. RL #10's wallpaper was peeling off the wall under the window and beside a sitting chair. RL #11's door and door frame were scuffed. RL #12 had paint peeling off the wall beside a sitting chair. RL #13's wallpaper was peeling off the wall under the window. Chunks of wallpaper were chipped off of the wall at the head of the bed. The door and frame had multiple scuffed areas. On 06/21/2016 at 3:27 PM, the following observations were made on the second floor: The hallway across from the elevator was noted with green paint chipped off of the wall with white and tan showing through. Further, the baseboards were very dirty. Black grime was collected at the door frame. The hallway consisting of RL #s 19 through 25 had scuffed walls on one side of the hallway. All doors were scraped and paint was missing. RL #19 was also noted to have paint scraped off in three large sections close to the hinge side of the door and two large scrapes in the middle of the door. The handrail located in the hall across from RL #19 had long areas of scraped green paint with yellow and white showing through. The bottom third of RL #20's door was noted with multiple scrapes all the way across the door. The wall going into RL #21 on the right side had a yellow and grey discoloration and scuff marks. The linen room at the end of the hall, located beside RL #22 had scraped paint on the door approximately 2 feet by one and a half inch area. The door frame on both sides of this door was scraped and had missing paint. RL #26's door had several large areas of missing paint on the bottom half of the door. RL #27's door was scraped and scuffed across the entire bottom portion of the door. The hallway outside of RL #28 had wall paper peeling from the top half of the wall. RL #29 had wallpaper peeling on the bottom half of the wall outside the doorway. Outside of RL #30,wallpaper was noted with long discolored strips. The wallpaper was yellowed and peeling. The wallpaper in the second floor dining room, where survey results were posted, was peeling from the wall on top of the windows and above the fishtank. During a resident group meeting on 06/22/16 at 11:30 AM, eleven of eleven residents in attendance agreed there were scratches on the walls and paint was missing. All eleven agreed the first and second floors were affected and said it looked bad. On 06/22/16 at 4:05 PM, Employee Identifier (EI) #12, Building Services Manager (for the hospital), was asked who was responsible for maintaining the environment such as peeling, scuffed paint, wallpaper and baseboards. EI #12 replied that would be maintenance. EI #12 was asked why there was so much work that needed repair on both floors. EI #12 stated he did not have a designated person. EI #12 was asked when was the last time the facility was painted. EI #12 replied, about three years ago and occasionally do touch ups, but wasn't sure when the last touch up was done. EI #12 further stated he did not have the man power or the finances for one person to be designated for the upkeep of the nursing home. EI #12 was asked what could be a potential concern. |EI #12 replied cosmetically it looks bad. The surveyor requested EI #12 to complete a walk through of the facility. EI #12 stated he was aware of all the concerns. On 06/23/16 at 8:15 AM, EI #13, Administrator, was asked who was responsible to oversee the environment of the facility. EI #13 replied it was a combination of himself and EI #12. EI #13 was asked why the paint on the walls, doors and door frames were peeling or scraped off. EI #13 replied it was from wheelchairs and dietary carts. EI #13 was asked who should have reported the walls, doors and door frames was peeling and scraped/scuffed areas. EI #13 replied that would be him. EI #13 was asked why wasn't it done. EI #13 replied it has been ongoing. EI #13 was asked to describe what the walls looked like. EI #13 replied the first floor hallway needed to be painted and it looked bad. EI #13 was asked how did he think the resident might feel about the way it looks considering this was their home. EI #13 replied if it was his personal home he would want it to look better than it does.

Based on interviews and record review, the facility failed to ensure residents were assessed for their voting preferences and assisted with voting during the 2015 and 2016 elections. This affected eight of eleven residents present during the 06/22/2016 Group Meeting and had the potential to affect all 31 alert and oriented residents in the facility able to exercise their right to vote. Findings include: Review of the facility's Admission packet revealed a document titled RESIDENTS' BILL OF RIGHTS which documented the following: . A RESIDENT HAS THE RIGHT TO: . * exercise his/her rights as a citizen of the United States and the state of Alabama including the right to vote . When asked for a facility policy related to voting, Employee Identifier (EI) #13, the Administrator, provided a copy of a new policy effective 06/22/2016. He stated there was no policy prior to that date. A Group Meeting was held on 06/22/2016 at 11:30 AM. Eleven residents were in attendance. Eight of the residents present when voting was discussed stated they did not know about voting and no one discussed it with them. These eight residents also stated they had not voted in the primary elections. On 06/22/2016 at 4:10 PM, EI #16, the Social Worker, was interviewed about resident voting. EI #16 explained a psychosocial assessment was completed upon admission to the facility, to include the residents' preference to register for voting. She said they also ask alert and oriented residents at the time of elections. When asked who was responsible for talking to alert and oriented residents prior to any upcoming elections, EI #16 said EI #17 with Activities was responsible for talking to residents to determine if they want to vote and arranging any needed transportation. EI #16 said it was important to discuss voting with residents and assist as needed so residents can still exercise their rights, even while in the facility. EI #17, Activity Coordinator, was interviewed on 06/22/2016 at 4:35 PM. When asked how often she discussed voting preferences with residents, EI #17 said they had some residents that were cognitive enough to let them know. She said with others, they are assessed upon admission and any time an election is coming up. When asked where it was documented that they discussed voting prior to any upcoming elections, EI #17 pulled a chart for review and said she did not see any documentation. EI #17 said it was important to discuss voting with the residents since it is their right to vote. When asked why eight of the residents in the Group Meeting said no one had discussed voting with them, EI #17 said she did not know. EI #17 was asked to provide documentation she met with residents prior to any upcoming elections to determine if they wanted to vote. On 06/23/2016 at 8:10 AM, EI #13, the Administrator, provided copies of the original admission assessments for the residents in attendance at the Group Meeting. EI #13 said they had no documentation related to the elections held since their last survey.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #4's physician was immediately notified after the resident sustained [REDACTED]. Further, the facility failed to ensure RI #2's physician was notified when the resident went greater then three days with no bowel movement (BM). This affected RI #s 2 and 4, two of 13 residents reviewed for physician notifications. Findings include: The facility's policy titled Resident's Condition Change Reporting, reviewed 08/31/2005, indicated the physician should be notified immediately when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention or when the need arose to alter treatment significantly. 1) RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A document titled INVESTIGATION FOLLOW-UP indicated RI #4 sustained a fall on 03/12/2016 at 8:30 PM. The resident was found on the floor on his/her left side at the foot of the bed. Redness was noted to RI #4's left side. The section on this form for . Was MD (medical doctor) notified? . was left blank. A review of RI #4's Nurse's Notes revealed the first documentation regarding physician notification was on 03/13/2016 at 11:30 AM when staff faxed a notification to RI #4's physician. However, since it was a weekend, the physician's office was closed. There was no documentation of a phone notification to the physician on call. On 06/23/2016 at 3:05 PM, during an interview with EI #5, the LPN present at the time of RI #4's fall on 03/12/2016, EI #5 stated she had not called the doctor but told the oncoming nurse. EI #5 said because it was the weekend, she could not contact the physician since their office was closed. EI #5 said had they noticed a fracture, they would have called the oncall doctor. EI #5 said she should have contacted RI #4's physician immediately in case of an injury. EI #5 said not contacting the doctor after a fall could delay orders or treatments, and the resident could have serious injury. During an interview with EI #4, the Director of Nursing, on 06/23/2016 at 5:33 PM, EI #4 reviewed the Nurses Notes related to RI #4's fall and said the physician should have been notified. 2) RI #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #2's current care plans dated 09/10/2015 indicated RI #2 was at risk for constipation. RI #2's Activities of Daily Living (ADL) Records for the month of March 2016 were reviewed and indicated RI #2 went from 03/09/2016 until 03/18/2016, with no evidence of bowel movements. RI #2's Nurses Notes for 03/09/2016 through 03/19/2016 contained no documentation the physician was notified when RI #2 exceeded three days with no bowel movements. The first and only evidence of physician notification was on 03/19/2016 when RI #2 was digitally disimpacted of a large amount of bowel movement. A review of all Laxative Lists provided by the facility for 03/09-03/19/2016 revealed RI #2 was only listed on 03/12/2016. This entry listed RI #2's name with the date of the last BM as 03/09/2016 with a notation unable to swallow. A line was drawn through the entry and was signed off by EI # 5, a Licensed Practical Nurse (LPN). On 06/22/2016 at 3:30 PM, EI # 5, the LPN who signed off the Laxative List for March 12th was interviewed. When asked what should have been done for RI #2 when he/she was unable to swallow the laxative, EI # 5 stated she should have tried to get RI #2 something else or should have called the doctor. On 06/24/2016 at 11:52 AM, the surveyor interviewed EI #4, the DON. She confirmed that any resident who did not have a BM for 3 days should be placed on the Laxative List. When asked what should have been done for RI #2 when the documentation reflected there was no BM from 03/09/2016 to 03/18/2016, EI #4 stated the doctor should have been notified and given a detailed notification. On 06/22/2016 at 3:08 PM, the surveyor interviewed EI #19, the Medical Director. The surveyor reviewed RI #2's MAR, ADL Record, and physician's orders [REDACTED]. He stated that he usually preferred a resident to have a BM every 24 to 48 hours. EI #19 further stated that he had many conversations with staff concerning RI #2 but did not recall any conversations about RI #2's BMs. When EI #19 was asked what could have been done for RI #2 when it was documented that she did not have a BM from 03/09/2016 to 03/18/2016 and was disimpacted on 03/19/2016, he stated they could have checked for an impaction sooner or could have given a [MEDICATION NAME] suppository.

Based on observations, interviews, and record reviews, the facility failed to ensure a Licensed Practical Nurse (LPN), Employee Identifier (EI) #1, washed her hands and applied clean gloves after cleaning RI #10's wound, after measuring the wound, and after touching her eye glasses before applying the clean dressing. This affected RI #10, one of four residents sampled for pressure ulcers and one of one wound care observation. Findings Include: A review of a facility policy and procedure dated 6/16 and titled, Hand-washing/Use of Gloves, revealed: .PURPOSE: To prevent the spread of infections .PROCEDURE: Hand washing or hand sanitizing with foam or gel will be performed after resident care is rendered and after handling contaminated articles. This includes the following: .4. Before and after touching wounds. 5. After contact with surfaces or items which are contaminated such as . blood or body fluids, body excretions . RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. On 6/22/2016 at 9:30 AM, Employee Identifier (EI #1), an LPN, was observed performing a dressing change to the opened blister on RI #10's right heel. EI #1 washed her hands and applied gloves then removed the dirty dressing. EI #1 then ungloved and washed her hands and applied clean gloves. EI #1 cleansed the open blister using gauze moistened with wound cleanser, then dried the wound. EI #1 then picked up her own eye glasses and put them on while wearing the gloves she had worn to clean and dry RI #10's wound. The surveyor then observed EI #1 place a measuring strip directly against the open blister to measure the wound. EI #1 used the same gloves she had worn to clean the wound, dry the wound, apply her glasses, and measure the wound, to obtain the 4x4 gauze she then placed on top of the wound and completed the dressing change. On 6/22/2016 at 10:30 AM, EI #1 was interviewed about RI #10's wound care observation. The surveyor asked EI #1 when did she wash her hands during the wound care on RI #10. EI #1 stated she washed before she entered the room, before she performed the care, after removing the dirty dressing, and when she had completed the care. The surveyor asked EI #1 if she had contaminated her gloves at any point during the wound care. EI #1 answered that she did not believe she did. The surveyor discussed the observation of the wound care with EI #1 regarding cleaning and drying the wound, her picking up her eye glasses to put them on, and then held the wound measuring device to the wound. The surveyor asked EI #1 if she could have contaminated the wound by this point in the wound care. EI #1 answered, Yes, I could have. The surveyor asked EI #1 if she should have washed her hands after measuring the wound and before she placed the clean dressing over the wound. EI #1 confirmed she should have washed her hands. The surveyor asked EI #1 what was the potential harm to the resident of not washing her hands and re-applying gloves after she touched her glasses and the dirty measuring device and before she touched the clean dressing. EI #1 answered that the potential harm was cross-contamination and a risk for infection. On 6/23/2016 at 4:10 PM, an interview was conducted with EI #2, LPN/ Infection Control Nurse. The surveyor asked EI #2 what a nurse should do after she cleaned, dried, and measured a wound and before she applied the clean dressing. EI #2 stated she should wash her hands. The surveyor asked EI #2 what a nurse should do after she cleaned a wound, dried a wound, and then used her gloved hands to apply her own eye glasses. EI #2 stated the nurse should have taken her gloves off and washed her hands and then applied new gloves. The surveyor asked EI #2 what was the potential harm to a resident if a nurse touched items that were potentially not clean, like eye glasses and a measuring device, and then applied a clean dressing on a resident's wound without washing her hands and re-applying gloves. EI #2 answered that there was a risk for infection.

Based on observation, interview, and record review, the facility failed to ensure Employee Identifier (EI) #3, a Registered Nurse (RN), did not leave a medication cart unlocked and unattended with two cognitively impaired residents and a visitor in close proximity. This had the potential to affect Resident Identifier (RI) #'s 28 and 29, and one of five medication carts in the facility. A review of an undated Pharmacy document titled, TIPS FOR MEDICATION ADMINISTRATION documented the following instructions: .MED CART: .4. ALWAYS lock med cart while unattended . RI #28 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review RI #28's Significant Change Minimum Data Set, dated dated [DATE], revealed RI #28 was severely impaired in cognition. RI #29 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of an annual Minimum Data Set, dated dated [DATE], revealed RI #29 was severely impaired in cognition. On 6/22/2016 at 3:55 PM, the surveyor observed an unlocked medication cart in front of the first floor nurse's station next to the lobby. There was no nurse observed standing close to the cart or in sight of the cart. EI #3, Registered Nurse, came out of a room on the hall and walked up to the nurse's station, then went back down the hallway and into a room not in sight of the medication cart. RI #28 and #29 were sitting approximately five feet away from the medication cart and a visitor walked by the unlocked and unattended medication cart. At 3:58 PM, EI #3 walked to the medication cart and began preparing medications to give to residents. On 6/22/2016 at 5:15 PM, an interview was conducted with EI #3. The surveyor asked EI #3 when she should lock the medication cart. EI #3 answered that the cart should be locked anytime the nurse walks away. The surveyor asked EI #3 when did she lock her medication cart. EI #3 stated she locked it when she came back up to the station and went on to say she may not have locked it when she walked away. The surveyor asked EI #3 why she left the medication cart unlocked and unattended while she was down the hall, with the cart not in her sight. EI #3 answered that there was no reason she should have left it unlocked and that there was no excuse for it. The surveyor asked EI #3 what was the potential for harm of not locking the medication cart and leaving it unattended. EI #3 answered that one of the residents could have gotten something from the cart and that it was left wide open for anyone who would want to get something. The surveyor asked EI #3 if she could have seen if anyone opened her medication cart and EI #3 answered, No. On 6/23/2016 at 4:32 PM, an interview was conducted with EI #4, RN/ Director of Nursing (DON). The surveyor asked EI #4 what a nurse should do to maintain the security of the medication cart and medications. EI #4 answered that the nurse should be sure to lock the cart when unattended and never leave medications unattended. The surveyor asked EI #4 what would be the danger of a nurse leaving a medication cart unlocked and unattended. EI #4 answered that the concern would be resident safety. EI #4 went on to say that a demented resident could get into the medication cart. The surveyor asked EI #4 what the potential outcome to a resident could be from having access to an unlocked and unattended medication cart. EI #4 answered that it went back to resident safety; a resident could open a drawer and pull something out. The surveyor asked EI #4 if there was a risk that a resident could ingest a medication and have a negative outcome. EI #4 confirmed there was a risk that a resident could ingest a medication and depending on what was ingested there could be a negative outcome.

Based on observations, interviews, and record review, the facility failed to ensure: 1) Employee Identifier (EI) # 3, a Registered Nurse (RN), did not pass medications to Resident Identifier (RI) #11 and three unsampled residents without performing hand hygiene between residents. 2) The facility further failed to ensure EI #3 wore gloves when administering eye drops to RI #30. These failures affected RI #11 and three unsampled residents, four of fourteen residents observed during medication observation and RI #30, one of two residents observed during eye drop administration. Findings Include: A review of a facility policy and procedure dated 6/16 and titled, Hand-washing/Use of Gloves, revealed: .PURPOSE: To prevent the spread of infections POLICY: 1. Hand washing/hand sanitizing will be done between residents . Using Gloves: 1. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin .could occur . A review of a facility policy and procedure dated 1/14/2015, titled, Hand-washing revealed: .PURPOSE: To provide guidelines for the proper handwashing to prevent the spread of infection. POLICY: 1. All facility personnel must wash their hands for 20 seconds under the following condition. PROCEDURE: .6. Before preparing or handling medications .9. Before performing resident care procedures. 1) On 6/22/2016 at 4:00 PM, EI #3 was observed by the surveyor as she administered medication by mouth to RI #11. EI #3 did not wash her hands or use hand sanitizer after the medication was administered. EI #3 went back to the medication cart and prepared medication for a second resident. The medication was administered to the second unsampled resident and again the nurse went back to the medication cart and prepared medication for the next resident without washing her hands or performing hand hygiene. EI #3 administered medication to the third unsampled resident and again did not perform hand hygiene. EI #3 then went back to the medication cart, prepared and administered medication to a fourth resident. At 4:32 PM, EI #3 again went to the medication cart and prepared medication for RI #30, who was prescribed an eye drop. Upon entering the resident's room to administer the eye drop, EI #3 then washed her hands. The eyedrops were placed on the bedside table. After drop instilled, EI #3 dabbed the left cheek with no gloves on. She placed the gauze on the pillow and used ungloved finger to attempt to raise eyelid. EI #3 picked the gauze up from the pillow and dabbed the right eye. EI #3 did not wear gloves while instilling eyedrops to RI #30. On 6/22/2016 at 5:15 PM, an interview was conducted with EI #3. EI #3 was asked when hand hygiene should be performed during a medication pass. EI #3 answered that she was not sure. The surveyor asked EI #3 when, during the medication pass, did she perform hand hygiene. EI #3 responded that she did it before the eye drops but could not recall performing hand hygiene prior to that. The surveyor asked EI #3 why it was important to perform hand hygiene during the medication pass. EI #3 stated it was important because she would not want to pass germs and bacteria back and forth between residents. On 6/23/2016 at 4:10 PM, an interview was conducted with EI #2, LPN/ Infection Control Nurse. EI #2 was asked when hand hygiene should be performed during a medication pass. EI #2 answered before beginning the medication pass, the nurse should wash her hands. EI #2 further stated if her hands do not get soiled, she can use hand sanitizer between three residents but before giving medication to a fourth resident her hands should be washed again. EI #2 was asked why hand hygiene during medication pass was important. EI #2 answered that hand hygiene was the first line of defense against the spread of infection. EI #2 went on to explain that if a nurse goes room to room giving medication without cleaning her hands she could spread infection. 2) RI #30 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #30's physician orders [REDACTED]. The directions were to instill two drops to each eye twice a day for Chronic Blepharitis. On 6/22/2016 at 4:32 PM, the surveyor observed EI #3, an RN, instill eye drops into both eyes for RI #30. EI #3 entered the room and washed her hands but did not apply gloves. EI #3 then instilled the prescribed eye drops into RI #30's left eye. EI #3 then used her bare finger to wipe at a drop of moisture that ran from RI #30's eye, down the resident's left cheek. EI #3 then used her bare finger to attempt to raise RI #30's right upper eyelid, instilled the prescribed drops and held a piece of gauze in her bare hand as she blotted the resident's right eye. On 6/22/2016 at 5:15 PM, an interview was conducted with EI #3. The surveyor asked EI #3 when gloves should be applied during eye drop administration. EI #3 answered that gloves should be applied before eye drops are administered. The surveyor asked EI #3 when had she applied gloves. EI #3 stated, I didn't. The surveyor asked EI #3 why it was important to wear gloves when instilling eye drops into a resident's eyes. EI #3 responded that the importance of wearing gloves was so she did not transfer something to the resident or get anything from the resident like bacteria or a virus. On 6/23/2016 at 4:10 PM, an interview was conducted with EI #2, Licensed Practical Nurse/Infection Control. EI #2 was asked what a nurse should do before instilling eye drops into a resident's eyes. EI #2 answered that the nurse should take the resident to a private area, wash her hands, and apply gloves. The surveyor asked EI #2 if it was appropriate for a nurse to instill eye drops into a resident's eyes without wearing gloves. EI #2 stated, No, it is never appropriate. EI #2 explained it was never appropriate to instill eye drops into a resident's eyes without wearing gloves because there was a risk of contamination and infection to a resident's eye and also a nurse could get something from the resident and spread it to other residents.

Based on observations, interviews, and record review, the facility failed to 1) ensure RI (Resident Identifier) #3's risk for fecal impaction was assessed and Care Planned; 2) complete ordered KUBs (an x-ray of the kidneys, ureters, and bladder); 3) consistently administer ordered [MEDICATION NAME] (laxative); 4) consistently document significant information regarding RI #3's risk of impactions; and 5) failed to monitor her fluids to ensure she was provided her fluid needs. This is a resident who was identified by the facility as having a [DIAGNOSES REDACTED]. On 04/21/11 RI #3 was identified as having another fecal impaction. The facility further failed to 1) ensure nursing staff followed standing orders for possible constipation for RI #5; and 2) develop a care plan for RI #5's potential for constipation. These failures affected two of seventeen sampled residents. Findings include: A review of the policy titled, "Guidelines for Maintenance of Optimal Patterns of Elimination," dated 08/31/05, revealed: "Purpose: To prevent fecal impactions and to protect regular and normal bowel habits. Policy: 1. The following are high risk residents: Residents who are confused. Residents with feeding problems. Residents who are dehydrated. Residents with decreased mobility (wheelchair - bedbound) Post-op residents. Residents with diagnosed GI disorders. ...Procedure: ...2. Give adequate fluids - approximately 3,000 cc (cubic centimeters) (three quarts) during each 24-hour period. Fluids include all liquids ingested. ... 9. Give laxative/suppository, as ordered by physician... 10. Suspect an impaction if one or more of the following symptoms present: If the resident has not had a bowel movement for three or more days. Absence of normal bowel movement for three or four days followed by frequent liquid stools, small pencil-like, or small, hard, dark masses of feces. Difficulty in passing stools. Distention with cramping pains in abdomen, headache, sluggishness, irritability, sense of fullness or pressure in the rectum. If the resident attempts to manually remove feces from rectum. If a resident has not had a BM (bowel movement) for 3 days, the nurse will check the resident for an impaction when she does the skin audit... ." 1) RI #3 was originally admitted to the facility on [DATE]. She was readmitted on [DATE] after a hospital visit for an [MEDICAL CONDITION]. Her [DIAGNOSES REDACTED]. A review of RI #3's Annual MDS (Minimum Data Set) Assessment, dated 11/04/10, revealed the resident had no cognitive impairment. This assessment also identified RI #3 as being frequently incontinent of bladder function, and occasionally incontinent of bowel function. RI #3 was assessed as requiring supervision ("oversight, encouragement or cueing"), with set up help for eating. RI #3 required extensive, physical assistance from one staff member for toileting. RI #3 was identified as having unclear speech that is slurred or mumbled, and is usually understood and usually understands. A review of RI #3's medical record revealed no further facility assessment to identify her risk and interventions for potential fecal impaction. A review of RI #3's "Nutritional Status RAP (Resident Assessment Protocol) Module," dated 11/11/10, revealed "Factors That Impede Ability To Consume Food," included: "Does resident have constipation/intestinal obstruction/pain that would inhibit appetite?" This question was marked "No." A review of all RI #3's Care Plans, last reviewed 02/10/11, revealed no Care Plan for her history of Volvulus, fecal impaction, dehydration, or constipation. The only approach related to these [DIAGNOSES REDACTED]. RI #3's kardex was posted on the inside of her bathroom door. This is what the CNAs (Certified Nursing Assistants) look at to know what to do for a resident. This kardex revealed that RI #3 was at risk for dehydration, but had no approaches for what CNAs were to do for this concern. The resident's October 2010 "Physician Orders" included an order for [REDACTED]. A review of the KUB reports since October 2010 revealed there was not one completed in November 2010 or February 2011. There was no documentation in the resident's record to indicate why they were not completed. A KUB report dated 03/16/11, revealed RI #3's Volvulus and the need for a CT (Computerized Tomography) scan. A physician's orders [REDACTED]. A review of the Physician order [REDACTED]." The 03/21/11 CT scan revealed RI #3 had fecal dilatation and constipation. A nurses' note on 03/23/11 revealed a new order was received to disimpact the resident and use tap water enema and "[MEDICATION NAME] (one) pack now." Another nurses' notes dated 03/23/11 revealed: "Resident received tap water enema (and) [MEDICATION NAME]. XL (extra large) BM immediately followed." (However, this note did not specify per policy, the color, consistency, odor, the presence of unusual matter, or the resident's symptoms). A review of a physician order [REDACTED]. (ounces) of fluid every other day." On 04/11/11 the [MEDICATION NAME] was changed to Monday, Tuesday, Wednesday, and Thursday only, omitting Fridays, Saturdays, and Sundays. A review of the KUB dated 04/21/11, revealed: "...Fever and abdominal pain. ...There does appear to be a large amount of stool in the rectum indicative of impaction..." A review of the MAR for April 2011 revealed the order for [MEDICATION NAME], Monday through Thursday, was not initialed for Wednesday the 27th and Thursday the 28th, indicating this laxative was not administered. There was no documentation on the MAR or in the nurses' notes to explain what took place, or if the resident did receive her [MEDICATION NAME]. A review of the staffing assignments revealed EI #5, an LPN (Licensed Practical Nurse) worked the day shift on April 27, 2011 with RI #3. On 05/05/11 at 10:10 AM, EI #5 was asked if he knew RI #3. He said he did. EI #5 was asked if he worked at the facility on 04/27/11. He said he did. EI #5 was asked why the MAR was blank on April 27th for [MEDICATION NAME]. He said he did not know, and that he could not remember. EI #5 was asked what he does when a resident refuses medication. He said he is supposed to chart it on the MAR and the nurses' notes. EI #4, another LPN, worked on April 28, 2011, day shift, with RI #3. On 05/05/11 at 3:00 PM, EI #4 was asked if he knew RI #3. He said he did. EI #4 was asked if RI #3 received her ordered [MEDICATION NAME] on his shift. He said she did not because the resident refused it. EI #4 was asked why there was no documentation in the resident's record explaining that situation. He said he was pulled away by the resident's roommate. EI #4 was asked what he was trained to do when a resident refuses medication. He said he was trained to circle his initials on the MAR and document the explanation. On 05/05/11 at 6:10 PM, RI #3 was asked if she remembered having a fecal impaction recently. She said she did. RI #3 was asked how bad it affected her. She responded, "Girl, I was hurtin' so bad I couldn't eat or sleep." RI #3 was asked how long she had to endure that pain. She said about a week. A review of RI #3's ADL records for April and May 2011 revealed a BM was documented every day, at least once a day, from April 1 to May 2. This record had no designated place to document fluids offered or consumed. A review of RI #3's "Nutritional Assessment," dated 11/04/10, revealed the [DIAGNOSES REDACTED]. RI #3's fluid needs were assessed to be 1935 to 2365 mL (milliliters) per day. The quarterly notes on 02/09/11 and 05/02/11 made no mention of fluids, her hydration status, or anything related to her history of fecal impaction. A review of RI #3's medical record revealed no documentation regarding how much fluid she is offered daily, how much she consumes daily, or whether or not she is receiving the amount that was assessed as needing each day. On 05/03/11 at 4:50 PM, RI #3 was observed in the dining room. Before the supper tray was delivered, there was a cup of water containing 100ccs on the table in front of her. The only beverage that came on her tray was tea (240ccs). She drank 100% of both drinks. On 05/04/11 at 7:30 AM, RI #3 was observed in her room in bed. She received her breakfast tray, on which the only beverage provided was coffee. There was a 10.1 oz. bottle of water on her bedside table, but RI #3 said she could not drink that because it was warm and she could not open it by herself anyway. RI #3 consumed 100% of the coffee (240 ccs) and 0% of the water. On 05/04/11 a continuous observation was done of RI #3 from 8:25 AM to 10:50 AM. During that entire 2 hour and 25 minute observation, RI #3 did not consume nor was she offered anything to drink. At 12:05 PM RI #3 was sitting in the dining room waiting for lunch tray. She had a cup of lemonade, a cup of water, and a diet coke on the table in front of her. The CNA who was working on the hall that RI #3 lives on was asked if they offered RI #3 anything to drink before coming into the dining room. She said she thought she did but activities and the receptionist usually pass the mid-morning hydration because they (CNAs) stay so busy getting residents up, bathed and dressed. EI #16 was asked when the coke, lemonade and water was provided. She said 11:45 AM (central time). No additional beverages were provided with her lunch tray. On 05/04/11 at 7:00 PM, RI #3's CNA who frequently works with her was interviewed, EI #11. EI #11 was asked if RI #3 was at risk for dehydration or fecal impaction. She said she was not. EI #11 was asked if RI #3 had regular BMs. She said she does. EI #11 said the resident had loose bowels. EI #11 was asked to describe RI #3's BMs. She said they are mostly runny, black; large in the mornings, and once or twice a week it will even get on the bed sheets. EI #11 was asked if RI #3 ever complained about her stomach hurting. She responded, "Yeah, because she had a problem with her stomach." EI #11 was asked if the resident complained of this often. She said the resident complained often that her stomach ached and then she (CNA) would report it to the nurse. EI #11 was asked if RI #3 could get her own fluids. She said the staff have to bring fluids to her because she cannot move one of her hands very well. EI #11 was asked how she knows what to do for a resident. She said she looks at the kardex in the room. EI #11 was asked if RI #3 required encouraging to drink fluids. She said she did. EI #11 was asked if she documented the resident's fluid intake. She said she does not. EI #11 was asked if the meal percentage that they document includes the fluids. She said it did not; it was just the food. EI #11 said they offer all residents three liquids with each meal. EI #11 was asked who provides the liquids at meals. She said one comes on the tray from dietary and the CNAs put the other two on the tray. She said at breakfast it is milk, coffee and juice; lunch is lemonade, water and tea, unless they want something else. EI #11 was asked if RI #3 could tell her when she had to toilet. She said she could not; only after she was soiled. On 05/04/11 at 6:35 PM, EI #12, a Unit Receptionist, was asked who was responsible for making sure the KUBs were completed as ordered. She said it was the Unit Receptionist and the floor nurses. She said if it was on the lab sheet it was the receptionist's responsibility. (RI #3 had a lab sheet in a book at the nurse's station for her KUBs that said they were to be done every month on the first Monday). EI #12 was asked why the KUB was not completed for November 2010 and February 2011. She said she was not the receptionist at that time; she started on this unit at the end of March 2011. EI #12 was asked why the April KUB was not done on the first Monday of the month. She said she honestly did not realize it said "1st Monday." On 05/04/11 at 2:36 PM, EI #13, RI #3's regular LPN, was asked what "encourage fluids" meant on the Care Plan. She said the staff should offer the resident water or juice, but RI #3 did not really like water, she liked [MEDICATION NAME] drinks. EI #13 explained that since she was a diabetic they gave her diet sodas, but she was not on a fluid restriction. EI #13 was asked if RI #3 was on a plan for receiving a particular amount of fluids. She said she was not, that the resident sips and does not drink a lot, even though she can drink all she wants. EI #13 was asked about the resident's history of fecal impaction. She said that was an issue because the resident had massive diarrhea at the same time she was impacted. EI #13 was asked to describe the stool. She said it was dark green, mostly soft, some solid here and there, but mostly runny and loose, with a ball here or there. EI #13 was asked if that was while she was taking [MEDICATION NAME]. She said it was. EI #13 was asked to describe the resident's bowel sounds. She said RI #3 usually has bowel sounds, but the upper part of the abdomen was firm. EI #13 said the KUBs always showed an impaction. EI #13 was asked if RI #3 ever had a good, normal, firm BM. She replied, "No." EI #13 was asked when she became aware that RI #3 had a history of [REDACTED]. EI #13 explained that when RI #3 has diarrhea they let it run it's course and do not treat it with anything because they don't want to stop her up because she has a high impaction and that would make matters worse. She said that was the first thing they taught her when she started working with RI #3. EI #13 was asked if any of this was documented. She said she did not think it was. EI #13 was asked how other nurses know this important information. She responded, "That's a very good question. I do not know." EI #13 was asked if they have an assessment for identifying risk for fecal impaction. She replied, "Not that I'm aware of." EI #13 was asked what RI #3's risk factors were for developing a fecal impaction. She said dehydration, history of fecal impaction, [DIAGNOSES REDACTED]. EI #13 was asked what they had in place to try to prevent RI #3 from getting another fecal impaction before [MEDICATION NAME] was ordered in March. She responded, "That's a good question." After looking through the resident's medical record, she said she did not see anything as far as medicine. EI #13 was asked how she monitors RI #3 for fecal impaction. She said she did not know because her impaction is high and cannot be felt by hand. EI #13 was asked if RI #3 was compliant with her diet. She said she is compliant in the facility, but not as compliant when she goes out with family. EI #13 was asked if the resident complained about her stomach hurting. She said she did not complain much. EI #13 was asked why they do not monitor her fluid intake to make sure she gets enough. She said she did not know. On 05/05/11 at 9:50 AM, EI #13 was asked if RI #3 usually refused her [MEDICATION NAME]. She said she did not. EI #13 was asked why she had to disimpact RI #3 on 03/23/11. She said it was because the CT scan showed fecal dilatation and constipation. EI #13 was asked to describe her BM after that. She said it was a lot and it was loose. EI #13 was asked why she did not describe it in more detail and describe her symptoms like the policy says. She looked at the policy and replied, "I have not seen this." On 05/04/11 at 5:48 PM, EI #14, an LPN who regularly works with RI #3 on the 3PM to 11PM shift, was asked when she became aware that RI #3 had a history of [REDACTED]. EI #14 explained that it was very important to keep RI #3's bowels moving because that was the only thing to keep her from getting impacted. She said the [MEDICATION NAME] was changed to Monday through Thursday because her family takes her out on the weekends and did not want to deal with that. EI #14 said the KUBs kept showing impaction high in the abdomen, so the stool was running around the impaction. EI #14 was asked where it was documented about the family wanting to change the [MEDICATION NAME] order. She said it may not be documented. EI #14 was asked if RI #3 ever complained of stomach pain. She said she does not, but sometimes she does complain of nausea and vomiting. On 05/05/11 at 8:05 AM, EI #6, the RD (Registered Dietitian) was asked what she does when they have a resident with a history of fecal impaction. She said the only thing she does is follow the ordered diet and make sure plenty of fluids are sent on the tray. EI #6 said they try to make sure all residents receive three beverages on each meal tray. EI #6 was asked if she was aware that RI #3 had a history of [REDACTED]." EI #6 was asked if dietary was doing anything to try to prevent RI #3 from getting another impaction. She said probably not because they just push fluids unless the doctor ordered high fiber or something like that. EI #6 was asked why she had not recommended fiber, ruffage, prunes or prune juice for RI #3. She said she did not feel like that was within her realm because she did not know the underlying condition. (However, the [DIAGNOSES REDACTED]. EI #6 was asked how they ensure her fluid needs are being met. She said that was a tricky question because all they could do was offer it, they could not ensure she accepts it. EI #6 was asked how she ensures the resident is offered her needed amount. She said by providing three beverages on each meal tray and CNAs should be offering in-between fluids. EI #6 was asked if they documented how much fluid RI #3 is offered or consumes. She said not that she was aware of. EI #6 was asked why they do not monitor her intake. She said it was not realistic to document her consumption, so they look at the more obvious signs like skin turgor. EI #6 was asked if she was aware that the facility policy stated residents at risk for fecal impaction should receive 3,000 ccs of fluid daily. She responded, "No. I was not. I would not give anybody 3,000 ccs of fluid." EI #6 explained that the amount of fluid needs depended on the resident's diagnoses, height, weight, etc; that was a broad statement, and a resident could get overhydrated and cause more problems. EI #6 said she could understand increasing fluids for certain diagnoses. On 05/05/11 at 10:15 AM, EI #8, the MDS/Care Plan Coordinator was asked who was responsible for assessing risk factors for determining a resident's risk for fecal impaction. She said she writes down the resident's [DIAGNOSES REDACTED]. EI #8 said when a resident has a history of fecal impaction or constipation, they will make sure a Care Plan is put in place to address those areas of concern. EI #8 was asked if there was an assessment for risk factors for fecal impaction. She said there was not, but if the resident was on a bunch of pain meds (medications) or iron, or certain other meds, they would need to be on a stool softener or laxative. EI #8 was asked why there was no Care Plan for RI #3 for fecal impaction, constipation, or dehydration. She said she thought there was one. (She looked through th resident's medical record). EI #8 was asked how staff know what to do for these concerns since there was no Care Plan for them. She said the nurses look at the BM record, and if no BM, they will give a laxative, monitor, then if still no BM, they will call the doctor and provide whatever orders are given. She said if there is still no BM, the doctor may order an x-ray or MRI, and the nurses also check digitally after the second laxative and no BM. EI #8 was asked how staff know what to do to try to prevent fecal impaction. She said they pass fluids with the hydration cart, they have a coke machine, and fluids are provided on meal trays. EI #8 stated RI #3 smokes a lot so her mouth stays dry. EI #8 was asked if it was important for CNAs to know if a resident is at risk for fecal impaction. She said it was important because they want CNAs to encourage fluids, and they want CNAs to document if the resident has not had a BM, and to notify the nurse, or to report that the resident's stomach hurts, or if there is difficulty having a BM. At 10:55 AM, EI #8 was asked who was responsible for ensuring a fecal impaction Care Plan was in place. She said that was the Restorative nurse's responsibility, but it was ultimately her responsibility. EI #8 acknowledged that there should have been a fecal impaction Care Plan for RI #3. EI #8 was asked why there was not one. She responded, "Restorative didn't Care Plan it and I didn't catch it." On 05/05/11 at 3:20 PM, the DON (Director of Nursing), EI #2, was asked what nurses are supposed to do when a resident refuses a medication. EI #2 said the nurse should try to encourage the resident to take the medicine and explain why it is important to take the medication, then circle it on the MAR and document that the resident refused, why they refused, and call the doctor. EI #2 further stated the nurse should document that phone call, and document the attempts to get the resident to take the medication. EI #2 was asked if she was aware there were no initials on RI #3's MAR for her [MEDICATION NAME] on April 27 and 28. She said she was not. EI #2 was asked how they monitor to make sure medications are given as ordered. She said the Infection Control Nurse goes back at the end of the month and looks for omissions, and disciplinary action is taken as needed; but usually the next oncoming nurse will report it. EI #2 was asked who was responsible for ensuring KUBs get completed as ordered. She said the charge nurse. EI #2 explained they also have a morning meeting with some of the supervisors in which they look at the shift report over the last 24 hours on every resident to make sure all labs are completed. EI #2 was asked if she was aware that RI #3's KUB was not completed on November 2010 and February 2011. She said she was not aware until yesterday (05/04/11). EI #2 said she would assume RI #2 refused, but if she did, it should have been documented. EI #2 was asked if they complete an assessment for risk factors for fecal impaction. She said all risk factors are usually done on admission, quarterly, and as needed, or if the resident starts to have problems with constipation. EI #2 was asked how they document risk factors for fecal impaction. She said she would look at test results, chronic constipation, if they do not drink enough fluids, if they are totally dependent on staff, and if they are ambulatory. EI #2 further stated they do not have a specific form for identifying risk for fecal impaction. EI #2 was asked if she was aware that RI #3 did not have a Care Plan for fecal impaction or a Care Plan for the [DIAGNOSES REDACTED]. She responded, "No I was not." EI #2 was asked how staff would know what to do since there was not a Care Plan - like what signs staff should look for, what to report, how much fluid to provide, etc. She said that was definitely something they needed to re-educate about. EI #2 was asked why the RD assessed RI #3 as needing 1935 mL to 2365 mL of fluid each day, but the facility policy required 3,000 ccs a day for a resident who was at risk for fecal impaction. She said RI #3 is alert and drinks what she wants, and they could not force fluids down her. EI #2 further stated the best thing they could do was to educate the resident on drinking more fluids. EI #2 was asked how they ensure RI #3 is offered enough fluids. She said they offer her fluids at breakfast, a snack at 10 AM, hydration cart, afternoon snack, fluids at lunch and supper, and a 9 PM snack. EI #2 said the resident had told her she did not want to drink a lot because she did not want to urinate on herself. EI #2 was asked if she documented that. She said she did not, but she should have. EI #2 was asked why they do not monitor and document RI #3's fluids. She replied, "We should." EI #2 also stated that since RI #3 does refuse, they should offer her more fluids. EI #2 was informed that there was a lack of documentation in the resident's chart, and even though the facility could not change the resident's [DIAGNOSES REDACTED]. EI #2 said she agreed and there should be better documentation. An interview was conducted with EI #3, the Medical Director, on 05/05/11 at 1:45 PM. He was asked what he would expect the facility to do to try to prevent another fecal impaction in a resident with a history of a volvulus with secondary fecal impaction. He said they give whatever they can to keep the bowels flowing; give fluids; and keep them active. EI #3 stated that RI #3 was an unusual problem that he had never encountered before. He explained the volvulus was when the colon gets twisted. EI #3 said RI #3 was not always compliant with fluids and was very large. He said her family requested the laxative not to be given on the weekends while she was with them. EI #3 said RI #3 also refused to have any more colonoscopies, and that was the only way to untwist the colon, besides surgery, which she was not a candidate for. EI #3 stated that even though the resident could be oppositional, he felt like she was reasonable enough to allow them to do what needed to be done if it got bad enough for her. EI #3 was asked if he would expect the facility to monitor RI #3's fluid intake and output. He said they should, to the best of their ability. He explained they could monitor it, but could not control it. EI #3 was asked why he ordered KUBs every month. He said that was how he could track it to see changes. EI #3 explained that a laxative would help keep her from getting an impaction, but it would not fix the volvulus; however, the volvulus could cause an impaction. EI #3 was informed that the facility policy revealed residents at risk for fecal impaction should receive 3,000 ccs of fluid each day. He said that was a lot of fluid, and RI #3 should definitely be offered fluids throughout the day. EI #3 further stated that RI #3 could probably handle that much fluid, but not some other residents. EI #3 was informed that there was no assessment for risk for fecal impaction; no Care Plan for volvulus, fecal impaction, dehydration, or constipation; two doses of [MEDICATION NAME] potentially not given; and two KUBs not completed. EI #3 said he did not know if there was a way to prevent a volvulus, but they should do maximal interventions to try to prevent a fecal impaction. 2.) RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5 was identified on his Significant Change MDS(Minimum Data Set) assessment, dated 03/24/11, as having severe cognitive impairment. RI #5 was identified as totally dependent, requiring one person physical assistance for bed mobility, transfers, personal hygiene, bathing and toileting. RI #5 was documented as "usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time" and "usually understands-misses some part/intent of message but comprehends most conversation." RI #5 was also identified as "Always Incontinent" of urine, "Frequently Incontinent" of bowels, and not having constipation during the assessment period. A review of RI #5's Care Plans, dated 03/31/11, revealed the "Potential for Dehydration related to: impaired mobility, impaired cognition/communication, and use of diuretic." The approaches of this care plan included: "... 10) Monitor for fever, diarrhea, impactions, pressure areas, pain, decreased appetite 11) Notify MD PRN of any abnormality." The "ADL Record" was the form that the CNAs document their monitoring on each day at the end of their shift on each resident that they care for that day. RI #5's ADL record for April 2011 revealed a "0," identifying no bowel movement (BM) took place on all three shifts on 04/02/11, 04/03/11, 04/04/11, 04/05/11 and 04/06/11, five consecutive days with no BM. The note revealed: "04/06/11 2230 (10:30 PM) Resident is refusing to allow nurse to assess for constipation. Will allow him to get settled and reattempt assessment." There was no documented follow up to this identified concern. On 04/14/11, 04/15/11, 04/16/11, 04/17/11, 04/18/11, 04/19/11 and 04/20/11 there was a "0" documented for all three shifts for BMs for RI #5. There was no documented assessment, implementation of interventions(Standing Orders or physician order [REDACTED]. Policy and Procedure "... (NAME) NURSING HOME STANDING ORDERS" dated 08/31/10, identified "MOM (Milk of Magnesia) 30 cc (cubic centimeters) po (by mouth) daily and PRN (as needed) for constipation x (for) 2 days then notify MD if no results. Fleet enema PRN constipation; digital rectal exam and remove any constipated stool." The MARs reflects MOM was given on 04/05/11, but not on 04/06/11 when he did not have a BM on the 5th or 6th. The policy stated to give MOM two consecutive days. On 4/13/11, a physician's orders [REDACTED]." In an interview with EI #9, an LPN, on 05/04/11 at 3:28 PM, she was asked what they do when a resident has not had a BM for several days. She said, "Get him on a routine stool softener." EI #9 was asked if fluids were monitored with the meal monitoring. She said she did not think the CNAs documented fluids unless the resident was on fluid restrictions. In an interview with a CNA, EI #17 on 05/05/11 at 10:55 AM, she explained "When a resident does not have a BM for 3 days then we (CNAs) tell his nurse." She was asked if she had noticed in April that RI #5 had not had a BM in several days. EI #17 said, "Yes, I did." She further stated, "I usually look when I chart for him when I worked with him." She confirmed that she would tell the nurse if a resident says their stomach is hurting and they need to go to the bathroom, but then they are not able to have a BM. EI #17 was asked if she told a nurse about RI #5. She said she did not work with RI #5 during these two periods of constipation in April. EI #17 said he had constipation a lot of the time, and had some constipation periods during March 2011. On 05/05/11 at 11:00 AM, an interview was conducted with another CNA, EI #15, who worked with RI #5 regularly. She revealed she did not always notify the licensed nurses when a resident did not have a BM in three days. When asked why, she said that they just get so busy and in a hurry and forget. An interview on 05/05/11 at 3:00 PM, with the Nurse Supervisor, EI #9, revealed the March 2011 ADL monitoring form could not be located. When asked for the normal protocol for constipation, she said they have a policy and procedure - if no BM for 3 days then they give a laxative. She said the 11-7 shift is supposed to put the resident's name on a Laxative List, then the 7-3 shift gives a laxative the next day. She said they check to see if it is effective, check bowel sounds, digitally check the rectum and then call the doctor to see what to do. EI #9 was asked who was responsible for checking over the CNAs' ADLs monitoring. EI #9 said another nursing supervisor does chart audits. In a phone interview on 05/05/11 with a CNA, EI #20, at 5:15 PM, she stated if a resident does not have a BM eve