Every finding on record at Haleyville Health Care Center

Based on interviews, medical record review, review of POTTER and PERRY FUNDAMENTALS OF NURSING and review of facility policies titled Medication - Adverse Consequences & (and) Medication Errors and Medication - Administration, the facility failed to ensure the medication pass administration conducted on 10/27/2022, was free of any significant errors. During the medication pass, Employee Identifier (EI), #2, an LPN (Licensed Practical Nurse) prepared and administered Resident Identifier (RI) #5's medications to RI #1. This deficient practice affected RI #1, one of four residents sampled for medication administration. Findings Include: A facility policy titled Medication - Adverse Consequences & (and) Medication Errors, with a revised date of 08/01/2015, revealed the following: . Procedure . 4. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Responsibility The Charge Nurse is responsible for the implementation of this policy and procedure . Pages 624 - 627 of Chapter 32 titled Medication Administration of FUNDAMENTALS OF NURSING NINTH EDITION with a copyright date of 2017, revealed: . Medication Errors A medication error can cause or lead to inappropriate medication use or patient harm. Medication errors include . administering the wrong medication, . Preventing medication errors is essential . Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors . When an error occurs, the patient's safety and well-being are the top priorities. You first assess and examine the patient's condition and notify the health care provider of the incident as soon as possible . Steps to Take to Prevent Medication Errors . * Follow the six rights of medication administration . Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation . Right Patient. Medication errors often occur because a patient gets a drug intended for another patient. Therefore an important step in safe medication administration is being sure that you give the right medication to the right patient . Another facility policy titled Medication - Administration, with a revised date of 03/22/2022, revealed the following: Purpose Medications shall be administered . as prescribed by the resident's attending physician or the facility' Health Care Practitioner. Policy Medications shall be given as ordered by the physician. Procedure . 2. Medications shall be administered . in accordance with the physician's written/verbal orders . On review of EI #2's LPN Orientation Checklist with a hire date of 08/15/2022, EI #2 reviewed and performed the facility's Medication system and identification system for residents on 08/18. RI #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's November 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #5's November 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's Departmental Note (Nurses Note) dated 10/27/2022 at 12:50 PM, revealed the following: . Medication error occurred at 10:15AM the Charge Nurse gave resident another resident's morning medications. Resident received [MEDICATION(S)] 100mg, [MEDICATION(S)] 10mg, [MEDICATION(S)] 10mg, [MEDICATION(S)] 150mg, [MEDICATION(S)] 25mg, Iron 325mg, Vitamin D3 1000 units, [MEDICATION(S)] 0.5mg, [MEDICATION(S)] 5mg, [MEDICATION(S)] 5mg, Sodium CL Nasal spray. Resident is alert . with periods of confusion. Resident denies pain or discomfort. Vital signs are BP (Blood Pressure) 122/66 Pulse 74 Resp 18 Temp (Temperature) 97.7 02 Sat (saturation) 936% on RA (Room Air) . Pharm D was in facility and was made aware. (Name of CRNP [Certified Registered Nurse Practitioner]) was made aware with new orders for Q (every) 15min vital signs, monitor heart rate due to Afib and watch for sedation, hold (his/her) scheduled morning medications today, [MEDICATION(S)] apply to bilateral nares for preventive measures. Body Audit was performed to monitor for any adverse reaction to blood thinner . Resident and representative (name of representative) was made aware . Addendum 10/28/2022 11:07 AM clarification sat 93% on RA . A review of RI #1's Medication Error Report dated 10/27/2022, documented: MEDICATION ERROR: Nurse gave the resident another residents morning medications [MEDICATION(S)] 300 mg, [MEDICATION(S)] 10mg, [MEDICATION(S)] 10mg, [MEDICATION(S)] 150mg, [MEDICATION(S)] 25mg, Iron 325mg, Vitamin D3 1000 units, [MEDICATION(S)] 0.5mg, [MEDICATION(S)] 5mg, Sodium CL nasal spray. ACTION TAKEN: Vital signs, assessments, notified Pharm D, (name of CRNP), (name of representative), orders to hold res (resident's) scheduled morning meds, give [MEDICATION(S)] ointment to nares as preventive measures, vital signs every 15 minutes, watch for sedation . RI #1's Departmental Notes revealed the following: . 10/28/2022 11:08 AM . late note for 10/27/2022 4pm. Update given to (name of representative). Resident remains alert with no sedation noted. Resident did take a nap after lunch. Vitals signs are stable. No respiratory distress noted. 10/28/2022 11:14 AM . Vital signs are stable. Resident is alert with periods of confusion at current baseline. Blood pressures have returned to normal limits and no other side effects or adverse reaction noted at this time . 10/28/2022 6:58 PM . B/P 128/76 P (Pulse) 76 R (Respirations) 18 T (Temperature) 97.7 and 02 sat 98% . On 11/09/2022 at 11:44 AM, the surveyor conducted a telephone interview with EI #2, the LPN administering RI #1 the wrong medications on 10/27/2022. The surveyor asked EI #2 what process she used when she prepared to administer RI #1 his/her medications. EI #2 said this was the first day she was by herself. EI #2 said the Internet was down on one end of the hall so after she pulled up the medications for RI #5 she walked the medications to RI #1's room. When asked how was it that RI #1 was administered the wrong medications, EI #2 said she pulled up RI #5's medications and went to RI #1's room and said, RI #5 here are your medications. EI #2 said RI #1 responded to RI #5's name so she thought RI #1 was RI #5. EI #2 said as soon as she stepped out the door, she realized the resident was RI #1 and not RI #5. When asked who she informed when she realized she had administered RI #1 the wrong medications, EI #2 said she asked someone to get EI #1, the Director of Nursing (DON). EI #2 said she did vital signs all day long on RI #1. EI #2 said the doctor was informed of the medication error and the pharmacy. The surveyor asked EI #2 was she in-serviced on how to pass medications after the incident. EI #2 said she got an in-service from RI #1 and the pharmacist, EI #3 told her to pay close attention and follow the protocols for administering medications. When asked what she was taught in orientation about administering medications to the residents, EI #2 said she believe the six rights of administering medications were gone over. When asked what are the six rights of administering medications, EI #2 said before you administer medication make sure you have the right resident, right medication, the right dose, it was the right time, and you are giving it the right way. The surveyor asked EI #2 why did she not follow that procedure when she administered RI medications on 10/27/2022, EI #2 said she thought she just did not pay enough attention to what she was doing. On 11/10/2022 at 9:36 AM, the surveyor conducted an interview with EI #3, the Pharmacist. EI #3 said he was at the facility the day the medication error occurred. EI #3 said after the incident occurred RI #1 did not appear to be overly sedated, hypotensive, and did not appear to be in any type of distress. When asked what kind of side effects a person would experience from taking the medication [MEDICATION(S)], EI #3 said one of the major ones would be SOB (shortness of breath) and sedation. When asked what kind of side effects a person would experience from taking the medication [MEDICATION(S)], EI #3 said you would think about lower blood pressure, so [CONDITION(S)]. When asked what kind of side effects a person would experience from taking the medication [MEDICATION(S)], EI #3 said you would think about lower blood pressure, so [CONDITION(S)]. When asked what kind of side effects a person would experience from taking the medication [MEDICATION(S)], EI #3 said that one may raise the blood pressure a little bit. When asked what kind of side effects a person would experience from taking the medication [MEDICATION(S)], EI #3 said you would think about lower blood pressure, so [CONDITION(S)] and it would also lower the heart rate. When asked what kind of side effects a person would experience from taking the medication Iron, EI #3 said constipation, but you would not see that with taking one dose. When asked what kind of side effects a person would experience from taking the medication Vitamin D3 1,000 units, EI #3 said from one dose probably nothing; but it can cause GI upset. When asked what kind of side effects a person would experience from taking the medication [MEDICATION(S)], EI #3 said you would see sedation. When asked what kind of side effects a person would experience from taking the medication [MEDICATION(S)] , EI #3 said you would probably experience bleeding over a period of time. When asked what kind of side effects a person would experience from taking the Sodium Cl Nasal spray, EI #3 said none. The surveyor asked EI #3 did the facility report to him RI #1 experienced any of those side effects. EI #3 said RI #1's BP was low a few times, but RI #1 did not have any symptoms from that. When asked what is there a potential for when a resident was given medications that are not prescribed for them, EI #3 said for one it would fall into a medication error category. EI #3 said situations like this could fall into adverse drug reaction or adverse drug event. The surveyor asked EI #3 were RI #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #3 said no. EI #3 said he was able to speak with EI #2 to get to the bottom of what caused the error. When asked what caused the error, EI #3 said EI #2 informed him when she walked into the room RI #1 responded to RI #5's name so she proceeded to administer the medications. EI #3 said he reminded EI #2 there were pictures of the residents on the electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/10/2022 at 10:46 AM, the surveyor conducted an interview with EI #4, the CRNP. EI #4 said she was called by EI #1 and EI #1 gave her the names of all the medications that had been administered to RI #1. EI #4 said EI #1 had done a body audit on RI #1 and did not see any changes. EI #4 said she told EI #1 to watch for the resident's BP (blood pressure) dropping, for decreased respirations, increased confusion, lethargic and any kind of anaphylactic symptoms, like difficulty swallowing or slurred speech. EI #4 said she informed EI #1 RI #1's BP would probably get low and to notify her if it did. EI #4 said she was informed it had dropped but it came back up. EI #4 said when she observed RI #1, RI #1 was in bed and was alert and awake. EI #4 said she asked RI #1 if his/her heart felt funny and if he/she had trouble breathing and RI #1 said no he/she felt fine. EI #4 said she informed RI #1 he/she was given medications that he/she was not prescribed, and RI #1 said he/she felt fine. The surveyor asked EI #4 what was there a potential for when a resident was given medications that are not prescribed for them. EI #4 said an allergic reaction and possible side effects. When asked were RI #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/10/2022 at 2:07 PM, the surveyor conducted an interview with the DON, EI #1. EI #1 said when she was made aware EI #2 had administered RI #1 RI #5's medications, she informed her staff to go ahead and get RI #1's vitals and informed them they would have to do them every 15 minutes. EI #1 said she called EI #4, the CRNP and EI #3, the pharmacist was at the facility and was informed RI #1 had gotten a lot of medicines that were not his/her own and a med error had occurred. EI #1 said she got a list of RI #5's medication and when she got on the phone with EI #4 she (EI #1) went over what RI #1 received and what RI #1 was supposed to have gotten. EI #1 said she informed EI #4 they were monitoring RI #1's vitals every 15 minutes and EI #4 told her to continue to do that and they discussed what to be looking for. When asked did EI #2 say what happened, EI #1 said EI #2 just said she got the two residents confused and that they kind of looked alike. EI #1 said when EI #2 went in and said, RI #5 I have your medications, RI #1 said Ok and she gave them to RI #1. EI #1 said EI #2 said when she got back to the computer was when she realized she had given the wrong medications. The surveyor asked were the physicians ordered followed when EI #2 administered RI #1 someone else's medications. EI #1 said no. When asked which of the medications would be considered significant medication, EI #1 said the narcotics, the beta blocker, and the blood thinners. This deficiency was cited as a result of the investigation of complaint/report #AL 168.

Based on record review, interviews, a review of facility Archived Time Card Report for Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), the review of the facility policy titled Abuse Prevention Program - Definitions, and a review of facility policy titled Medication - Controlled Substances, the facility failed to ensure: 1) Resident Identifier (RI) #2, 4, and 7 were free from misappropriation of property when these controlled substances could not be reconciled and accounted for disposition and 2) EI #6 did not remove two doses of controlled substance medications for a single time and date for RI #1, 2, 3, and 4. This affected five of seven residents sampled for misappropriation of controlled substances. Findings Include: The review of the facility policy titled Abuse Prevention Program - Definitions with an effective date of [DATE] and last revised on [DATE] revealed . Policy The resident has the right to be free from . misappropriation of property . Definitions . 9. Misappropriation of Resident Property means .wrongful, temporary, or permanent use of a resident's belongings . without the resident's consent . The review of the facility policy titled Medication -Controlled Substances with a last revised date of [DATE] revealed . Purpose . To maintain control and proper usage of controlled substances . Policy . To provide safeguards against diversion . and loss of controlled substances. Procedure . B. Procedure for Receiving Controlled Substances 1. The Charge Nurse and the Unit Supervisor will complete the Master Narcotic Control Records - Log in form. 2. The Individual Narcotic Control Record (NCR), Form # 071, shall be assigned an individual number from the Master Narcotic Control Record- Log In form by the Unit Supervisor. a. After the Individual Narcotic Control Record (#071) is completed the yellow copy shall be removed and given to the Unit Supervisor for safekeeping. 4. When controlled substances are received from pharmacy, an Individual Narcotic Control Record (#071) shall be completed immediately .The records are maintained in the MAR (Medication Administration Record). (White Copy for the MAR and yellow copy to the Unit Supervisor). When the entire drug is given, the white copy of the Individual Narcotic Control Record, (#071) shall be turned in to the Unit Supervisor. The Unit Supervisor will reconcile by putting the white with yellow copy to ensure when all medication given. 5. The Unit Supervisor will complete an audit of the Individual Narcotic Control Record, (#071), and compare with the Master Narcotic Control Records - Log In Form as well as using the yellow copy of the Individual Narcotic Control Record (#071) to ensure narcotics are present and accounted for Monday thru Friday. 1) a) RI #2 was admitted to the facility on [DATE] and expired on [DATE]. RI #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #2's Physician Orders revealed an order dated [DATE] for [MEDICATION(S)] ,d+[DATE] TABLET .GIVE ONE TAB BY MOUTH EVERY FOUR HOURS . A review of the Master Narcotic Control Records- Log In for entries for RI #2's [MEDICATION(S)] 5 milligram (mg) and RI #2's Individual Narcotic Control Record for [MEDICATION(S)] revealed no disposition for Individual Narcotic Control Record (NCR) Number dated [DATE] for 30 tablets of [MEDICATION(S)] 5 mg and NCR Number dated [DATE] for 30 tablets of [MEDICATION(S)] 5 mg. A review of RI #2's Electronic Medication Administration Record (eMAR) for the month of May revealed 30 doses of [MEDICATION(S)] ,d+[DATE] were signed on the eMAR as administered and did not match to an entry on the Individual Narcotic Control Record. The remaining 30 tablets of [MEDICATION(S)] ,d+[DATE] mg were unable to be reconciled to administration on the eMAR. A review of the Master Narcotic Control Records- Log In for entries for RI #2's [MEDICATION(S)] and RI #2's Individual Narcotic Control Record for [MEDICATION(S)] revealed no record of administration for: NCR Number dated [DATE] for 30 tablets of [MEDICATION(S)] 10 mg, NCR Number dated [DATE] for 30 tablets of [MEDICATION(S)] 10 mg; and NCR Number dated [DATE] for 30 tablets of [MEDICATION(S)] 10 mg. A review of RI #2's eMAR for the month of [DATE] and Individual Narcotic Control Record revealed 24 doses of [MEDICATION(S)] ,d+[DATE] were signed on the eMAR as administered and did not match an entry on the Individual Narcotic Control Record. A review of RI #2's eMAR for the month of [DATE] and Individual Narcotic Control Record revealed 19 doses of [MEDICATION(S)] ,d+[DATE] were signed on the eMAR as administered and did not match an entry on the Individual Narcotic Control Record. A total of (24 plus 19) 43 tablets of [MEDICATION(S)] ,d+[DATE] were documented as administered and did not have an Individual Narcotic Control Record to reconcile. The remaining 47 tablets of [MEDICATION(S)] ,d+[DATE] whose NCR forms were without record of administration were unable to be reconciled with the eMAR. b) RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #4's Physician Orders revealed an order dated [DATE] for [MEDICATION(S)] ,d+[DATE] TABLET . GIVE ONE TABLET EVERY SIX HOURS FOR PAIN . A review of the Master Narcotic Control Records- Log In for RI #4's [MEDICATION(S)] 10 mg entries and Individual Narcotic Control Record for [MEDICATION(S)] 10 mg revealed no disposition for NCR Numbers: dated [DATE] for 30 tablets of [MEDICATION(S)] 10 mg; dated [DATE] for 30 tablets of [MEDICATION(S)] 10 mg; dated [DATE] for 30 tablets of [MEDICATION(S)] 10 mg; and dated [DATE] for 30 tablets of [MEDICATION(S)] 10 mg. A review of RI #4's eMAR for the month of [DATE] and Individual Narcotic Control Record revealed 71 doses of [MEDICATION(S)] ,d+[DATE] were documented as administered and not matched to an entry on the Individual Narcotic Control Record. The remaining 49 tablets of [MEDICATION(S)] ,d+[DATE] were unable to be reconciled as administered on the eMAR. c) RI #7 was admitted to the facility on [DATE] and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #7's Individual Narcotic Control Record revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one tablet by mouth every eight (8) hours . A review of the Master Narcotic Control Records- Log In entries, for RI #7's [MEDICATION(S)] 10 mg and Individual Narcotic Control Record revealed no disposition or administration record for NCR number dated [DATE] for 30 tablets of [MEDICATION(S)] 10 mg. The 30 tablets of [MEDICATION(S)] 10 mg that were unaccounted for and could not be reconciled with the eMAR. On [DATE] at 4:00 PM an interview was conducted with EI #7, Licensed Practical Nurse (LPN). EI #7 was asked, where were narcotics stored. EI #7 replied, currently all narcotics were locked on the medication cart and previously overflow narcotics were in a locked cabinet in the medication room and the narcotic cards being used were in the locked medication cart. EI #7 was asked, who previously had access to medication storage room. EI #7 replied, it had not changed; each medication cart had keys to the unit's storage room and medication cart. EI #7 continued, previously, before the issue was identified around the beginning of January, each unit's nurse could go to the other unit and the medication cart nurse would give key to the nurse to medication storage room to pull stock medications. EI #7 added, now, the person holding the key to the storage room goes with the other nurse to pull anything needed from the medication storage room. EI #7 was asked, when did the process change. EI #7 replied, when it was recognized that there were drugs unaccounted for. The process had not changed except where overflow narcotics were kept, keeping one count sheet for entire order, and enforcing the policy for counting and verifying controlled substances. EI #7 was asked, what process was in place for removing narcotics from the overflow cabinet. EI #7 replied, when the narcotics or controlled substances were in the medication room in the cabinet the nurse would remove the needed medication card for the resident. EI #7 continued, then find the count sheet that matched the medication from the narcotic book that was kept on the counter in the medication room. EI #7 added, there was not a log of overflow medications that were put in or removed from the medication storage overflow cabinet. EI #7 was asked, what was it considered when a resident was missing medication. EI #7 replied, misappropriation of property. When asked about RI #4's missing narcotics he reported that one afternoon EI #3, Registered Nurse (RN), Unit One Supervisor went to pharmacy to pick up [MEDICATION(S)] 10 mg for RI #4. He reported that it was late in the afternoon and EI #3 brought the medication and count sheet to him and he immediately locked a medication card in the medication cart and placed the Individual Narcotic Control Record (NCR form) in the binder. Then placed the other medication cards in the locked storage cabinet in the medication room and placed the count sheets in the narcotic book. He did not recall the quantity of cards but reported that he and RI #3 counted each card and the NCR form; there was a card for each NCR form. EI #7 added that when a resident's narcotic card was depleted, and the NCR form was completed that the NCR form was previously placed in the inbox at Minimum Data Set (MDS) Office and currently it was being placed in an inbox at unit supervisor's office. On [DATE] at 6:15 PM an observation was made of EI #3 as she returned to the facility with resident's medications. EI #3 reported that all narcotics brought to or delivered to the facility were logged into the Master Narcotic Control Record book. EI #3 reported that it was not a new process. On [DATE] at 7:10 PM an interview was conducted with EI #8, RN. EI #8 reported that she was a charge nurse and usually worked at night. When asked how she was made aware that there was a concern with missing narcotics. EI #8 replied that on [DATE] she thought, she and EI #9, LPN was counting and became aware that RI #4's supply of [MEDICATION(S)] was near depleted, and he/she had a day or two of supply remaining. EI #8 continued, apparently when EI #9 called that pharmacy the pharmacy said it was too soon and that the medication was not due to refill until [DATE]. EI #8 was asked, had she ever witnessed a discrepancy in RI #4's narcotic count. EI #8 replied, no, but she was aware that there was a discrepancy, but when they counted each evening, the count was correct. On [DATE] at 8:30 AM an interview was conducted with EI #3. EI #3 was asked, where were narcotic medications stored. EI #3 replied, in the medication cart and previously the narcotic overflow was stored in the medication rooms in a locked cabinet. EI #3 was asked, who currently had access to those medications. EI #3 replied, the charge nurse on the hall. EI #3 was asked, were nurses sharing keys to the medication room. EI #3 replied, yes. EI #3 was asked if she was aware that was happening, and she replied yes. EI #3 was asked, why were nurses sharing keys to the medication storage room. EI #3 replied, if a nurse on unit two needed an antibiotic, the nurse would ask the unit one's nurse for the keys to the medication storage room. EI #3 was asked, when did she recognize the sharing of keys was a potential problem. EI #3 replied, at the beginning of January when the problem of missing narcotics was identified. EI #3 was asked, what process was currently in place for receiving narcotics. EI #3 replied, when a narcotic was picked up or received from a pharmacy, usually one of the RNs verified the order and entered the medication into the Master Narcotic Control Record -Log In book and then assigned the NCR number. EI #3 continued, the information for the resident and medication was entered onto an Individual Narcotic Control Record which was carbon copied onto a yellow copy. EI #3 continued, the Master Narcotic Control Record- Log In form, the medication card, and NCR form's white copy was taken to the nurse working the medication cart. EI #3 said, she and the nurse working the medication cart did a read back to verify and if everything was correct the medication cart's nurse signed the Master Narcotic Control Record- Log In. EI #3 stated, she watched the nurse place the card in the secure narcotic box before she walked away. EI #3 was asked, how was the process different. EI #3 replied, the medication nurse was coming to the office to pick up the medication, but now the RN who signed the medication in take the forms and cards to the nurse on the hall, verified and observed the drug being locked. EI #3 added, everyone was being more consious about verifying the narcotics and where the controlled medications were kept. EI #3 was asked, when did the process change. EI #3 replied, in January when the concern was identified. EI #3 was asked, with RI #4's missing [MEDICATION(S)], what could she report about it. EI #3 replied, that she picked up the medication from the back-up pharmacy after RI #4's supply was near depleted and it was determined that she would run out before the weekend was over. EI #3 reported that she picked up four cards of 30 tablets of [MEDICATION(S)] for RI #4 and signed them into the Master Narcotic Control Record- Log In book and assigned each card an NCR number and form and then took the medications to EI #7. EI #7 was at his cart in the hallway, and she handed the cards to EI #7 and walked away. EI #3 was asked, did EI #7 sign for the medications. EI #3 replied, no, in the past, when medications were picked up from backup pharmacy she just wrote the name of the pharmacy to the side and did not get the receiving nurse to sign. They had changed that now so that all narcotics were signed on the Master Narcotic Control Record-Log In as received by the medication cart nurse and the nurse that picked up the medication. EI #3 was asked, before [DATE], when did supervisor take the yellow copy of the NCR form to the medication cart or medication storage room and count all narcotics. EI #3 replied, she did not and that it was a new process that was started when the problem was identified. EI #3 was asked, what was it considered when a resident was missing medication. EI #3 replied, misappropriation of property. 2) a) RI #1 was admitted to the facility on [DATE] and discharged on [DATE]. RI #1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #1's Physician Orders revealed orders dated [DATE] for .[MEDICATION(S)] ,d+[DATE] TABLET GIVE ONE TABLET BY MOUTH TWICE A DAY . and [MEDICATION(S)] 50 MG TABLET GIVE ONE TABLET BY MOUTH EVERY SIX HOURS AS NEEDED . A review of RI #1's Individual Narcotic Control Record with assigned NCR number of for [MEDICATION(S)] ,d+[DATE] final entries revealed a dose signed as administered on ,d+[DATE] at 9a with quantity remaining 1 signed by EI #6 and a dose signed as administered on ,d+[DATE] at an illegible time with a quantity remaining of 0 signed by EI #6. A review of RI #1's Individual Narcotic Control Record with assigned NCR number of for [MEDICATION(S)] 5 mg revealed the first dose signed as administered on ,d+[DATE] at 5p with a quantity remaining of 29 signed by EI #6. Two doses were signed from the narcotic count, NCR form, and only one dose was documented as administered. A review of RI #1's Electronic Medication Administration Record (eMAR) for the month of [DATE] for [MEDICATION(S)] ,d+[DATE] TABLET . revealed a dose documented on [DATE] at 9:00 AM and a dose documented on [DATE] at 5:00 PM, both by EI #6. No other doses were documented on [DATE] by EI #6. Two doses were signed from the narcotic count, NCR form, and only one dose was documented as administered. Two doses were signed from the narcotic count for the same time. A review of RI #1's Individual Narcotic Control Record with assigned NCR number of for [MEDICATION(S)] 50 mg's final entry was on ,d+[DATE] at 930 with a quantity remaining of 0 signed by EI #6. A review of RI #1's Individual Narcotic Control Record with assigned NCR number of for [MEDICATION(S)] 50 mg's first entry was on ,d+[DATE] at 9:30a with a quantity remaining of 29 signed by EI #6. Two doses were signed from the narcotic count, NCR form, and only neither dose was documented as administered. Two doses were signed from the narcotic count for the same time. A review of RI #1's eMAR for the month of [DATE] for [MEDICATION(S)] 50 MG TABLET . revealed no doses documented by EI #6 after [DATE]. b) A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The final entry on the form was on ,d+[DATE] at 12p by EI #6. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first entry on the form was on ,d+[DATE] at 12p by EI #6. Two doses were signed from the narcotic count for the same time on seperate forms. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The final entry on the form was on ,d+[DATE] at 6p by EI #6. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first entry on the form was on ,d+[DATE] at 6P by EI #6. Two doses were signed from the narcotic count for the same time on seperate forms. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The final entry on the form was on ,d+[DATE] at 6P by EI #6. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first entry on the form was on ,d+[DATE] at 6P by EI #6. The final entry on the form was on ,d+[DATE] at 2P by EI #6. Two doses were signed from the narcotic count for the same time on seperate forms. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first entry on the form was on ,d+[DATE] at 2P by EI #6. The final entry was on ,d+[DATE] at 10a by EI #6. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first entry on the form was on ,d+[DATE] at 10a by EI #6. Two doses were signed from the narcotic count for the same time on seperate forms. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Two entries were made on ,d+[DATE] by EI #6 between entries on ,d+[DATE] at 6a and 2p. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Two entries were made on ,d+[DATE] by EI #6 between entries on ,d+[DATE] at 6a and 2p. The final two entries were on ,d+[DATE] at 2p and 6p by EI #6. Two doses were signed from the narcotic count for the same time on seperate forms on two occasions. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first two entries were on ,d+[DATE] at 2p and 6p by EI #6. The final entry was on ,d+[DATE] at 10a by EI #6. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first entry was on ,d+[DATE] at 10a by EI #6. Two doses were signed from the narcotic count for the same time on seperate forms. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Two entries were made on ,d+[DATE] at 10a by EI #6. The final two entries were on ,d+[DATE] at 10a and 2p by EI #6. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first two entries were on ,d+[DATE] at 10a and 2p by EI #6. Two doses were signed from the narcotic count for the same time on seperate forms on two occasions. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Two entries were made on ,d+[DATE] at 10a. Two doses were signed from the narcotic count for the same time on seperate forms. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The final entry was on ,d+[DATE] at 10a by EI #6. A review of RI #2's Individual Narcotic Control Record with assigned NCR number revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first entry was on ,d+[DATE] at 10a by EI #6. Two doses were signed from the narcotic count for the same time on seperate forms. c) RI #3 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE]. RI #3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #3's Physician Orders revealed an order dated [DATE] for .[MEDICATION(S)] 7.,d+[DATE] TABLET GIVE ONE TABLET BY MOUTH TWICE DAILY . and an order dated [DATE] for [MEDICATION(S)] 7.,d+[DATE] GIVE ONE TABLET BY MOUTH EVERY 12 HOURS AS NEEDED . A review of RI #3's Individual Narcotic Control Record with assigned NCR number for [MEDICATION(S)] 7.5 mg revealed the final entry was on ,d+[DATE] at 9A by EI #6. A review of RI #3's Individual Narcotic Control Record with assigned NCR number for [MEDICATION(S)] 7.5 mg revealed the first entry was on ,d+[DATE] at 9A by EI #6. Two doses were signed from the narcotic count for the same time on seperate forms. d) A review of RI #4's Individual Narcotic Control Record with assigned NCR number for [MEDICATION(S)] 10 mg revealed an entry dated ,d+[DATE] at 6P with a quantity remaining of one by EI #6 and an entry on ,d+[DATE] at 6P with a quantity remaining of zero by EI #6. A review of RI #4's eMAR for the month of October for [MEDICATION(S)] ,d+[DATE] TABLET . revealed a dose administered on [DATE] at 6:00 PM by EI #6. There was no dose administration by EI #6 on [DATE] at any time. A review of EI #6's Archived Time Card Report revealed she did not work on [DATE]. On [DATE] at 2:20 PM an interview was conducted with EI #6. EI #6 reported that she worked dayshift, 7:00 AM to 7:00 PM, and usually was assigned a medication cart. EI #6 was asked, prior to the investigation in [DATE], where were the overflow narcotics stored. EI #6 replied, on each station in a locked cabinet in the medication room. EI #6 was asked, who all had access to the medications. EI #6 replied, the charge nurse on the hall. EI #6 was asked, what process was in place for removing narcotics from the overflow cabinet before the investigation. EI #6 replied, when a medication card was depleted in the medication cart, she would just go into the medication room and pull a new card from the cabinet and put it on the cart. EI #6 was asked, had she ever worked station one and another nurse asked for her medication room keys to get something from the stat box. EI #6 replied, it had been a long time, but she was sure that had happened before and she either gave them the keys or went with the nurse. EI #6 was asked, was the key to the cabinet with station one's resident's narcotics on the key ring. EI #6 replied, yes. EI #6 was asked, what was the concern with another nurse having the keys and going in the medication room by themselves. EI #6 replied, the concern would be that it was not secured to one nurse assigned to the hall. EI #6 was asked, what did she do when she administer a narcotic medication. EI #6 replied, supposed to sign after it was given was normally how she did it. EI #6 was asked, when did she sign out the narcotic on the narcotic log sheet. EI #6 replied, after she gave it. EI #6 was asked, when did she document the administration of the medication that she was putting in the medication cups at the beginning of the shift. EI #6 replied, later on during the shift. EI #6 was asked, had she ever witnessed a discrepancy in RI #4's narcotic count. EI #6 replied, no, not until they showed her the mistake of signing a single scheduled dose out of the narcotic count twice when she was at the facility the prior week. EI #6 was asked, to tell more about what happened and what she was shown. EI #6 replied that when she went to the facility for her second interview administrative staff investigating showed her that she had signed out RI #4's medication, two on one sheet and two on the other, EI #6 continued, she did not know how she did it, she did not even realize she did it until it was brought it to her attention. EI #6 added, she knew it was no excuse, but it was hectic, and she might not have done things like she was supposed to and that was her mistake, and she would have to answer for it. EI #6 was asked, why did she think she had signed out for narcotics on separate sheets for the same date and time. EI #6 replied, she did not know why. EI #6 was asked, what happened to the other narcotics that she signed out. EI #6 replied, if she punched them out, she gave them to the resident. EI #6 was asked in retrospect, what did she not do like she was supposed to do that may have caused the mistakes. EI #6 replied, sometimes when she would get there early, she would pull the residents' medications, put them in medication cups, label them, start giving out medicines and work on whatever came up. EI #6 was asked, would she also do that with the narcotics and punch them into the medication cups with the other medications. EI #6 replied, yes, she did. EI #6 was asked, on [DATE] and [DATE], a new Individual Narcotic Control Record (NCR) form was started for RI #4's for [MEDICATION(S)]. The previous doses' NCR forms were missing and according to the pharmacy record, there should have been doses remaining on the cards used previously, what could she recall about those dates and the [MEDICATION(S)]'s NCR form or doses remaining. EI #6 replied, she did not recall specifically, but she always tried to put the completed sheets in the bin at the nurses' desk and thought she put the completed forms in the appropriate location. EI #6 was asked, on [DATE] at 9:00 AM she signed for [MEDICATION(S)] 7.5 mg for RI #3 as the final entry on NCR number and again at the same time, [DATE] at 9:00 AM, for the first dose on NCR , could she explain why there were two tablets removed for a single scheduled dose for the same date and time. EI #6 replied, she did not know. EI #6 was asked, where would the additional dose have gone. EI #6 replied, if she signed it out and pulled the medication, she would have given the dose to the resident. EI #6 was asked, so if the eMAR indicated one dose was given, but two doses were signed out on the NCR form, what happened. EI #6 replied, she did not know, that she could have made an error when pulling medications early. EI #6 was asked, on [DATE] at 9:30 AM she signed for [MEDICATION(S)] 50 mg for RI #1 as the final entry on NCR number and [DATE] at 9:30 AM for the first dose on NCR , how could she explain why there were two tablets removed for the same date and time. EI #6 was replied, if she signed it out and pulled the medication, she would have given the dose to the resident. EI #6 was asked, on [DATE] at 10:00 AM and 2:00 PM she signed for [MEDICATION(S)] 10 mg for RI #2 as the final entry on NCR number and [DATE] at 10:00 AM and 2:00 PM for the first dose on NCR , how could she explain why there were two tablets removed for the same date and time. EI #6 replied, if she signed it out and pulled the medication, she would have given the doses to the resident. EI #6 added, she thought maybe she pulled the narcotics in the morning, pulled the new sheet, and then she gave the doses twice. EI #6 continued and said that she pulled the doses when she arrived and could have gotten a new card and added an additional dose to the prepared medication cup. EI #6 was asked, on [DATE] at 10:00 AM she signed for [MEDICATION(S)] 10 mg for RI #2 as the final entry on NCR number and [DATE] at 10:00 am for the first dose on NCR , could she explain why there were two tablets removed for the same date and time. EI #6 replied, the same answer, that she could have pre-prepared the medication and used the final dose of a card and then mistakenly gotten a new card and added an additional dose. EI #6 was asked, there were over 15 instances on the narcotic record of multiple doses being signed out at the same date and time for RI #2, could she explain. EI #6 replied, no, the same answer, she could have mistakenly signed the dose out twice. EI #6 was asked, what happened to the extra medication. EI #6 replied, she did not know, she must have administered it to RI #2 if she signed it out. EI #6 was asked, on [DATE] at 6:00 PM the final dose of [MEDICATION(S)] 10 mg was documented by her on RI #4's [MEDICATION(S)] NCR form number , but the timecard indicated that she did not work that day, how could she explain this. EI #6 replied she did not know, maybe it was dated incorrectly. On [DATE] at 6:00 PM an interview was conducted with EI #5, Pharmacist Consultant. EI #5 reported that he ensured that the facility had a system in place to track controlled substances in the facility. EI #5 was asked, when did he become aware of the concern with RI #4's [MEDICATION(S)]. EI #5 replied, around the first of the year he was in the building and EI #2, Director of Nursing told him a nurse had called to refill a resident's controlled medication and the pharmacy thought it was too soon. He reported that he began investigating and discovered issues. EI #5 was asked, what issues were discovered. EI #5 replied, that he noticed that the NCR forms were being used out of sequence, began looking deeper, did a count back with the yellow copy NCR forms and the medication cart and found there were missing medication cards. EI #5 was asked, how many medication cards were found to be missing. EI #5 reported that he did not remember, some of the forms had not been returned or were misplaced, so from there they had to start looking through the nurses' desk for misplaced NCR forms, the chart for administered doses, and the destruction book for destroyed doses. EI #5 was asked, what was the concern when RI #4's controlled drugs were reviewed. EI #5 replied, there were missing NCR sheets, they checked the eMAR and could not account for all the missing tablets per the NCR forms. EI #6 signed as the final entry for an NCR sheet and redocumented the same dose on the beginning of the next and the same dose was double documented on the NCR forms. EI #5 was asked, what was the concern with RI #7's controlled drug's review. EI #5 replied, RI #7 had a missing NCR form for [MEDICATION(S)] that could not be reconciled with the eMAR. EI #5 was asked, what was the concern with RI #2's controlled drug's record. EI #5 replied, there were several NCR sheets that were not located, and multiple doses were not able to be reconciled with the eMAR. EI #5 continued, there were a lot, over a dozen, in

Based on interviews, medical record reviews, a review of a complaint and email submitted by the facility to the Alabama Board of Nursing, a review of facility policy titled Medication - Administration, and review of POTTER & PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, 2017, the facility failed to ensure Employee Identifier (EI) # 6, a Licensed Practical Nurse (LPN), followed the standards of practice for signing out narcotics and did not prepare medications for multiple residents in advance. This affected four of seven sampled residents. Findings Include: A review of a complaint submitted by the facility to the Alabama Board of Nursing on [DATE] revealed: . (Name of EI #6, LPN) did not follow the Standard of practice for signing out narcotics. A review of an email from the Alabama Board of Nursing to the facility on [DATE] documented: . Complaint (including what, when, and where): (Name of EI #6) did not follow the Standard of practice for signing out narcotics. She would date and sign at bottom of one page then use same date and time at top of next page to sign out same narcotic. For example on [DATE] [MEDICATION(S)] 10mg (milligrams) NCR# signed out for 10am and 2pm doses at bottom of individual narcotic record to zero out this sheet/medicine then at top of next individual narcotic record for [MEDICATION(S)] 10mg NCR # signed out for [DATE] for 10am and 2pm dose again. This has happened on several occasions. This is under investigation at ADPH and (Name of Agent), Special Agent for Attorney General Office Matter ID ,d+[DATE]. There are narcotics that are not accounted for. A review of POTTER & PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, 2017, Chapter 32, Medication Administration, p. 610 and p. 625, documented: . Medication Regulations and Nursing Practice. A nurse is responsible for following legal provisions when administering controlled substances . Violations of the Controlled Substances Act are punishable by fines, imprisonment, and loss of nurse licensure. p. 625, BOX ,d+[DATE] Steps to Take to Prevent Medication Errors Prepare medications for only one patient at a time. Document all medications as soon as they are given. BOX ,d+[DATE] Informatics and Medication Safety . Application to Nursing Practice . Always follow agency policies when administering medications. A review of facility policy titled Medication - Administration with an effective date of [DATE] and last revised on [DATE] revealed . Purpose Medications shall be administered . as prescribed by the resident's attending physician . Procedure . 8. Medication may not be prepared in advance . 1) RI #1 was admitted to the facility on [DATE] and discharged on [DATE]. RI #1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] ,d+[DATE] TABLET GIVE ONE TABLET BY MOUTH TWICE A DAY . and [MEDICATION(S)] 50 MG TABLET GIVE ONE TABLET BY MOUTH EVERY SIX HOURS AS NEEDED . A review of RI #1's Individual Narcotic Control Records revealed EI #6 documented administration of two doses of [MEDICATION(S)] for a single date and time on two separate occasions. 2) RI #2 was admitted to the facility on [DATE] and expired on [DATE]. RI #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .GIVE ONE TAB BY MOUTH EVERY FOUR HOURS . A review of RI #2's Individual Narcotic Control Records revealed EI #6 documented administration of two doses of [MEDICATION(S)] 10 MG for a single date and time on ten separate occasions. 3) RI #3 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE]. RI #3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 7.,d+[DATE] TABLET GIVE ONE TABLET BY MOUTH TWICE DAILY . and an order dated [DATE] for [MEDICATION(S)] 7.,d+[DATE] GIVE ONE TABLET BY MOUTH EVERY 12 HOURS AS NEEDED . A review of RI #3's Individual Narcotic Control Records revealed EI #6 documented administration of two doses of [MEDICATION(S)] for a single date and time on [DATE] at 9 AM. 4) RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . GIVE ONE TABLET EVERY SIX HOURS FOR PAIN . A review of RI #4's Individual Narcotic Control Records revealed EI #6 documented administration of [MEDICATION(S)] 10 mg on [DATE] while she was not working in the facility. A review of EI #6's Archived Time Card Report revealed she did not work on [DATE]. On [DATE] at 2:20 PM an interview was conducted with EI #6. EI #6 reported that she worked dayshift, 7:00 AM to 7:00 PM, and usually was assigned a medication cart. EI #6 was asked, what did she do when she administered a narcotic medication. EI #6 replied, supposed to sign after it was given was normally how she did it. EI #6 was asked, when did she sign out the narcotic on the narcotic log sheet. EI #6 replied, after she gave it. EI #6 was asked, when did she document the administration of the medication that she was putting in the medication cups at the beginning of the shift. EI #6 replied, later on during the shift. EI #6 was asked, had she ever witnessed a discrepancy in RI #4's narcotic count. EI #4 replied, no, not until they showed her the mistake she made when she was at the facility the prior week. EI #6 was asked, to tell more about what happened and what she was shown. EI #6 replied that she went up to the facility for her second interview, administrative staff investigating showed her that she had signed out RI #4's medication, two duplicates on one sheet and two duplicates on the other, EI #6 continued, she did not know how she did it, she didn't even realize she did it until it was brought it to her attention. EI #6 added, she knew it was no excuse, but it was hectic, and she might not have done things like she was supposed to and that was her mistake, and she would have to answer for it. EI #6 was asked, why did she think she had signed out for narcotics on separate sheets for the same date and time. EI #6 replied, she did not know why. EI #6 was asked, what happened to the other narcotics that she signed out. EI #6 replied, if she punched them out, she gave them to the resident. EI #6 was asked in retrospect, what did she not do like she was supposed to do that may have caused the mistakes. EI #6 replied, sometimes when she would get there early, she would pull the residents' medications and put them in medication cups and label them and start giving out medicines and work on whatever came up. EI #6 was asked, would she also do that with the narcotics and punch them into the medication cups with the other medications. EI #6 replied, yes, she did. When asked if she was following the nursing standards of practice and facility policy when she was preparing medications ahead of time, EI #6 said no. On [DATE] at 7:00 PM an interview was conducted with EI #1, Administrator. EI #1 was asked, what was the concern identified during RI #7's controlled drug review. EI #1 replied, during match back it was discovered that RI #7 had an NCR Form and medication card of [MEDICATION(S)] 10 mg 30 tablets that was unable to be reconciled with the eMAR. EI #1 was asked, what was the concern with that. EI #1 replied, the staff were unable to know where the medication was, and it was missing. EI #1 was asked, what was the concern identified during RI #3's controlled drug review. EI #1 replied, EI #6 signed a dose of [MEDICATION(S)] on the bottom of an NCR form and then again on the top of another; EI #6 signed one dose twice. EI #1 was asked, so, either the nurse administered two doses or diverted the medication. EI #1 replied, yes, but there was no way to know and no witnesses. EI #1 was asked, what was the concern identified during RI #4's controlled drug review. EI #1 replied, it was discovered that EI #6 had signed out a dose on [DATE] at 6:00 PM and then another dose on [DATE] at 6:00 PM. EI #1 continued, the first issue was there were three doses that should have been administered between the doses and were documented by the scheduled nurse, but EI #6 signed a dose twice at the bottom of the sheet which was one tablet that was documented on the NCR but not reconciled with the eMAR. EI #1 continued, EI #6 did not work on [DATE]. EI #1 continued, RI #4 also had four NCR forms that were unaccounted for, and 49 tablets of [MEDICATION(S)] 10 mg were not reconciled with the eMAR and were missing. EI #1 was asked, what was the concern identified during RI #2's controlled drug review. EI #1 replied, there were numerous times that EI #6 signed a single dose twice and there were five missing NCR forms for [MEDICATION(S)], and some of the doses were able to be accounted for on the eMAR, but 77 tablets were unaccounted for and missing. EI #1 was asked what was the concern identified during RI #1's controlled drug reviewed. EI #1 replied, EI #6 signed a dose at the bottom of an NCR form and at the top of the next NCR, double documented for same dose of medication. EI #1 was asked, when should a controlled drug be received by the facility and the facility be unable to account for the drugs disposition. EI #1 replied, never, the facility should maintain accounting of all drugs administered, especially narcotics. ************************* Once the facility became aware of the incident involving RI # 4's missing narcotics on [DATE], the following corrective action plan was developed and implemented: *[DATE] Med room doors - Do not prop open *[DATE] Med room and med carts do not allow anyone in either unless you are present and do not share keys with anyone. (Only nurse on station at time and DON has keys) *[DATE], Individual Narcotic Sheets - Effective immediately all medication with same RX (prescription) numbers will be written on one sheet (i.e. if there are 66 signature lines on 1 individual narcotic control sheet so if there are 30 tablets received 1 sheet assigned/1NCR number, 60 tablets received 1 sheet assigned/1 NCR number, 90 tablets received 2 sheets assigned/1 NCR number, 120 tablets received 2 sheets assigned/1 NCR number, 150 tablets received 3 sheets assigned/1 NCR number, 180 tablets received 3 sheets assigned/1 NCR number.) If more than 1 sheet is assigned the RN will keep in their binder with yellow copies until needed. All sheets on Station 1 and Station 2 med carts were reconciled and total count of narcotics on 1 sheet. *[DATE] Added another lock box to med cart and all resident assigned narcotics moved to med cart. No more resident assigned narcotics kept in locked cabinet in med rooms. Stat narcotics kept in lock box in Station 2 med room. *[DATE] When narcotics picked up from Major's Drugs they are to be signed in immediately as brought in the facility and nurse on station to sign off when received. *[DATE] when medications counted in from Economed the narcotics are to be brought to the station along with the Master Narcotic Control Log for nurse to sign. *[DATE] started RN supervisor or designee will match back yellow individual narcotic sheet to white individual narcotic sheet on med cart to narcotic (drug card) on med cart every Monday, Wednesday, and Friday. *[DATE] instructed RN Supervisor or designee to date and sign yellow copy as reconciled as proof of reconciliation.) *Continuing to investigate any missing individual narcotic sheets identified since [DATE] and [DATE] investigations reported to state with match back of yellow and white copies to MAR to determine if any additional Policy and Procedure changes are needed. *The Master Narcotic Records are forms that are used for tracking purposes to assign NCR number when a narcotic is received from the pharmacy. This file is accessible from the x drive entitled USA-Master Narcotic Control record file. The facility level access is only given to Administrator and Director of Nursing ************************* After review of the information provided in the facility's corrective action plan, in-service/education records, as well as staff interviews, the survey team determined the facility implemented corrective actions from [DATE]-[DATE]; thus past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 683.

Based on observation, interviews, and a facility policy titled, Handwashing-Hand Hygiene, the facility failed to ensure a licensed nurse washed her hands after removing gloves, prior to administering a topical medication to Resident Identifier (RI) #33. This affected one of three licensed nurses observed during medication administration pass and RI #33, one of four residents observed during medication administration pass. Findings Include: RI #33 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of a facility policy titled, Handwashing-Hand Hygiene with a revised date of 03/01/2017, revealed Handwashing-Hand Hygiene Purpose To prevent the spread of infection . 5. Employees must wash their hands . under the following conditions: . u. After removing gloves . 8. The use of gloves does not replace handwashing/hand hygiene. On 3/20/19 at 8:51 a.m., the surveyor observed Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), during a medication administration pass for RI #33. The surveyor observed EI #1 remove her gloves after giving an eye drop medication to RI #33. EI #1 then removed her gloves and put on another pair of gloves to apply a tropical cream to RI #3's neck. EI #1 did not wash her hands prior to putting on the other pair of gloves. On 3/20/19 at 1:58 p.m., an interview was conducted with EI #1. She was asked did she wash her hands after removing her gloves, and prior to putting on another pair of gloves before applying a topical cream on RI #33's neck. EI #1 stated no. EI #1 was asked why she did not wash her hands after removing her gloves and prior to putting on another pair of gloves before applying the cream on RI #33's neck. EI #1 stated she just forgot to wash her hands. EI #1 was asked what was the facility policy on hand hygiene after removing gloves when giving medications to a resident. EI #1 replied that you should wash your hands after removing gloves. EI #1 was asked what would be the concern in not washing her hands after removing gloves prior to giving a resident a topical medication. EI #1 stated it could cause contamination or infection to a resident. On 3/20/19 at 2:03 p.m., an interview was conducted with EI #2, Registered Nurse/Infection Control Preventionist. EI #2 was asked what was the facility policy regarding hand hygiene after removing gloves when giving medications to a resident. EI #2 stated you should always wash your hands or use hand sanitizer. EI #2 was asked what would be the concern with not washing your hands after removing gloves prior to giving a resident a topical medication. EI #2 stated it could cause cross contamination and could cause an infection to the resident.

Based on observation, interviews, review of a facility policy titled Milkshake Protocol, and review of the 2013 Food and Drug Administration Food Code, the facility failed to ensure that commercially prepared milkshakes were labeled with the correct use by dates; and two plastic wrapped hams placed in the refrigerator to thaw were labeled appropriately. These concerns had the potential to affect all residents for whom meals were prepared in the kitchen. The CMS (Center for Medicare and Medicaid Services) Form-562 indicated the facility had a census of 75 residents. Findings included: A facility policy titled, Milkshake Protocol with a revised date of 12/01/13 revealed: Policy To thaw, date and use milkshakes within appropriate time frame. Procedure .2. Milkshakes are to be placed in Dietary Refrigerator to thaw .3. The date milkshakes are put in refrigerator to thaw is to be written on each individual milkshake. This is to be identified as the thaw date. 4. The milkshake is to be disposed of 14 days after thawing, this is to be identified as the use by date. A use by date is to be written on each individual milkshake carton .5. Dietary will check dates on milkshake cartons in .refrigerators daily. A review of the 2013 Food and Drug Administration's Food Code 3-501.17(A) revealed: .refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD .held in a Food Establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, .or discarded . On 2/7/2017 at 1:47 p.m. during the initial tour of the kitchen, four 4 oz. (ounce) commercially prepared milkshakes were observed in the walk in refrigerator with thaw dates of 2/7 and use by dates of 1/7. Two hams wrapped in plastic wrap were observed on the bottom right shelf of the walk in refrigerator. These hams contained no labels referencing thaw dates or use by dates. On 2/8/2017 at 3:16 p.m. an interview was conducted with Employee Identifier (EI) #1, the Dietary Manager. EI #1 was asked if the above mentioned milkshakes were labeled with the correct use by dates. EI #1 responded, No, I don't know what those numbers were supposed to be. All those milkshakes were removed immediately. She further explained the milkshake should be labeled with the date it was laid out (thaw date) and a use by date, being 14 days after the laid out date. She explained not following this policy could result in expired milkshakes being sent out to the residents and possible illness. When asked if the two hams thawing on the bottom shelf of the walk in refrigerator were labeled with thaw/use by dates, EI #1 responded, no they were not labeled. She explained the hams should have been labeled with the date they were laid (thaw date) and the date they should have been used. EI #1 further explained the potential harm in having unlabeled foods in the refrigerator could result in foods not being used in the proper time frame and this could result in a potential illness for the residents if consumed.

Based on observations, interviews and review of a document titled HIPAA (Health Insurance Portability and Accountability Act)-Confidentiality & Non-Disclosure Agreement, the facility failed to ensure protected health information for Resident Identifiers (RI) #16, #17, #18, #19, and #20 were not placed on the residents' closet door for anyone to see. This affected 5 of 18 sampled residents. Findings include: A facility document titled, HIPAA-Confidentiality & Non-Disclosure Agreement, dated 04.01.11 revealed: The facility's information .contain confidential records pertaining to the .residents Because this information is vital . in providing quality care and services to the residents, it must be protected . As an employee of this facility .YOU AGREE: .3. To disclose confidential resident .information ONLY to those authorized to receive it On 02/07/2017 during the initial tour beginning at 2:15 p.m., the surveyor observed sheets posted on RI #16, RI #17, RI #18, RI #19 and RI # 20's closet doors titled: FMP (Functional Maintenance Plan) All sheets had the residents' names at the bottom. On 02/08/2017 at 8:15 a.m., the surveyor observed sheets posted on RI #16, RI #17, RI #18, RI #19 and RI #20's closet doors titled: FMP (Functional Maintenance Plan) All sheets had the residents' names at the bottom. RI #16 was admitted to the facility on [DATE] and readmitted to the facility to 02/03/14. RI # 16's FMP sheet documented: . Resident is mechanical lift for transfers out of bed.should receive positioning that will protect bony prominences from pressure and friction.should receive ROM (Range of Motion) exercises and strengthening RI #17 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. RI #17's FMP sheets documented: - .Transfers . Resident is Dependent for all functional transfers and requires a mechanical lift. Resident is unable to stand at this time - .ADLs (Activities of Daily Living) . Patient requires Mod (Moderate) A (Assistance) and UB (Upper Body) dressing. Patient to perform B (Body) UE Upper Extremity AROM (Active Range of Motion) exercises when performing ADLs RI #18 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. RI # 18's FMP sheets documented: - .Cognition .The pt (patient) is oriented to person, place and time. Pt is able to communicate most wants/needs as well as respond to questions. Pt is able to participate in ADLs provided set up . - . 1. UB (Upper Body) dressing . 2. WC (wheelchair) positioning . Provide set up of clothing and allow pt to perform upper body dressing while seated in WC . - . 1. Donning and Doffing Bilateral Multipodas boots 2. Gently Static Stretched to Bilateral Ankles .Perform gentle static stretching to Bilateral Achillie's Tendon to allow for proper fitting of Multipoda Boots RI #19 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. RI#19's FMP sheets documented: .1. UB (Upper Body) dressing 2. LB (Lower Body) dressing Pt currently performs UB (Upper Body) dressing task with touching assistance. 2. Pt currently performs LB (Lower Body) dressing tasks with substantial assistance. 1. Transfers 2. Lower (extremities) strengthening . Resident requires mechanical lift for all transfers .1. Cognition and communication 2. Hearing . Provide set up for ADL's and assistance as necessary, giving explanations of new situation and expectations RI #20 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. RI #20's FMP sheets documented: . 1. application of multipodas boot to R(right) foot 2. patient will assist with rolling side to side 3. mechanical lift for transfers . Restorative staff will provide stretching to right ankle followed by application of multipodas boot to R (right) . 1. ADLs 2. B UE AROM Exercise .1. Patient requires Max (Maximum ) A (assistance) with UB dressing and Setup for grooming and hygiene . On 02/08/17 at 4:45 p.m., an interview was conducted with EI (Employee Identifier) #3, the Restorative Nurse. EI #3 was asked why white sheets of paper were posted on resident's closet doors. EI #3 said every resident that is on an FMP, the sheet is on the closet door. EI #3 further explained, the sheet is to help the CNAs (Certified Nursing Assistants) know how to care for the resident,by giving them a guide. EI #3 was asked can anyone see this sheet placed on the residents' closet doors. EI #3 said yes they can with the sheet being on the outside of the closet door. On 02/09/2017 at 2:00 p.m., an interview was conducted with EI #2, the DON (Director of Nurses). EI #2 was asked why residents' FMP sheets were posted on the closet doors. EI #2 said to inform staff how to care for the residents. EI #2 was asked can anyone, staff and visitors, see residents' information. EI # 2 said anyone that comes in the room can see it. EI #2 was asked should anyone be allowed to see residents' information. EI #2 said probably not, only the patient and staff involved in providing care to the resident.

Based on observation, record review, staff interview, and review of a facility policy titled Medication- Administration, the facility failed to ensure a licensed nurse followed physician orders when the wrong medication was administered to Resident Identifier (RI) RI #10 during Medication Pass Observation on 02/07/2017. This affected RI #10, 1 of 4 residents observed during Medication observation. Findings include: A review of the facility policy, revised 01/13/2016, entitled: Medication - Administration revealed, . Policy Medications shall be given as ordered by a physician. Procedure . 2. Medications shall be administered in a timely manner and in accordance with the physician's written/verbal orders .9. The nurse administering the medication shall ensure that the right resident, right medication, right dosage, right, time, right method of administration are verified before the medication is administration. RI # 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/21/2016 revealed a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident had severely impaired cognition. On 2/7/17 at 5:00 p.m., EI #4, Licensed Practical Nurse, was observed administering [MEDICATION NAME] Solution 10 grams/15 milliliters to RI #10. During reconciliation of the drug administration, RI #10's Physician Medication Orders were reviewed, and it was noted RI #10 did not have a physician's order for [MEDICATION NAME] Solution. Instead, there was an order for [REDACTED]. During an interview on 2/8/17 at 5:30 PM with EI #4, the nurse observed administering medication to RI #10, the surveyor asked to see the bottle of [MEDICATION NAME]. RI #10's name was not on the bottle. EI #4 said she was unaware she made an error until the Director of Nursing told her. EI #4 agreed [MEDICATION NAME] and [MEDICATION NAME] were not the same medication.

Based on observation, record review, and interviews, the facility failed to ensure: 1) staff washed hands after re-entering the kitchen, prior to resuming duties to prevent the potential for cross contamination; 2) staff checked the temperature of milk prior to serving to ensure a temperature of less than or equal to 40 degrees Fahrenheit (F); and 3) staff did not transport beverages uncovered to the end of the hallway. These failures had the potential to affect all 77 residents for whom meals were prepared and served during the survey. Findings Include: 1) Review of the Food and Drug Administration Food Code 2013, Chapter 2 Management and Personnel, pages 47 and 48, revealed the following: .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES and: . (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . (I) After engaging in other activities that contaminate the hands. During trayline observations on 1/13/2016 beginning at 10:30 AM, two dietary staff members, Employee Identifier (EI) #s 11 and 12, were observed leaving the kitchen. Upon their return, neither washed their hands prior to resuming their duties. EI #11 was responsible for placing utensils for the meal on residents' trays. EI #11 left the kitchen to deliver a cup to the dining room, and when she returned she did not wash her hands and immediately began handling residents' trays, cups, utensils, tray cards, and condiments. EI #12 was responsible for delivering all the tray carts to the dining room. EI #12 did not wash her hands and resumed her duties of covering trays and placing bowls of dessert and rolls on residents' trays. EI #4, the Dietary Manager, was interviewed on 01/14/2016 at 10:10 AM. EI #4 said dietary staff should wash their hands anytime they go from one job to another or when in and out of the kitchen. EI #4 explained when staff leave the kitchen they have to touch the door, which could result in cross contamination if hands were not washed. 2) Review of the facility's policy titled Food Temperatures, revised 12/01/2013, revealed the following: Purpose To ensure that food is served at acceptable temperatures. Policy Temperature of foods should be taken prior to meal service . Procedure Utilize the following guidelines to ensure proper service temperatures of individual foods . B. Cold Food 1. All cold food should be 41 degrees or below . During trayline observations on 01/13/2016 beginning at 10:30 AM, staff was observed testing the temperatures of items to be served for the meal; however, there was no temperature of milk obtained prior to meal service. Staff began plating trays at 11:00 AM and the first cart left the kitchen at 11:10 AM. It was noted that milks and beverages were not placed on the trays. EI #4, the Dietary Manager, was asked when residents received their beverages. EI #4 said they sent them out in coolers (which were already in the Dining Room). When asked if they checked the temperature of the milk before sending out of the kitchen, EI #4 said, I knew we forgot something. During an interview on 01/14/2016 at 10:10 AM, EI #4, the Dietary Manager, said the temperature of milk should be checked before serving to make sure it was being served at the proper temperature. EI #4 said if they did not check the temperature of the milk before sending it out, they could not ensure it was at the proper temperature. 3) On 01/13/2016 at 12:03 PM, the surveyor followed a cart out of the kitchen. Once on the hall, staff were observed pouring beverages from a cart located at the nurses station. Staff poured the beverages, placed them on trays, then carried the trays down the length of the hall with the beverages uncovered to deliver the trays to the residents. On 01/14/2016 at 10:10 AM, EI #4, the Dietary Manager, said staff were not supposed to walk down the hall with beverages uncovered, but should instead pour them at each door. She said if staff transported the beverages down the hall uncovered there was a potential for cross contamination.

Based on observation, interviews and record reviews, the facility failed to ensure a licensed staff member followed physician orders [REDACTED]. This affected 8 of 24 sampled residents. The facility further failed to ensure a licensed staff member failed to confirm the narcotic count prior to administration of narcotics. This affected 1 of 2 nurses observed during medication administration on 01/13/2016. Findings Include: A review of Alabama Administrative Code revealed the following: Chapter 610-X-6 Standards of Nursing Practice . 610-X-6-.07 Medication Administration and Safety (1) The registered nurse or licensed practical nurse shall have applied knowledge of medication administration and safety, including but not limited to . (d) Expected monitoring. (2) The registered or licensed practical nurse shall exercise decision-making skills when administering medications, to include but not limited to: (a) If medications should be administered. (4) Documentation of medication administration shall comply with the principles of documentation and include safety precautions of medication administration, controlled drug records per federal and state law, and facility policy. A review of a facility policy titled Medication- Controlled Substances with a revised date of 02/01/15 revealed: Purpose To maintain control and proper usage of controlled substances Policy To provide safeguards against diversion, accidental exposure and loss of controlled substances. A review of a facility titled Medication - Administration with a revised date of 01/13/2016 revealed the following: Purpose Medications shall be administered . as prescribed by the resident's attending physician Policy Medications shall be given as ordered by a physician. Procedure . 2. Medications shall shall be administered in . accordance with the physician's written/verbal orders. 4. The resident's identity must be verified prior to administering the medication and assess for any contraindications. 7. a. Assess vital signs as ordered prior to administering medications.15. Any explanatory note on the reverse side of the MAR (Medication Administration Record) shall be entered when drugs are withheld, refused, or given other than at scheduled times. 1) Resident Identifier (RI) #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's physician's orders [REDACTED].[MEDICATION NAME] 25 MG (milligram) TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD (Medical Director/Doctor) . [MEDICATION NAME] HCT ([MEDICATION NAME]) 160-12.5 MG TAB (tablet) GIVE ONE TABLET BY MOUTH EVERY DAY CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . A review of the RI #3's Medication Administration Record [REDACTED] . [MEDICATION NAME] 25 MG TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . was initialed as given on the following: 12/10/15, 12/14/15,12/18/15,12/22/25,12/23/15,12/24/15,12/27/15 and 12/28/15 with no blood pressure or pulse rate documented. .[MEDICATION NAME] HCT 160-12.5 MG TAB GIVE ONE TABLET BY MOUTH EVERY DAY . was initialed as given on the following: 12/10/15,12/16/15,12/20/15 and 12/21/15 with no blood pressure documented. RI #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #19's physician's orders [REDACTED]. . Order Date . 12/16/2015 . [MEDICATION NAME] 25 MG TAB GIVE ONE TABLET BY MOUTH EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD . A review of RI #19's MAR for the month of December 2015 revealed the following: . [MEDICATION NAME] 25 MG TAB . was initialed as given 12/22/15 and 12/29/15 with no heart rate or blood pressure documented. RI #20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #20's physician's orders [REDACTED]. .Order Date . 10/13/2015 . [MEDICATION NAME] HCL ([MEDICATION NAME]) 0.2 MG TABLET GIVE ONE TABLET BY MOUTH THREE TIMES A DAY . HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD . A review of RI #20's MAR for the month of December 2015 revealed the following: . [MEDICATION NAME] HCL 0.2 MG TABLET GIVE ONE TABLET BY MOUTH . was initialed as given with no blood pressure or pulse rate documented on 12/04/15 at 6:00 AM and the 10:00 PM dose was initialed as given with no blood pressure or pulse rate documented. On 12/18/15 and 12/20/15, the 2:00 PM was initialed as given with no pulse rate documented. RI #21 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #21's physician's orders [REDACTED]. .Order Date .06/18/2015 .[MEDICATION NAME] HCL 100 MG TABLET GIVE ONE TABLET BY MOUTH TWICE DAILY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD . A review of RI #21's MAR for the month of December 2015 revealed the following: .[MEDICATION NAME] HCL 100 MG TABLET GIVE ONE TABLET BY MOUTH TWICE DAILY . on 12/05/15,12/06/15,12/20/15 and 12/24/15 the 5:00 PM dose was initialed as given with no blood pressure or pulse rate documented. RI #22 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #22's physician's orders [REDACTED]. [MEDICATION NAME] 20 MG TABLET GIVE ONE PER GASTRONOMY (GASTROSTOMY) TUBE EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . and a order date of 06/02/2014 . [MEDICATION NAME] 10 MG TABLET GIVE ONE TABLET PER GASTRONOMY (GASTROSTOMY)TUBE EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . A review of RI #22's MAR for the month of December 2015 revealed the following: . [MEDICATION NAME] 20 MG TABLET GIVE ONE PER [DEVICE] EVERY DAY . was initialed as given at 6:00 AM on 12/04/15 and 12/15/15 with no blood pressure documented. The MAR further revealed . [MEDICATION NAME] 10 MG TABLET GIVE ONE TABLET PER [DEVICE] EVERY DAY . was initialed as given at 6:00 AM on 12/04/15 and 12/29/15 dose with no blood pressure documented. RI #23 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review RI #23's physician's orders [REDACTED]. [MEDICATION NAME] 100 MG TAB GIVE ONE TABLET BY MOUTH EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD . [MEDICATION NAME] 40 MG TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . [MEDICATION NAME] 10 MG TABLET GIVE ONE TABLET BY MOUTH EVERYDAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . A review of RI #23's MAR for the month of December 2015 revealed the following: . [MEDICATION NAME] 100 MG TAB GIVE ONE TABLET BY MOUTH EVERY DAY . was initialed as given on 12/16/15 and 12/23/15 with no blood pressure or pulse rate documented . [MEDICATION NAME] 40 MG TABLET GIVE ONE BY MOUTH EVERY DAY . was initialed as given on 12/23/15 with no blood pressure documented . [MEDICATION NAME] 10 MG TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . was initialed as given on 12/23/15 with no blood pressure documented. RI #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #24's physician's orders [REDACTED]. . [MEDICATION NAME] 40 MG TABLET GIVE ONE TABLET BY MOUTH TWICE A DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND NOTIFY MD . A review of RI #24's MAR for the month of December 2015 revealed the following: .[MEDICATION NAME] 40 MG TABLET GIVE ONE TABLET BY MOUTH TWICE A DAY . was initialed as given on 12/16/15 at 9:00 AM and on 12/27/15 the MAR indicated [REDACTED]. RI #25 was readmitted to the facility 05/27/2015 with [DIAGNOSES REDACTED]. A review of RI #25's physician's orders [REDACTED]. . [MEDICATION NAME] 125 MCG (microgram) TABLET GIVE ONE TABLET BY MOUTH DAILY . CHECK PULSE AND HOLD IF PULSE IS LESS THAN 60 OR GREATER THAN 100 AND CALL MD . An order date of 05/27/2015 revealed the following : . [MEDICATION NAME] 25 MG TAB GIVE ONE TABLET BY MOUTH TWICE A DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN <60 AND CALL MD . A review of RI #25's MAR for the month of December revealed the following: . [MEDICATION NAME] 25 MG TAB GIVE ONE TABLET BY MOUTH TWICE A DAY . was initialed as given on 12/05/15 and 12/22/15 for the 9:00 AM dose with no blood pressure and no pulse documented. The MAR further revealed . [MEDICATION NAME] 125 MCG TABLET GIVE ONE TABLET BY MOUTH DAILY . was initialed as given with no pulse rate documented. On 01/13/2016 at 9:45 AM, an observation was made during medication administration with EI (Employee Identifier) #16, LPN (Licensed Practical Nurse). EI #16 entered RI #25's room and administered [MEDICATION NAME] and [MEDICATION NAME] to RI #25. EI #16 did not take RI #25's blood pressure or pulse rate. A review of the vital sign board on the medication cart was blank for RI #25. EI #16 was asked were the vital signs done and EI #16 replied no. On 01/14/2016 at 10:55 AM, an interview was conducted with EI #16. EI #16 was asked what was the facility's policy on [MEDICATION NAME] and [MEDICATION NAME]. EI #16 said check the pulse and blood pressure before administration. EI #16 was asked what did the physician order [REDACTED].#16 said it specified to check the blood pressure and heart rate prior to administration. EI #16 was asked what should she have done prior to administering the [MEDICATION NAME] and [MEDICATION NAME]. EI #16 said she should have checked the heart rate and the blood pressure. EI #16 was asked what did she do during medication administration with RI #25 medications. EI #16 said she did not check the blood pressure and heart rate prior to administering the [MEDICATION NAME] and [MEDICATION NAME]. EI #16 was asked why should the pulse and blood pressure be checked prior to administration. EI #16 said [MEDICATION NAME] and [MEDICATION NAME] can cause a decrease in heart rate and blood pressure. EI #16 was asked what was the potential for harm in not checking the blood pressure and heart rate. EI #16 said it could cause [MEDICAL CONDITION]. On 01/14/2016 at 11:30 AM, an interview was conducted with EI #1 RN (Registered Nurse)/Administrator. EI #1 was asked what was the policy and procedure on administering [MEDICATION NAME] and [MEDICATION NAME]. EI #1 said assess and take vital signs as ordered. EI #1 was asked what should be done before administering [MEDICATION NAME] and [MEDICATION NAME]. EI #1 said take the vital signs, blood pressure and heart rate, and verify the acceptable range. EI #1 was asked why was the blood pressure and heart rate not taken. EI #1 said she did not know why the nurse did not take the vital signs. EI #1 was asked what did the physician order [REDACTED].#1 said [MEDICATION NAME] check the pulse if less than 60 or greater than 100 hold, [MEDICATION NAME] hold if systolic blood pressure is less than 100 or pulse is less than 60. EI #1 was asked what was the potential harm in not assessing the vital signs. EI #1 said you would not know if the blood pressure and heart rate were in an acceptable range. On 01/14/2016 at 5:50 PM, an interview was conducted with EI #2 RN/DON (Director of Nursing). EI #2 was asked what should be done prior to administering [MEDICATION NAME] and blood pressure medication. EI #2 said check the blood pressure. EI #2 was asked what was the potential harm with not taking the blood pressure and heart rate before administering [MEDICATION NAME] and blood pressure medication. EI #2 said blood pressure and heart rate could decrease. 2) RI #20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #20's physician's orders [REDACTED]. . [MEDICATION NAME] 10-325 TABLET GIVE ONE TABLET BY MOUTH EVERY FOUR HOURS. [MEDICATION NAME]-COD ([MEDICATION NAME]) 50-300-40-30 CAP (capsule) GIVE ONE TABLET BY MOUTH EVERY FOUR HOURS . On 01/13/2016 at 9:30 AM, Medication Administration was observed with EI #16. EI #16 obtained [MEDICATION NAME] and [MEDICATION NAME] from the narcotic box and dispensed the tablets into the medication cup. EI #16 then placed the narcotics back into the narcotic drawer. EI #16 did not check the narcotic count with the narcotic book. EI #16 locked the cart and covered the MAR. EI #16 walked away from the medication cart and proceeded into RI #20's room and administered the medication. EI #16 then returned to the medication cart and signed the narcotic book and MAR. On 01/14/2016 at 11:05 AM an interview was conducted with EI #16 LPN. EI #16 was asked what was the policy and procedure on narcotic administration. EI #16 said check the MAR, right patient and right medication, check the count in the narcotic book and sign the narcotic. EI #16 was asked what did you do with narcotic administration with RI #20. EI #16 said I did not check the narcotic count book and I did not sign the narcotic book, I signed it after administration to RI #20. EI #16 was asked what should she have done. EI #16 said checked the narcotic count and signed the narcotic book before administration. EI #16 was asked what was the potential harm in not checking the narcotic count with the narcotic book and not signing the narcotic book. EI #16 said the count could be wrong and the medication was not given. On 01/14/2016 at 12:03 PM an interview was conducted with EI #1 RN/Administrator. EI #1 was asked what was the policy and procedure on narcotic administration. EI #1 said compare count with the narcotic book and sign the narcotic book. EI #1 was asked when should you compare the narcotic count and sign the narcotic book. EI #1 said when the narcotic is taken out. EI #1 was asked why should you compare the narcotic count. EI #1 said to ensure accuracy. EI #1 was asked why was the narcotic book to be signed before administering the narcotic. EI #1 said to account for the narcotic and to keep the count accurate. EI #1 was asked what was the potential harm in not checking the count or signing the narcotic book. EI #1 said inaccurate narcotic count.

Based on observations, interviews and record review, the facility failed to provide appropriate monitoring of blood pressure and heart rate prior to administering medications to RI (Resident Identifier) #3 and RI #'s19 thru 25 to prevent an adverse side effect such as low blood pressure and heart rate. This affected RI #3 and RI #'s19 thru 25. Findings Include: A review of a facility document titled Medication - Administration with a revised date of 01/13/2016 revealed the following: Purpose Medications shall be administered . as prescribed by the resident's attending physician . Policy Medications shall be given as ordered by a physician. Procedure .7. a. Assess vital signs as ordered prior to administering medications. A review of Alabama Administrative Code revealed the following: Chapter 610-X-6 Standards of Nursing Practice . 610-X-6-.07 Medication Administration and Safety (1) The registered nurse or licensed practical nurse shall have applied knowledge of medication administration and safety, including but not limited to . (d) Expected monitoring. (2) The registered or licensed practical nurse shall exercise decision-making skills when administering medications, to include but not limited to: (a) If medications should be administered. (4) Documentation of medication administration shall comply with the principles of documentation and include safety precautions of medication administration . per federal and state law, and facility policy. 1) Resident Identifier (RI) #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's physician's orders [REDACTED].[MEDICATION NAME] 25 MG (milligram) TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD (Medical Director/Doctor) . [MEDICATION NAME] HCT ([MEDICATION NAME]) 160-12.5 MG TAB (tablet) GIVE ONE TABLET BY MOUTH EVERY DAY CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . A review of RI #3's Medication Administration Record [REDACTED] . [MEDICATION NAME] 25 MG TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . was initialed as given on the following: 12/10/15, 12/14/15,12/18/15,12/22/25,12/23/15,12/24/15,12/27/15 and 12/28/15 with no blood pressure or pulse rate documented. . [MEDICATION NAME] HCT 160-12.5 MG TAB GIVE ONE TABLET BY MOUTH EVERY DAY . was initialed as given on the following: 12/10/15,12/16/15,12/20/15 and 12/21/15 with no blood pressure documented. RI #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #19's physician's orders [REDACTED]. . Order Date . 12/16/2015 . [MEDICATION NAME] 25 MG TAB GIVE ONE TABLET BY MOUTH EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD . A review of RI #19's MAR for the month of December 2015 revealed the following: . [MEDICATION NAME] 25 MG TAB . was initialed as given 12/22/15 and 12/29/15 with no heart rate or blood pressure documented. RI #20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #20's physician's orders [REDACTED]. .Order Date . 10/13/2015 . [MEDICATION NAME] HCL ([MEDICATION NAME]) 0.2 MG TABLET GIVE ONE TABLET BY MOUTH THREE TIMES A DAY . HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD . A review of RI #20's MAR for the month of December 2015 revealed the following: . [MEDICATION NAME] HCL 0.2 MG TABLET GIVE ONE TABLET BY MOUTH . was initialed as given with no blood pressure or pulse rate documented on 12/04/15 at 6:00 AM and the 10:00 PM dose was initialed as given with no blood pressure or pulse rate documented. On 12/18/15 and 12/20/15, the 2:00 PM dose was initialed as given with no pulse rate documented. RI #21 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #21's physician's orders [REDACTED]. .Order Date .06/18/2015 .[MEDICATION NAME] HCL 100 MG TABLET GIVE ONE TABLET BY MOUTH TWICE DAILY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD . A review of RI #21's MAR for the month of December 2015 revealed the following: .[MEDICATION NAME] HCL 100 MG TABLET GIVE ONE TABLET BY MOUTH TWICE DAILY . on 12/05/15,12/06/15,12/20/15 and 12/24/15 the 5:00 PM dose was initialed as given with no blood pressure or pulse rate documented. RI #22 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #22's physician's orders [REDACTED]. [MEDICATION NAME] 20 MG TABLET GIVE ONE PER GASTRONOMY (GASTROSTOMY) TUBE EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . and a order date of 06/02/2014 . [MEDICATION NAME] 10 MG TABLET GIVE ONE TABLET PER GASTRONOMY (GASTROSTOMY)TUBE EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . A review of RI #22's MAR for the month of December 2015 revealed the following: . [MEDICATION NAME] 20 MG TABLET GIVE ONE PER [DEVICE] EVERY DAY . was initialed as given at 6:00 AM on 12/04/15 and 12/15/15 with no blood pressure documented. The MAR further revealed . [MEDICATION NAME] 10 MG TABLET GIVE ONE TABLET PER [DEVICE] EVERY DAY . was initialed as given at 6:00 AM on 12/04/15 and 12/29/15 dose with no blood pressure documented. RI #23 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review RI #23's physician's orders [REDACTED]. [MEDICATION NAME] 100 MG TAB GIVE ONE TABLET BY MOUTH EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN 60 AND CALL MD . [MEDICATION NAME] 40 MG TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . [MEDICATION NAME] 10 MG TABLET GIVE ONE TABLET BY MOUTH EVERYDAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND CALL MD . A review of RI #23's MAR for the month of December 2015 revealed the following: . [MEDICATION NAME] 100 MG TAB GIVE ONE TABLET BY MOUTH EVERY DAY . was initialed as given on 12/16/15 and 12/23/15 with no blood pressure or pulse rate documented . [MEDICATION NAME] 40 MG TABLET GIVE ONE BY MOUTH EVERY DAY . was initialed as given on 12/23/15 with no blood pressure documented . [MEDICATION NAME] 10 MG TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . was initialed as given on 12/23/15 with no blood pressure documented. RI #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #24's physician's orders [REDACTED]. . [MEDICATION NAME] 40 MG TABLET GIVE ONE TABLET BY MOUTH TWICE A DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 AND NOTIFY MD . A review of RI #24's MAR for the month of December 2015 revealed the following: .[MEDICATION NAME] 40 MG TABLET GIVE ONE TABLET BY MOUTH TWICE A DAY . was initialed as given on 12/16/15 at 9:00 AM and on 12/27/15 the MAR indicated [REDACTED]. RI #25 was readmitted to the facility 05/27/2015 with [DIAGNOSES REDACTED]. A review of RI #25's physician's orders [REDACTED]. . [MEDICATION NAME] 125 MCG (microgram) TABLET GIVE ONE TABLET BY MOUTH DAILY . CHECK PULSE AND HOLD IF PULSE IS LESS THAN 60 OR GREATER THAN 100 AND CALL MD . An order date of 05/27/2015 revealed the following : . [MEDICATION NAME] 25 MG TAB GIVE ONE TABLET BY MOUTH TWICE A DAY . CHECK AND HOLD IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 100 OR PULSE IS LESS THAN <60 AND CALL MD . A review of RI #25's MAR for the month of December revealed the following: . [MEDICATION NAME] 25 MG TAB GIVE ONE TABLET BY MOUTH TWICE A DAY . was initialed as given on 12/05/15 and 12/22/15 for the 9:00 AM dose with no blood pressure and no pulse documented. The MAR further revealed . [MEDICATION NAME] 125 MCG TABLET GIVE ONE TABLET BY MOUTH DAILY . was initialed as given with no pulse rate documented. On 01/13/2016 at 9:45 AM, an observation was made during medication administration with EI (Employee Identifier) #16, LPN (Licensed Practical Nurse). EI #16 entered RI #25's room and administered [MEDICATION NAME] and [MEDICATION NAME] to RI #25. EI #16 did not take RI #25's blood pressure or pulse rate. A review of the vital sign board on the medication cart was blank for RI #25. EI #16 was asked were the vital signs done and EI #16 replied no. On 01/14/2016 at 10:55 AM, an interview was conducted with EI #16 ). EI #16 was asked what was the facility's policy on [MEDICATION NAME] and [MEDICATION NAME]. EI #16 said check the pulse and blood pressure. EI #16 was asked what did the physician's orders [REDACTED].#16 said it specified to check the blood pressure and heart rate prior to administration. EI #16 was asked what should she have done prior to administering the [MEDICATION NAME] and [MEDICATION NAME]. EI #16 said check the heart rate and blood pressure. EI #16 was asked what did she do during medication administration with RI #25. EI #16 said she did not check the blood pressure and heart rate prior to administering the [MEDICATION NAME] and [MEDICATION NAME]. EI #16 was asked why should the pulse and blood pressure be checked prior to administration. EI #16 said [MEDICATION NAME] can cause a decrease in heart rate and blood pressure. [MEDICATION NAME] can cause decrease in heart rate and blood pressure. EI #16 was asked what was the potential harm in not checking the blood pressure and heart rate. EI #16 said it can cause [MEDICAL CONDITION]. EI # 16 was asked what was documented on the vital sign sheet for RI #25. EI #16 said it was blank for RI #25. On 01/14/2016 at 11:30 AM, an interview was conducted with EI #1 RN/Administrator. EI #1 was asked what was the policy and procedure on administering [MEDICATION NAME] and [MEDICATION NAME]. EI #1 said assess and take the vital signs as ordered. EI #1 was asked what should be done before administering [MEDICATION NAME] and [MEDICATION NAME]. EI #1 said take the vital sign, blood pressure and heart rate, and verify the acceptable range. EI #1 was asked why was the blood pressure and heart rate not taken. EI #1 said she did not know why the nurse did not take the vital signs. EI #1 was asked what did the physician's orders [REDACTED].#1 said [MEDICATION NAME] check the pulse if less than 60 or greater than 100, hold and [MEDICATION NAME] hold if systolic blood pressure is less than 100 or pulse is less than 60. EI #1 was asked what was the potential harm in not assessing the vital signs. EI #1 said you would not know if the blood pressure and heart rate were in an acceptable range. EI #1 was asked were the MD orders followed. EI #1 said the nurse did not take the vital signs before administering the [MEDICATION NAME] and [MEDICATION NAME] to RI #25. On 01/14/2016 at 5:50 PM, an interview was conducted with EI #2 RN/DON (Director of Nursing). EI #2 was asked what should be done prior to administering [MEDICATION NAME] and blood pressure medication. EI #2 said check the blood pressure. EI #2 was asked what was the potential harm with not taking the blood pressure and heart rate before administering [MEDICATION NAME] and blood pressure medication. EI #2 said blood pressure and heart rate could decrease.

Based on record review, observation and interview, the facility failed to ensure a staff member did not stand while feeding RI (Resident Identifier) #17 and RI #18 during the lunch meal on 1/13/2016. This affected RI #17 and RI #18, two of eight residents observed during meal time. Findings Include: A review of a facility policy titled, Quality of Life-Dignity with an effective date of 02/01/2015 revealed: Policy Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Procedure 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 12. Staff shall treat cognitively impaired residents with dignity and sensitivity. 1) RI# 17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/04/2015 revealed a BIMS (Brief Interview for Mental Status) score of 5, which indicated the resident was severely cognitively impaired. The MDS also revealed RI #17 was totally dependent on staff for eating. On 1/13/2016 at 11:54 AM, EI (Employee Identifier) #5, CNA (Certified Nursing Assistant) was observed standing and feeding RI #17. On 1/13/2016 at 12:00 PM, EI #5 was observed to continue to stand and feed RI #17. On 1/13/2016 at 12:25 PM, an interview was conducted with EI #5. EI #5 was asked what position she was in when feeding lunch to RI #17. EI #5 said she was standing up. EI #5 was asked what position she should have been in when feeding RI #17. EI #5 said she should have been sitting in a chair facing the resident. EI #5 was asked why she was standing when feeding lunch to RI #17. EI #5 said there was no chair. EI #5 was asked if she could have gotten a chair. EI #5 said she could have. EI #5 was asked what the facility policy said about feeding residents. EI #5 said staff should be sitting down and facing the resident. EI #5 was asked what the potential harm was in standing and feeding a resident. EI #5 said they could choke or aspirate. EI #5 was asked how she thought it made the resident feel when she stood over the resident and fed the resident. EI #5 said it would not make them feel very good and it would make them feel awkward with someone over them. On 1/13/2016 at 12:30 PM, RI #17 was asked how it made her/him feel when the staff member stood over her/him and fed her/him. RI #17 said, Like a two year old. On 1/14/2016 at 10:17 AM, an interview was conducted with EI #6, RN (Registered Nurse) Supervisor. EI #6 was asked what position staff should be in when feeding residents. EI #6 said sitting at the bedside. EI #6 was asked if it was an acceptable practice of that facility for a CNA to stand and feed a resident. EI #6 said absolutely not. EI #6 was asked what the potential harm was when a CNA stood to feed a resident. EI #6 said aspiration. EI #6 was asked how she thought it made the resident feel when a CNA stood over them and fed them. EI #6 said it would make them feel like they were in a hurry. 2) RI #18 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a most recent annual MDS with an ARD of 12/18/2015 revealed a BIMS score of 5, indicating RI #18 was severely impaired for daily decision making. Further review of the resident's MDS revealed RI #18 was able to feed themselves with set up assistance of the tray. On 01/13/2016 at 12:46 PM, an observation was made of EI #13, CNA, standing and feeding RI #18. Another observation was made at 12:50 PM, of EI #8 standing and feeding RI #18 who was sitting up in his/her bed. On 1/13/2016 at 5:59 PM, an observation was made of RI #18 sitting up in bed with the head of bed elevated feeding him/herself dinner. RI #18 was asked how his/her meal tasted, and the resident was alert but unresponsive. On 01/14/2016 at 10:18 AM, an interview was conducted with EI #13. EI #13 was asked how was she positioned while assisting RI #18 with eating his/her lunch meal on 01/13/2016. EI #13 explained that she was standing and trying to squat to RI #18's eye level. EI #13 was asked how was she to be positioned while feeding RI #18. EI #13 replied, sitting down. EI #13 was asked why was she feeding RI #18. EI #13 explained that when she walked past RI #18's room she noticed that RI #18 was having trouble with feeding himself/herself and decided to assist him/her finish their meal. EI #13 was asked what was the facility's policy and procedure regarding feeding residents. EI #13 explained that staff was supposed to sit at the resident's eye level. EI #13 was asked was that what she had done. EI #13 stated,no. EI #13 was asked how she thought it made RI #18 feel when she was standing while feeding him/her. EI #13 stated that she may have made RI #18 feel bad like she was hovering over him/her. EI #13 was asked what was the potential harm in standing while feeding a resident. EI #13 explained that if staff was standing, they could not tell if the resident was ready for another bite or if they had swallowed their food. On 01/14/2016 at 3:39 PM, an interview was conducted with EI #14, RN. EI #14 was asked how was staff to be positioned when feeding residents. EI #14 explained that staff was to be sitting and at the resident's eye level. EI #14 was asked what was the facility's policy regarding staff feeding residents. EI #14 explained that she was unsure. EI #14 was asked what was the potential harm in staff standing while feeding residents. EI #14 explained that a resident could choke.

Based on record review and interviews, the facility failed to address Resident Identifier (RI) #7's psychosocial needs following the death of a family member. This affected RI #7, a resident that experienced increased depression and grief, one of seven residents sampled for depressive symptoms. Findings Include: Review of the Social Services Coordinator Job Description, dated 03/01/2011, revealed the following: Social Services Coordinator Job Description- Social Services General Purpose: To act as a liaison and representative of the residents' social interests and to plan, organize, develop, and direct the overall operation of the Social Services Department . to ensure that the medically-related emotional and social needs of the residents are met and maintained on an individual basis . Essential Job Functions: . C. Quality Assurance Functions Duties: Assist in developing for each resident a preliminary and comprehensive assessment and written care plan that identifies the emotional and social problems and/or needs of the resident . participate in assessing, reviewing and revising care plans as required . D. Residents' Rights Functions: Duties: . monitor social services to ensure that residents' emotional and social needs are met; ensure that all social services personnel are knowledgeable concerning residents' emotional and social needs RI #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 08/11/2015, RI #7's physician documented the following: . seems to be experiencing grief depression. She/He is quiet and not talking much . RI #7's Significant Change in Status Minimum Data Set (MDS), dated [DATE], indicated RI #7 was cognitively intact and had a Total Mood Severity Score of 9, indicating moderate depression. On 09/11/2015, Employee Identifier (EI) #8, the former Social Services Director, documented the following for RI #7: .(resident) voiced feeling down, depressed and hopeless, feeling tired and having little energy, feeling bad about (him/her)self and that (he/she) is a failure and has let (him/her)self and (his/her) family down. (RI #7) voiced that (he/she) thinks (he/she) feels this way because of the recent loss of (his/her) x (ex) husband/ father of (his/her) children and voiced that (he/she) still loved him even though they were divorced . There were no other Social Services Notes following this entry. A Consultant Pharmacist Communication to Nursing form, signed 09/30/2015, indicated RI #7 had a [DIAGNOSES REDACTED].the symptoms are significant enough that the resident is experiencing one or more of the following: inconsolable or persistent distress . a significant decline in function; and/or substantial difficulty receiving needed care . On 12/09/2015 RI #7's physician wrote a prescription to add Zoloft 50 milligrams due to worsening depression. Review of RI #7's Comprehensive Care Plans, last reviewed 12/01/2015, revealed there was no care plan developed related to grief due to the recent loss of a family member. On 1/13/2016 at 12:07 PM, RI #7 was observed seated in a wheelchair beside the Nurses' Station. At this time, EI #4, Dietary Manager, explained RI #7's ex-husband passed away a few months prior and RI #7 had not been the same since. EI #9, the Current Social Services Director, was interviewed on 01/14/2016 at 9:00 AM. EI #9 explained she normally interviews residents every 7, 14, 30, 60 and 90 days, as well as quarterly, annually and significant changes. When asked if there were any situations in which she would follow up with residents more often than that, EI #9 said if something was going on with the resident, such as if staff noticed they were sad. When asked how she helped residents deal with the loss of a family member, EI #9 said she did not know and that was a hard question. EI #9 said she could try a lot of things but sometimes nothing helped. EI #9 said she was not the Social Services Director when RI #7's ex-husband passed away. EI #9 was asked if she had done any further follow up or notes since EI #8 documented on RI #7 in September 2015. EI #9 said no. EI #9 then read over the note made by EI #8 on 09/11/2015. When asked what sort of follow-up would be required, EI #9 said she should check on the resident, give the resident attention, make sure the resident was care planned, one on one visits, etc (et cetera). EI #9 was asked if RI #7 was offered grief counseling or if staff had followed up with RI #7 more often due to increased depression and grief. EI #9 said no, she had not addressed the grief or depression. When asked if she should have addressed RI #7's increased depression and grief, EI #9 said had she known RI #7 was having those issues she would have. EI #9 said she was unaware RI #7 had voiced the feelings documented in September. EI #9 said she only looked at RI #7's Mood Score on the MDS. EI #9 was asked how she would have addressed RI #7 if she had been aware of RI #7's feelings. EI #9 said she would have talked to RI #7 about it and would have developed a care plan for grief. EI #9 also said staff discussed RI #7's care plans in December due to the death of a sister. EI #9 confirmed she had not care planned RI #7 for the loss of the ex-husband or sister. EI #9 said RI #7 was on a list to develop a care plan but she had not gotten to it yet. EI #9 said she had never spoken with RI #7 regarding the death of RI #7's ex-husband and sister. EI #9 further stated she tried not to bring up the bad things. EI #9 explained she based her decision on how to address RI #7 on the fact RI #7's Mood Severity Score did not increase. EI #9 said she also reviewed Nurses' Notes and relied on staff to inform her. On 01/14/2016 at 3:10 PM, EI #9, the Social Services Director, stated there was no policy addressing grief. EI #9 said she was just supposed to care plan for it. When asked what a grief care plan would entail, EI #9 said one on one visits, encourage resident to vent, give resident time, encourage family and friends to visit, and call the pastor for grief counseling if the resident chose to. EI #9 again confirmed there was no care plan for RI #7 related to grief. When asked at what point a care plan should have been developed for RI #7, EI #9 said as soon as Social Services was aware. EI #9 explained she needed to look at all of her resources, not just the Nurses' Notes. EI #9 admitted there were other resources other than what she was using. EI #1, the Administrator, was interviewed on 01/14/2016 at 4:05 PM. EI #1 said a care plan should have been developed to address RI #7's grief and also said Social Services should have done follow-up with RI #7 to ensure RI #7's psychosocial wellbeing and make sure RI #7 was coping with the grieving process.

Based on record review and interviews, the facility failed to develop a care plan for Resident Identifier (RI) #7 related to grief following the loss of a family member and also refusal of care. This affected RI #7, one of 13 residents for whom care plans were reviewed. Findings include: RI #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #7's Significant Change in Status Minimum Data Set (MDS), dated [DATE], indicated RI #7 was cognitively intact and had a Total Mood Severity Score of 9, indicating moderate depression. On 09/11/2015, Employee Identifier (EI) #8, the former Social Services Director, documented the following for RI #7: .(resident) voiced feeling down, depressed and hopeless, feeling tired and having little energy, feeling bad about (him/her)self and that (he/she) is a failure and has let (him/her)self and (his/her) family down. (RI #7) voiced that (he/she) thinks (he/she) feels this way because of the recent loss of (his/her) x (ex) husband/ father of (his/her) children and voiced that (he/she) still loved him even though they were divorced . Review of RI #7's December 2015 ADL (Activities of Daily Living) Log indicated RI #7 refused a shower and/ or bath 20 out of 31 days of the month. Review of RI #7's Comprehensive Care Plans, last reviewed 12/01/2015, revealed there was no care plan developed related to grief due to the recent loss of a family member. There was also no care plan related to RI #7's refusal of showers and/or baths. On 1/13/2016 at 12:07 PM, EI #4, the Dietary Manager, explained RI #7's ex-husband passed away a few months prior and RI #7 had not been the same since. EI #9, the Current Social Services Director, was interviewed on 01/14/2016 at 9:00 AM. EI #9 explained she normally interviewed residents every 7, 14, 30, 60 and 90 days, as well as quarterly, annually and significant changes. EI #9 read over the note made by EI #8 on 09/11/2015. EI #9 then said she had not addressed RI #7's grief or depression. When asked if she should have addressed RI #7's increased depression and grief, EI #9 said had she known RI #7 was having those issues she would have. EI #9 said she was unaware RI #7 had voiced the feelings documented in September. EI #9 was asked how she would have addressed RI #7 if she had been aware of RI #7's feelings. EI #9 said she would have talked to RI #7 about it and would have developed a care plan for grief. EI #9 also said staff discussed RI #7's care plans in December due to the death of a sister. EI #9 confirmed she had not care planned RI #7 for the loss of the ex-husband or sister. EI #9 said RI #7 was on a list to develop a care plan but she had not gotten to it yet. On 01/14/2016 at 3:10 PM, EI #9, the Social Services Director, stated there was no policy addressing grief. EI #9 said she was just supposed to care plan for it. When asked what a grief care plan would entail, EI #9 said one on one visits, encourage resident to vent, give resident time, encourage family and friends to visit, and call the pastor for grief counseling if the resident chooses. EI #9 again confirmed there was no care plan for RI #7 related to grief and said she also checked and did not see a care plan related to refusal of care. When asked who would be responsible for developing a care plan to address refusal of care, EI #9 said she would. EI #9 reviewed RI #7's ADL logs and said the Rs would mean RI #7 refused the shower or bed bath. EI #9 said she would need to talk with the resident and care plan the refusals if they were consistent. When asked at what point a care plan should have been developed for RI #7, EI #9 said as soon as Social Services was aware. EI #9 was asked if she was aware RI #7 was refusing care, and EI #9 said no. EI #9 explained she should have been reviewing the logs but said she had been relying on other staff to pick up the phone and let her know. EI #9 explained she needed to look at all of her resources, not just the Nurses' Notes. EI #9 admitted there were other resources other than what she was using.

Based on record review and interviews. the facility failed to ensure staff assessed Resident Identifier (RI) #11's Bruit and Thrill each shift to ensure patency of RI #11's [MEDICAL TREATMENT] shunt. The facility further failed to communicate on an ongoing basis with the [MEDICAL TREATMENT] center in a manner to ensure continuity of RI #11's care. This affected one of one residents sampled for [MEDICAL TREATMENT]. Findings include: Review of the facility's policy [MEDICAL TREATMENT]-Access Care, revised 02/01/2015, revealed the following: Purpose To provide care for residents receiving [MEDICAL TREATMENT]. Procedure . 4. Palpate the shunt for a thrill ., which indicates normal blood flow. Use the stethoscope to auscultate the shunt between the arterial and venous exit sites. A bruit confirms normal blood flow. Check for patency of the site every shift . Responsibility The Charge Nurse is responsible for the implementation of this policy and procedure. The Director of Nursing is responsible for the overall compliance of this policy and procedure. RI #11 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #11's readmission orders [REDACTED] .Resident to receive [MEDICAL TREATMENT] at ([MEDICAL TREATMENT] center) on Monday, Wednesday, and Friday . There were no orders specifying when to check RI #11's Bruit and Thrill. RI #11's Significant Change in Status Minimum Data Set Assessment, dated 12/11/2015, indicated RI #11 was receiving [MEDICAL TREATMENT]. RI #11's care plan addressing [MEDICAL TREATMENT], last reviewed 12/16/2015, listed the following interventions: . *My [MEDICAL TREATMENT] staff will communicate weights, fluid restrictions, and any pertinent information weekly and PRN (as needed) to nursing facility . * Check bruit per MD (Medical Doctor) orders and prn . RI #11's January 2016 orders indicated RI #11 was still receiving [MEDICAL TREATMENT] three days a week, on Monday, Wednesday, and Friday. RI #11's Medication and Treatment Records for December 2015 and January 2016 did not contain any documentation indicating nursing staff was checking RI #11's Bruit and Thrill every shift as specified by the facility's policy; nor did RI #11's Nurses' Notes and Body Audits. RI #11's medical record only contained [MEDICAL TREATMENT] Communication forms for the following dates: 12/16/2015 12/21/2015 12/22/2015 12/28/2015 12/30/2015 01/02/2016 01/06/2016 01/11/2016 01/13/2016 Of these forms, only one form (12/28/2015) contained information related to RI #11's treatment and was signed by the [MEDICAL TREATMENT] Center. The remaining forms were blank and had no signatures. The portion of the form left incomplete by the [MEDICAL TREATMENT] Center contained spaces for the following information: . AFTER [MEDICAL TREATMENT] % of Any Foods Consumed at [MEDICAL TREATMENT] Vital Signs Weight Meds Given Labs Drawn New Orders .Summary Condition and Location of Graft Used Any Documents Sent with Resident/Family? . Yes. If yes, please list: . No: . Resident seen by MD or CRNP (Certified Registered Nurse Practitioner)? . Comments or Scheduled Appointments [MEDICAL TREATMENT] nurse Signature . Employee Identifier (EI) #3, Registered Nurse/ Unit Manager, was interviewed on 01/14/2016 at 12:15 PM. When asked where the facility documented communication with the [MEDICAL TREATMENT] center for RI #11, EI #3 stated they send a [MEDICAL TREATMENT] Communication form with RI #11 to each [MEDICAL TREATMENT] visit. EI #3 said the [MEDICAL TREATMENT] center should document any changes or other information and send it back to the facility. When asked where the [MEDICAL TREATMENT] Communication forms were kept, EI #3 said they should be placed with the Body Audit and Nurses' Notes each time RI #11 goes to [MEDICAL TREATMENT]. When asked how often the facility should receive [MEDICAL TREATMENT] Communication forms, EI #2 said they send one each time RI #11 goes to [MEDICAL TREATMENT] and should also receive one to put in RI #11's chart upon return from [MEDICAL TREATMENT]. EI #3 reviewed RI #11's chart and and was only able to locate the following [MEDICAL TREATMENT] Communication forms: 12/16/2015, 12/21/2015, 12/28/2015, 1/6/2016, 1/11/2016, and 1/13/2016. When asked if the forms contained any information from the [MEDICAL TREATMENT] center or a signature, EI #3 reviewed the form from 12/16/2015 and said no, sometimes they do not put anything on it. When asked how often staff should be checking the Bruit and Thrill for RI #11's shunt, EI #3 said one time per day on day shift. She said they should also check to make sure there was no bleeding and document it in the Nurses' Notes. EI #3 reviewed RI #11's chart and stated she saw a few notes where RI #11's dressing was checked but no notes for checking the Bruit and Thrill. EI #3 explained it was important to check the Bruit and Thrill for [MEDICAL TREATMENT] patients because nurses need to make sure the vein was not getting too large or developing an aneurysm or weakened spot. She said they should also make sure there was no bleeding under the skin. EI #3 said these things were important to make sure the shunt was okay. When asked what potential harm could occur if staff were not checking the Bruit and Thrill, EI #3 said RI #11 could have bleeding and it could be very bad and could result in complications with the shunt or complications while at [MEDICAL TREATMENT]. EI #2, the Director of Nursing, was interviewed on 1/14/2016 at 3:45 PM. EI #2 said she was unsure how often staff should be checking the Bruit and Thrill for [MEDICAL TREATMENT] patients. At 3:55 PM, EI #2 returned with a copy of the facility's policy related to [MEDICAL TREATMENT]. EI #2 said staff should be checking the Bruit and Thrill every shift to ensure patency of the shunt. She said she would expect staff to document the checks on the MAR (Medication Administration Record). When asked what potential harm could occur if staff were not checking RI #11's Bruit and Thrill, EI #2 said it could hinder RI #11's [MEDICAL TREATMENT] treatment.

Based on observation, record review and interview, the facility failed to ensure RI (Resident Identifier) #6 ,a resident with a [MEDICAL CONDITIONS] diagnosis, had an O2 ( Oxygen) humidifier bottle that was filled with water on 1-12-2016, one of three days of the survey. The facility further failed to ensure RI #8, a resident with a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. This affected two of four residents sampled for O2 therapy. Findings Include: A review of a facility policy titled, Oxygen -Administration with a revised date of 02/01/2015 revealed: . Policy Oxygen therapy is administered as ordered by the physician.Procedure . 12. Be sure there is water in the humidifying bottle and that the water level is high enough that the water bubbles as oxygen flows through. 13. Observe the resident .to be sure oxygen is being tolerated . A review of a document titled, Physician order [REDACTED]. CHANGE PRE-FILLED 02 HUMIDIFIER BOTTLE . AS NEEDED . 02 AT 2L (liter) PM (Per Minute) VIA NASAL CANNULA PER CONCENTRATOR . A review of the manufacturer's guidelines for a manual oxygen concentrator revealed: . Oxygen with Humidifier . 2. Fill the reservoir with cool or cold water . to the fill line indicated on the bottle. RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/04/2015 revealed the resident was severely impaired for daily decision making. The MDS further revealed the resident received oxygen therapy while a resident. On 1/12/2016 at 2:15 PM, the surveyor observed no water in the resident's O2 humidifier bottle and on 1/12/2016 at 5:10 PM, the surveyor observed no water in the resident's O2 humidifier bottle. On 1/14/2016 at 11:00 AM, a telephone interview was conducted with EI (Employee Identifier) #7, LPN (Licensed Practical Nurse). EI #7 was asked what was the purpose of the O2 humidifier bottle. EI #7 replied, to keep the resident's nose from drying out, and humidifying the air. EI #7 was asked why should the resident's O2 bottle be filled with water. EI #7 replied, to humidify the air. EI #7 was asked when should residents O2 bottle be filled with water. EI #7 replied, when the water was one fourth of the way down to keep it from completely running out. EI #7 was asked what was in RI #6's O2 humidifier bottle. EI #7 replied, it was empty, nothing was in it. EI #7 was asked why was there no water in the O2 humidifier bottle. EI #7 replied, no one realized it was empty. EI #7 was asked when was the bottle changed. EI #7 replied, it was probably around eight or nine o'clock pm on 1/12/16, it was close to shift change. EI #7 was asked why was the bottle not changed prior to running out. EI #7 replied, nobody saw it. EI #7 was asked who was responsible for changing the 02 humidifier bottle. EI #7 replied, the LPN on duty from 11 PM to 7 AM had the responsibility to change it every week or whoever it ran out on was to report it to the charge nurse. EI #7 was asked what was the potential harm when a resident with [MEDICAL CONDITION] 02 humidifier bottle was out of water. EI #7 replied, it could cause more nasal problems. On 01/14/2016 at 11:28 AM, an interview was conducted with EI #6, RN (Registered Nurse). EI #6 was asked what was the purpose of the O2 humidifier bottle. EI #6 replied to humidify the air, to keep nasal cavity moist, and to humidify the oxygen going to the resident. EI #6 was asked when should a resident's O2 bottle be filled with water. EI #6 replied, when they are a fourth of the way empty and as needed. EI #6 was asked what was in RI #6's O2 humidifier bottle. EI #6 replied, nothing. EI #6 was asked why was there no water in the O2 humidifier bottle. EI #6 replied, they did not know it was empty. EI #6 was asked who was responsible for changing the 02 humidifier bottle. EI #6 replied, charge nurses, RN supervisors, and anybody can report an empty bottle to the charge nurse. EI #6 was asked what was the potential harm when a resident's 02 humidifier bottle was empty and the resident had a [DIAGNOSES REDACTED].#6 replied they will have a dry nasal cavity, increase risk for infection and aspiration. 2) RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's most recent Quarterly MDS with an ARD of 12/18/2015 revealed the resident had a BIMS score of 6, which indicated the resident was severely impaired for daily decision making. The MDS also revealed the resident received oxygen therapy. A review of RI #8's care plan revealed: .Problem/Need . I have a dx (diagnosis) of [MEDICAL CONDITION], hypertension, a-fib .These put me at risk for complications such as chest pain, SOB (Shortness of Breath) . Approaches . Provide O2 as ordered. A review of RI #8's January 2016 Physician order [REDACTED].O2 @ (at) 2 LPM VIA NASAL CANNULA . On 1/13/2016, RI #8 was observed from 10:30 AM to 12:45 PM without any O2 on. On 1/14/2016 at 2:46 PM, a telephone interview was conducted with EI # 15, CNA (Certified Nursing Assistant). EI #15 was asked what she did when she performed incontinent care and changed RI #8's clothes on 1/13/2016. EI #15 said she took the O2 off to put on a clean shirt. EI #15 was asked what she should have done with the O2. EI #15 said put the O2 back on. EI #15 was asked where RI #8 went. EI #15 said the beauty shop. EI #15 was asked what the potential harm was in RI #8 not having O2 on from 10:30 AM to 12:45 PM. EI #15 said the O2 level would be lower, the mental status would be lower and the resident could lose consciousness. On 1/14/2016 at 3:18 PM, an interview was conducted with EI #6. EI #6 was asked if RI #8 was on O2. EI #6 said yes ma'am. EI #6 was asked what the physician's orders [REDACTED]. EI #6 said it was to be continuous. EI #6 was asked what should have been done during incontinent care and changing of the resident's clothes when the resident was observed without O2 from 10:30 AM to 12:30 PM. EI #6 said the nasal cannula should have been put back on and the resident taken to the beauty shop with portable O2. EI #6 was asked why the resident was receiving O2. EI #6 said for a [DIAGNOSES REDACTED].#6 was asked what the care plan said about the O2. EI #6 said provide O2 as ordered. EI #6 was asked what the potential harm was in RI #8 being without O2 from 10:30 AM to 12:45 PM. EI #6 said low O2 sats (saturation).

Based on record review, observation and interview, the facility failed to ensure a licensed staff member did not place medications that were not given into a garbage can during medication administration on 1/13/2016. This affected one of two licensed staff members observed during medication administration. Findings Include: A review of a facility policy titled, Medication-Administration with a revised date of 1/13/2016 revealed: .Procedure . 13.If medication is withheld and/or refused dispose by placing in a nearby sharps container. On 1/13/2016 at 8:45 AM, EI (Employee Identifier) #7, LPN (Licensed Practical Nurse) was observed preparing medication. EI #7 placed Oxybutynin 5 mg (milligrams), Zyrtec 10 mg, Ferrous Sulfate 325 mg, Folic Acid 1 mg, Depakote 500 mg and Celexa 10 mg in a medication cup. The resident was in therapy at that time and EI #7 placed the medications in the garbage can. On 1/13/2016 at 8:50 AM, EI #7 was again observed preparing medications. EI #7 placed Ferrous Sulfate 325 mg, Allbee C Multivitamin and Pepcid 40 mg into a medication cup. The resident was in the hallway in the wheelchair. The resident was taken to the room in the wheelchair. The resident refused the medication and EI #7 placed the medication in the garbage can. On 1/13/2016 at 3:05 PM, an interview was conducted with EI #7. EI #7 was asked how medication should be disposed of when a resident refused the medication or the medication was not given. EI #7 said to put the medication in the sharps box or flush it unless it was a narcotic and a RN (Registered Nurse) would have to waste it then flush it. EI #7 was asked during medication pass that day (1/13/2016), how she disposed of the medication that was not given. EI #7 said she put it in the garbage. EI #7 was asked if it was an acceptable practice of that facility for a nurse to place medications that were not given in the garbage can. EI #7 said no ma'am. EI #7 was asked why the medications that were not given were placed in the garbage can. EI #7 said she got nervous and put them in there without thinking about it. EI #7 was asked what the potential harm was in placing medications that were not given in the garbage can. EI #7 said another resident could get them. On 1/14/2016 at 10:20 AM, an interview was conducted with EI #6, RN Supervisor. EI #6 was asked how medications that were not given should be disposed of. EI #6 said non-narcotics went in the sharps box and narcotics were to be crushed with a witness and flushed. EI #6 was asked if it was an acceptable practice of that facility for a nurse to place medications that were not given in the garbage can. EI #6 said no. EI #6 was asked what the potential harm was in placing medications that were not given in the garbage can. EI #6 said a resident in the hallway could get the medications out and take them.

Based on record review, observation and interview, the facility failed to ensure a licensed staff member verified the narcotic count and signed the narcotic book immediately after removing narcotics from the lock box. This affected one of two nurses observed during medication administration on 1/13/2016. Findings Include: A review of a facility's policy titled, Medication-Controlled Substances with a revision date of 02/01/2015 revealed: Purpose To maintain control and proper usage of controlled substances Policy To provide safeguards against diversion, accidental exposure and loss of controlled substances. On 1/13/2016 at 9:30 AM, EI (Employee Identifier) #16/LPN (Licensed Practical Nurse), was observed preparing medication for RI #20. EI #16 removed [MEDICATION NAME] 10-325 mg (milligram) and [MEDICATION NAME] 50-325-40 mg from the locked box and did not compare the narcotic count with the narcotic book. EI #16 did not sign the narcotic book when she removed the medications. On 1/14/2016 at 11:05 AM, an interview was conducted with EI #16. EI #16 was asked what was the policy and procedure on narcotic administration. EI #16 said to check the count in the narcotic book and sign the narcotic book. EI #16 was asked if she administered any narcotics during medication administration on 1/13/2016. EI #16 said yes. EI #16 was asked what did she do at that time. EI #16 said she did not check the narcotic count book nor did she sign the narcotic book. EI #16 was asked what should she have done. EI #16 said she should have signed the narcotic book before she administered the narcotic and she should have checked the count. EI #16 was asked what the potential harm was in not checking the count with the narcotic book and not signing the narcotic book. EI #16 said the count could be wrong and it could look like the medication was not given. On 1/14/2016 at 12:03 PM, an interview was conducted with EI #1 (Administrator). EI #1 was asked what was the policy and procedure on narcotic administration. EI #1 said to compare the count with the narcotic book and sign the narcotic book. EI #1 was asked when should the narcotic book be signed. EI #1 said when a narcotic is removed. EI #1 was asked why should the narcotic book be signed. EI #1 said to account for narcotics and keep an accurate count. EI #1 was asked what the potential harm was in not checking the count or signing the narcotic book. EI #1 said an inaccurate narcotic count.

Based on record review, observation and interview, the facility failed to ensure the Daily Report of Nursing Staff Directly Responsible for Resident Care form did not have the staff for all three shifts documented at 2:47 PM on 1/12/2016. The facility also failed to ensure the staffing totals and actual hours worked were documented on the Daily Report of Nursing Staff Directly Responsible for Resident Care form at the beginning of the shift on all three days of the survey. This had the potential to affect all 76 residents who reside at the facility. Findings Include: A review of a facility document titled, Posting of Licensed & (and) Unlicensed Nursing Staff with a revised date of 07/01/2015 revealed: Policy The Nursing Facility shall post the Census numbers, shifts, categories, actual hours worked and staffing totals of licensed and unlicensed nursing staff daily, at the beginning of each shift, in a prominent location. On 1/12/2016 at 2:54 PM, the Daily Report of Nursing Staff Directly Responsible for Resident Care form was observed with total number of staff documented for all three shifts. There were no actual hours worked or staffing totals documented for the 7AM- 3PM shift at that time. On 1/12/2016 at 4:55 PM, the Daily Report of Nursing Staff Directly Responsible for Resident Care form was observed. There were no actual hours worked or staffing totals documented for the 3PM-11PM shift at that time. EI (Employee Identifier) #1, Administrator, stopped the surveyor and stated she noticed the form was not correct when the surveyor got the copy of the Daily Report of Nursing Staff Directly Responsible for Resident Care form at 2:47 PM. EI #1 said EI #10, Staff Development Coordinator, had already been in-serviced. On 1/13/2016 at 8:15 AM, the Daily Report of Nursing Staff Directly Responsible for Resident Care form was observed. There were no actual hours worked or staffing totals documented for the 7AM-3PM shift at that time. On 1/13/2016 at 4:30 PM, the Daily Report of Nursing Staff Directly Responsible for Resident Care form was observed. There were no actual hours worked or staffing totals documented for the 3PM-11PM shift at that time. On 1/14/2016 at 8:49 AM, the Daily Report of Nursing Staff Directly Responsible for Resident Care form was observed. There were no actual hours worked or staffing totals documented for the 7AM-3PM shift at that time. On 1/14/2016 at 10:25 AM, an interview was conducted with EI #10. EI #10 was asked who was responsible for posting the daily nurse staffing forms. EI #10 said the 7AM-3PM nurse started the form, then the 3PM-11PM nurse started it for the 3PM-11PM shift and 11PM-7AM started it for their shift. EI #10 was asked what her involvement was in the daily nurse staff postings. EI #10 said she usually went up at 3PM and made sure the daily nurse staffing form was correct for dayshift and the 3PM-11PM daily nurse staffing form was started or she would start it. EI #10 was asked when the daily nurse staff posting form should be posted. EI #10 said it was supposed to be up by the start of the shift. EI #10 was asked what information should be present on the daily nurse staffing forms when it was posted. EI #10 said it should have the count of nurses on the floor, CNAs (Certified Nursing Assistant), census, facility name and the date. EI #10 was asked to read the policy and tell the surveyor what information the policy said should be there. EI #10 said actual hours worked. EI #10 was informed that the daily nurse staffing form was observed on 1/12/2016 at 2:47 PM with all three shifts documented. EI #10 was asked if she could tell the surveyor why. EI #10 said she was just trying to help out the other nurses. EI #10 was asked if it was an acceptable practice of that facility for the daily nurse staffing forms to contain all three shifts at 2:47 PM. EI #10 said no. EI #10 was asked if it was an acceptable practice of that facility for total work hours not to be documented on the daily nurse staffing form at the time it was posted. EI #10 said no. EI #10 was informed that on 1/13/2016 at 8:15 AM, the daily nurse staffing form was observed without any total actual hours documented. EI #10 was asked if she could tell the surveyor why. EI #10 said they were not aware it had to be filled out. EI #10 was asked why the daily nurse staffing forms should be accurate and complete with the required information when it was posted. EI #10 said it was Medicare and Medicaid information and resident and family information the facility was required to provide to them. EI #10 was asked to look at the daily nurse staffing forms for 1/12/2016, 1/13/2016 and 1/14/2016 and tell the surveyor if any required information was missing. EI #10 looked at the forms and said yes, the following information was missing from the forms: On 1/14/2016 at 8:41 AM, the actual hours worked and staffing totals; On 1/13/2016 at 4:30 PM, 3PM-11PM actual hours worked and staffing totals; On 1/13/2016 at 8:15 AM, 7AM-3PM actual hours worked and staffing totals; On 1/12/2016 at 4:55 PM, 3PM-11PM actual hours worked and staffing totals and On 1/12/2016 at 2:54 PM, 7AM-3PM actual hours worked and staffing totals and the number of staff should not be documented for 3PM-11PM and 11PM-7AM. On 1/14/2016 at 2:58 PM, an interview was conducted with EI #1. EI #1 was asked who was responsible for posting the daily nurse staffing forms. EI #1 said EI #10 was in charge of the posting. EI #1 was asked when the daily nurse staff posting forms should be posted for each shift. EI #1 said she could not remember the time frame. EI #1 was asked what information should be posted on the daily nurse staffing form when it was posted. EI #1said they had to look at RNs (Registered Nurse), LPNs (Licensed Practical Nurse), and CNAs. EI #1 was asked if it was an acceptable practice of that facility for the daily nurse staff posting form to have the total number of staff for all three shifts present at 2:47 PM. EI #1 said no ma'am. EI #1 was asked, when she told the surveyor the daily nurse staffing form was not correct on 1/12/2016, what was not correct about the form. EI #1 said the form actually had staffing for all three shifts filled in. EI #1 was asked what she had in-serviced EI #10 on. EI #1 said on the policy and on making sure that at the beginning of the shift the staffing was documented. EI #1 was asked to look at the facility policy and tell the surveyor what information was supposed to be on the daily nurse staffing form at the beginning of the shift. EI #1 said census numbers, shifts, categories, actual hours worked and staffing totals of licensed and unlicensed nursing staff. EI #1 was asked why it was important for daily nurse staff posting forms to be accurate and complete at the time of posting. EI #1 said to inform family and residents of nursing personnel providing care and so the form could be viewed by residents, visitors and facility staff.

Based on observation, interviews and record reviews, the facility failed to ensure Resident Identifier (RI) #6 was assessed for the continued use of a Foley catheter. This deficient practice affected RI #6, one of two sampled residents observed with a catheter. Findings include: RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set with an assessment reference date of 08/27/12, identified RI #6 as being severely impaired in cognitive skills for daily decision making with long and short term memory problems. RI #6 was assessed as being totally dependent on staff for all Activities of Daily Living. RI #6 was further assessed as being always incontinent of bowel and having an indwelling catheter for bladder functions. RI #6's "Physician Orders" for the month of November 2012 documented " ... Indwelling Urinary Cath (catheter) ... ." On 11/06/12 at 11:45 AM, RI #6 was observed in bed and a Foley catheter was attached the bed frame within a privacy bag. During an interview on 11/08/12 at 1:55 PM, Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN) acknowledged she inserted RI #6 catheter in April 2012 because the resident had went approximately 16 hours without voiding. When asked if RI #6 had been assessed for the need to continue the use of the catheter, EI #4 said no. EI #4 was then asked should RI #6 have been assessed for the continued use of the catheter and she (EI #4) said yes. During an interview on 11/08/12 at 2:55 PM, EI #5, the Director of Nurses, was asked if RI #6 had been assessed for the continued use of the catheter. EI #5 replied not that she was aware of. When asked should RI #6 have been assessed for the continued use of the catheter, EI #5 said yes.

Based on observation, interviews and record reviews, the facility failed to ensure Resident Identifier (RI) #5 received incontinence care in a manner to prevent the potential for Urinary Tract Infections. This deficient practice affected RI #5, one of six residents reviewed for incontinence. Findings include: The facility's policy and procedure titled "Perineal Care (NAPP 850)" with a revised date of 08/28/12, documented " ... Purpose To cleanse the perineum and assist in preventing infection, skin irritation and odors ... Procedure ... 5. Wash entire perineal area moving front to back ... ." RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 08/21/12, identified RI #5 as being severely impaired in cognitive skills for daily decision making with long and short term memory problems. RI #5 was assessed as being totally dependent on staff for all Activities of Daily Living (ADLs). RI #5 was further assessed as always incontinent of bladder and bowel functions. During an observation on 11/07/12 beginning at 9:02 AM, Employee Identifier (EI) #2 and EI #3, both Certified Nursing Assistants, provided incontinence care to RI #5. EI #2 cleaned RI #5's labia, right and left groin areas with an upward (back to front) wipe. During an interview on 11/07/12 at 3:10 PM, EI #3 acknowledged that she assisted EI #2 in providing incontinence care to RI #5. EI #3 was then asked what direction did EI #2 wipe when she (EI #2) cleansed RI #5's labia and groin areas, EI #3 said EI #2 wiped in an upward motion which could cause bowel to spread from the rectal area to the labia. An interview was conducted with EI #4, the Licensed Practical Charge Nurse, on 11/08/12 at 1:55 PM. EI #4 was asked what could wiping upward from the rectal area over a female's labia and groin areas cause, EI #4 said a Urinary Tract Infection from spreading feces and bacteria from the rectal area.