Every finding on record at Life Care Center of Ooltewah

Based on facility policy review, medical record reviews, observations, and interviews, the facility failed to maintain infection control practices when staff did not use Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) for 1 resident (Resident #21), and failed to identify and implement EBP for 4 residents (Residents #44, #90, #110, and #112) of 15 residents reviewed for EBP needs.The findings include:Review of the facility's policy titled, Enhanced Barrier Precautions, dated 8/2025, revealed .The facility should use Enhanced Barrier Precautions (EBP) .during high-contact resident care activities .EBP are indicated for residents with .wounds and/or indwelling medical devices .wounds generally include chronic wounds .examples of chronic wounds include .pressure ulcers, diabetic foot ulcers, unhealed surgical wounds .indwelling medical device examples include .urinary catheters .examples of high-contact resident care activities requiring gown and glove use include .dressing .bathing .changing briefs .Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Prostate Cancer, and Spinal Disc Degeneration.Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact.Review of the Physician's Orders for Resident #21 revealed an order dated 4/14/2026, .Enhanced Barrier Precautions Diagnoses: Nephrostomy Drain [thin tube inserted through the skin into the kidney to drain urine directly into an external bag] .During an observation on 4/27/2026 at 3:25 PM, revealed a sign posted outside the resident's door which indicated the resident required EBP as follows: .Wear gloves and a gown for the following High-Contact Resident Care Activities .Dressing .Bathing///Providing Hygiene .Changing briefs . Certified Nursing Assistant (CNA) B and Certified Occupational Therapy Assistant (COTA) A performed direct care for Resident #21 in the resident's room. CNA B and COTA A wore gloves but did not don gowns as indicated by EBP.During an interview on 4/27/2026 at 3:35 PM, CNA B confirmed she [CNA B] and COTA A had performed direct care for Resident #21 including bathing, dressing, changing of brief, and positioning, and confirmed they [CNA B and COTA A] wore gloves, but did not don gowns prior to resident care. CNA B stated .it [the PPE bin] was out of gowns so we didn't use any .Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including Fibromyalgia, Peripheral Vascular Disease, and Neuromuscular Dysfunction of Bladder. Review of the current Physician's Orders for Resident #44 revealed an order dated 4/13/2026, .Indwelling [urinary] catheter . Further review revealed no Physician's Order was present for EBP.Review of the admission MDS assessment dated [DATE], revealed Resident #44 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident had an indwelling [urinary] catheter.Review of the medical record revealed Resident #90 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Peripheral Vascular Disease, and Chronic Ulcers of Both Feet. Review of the admission MDS assessment dated [DATE], revealed Resident #90 scored an 8 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident had diabetic foot ulcers.Review of the current Physician's Orders for Resident #90 revealed an order dated 4/23/2026, .PU [Pressure Ulcer] to L [left] 2nd toe, cleanse with NS [normal saline] apply honey [topical medication] alginate [dressing used for draining wounds to absorb the drainage] cover with foam dressing . Further review revealed no Physician's Order was present for EBP.Review of the Wound Observation Tool dated 4/23/2026, revealed Resident #90 had a diabetic ulcer to the left 2nd toe, which had clear drainage, slough (dead or necrotic) tissue present. Further review revealed no signs of infection.Review of the medical record revealed Resident #110 was admitted to the facility on [DATE] with diagnoses including Spinal Abscess, Spinal Cord Compression, and Heart Disease. Review of the current Physician's Orders for Resident #110 revealed an order dated 4/23/2026 to clean and apply a dressing to the surgical wound on the resident's mid-back. Further review revealed no Physician's Order was present for EBP.Review of the Wound Observation Tool dated 4/24/2026, revealed Resident #110 had a surgical wound to mid-back with a depth of 0.1 mm (millimeters). Further review revealed no signs of infection.Review of the Social Services BIMS assessment dated [DATE], revealed Resident #110 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the medical record revealed Resident #112 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Chronic Kidney Disease, and Peripheral Vascular Disease. Review of the current Physician's Orders for Resident #112 revealed an order dated 4/23/2026, to clean and apply a thick cream to the pressure ulcer on the resident's sacrum and buttocks. Further review revealed no Physician's Order was present for EBP.Review of the Wound Observation Tool dated 4/25/2026, revealed Resident #112 had a Pressure Ulcer, partial thickness [loss of skin with exposed dermis] to sacrum and bilateral buttocks, with a depth of 0.1 mm. Further review revealed no signs of infection.Review of the Social Services BIMS assessment dated [DATE], revealed Resident #112 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation and interview on 4/28/2026 at 2:30 PM, the Registered Nurse Infection Preventionist (RN/IP) confirmed there was no sign for EBP on Resident #44's door and confirmed the resident should be under EBP due to having an indwelling device (urinary catheter). During further observation and interview, the RN/IP confirmed there were no signs for EBP on the rooms for Residents #90, #110, and #112, and confirmed these residents should be under EBP due to having open wounds.

Based on facility policy review, manufacturer guidelines review, observations, and interviews, the facility failed to properly store a controlled substance for 1 resident in 1 medication room (Resident #112 in the 100 medication room), and failed to maintain refrigerator temperatures specified for vaccine storage in 1 medication room (200 medication room) of 3 medication rooms observed.The findings include:Review of the facility's policy titled, Inventory Control of Controlled Substances, dated 12/2007, revealed .facility should maintain separate individual controlled substance records on all Schedule II medications [medications with a risk of abuse of diversion] .should include .resident name .medication .quantity received by the facility .quantity remaining .the facility should ensure the incoming and outgoing nurses count all Schedule II controlled substances .at the change of shift .and document the results on a Controlled Substance Count Verification/Shift Count Sheet .Review of the facility's policy titled, Medication Storage in Refrigerator/Freezer, dated 9/2025, revealed .The facility will ensure that medications which require refrigeration are stored appropriately per manufacturer's instructions .safe temperature for refrigeration is between 36 *F [degrees Farenheight] and 46 *F .the facility should monitor the temperature for vaccine storage twice a day .If the nurse checks the temperature and it is out of range, the nurse should adjust the setting to increase or decrease the temperature accordingly. The medication should be removed and placed in an alternate storage area .if the refrigerator has multiple out of range readings in a row or there appears to be an issue with it's normal functioning, the maintenance department should be notified and medication moved until the issue is resolved . Review of the undated manufacturer guidelines titled, Influenza Vaccine . revealed, .Store [vaccine] between 36 *F to 46 *F .Review of the medical record revealed Resident #112 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Chronic Kidney Disease, and Peripheral Vascular Disease. Review of the Social Services Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed Resident #112 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation and interview on 4/27/2026 at 8:30 AM, the Registered Nurse/Staff Development Coordinator (RN/SDC) confirmed in 100-hall medication room there was a plastic ziplock bag with home medications for Resident #112 in a cupboard. The medication room was locked, but the cupboard was not locked. After reviewing the medications, the RN/SDC confirmed these were resident #112's medications from home, and the medications included a bottle of Hydrocodone/Acetaminophen (a narcotic used to treat pain and a controlled substance) 5/325 mg (Milligram), filled by the pharmacy 5/2025, with a quantity of 5, and the bottle contained 4 whole tablets, and 1 half-tablet. The RN/SDC took the bag of home medications to a nurse's medication cart and asked the nurse to lock the bag in the cart and lock the Hydrocodone/Acetaminophen bottle in the narcotic drawer. The RN/SDC told the nurse she (the RN/SDC) would come back later and bring a narcotic count sheet, and the RN/SDC did not count the narcotic bottle with the nurse at that time. The RN/SDC confirmed narcotics were to be stored double-locked, and home medications were to be sent home with the family when residents are admitted to the facility. Review of the current Physician's Orders for Resident #112 revealed no order was present for Hydrocodone/Acetaminophen.During an observation and interview on 4/27/2026 at 8:45 AM, the RN/SDC confirmed the 200-hall medication room refrigerator contained 2 boxes of Influenza Vaccines, each box held 10 pre-filled syringes of the Influenza vaccine, and confirmed the boxes stated .store between 36 *F and 46 *F . The RN/SDC confirmed the 200 hall medication room's refrigerator temperature log for 4/2026 revealed there were 3 times the refrigerator temperatures were not documented (PM shifts on 4/17/2026, 4/18/2026, and 4/19/2026), 15 times the refrigerator temperatures were out of the storage range without corrections documented (AM shift on 4/8/2026, 4/9/2026, 4/13/2026, 4/14/2026, 4/15/2026, 4/24/2026, and 4/25/2026, PM shifts on 4/4/2026, 4/5/2026, 4/8/2026, 4/13/2026, 4/20/2026, 4/22/2026, 4/23/2026, and 4/24/2026), and 5 days the refrigerator temperatures were out of the storage range and corrective adjustments were documented (4/3/2026, 4/6/2026, 4/7/2026, 4/20/2026, 4/26/2026). The RN/SDC confirmed there were 3 blanks on the refrigerator temperature log and confirmed the refrigerator log had temperatures recorded that were out of range per policy and manufacturer's storage guidelines.During an interview on 4/2/2026 at 4:00 PM, the Director of Nursing (DON) confirmed home medications belonging to residents should be sent home with the family, and confirmed narcotics are controlled substances requiring counting by 2 licensed nurses, and storage with 2 locks.

Based on facility policy review, medical record review, and interviews, the facility failed to accurately assess the resident upon admission and develop a care plan to account for the resident's experience and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 resident (Resident #107) of 2 residents reviewed with Post Traumatic Stress Disorder (PTSD). The findings include:Review of the facility policy titled, Trauma-Informed Care, dated 1/6/2026, revealed, .The facility will use a multi-pronged approach to identifying resident's with PTSD or history of trauma .assessing .for indicators of trauma upon admission .this assessment will include asking the resident about triggers that may be stressors or may prompt a recall of a previous traumatic event .the facility should collaborate with resident trauma survivors, and as appropriate, the resident family .and any other healthcare professionals .the facility should still attempt to identify triggers .and develop care plan interventions which minimize or eliminate the effect of the trigger .Review of the medical record revealed Resident #107 was admitted to the facility on [DATE], with diagnoses of PTSD, Anxiety Disorder, Claustrophobia, and Depression. Review of the comprehensive care plan dated 4/22/2026, revealed Resident #107 had a diagnosis of PTSD with a goal of .receives as much social support as wanted .Interventions .coordination of resources to address social needs .refer to social worker . Further review revealed no cause of PTSD or interventions and no care plan for Claustrophobia in place for Resident #107. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #107 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and had diagnoses of PTSD, Anxiety Disorder, Claustrophobia, and Depression. During an observation and interview on 4/26/2026 at 4:30 PM, in Resident #107's room, the resident was lying in bed watching television. During the interview Resident #107 stated she had PTSD and was under the care of a psychiatrist prior to this admission. The resident stated her son was in the military and worked as a medic on the medical helicopter and her fear was of him being a target with a big red cross on the helicopter. Resident #107 stated she could not see visuals or hear conversations of emergency situations involving helicopters, war, and events of that nature. When this surveyor asked how staff were managing her triggers, she stated, .the facility has not asked me about any of my triggers, they are only concerned with my tailbone . During an interview on 4/28/2026 at 9:42 AM, the Social Service Director (SSD) stated she interviewed the resident upon admission using the Trauma Informed Care form asking the questions as written and stated .if the resident doesn't have anything on the list, we would not document any triggers. Further interview revealed the SSD was unaware Resident #107 had PTSD related to the Resident's son being in the military or having a diagnosis of Claustrophobia. The SSD stated, .I was not aware she had claustrophobia as a diagnosis. That would require us to have a conversation with her to find out what her triggers are. We would educate the staff on the triggers. We have not done that yet . Review of a Trauma Informed Care document dated 4/28/2026 (7 days after admission and after surveyor brought diagnoses to SSD's attention), revealed Resident #107 had experienced repeated and disturbing dreams of the stressful experience, feeling very upset when something reminded of the stressful event, strong physical reactions when reminded of the event, avoiding memories, avoiding external reminders (people, places, conversations, situations .) and trouble falling or staying asleep. Further review revealed Resident #107's triggers for Claustrophobia was related to very small spaces or objects over her face. During an interview on 4/28/2026 at 1:15 PM, the SSD stated, .We would not have care planned the clinical side (Claustrophobia) only the PTSD; Claustrophobia was added today [4/28/2026] .During an interview on 4/28/2026 at 3:10 PM, The MDS Coordinator confirmed PTSD and Claustrophobia were listed on the admission MDS assessment dated [DATE], confirmed PTSD was care planned without triggers listed, and confirmed Claustrophobia and triggers had not been care-planned. During an interview on 4/28/2026 at 3:20 PM, the Registered Nurse (RN) care plan coordinator stated, .reports are run every morning to catch changes of diagnoses to allow for updates to the care plan .I may miss it sometimes . The care plan coordinator reviewed the care plan and confirmed Claustrophobia and associated triggers were not on the care plan.

Based on the facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention for 1 resident (Resident #42) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Fall Management, reviewed 9/29/2022, showed .Implement interventions .consistent with a resident's .care plan .Supervision .Refers to an intervention and means of mitigating the risk of an accident .During the admission .a care plan will be developed .interdisciplinary team will review and revise the care plan .upon a fall . Resident #42 was admitted to the facility on [DATE] with diagnoses including Fracture of Third Lumbar Vertebra, Wedge Compression Fracture of Fourth Lumbar Vertebra and Muscle Weakness. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #42 was severely cognitively impaired. The resident was dependent of 2 staff members for bed mobility and toileting. Review of the facility's fall investigation dated 11/21/2022, showed Resident #42 had an unwitnessed fall from the bed. The resident was found lying on the floor with a skin tear to the left knee and left toe. The immediate action taken was .Gym mats . Review of the Care Plan dated 11/22/2022, showed Resident #42 had an actual fall with minor injury and was updated on 11/29/2022 with an intervention of fall mats. During an observation on 12/12/2022 at 12:02 PM, Resident #42 was lying in bed with no fall mats beside the bed. During an observation on 12/13/2022 at 1:41 PM, the resident was lying in bed with no fall mats beside the bed. During an interview on 12/13/2022 at 2:13 PM, the 100-Hall Unit Manager confirmed that there were no fall mats in Resident #42's room. After the interview, the Unit Manager brought fall mats to the resident's room for placement. During an interview on 12/14/2022 at 10:24 AM, the MDS Coordinator stated new interventions were put on the care plan by unit managers after a fall was discussed. She stated the interventions should be put into place before the intervention was added on the care plan.

Based on medical record review and interview, the facility failed to maintain an accurate medical record for 1 resident (Resident #56) of 18 residents reviewed for medical records. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, and Dorsalgia (back pain). Review of the [named facility] PHYSICAL MEDICINE & REHABILITATION prescription dated 9/28/2022, showed .Methadone 10 mg [milligrams] .3 tabs [tablets] PO [by mouth] QAM [every morning] .#9 (nine) .NO REFILLS . Review of a Controlled Substance Verbal Prescription Order from Practitioner dated 10/1/2022, showed .Methadone 10 mg .Dispense Quantity .#9 .3 tabs PO QAM (for pain) . No refills were ordered. Review of a prescription dated 10/3/2022, showed .METHADONE 10 MG TABLET .Take 3 tablet by mouth once a day .PRESCRIBED QUANTITY: 6 (SIX) TABLETS .DAYS SUPPLY: 2 .DIAGNOSIS .DORSALGIA .REFILLS .0 (ZERO) . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact and received scheduled and PRN (as needed) pain medications. Resident #56 received Opioid (narcotic medications used for severe pain control) medications on all 7 days of the look back period. Review of the Medication Administration Record (MAR) dated 10/1/2022 - 10/31/2022, showed an order dated 9/28/2022 for .Methadone .10 MG .Give 3 tablet by mouth one time a day for chronic back pain . It was noted that the resident did not receive the Methadone on 10/8/2022, 10/9/2022, 10/10/2022, 10/11/2022, 10/12/2022, or 10/13/2022. Continued review showed an order dated 9/28/2022 for .OxyCODONE-Acetaminophen [opioid] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain. The resident received the medication on 10/1/2022 at 5:27 PM, 10/2/2022 at 6:33 AM, 1:27 PM, and 9:30 PM, 10/3/2022 at 5:16 AM, 1:26 PM, and 7:57 PM, 10/4/2022 at 3:29 AM and 9:00 PM, 10/5/2022 at 2:39 AM, 8:36 AM, 2:29 PM, and 9:18 PM, 10/6/2022 at 4:10 AM, 1:54 PM, and 8:11 PM, 10/7/2022 at 5:12 AM, 12:25 PM, and 7:32 PM, 10/8/2022 at 6:05 AM, 12:05 PM, and 7:58 PM, 10/9/2022 at 6:27 AM and 7:45 PM, 10/10/2022 at 1:58 AM, 9:58 AM, 4:00 PM, 10:10 PM, 10/11/2022 at 4:59 AM, 10/12/2022 at 6:28 AM and 1:47 PM, 10/13/2022 at 4:10 PM, 12:01 PM, and 6:01 PM. It was noted that all Oxycodone-Acetaminophen administrations were effective at treating Resident #56's pain. Review of the Orders - Administration Note dated 10/8/2022 at 8:26 AM, showed .Methadone . Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/9/2022 at 8:13 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/10/2022 at 9:57 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .waiting on pharmacy . Review of the Orders - Administration Note dated 10/11/2022 at 10:05 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .waiting on pharmacy . Review of the Orders - Administration Note dated 10/12/2022 at 8:53 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/13/2022 at 9:01 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .Waiting on pharmacy . Review of a prescription dated 10/13/2022, showed .METHADONE 10 MG TABLET .Take 3 tablet by mouth once a day .PRESCRIBED QUANTITY: 63 (SIXTY-THREE) TABLETS .DAYS SUPPLY: 21 .DIAGNOSIS .CHRONIC PAIN .REFILLS .0 (ZERO) . Observation and interview with Resident #56 on 12/13/2022 at 4:04 PM, in the resident's room, showed the resident lying in bed eating a snack and watching TV with no signs of distress observed. Resident #56 stated he had chronic neck and back pain. Pain control interventions included medications, therapy, and repositioning. Resident #56 stated the pain control interventions .help . his pain but did not .cure it . Resident #56 stated he had been taking Methadone .for a long time . and there had been .a few times . the Methadone was not administered at the facility. Resident #56 denied any changes or worsening in his pain. During a telephone interview on 12/13/2022 at 5:14 PM, Nurse Practitioner #1 stated Resident #56 was admitted to the facility after a stroke. Resident #56's daughter reported that the resident had been seen at an outpatient clinic for pain control and was taking methadone. Resident #56's daughter stated he was always in pain. Resident #56 was on a scheduled and as needed pain medication regimen at the facility. Nurse Practitioner #1 saw Resident #56 on 10/3/2022, 10/10/2022, and 10/24/2022 and no acute signs of distress were noted. Nurse Practitioner #1 ordered a .few days . supply of Methadone after her 10/3/2022 visit. Methadone required a specific prescribing diagnosis to order routinely, and it was unclear what Resident #56's diagnosis was in order to receive a continuous daily supply of Methadone, so a pain management consult was requested on her 10/10/2022 visit. During an interview on 12/14/2022 at 10:00 AM, the Regional Director of Clinical Services stated the 9/28/2022 order for Methadone was for a 3-day supply and should have been discontinued after 3 days. The order for Methadone obtained on 10/1/2022 was for a 3-day supply and should have been discontinued after 3 days. The Methadone order dated 10/3/2022 was for a 2-day supply and should have been discontinued after 2 days. Another order for Methadone was received 10/13/2022. Resident #56 did not have an active order for Methadone from 10/8/2022 - 10/13/2022. The Regional Director of Clinical Services confirmed Resident #56's Methadone order was entered into the facility's system incorrectly upon admission on 9/28/2022 as daily without a discontinue date. Each subsequent order for Methadone should have been entered into the facility's system with the start date it was ordered and discontinued after the prescribed quantity was administered. During an interview on 12/14/2022 at 11:19 AM, the Regional Director of Clinical Services confirmed Resident #56's Methadone orders were entered into the facility's system incorrectly and the medical record was inaccurate.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician's order for medication administration for 1 resident (Resident #56) of 6 residents reviewed for medications. The findings include: Review of the facility's policy titled, Administration of Medications, reviewed on 8/25/2022, showed .The facility will ensure medications are administered safely and appropriately per physician order . Resident #56 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, and Dorsalgia (back pain). Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #56 was cognitively intact and received scheduled and as needed pain medication. The resident received Opioids (narcotic pain relieving medication) on all 7 days of the look back period. Review of the Medication Administration Record (MAR) dated 10/1/2022-10/31/2022 showed an order dated 9/28/2022 for .Lidocaine Patch [an over the counter medication used to relieve mild pain] 4% [percent] .Apply to lower back topically [medication applied to a particular place on the body] one time a day for back pain .apply 2 patches and remove per schedule . The Lidocaine Patch was not administered as ordered on 10/1/2022, 10/2/2022, 10/3/2022, 10/6/2022, 10/8/2022, 10/9/2022, 10/12/2022, 10/13/2022, 10/18/2022, 10/21/2022. Registered Nurse (RN) #1 documented the 10/1/2022, 10/2/2022, and 10/3/2022 doses as not administered. Licensed Practical Nurse (LPN) #1 documented the 10/6/2022 dose as not administered and LPN #2 documented the 10/8/2022, 10/9/2022, 10/12/2022, 10/13/2022, 10/18/2022, and 10/21/2022 as not administered. Review of the Orders - Administration Note dated 10/1/2022 at 11:32 PM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .No patch to remove . Review of the Orders - Administration Note dated 10/2/2022 at 10:41 PM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .No patch found to remove . Review of the Orders - Administration Note dated 10/6/2022 at 10:05 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/8/2022 at 8:22 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/9/2022 at 8:11 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/12/2022 at 8:50 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/13/2022 at 9:03 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/18/2022 at 8:34 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/21/2022 at 8:44 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on Pharmacy . Observation and interview with Resident #56 on 12/13/2022 at 4:04 PM, in the resident's room, showed the resident lying in bed eating a snack and watching TV with no signs of distress observed. Resident #56 stated he had chronic neck and back pain. Pain control interventions included medications, therapy, and repositioning. Resident #56 stated the pain control interventions .help . his pain but did not .cure it . Resident #56 denied any changes or worsening in his pain. During a telephone interview on 12/13/2022 at 4:46 PM, the Director of Nursing (DON) and the Medical Director stated Resident #56 had chronic pain and received scheduled and as needed medications for pain. Continued interview confirmed it was their expectation that physician's orders were followed. The Medical Director stated that Resident #56 had no change in pain characteristics or behaviors as a result of not receiving Lidocaine patches as ordered. During an interview on 12/14/2022 at 8:16 AM, the Administrator stated Resident #56 had an order for Lidocaine 4% patches. Lidocaine 4% patches are over the counter medications and available as house stock in the facility. Lidocaine 5% must be dispensed by the pharmacy. The Administrator stated some of the nurses did not realize the difference in the 2 patches and did not realize the Lidocaine 4% patches that Resident #56 had ordered were available in the facility and did not have to come from the pharmacy. The Administrator confirmed Resident #56 did not receive Lidocaine patches as ordered by the physician and it was the facility's expectation that physician's orders were followed. During a telephone interview on 12/14/2022 at 10:01 AM, RN #1 stated there were occasions when Resident #56's Lidocaine patch was unavailable to administer and she would notify the pharmacy the patches were unavailable. RN #1 stated she was recently made aware that the Lidocaine Patches were facility stocked and did not have to come from the pharmacy. Resident #56 had scheduled and as needed pain medications, which were given and managed the resident's pain. Resident #56's pain remained at baseline with no changes. Interview revealed RN #1 requested the lidocaine patches from the pharmacy, who did not have the 4% patches, when the patches should have been obtained from the facility's central supply. Attempted telephone interview with Licensed Practical Nurse (LPN) #1 unsuccessfully on 12/14/2022 at 10:10 AM. During an interview on 12/14/2022 at 10:30 AM, LPN #2 stated she was unable to recall any time when Lidocaine Patches were unavailable to administer and Resident #56 always showed the same demeanor during her interactions with the resident and no distress was noted.

Based on review of the facility policy, medical record review, and interview the facility failed to follow professional standards of practice for 1 resident (#1) of 1 resident reviewed for monitoring and maintenance of a nephrostomy tube. The findings include: Review of the facility policy, titled Percutaneous Abdominal or Pelvic Care, revised 11/20/2020 showed .Nephrostomy tube irrigation .Nephrostomy tube irrigation helps maintain tube patency. It requires gentle technique to avoid damaging the kidney and sterile no-touch technique to reduce the patient's risk of infection .Irrigating a nephrostomy tube requires an order specifying the frequency of irrigation and the type and amount of solution to be used .Implementation .verify practitioner's order .Note the volume and characteristics of the nephrostomy tube drainage .Document the procedure .Documentation .Note the type and volume of irrigant instilled. Describe the color and amount of drainage from the nephrostomy tube and record any color changes as they occur. Note markings on the tube at the exit site . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact, and had an indwelling catheter (including nephrostomy tube which drains urine from the kidney into a bag outside the body). Review of a Comprehensive Care Plan dated 7/23/2021 showed Resident #1 had a potential/actual impairment to the skin integrity due to a nephrostomy tube to the left lower back. Continued review showed no interventions for the care and monitoring of the nephrostomy tube. Medical record review of a Physician's order dated 7/23/2021 showed .Nephrostomy tube to L [left] lower back Cleanse with NS [normal saline], cover with dry drsg [dressing] 3 x [times] wk [week] and PRN [as needed] . Further review showed no order to flush the nephrostomy tube or to monitor drainage. Review of the Electronic Treatment Record (ETAR) dated 8/2021-9/18/2021 showed the dressing for the left neprostomy were completed as ordered. Continued review showed no order to flush the nephrostomy tube or monitor drainage. Review of a Nurse Practitioner's note dated 9/13/2021 showed .Resident has nephrostomy tube to left lower back . Continued review showed no documentation of the description or the amount of drainage from the nephrostomy. Review of a Nurse's notes dated 9/16/2021, 9/17/2021 and 9/18/2021 showed .nephrostomy tube to left lower back . Continued review showed no documentation if the nephrostomy tube was patent, draining or the amount of drainage noted from nephrostomy. During an interview on 10/19/2021 at 2:30 PM, Registered Nurse (RN)#1 stated Resident #1 had a nephrostomy tube which at times .had trouble getting it to drain . He stated he did not keep track of the nephrostomy tube out-put. RN#1 stated he had to flush it (nephrostomy tube) a few times (unable to provide date received order and flushed the nephrostomy tube). He stated he called the nephrologist for an order to flush the nephrostomy tube.the order should be around somewhere . During a telephone interview on 10/20/2021 at 2:30 PM, with the Medical Director she stated the care of a nephrostomy tube is deferred to the Nephrologist for flushes and maintenance. During an interview on 10/20/2021 at 2:45 PM, Licensed Practical Nurse (LPN) #1 stated .We don't keep track of intake and output here . LPN #1 confirmed Resident #1's nephrostomy tube had sediment and she had to flush it. The LPN stated she called the nephrologist office and they instructed her to flush the nephrostomy tube with normal saline as needed (unable to provide date received order and flushed the nephrostomy tube). LPN #1 confirmed she did not document the order she received and there was not documentation the nephrostomy tube had been flushed. During an interview on 10/20/2021 at 2:35 PM, the Director of Nursing (DON) stated at this facility intake and output is not recorded unless there is a specific Physician's order. The DON stated it would be her expectation that nursing would monitor the nephrostomy tube, document the tube is draining, notify the Physician with any problems and document the information in the resident's chart. She stated there was not a Physician's order or documentation the nephrostomy was draining or the tube had been flushed by 2 nurses. She stated the nurses did not follow the facility's policy.

Based on medical record review and interview the facility failed to complete an accurate Discharge Minimum Data Set (MDS) Assessment for 1 resident (#48) of 3 residents reviewed for discharge. The findings include: Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].Patient to discharge home . Medical record review of the discharge summary note dated 8/19/19 revealed .Patient discharged home with daughter left per private vehicle . Medical record review of the Discharge MDS assessment dated [DATE] revealed .Discharge Status .Acute hospital . Interview with the MDS Coordinator on 9/25/19 at 3:16 PM, in the MDS office, confirmed Resident #48 had been discharged home and the Discharge MDS Assessment reflected an inaccurate discharge status.

Based on facility policy review, medical record review, and interview, the facility failed to address the risk for pain on the baseline care plan for 1 resident (#248) of 9 residents reviewed for pain of 28 residents sampled. The findings include: Review of the facility policy Baseline Care Plan issued 8/24/17 revealed .develop a baseline care plan .that incorporates the resident's goal, preferences, and services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being .provide effective person-sentered (centered) care of the resident that meet professional standards of care .update the baseline care plan as needed to reflect current needs until the comprehensive care plan is developed . Medical record review revealed Resident #248 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an incomplete 5 day Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of the baseline care plan dated 9/17/18 revealed no documentation of the risk for pain. Medical record review of the Physician's orders dated 9/14/18 revealed .[MEDICATION NAME] (pain medication) .tablet every 8 hours PRN (as needed) .pain . further review revealed .Pain assessment every shift . Medical record review of a Physician's orders dated 9/20/18 revealed .[MEDICATION NAME] (pain medication) prn pain . Medical record review of the Medication Administration Record [REDACTED]. Interview with Resident #248 on 9/24/18 at 2:31 PM, in the resident's room, revealed the resident had pain .I do .I have [MEDICAL CONDITION] spine disease . Interview with the Director of Nursing on 9/26/18 at 8:05 AM, in the conference room, confirmed the resident had complained of pain since admission and had received pain medication. Continued interview confirmed the facility failed to care plan the risk for pain on Resident #248's baseline care plan.

Based on medical record review, observation, and interview, the facility failed to follow physician's orders for 2 residents (#13, #248) of 28 residents sampled. The findings include: Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) (YEAR) Physician Orders revealed an order dated 8/6/18 .LLE (Left Lower Extremity) Boot to be worn for transfers and when OOB (Out Of Bed). (MONTH) remove for skin checks/therapy . Observation and interview with Resident #13 on 9/25/18 at 10:15 AM, revealed she wears her boot at bedtime, staff assist with transfers by placing the wheel chair next to the bed, put the walker in front of her, and she does most of the work to stand turn and sit on the bed, the staff have to lift her legs. Observation revealed the resident was sitting in the wheel chair and had tennis shoes on with no boot present. Observation and interview on 9/26/18 at 8:50 AM in Resident #13's room, revealed Certified Nurse Assistant (CNA) #1, CNA #2 and Restorative CNA #3 assisted Resident #13 to sit on the side of the bed, using a gait belt assisted her to stand, placed the walker in front of the resident, and with 2 CNA's using the gait belt the resident walked to the wheel chair and sat down. Interview with the 3 CNA's revealed Resident #13 only wears a boot when in bed. Further interview confirmed the resident did not have a boot on when transferring from the bed to the wheel chair. Interview with the Director Of Nursing and the Licensed Practical Nurse Unit Manager #1 on 9/26/18 at 9:22 AM, at the 100 hallway nurse's station confirmed the physician's order for the boot to be worn during transfers was not followed. Medical record review revealed Resident #248 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an incomplete 5 day Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of a Physician's order dated 9/18/18 revealed .[MEDICATION NAME] 50mg (milligrams) .(1tablet) po (by mouth) q (every) 4hrs prn (as needed) pain 1-5 (based on a pain scale of 1-10 with 1 being mild pain and 10 being the worst pain imaginable) .(2 tablets) .po q 4hrs prn pain 6-10 . Medical record review of a Physician's orders dated 9/20/18 revealed .[MEDICATION NAME] 50mg (1 tablet) po q 4hrs prn pain . Medical record review of the Medication Administration Record [REDACTED]. Further review revealed [MEDICATION NAME] 2 tablets had been administered 4 times since 9/20/18. Interview and observation with Resident #248 on 9/25/18 at 4:04 PM, in the resident's room, revealed the resident had requested pain medication due to current pain level of 6. Observation revealed Registered Nurse #1 entered the resident's room and administered 2 [MEDICATION NAME] tablets to Resident #248. Interview with the Director of Nursing on 9/26/18 at 8:05 AM, in the conference room, confirmed the MAR indicated [REDACTED].

Based on of facility policy review, facility documentation, and interviews the facility failed to maintain personal privacy and confidentiality of a medical record for 1 resident #5 of 3 residents reviewed for privacy. The findings included: Review of facility policy, Safeguarding and Storage of Medical Records, revised 8/1/08 revealed .The facility must maintain medical records .The medical record is a legal document that contains confidential resident information and should be safeguarded against loss, tampering, or unauthorized use at all times . Medical record review revealed resident #5 was admitted to the facility on [DATE] and discharged on [DATE] with the [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #5, revealed a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Review of the facility's documentation for the HIPPA Case File Breach dated 8/7/17 revealed .Date of Report 8/7/17 .Date of Alleged Incident 6/15/17 .Date case closed 8/15/17 .Details of Alleged Incident: A discharge audit was done on a medical record and it was found that the (MONTH) (YEAR) MAR's (Medication Administration Record) and TAR's (Treatment Administration Record) were missing from the record . Interview on 3/5/18 at 8:55 AM, with the Health Information Manager, in her office, revealed Health Information completed a discharge audit on all medical records when a resident was discharged from the facility. Continued interview confirmed when the audit was completed on Resident #5's medical record the MAR and TAR for (MONTH) (YEAR) were missing. Further interview revealed the MAR and TAR contained information including the resident's name, medical diagnoses, admitted , medication list, and the location of the facility he had resided. Interview on 3/5/18 at 10:45 AM, with Resident #5, via telephone revealed the facility had notified him of the missing information from his medical record. Continued interview revealed he had no issues as a result from the missing MAR and TAR from (MONTH) (YEAR). Interview on 3/5/18 at 2:43 PM, with the Executive Director, in the private dining room confirmed the MAR and TAR for (MONTH) (YEAR) were missing from Resident #5's medical record, and the facility failed to safeguard and protect the confidentiality and privacy contained in the medical record.

Based on medical record review, observation, and interview, the facility failed to revise a care plan for 1 (#26) resident with an immobilizer, of 26 residents reviewed, resulting in Harm to the resident. The findings included: Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 8/19/16 revealed .Knee Immobilizer R (Right) leg . Continued review revealed no interventions related to the assessment of the knee immobilizer. Medical record review of a Nurses Progress Note dated 8/27/16 revealed .pt (patient) was being bathed and 2 new wounds were found on the distal end of the calf. Wounds were approximately the size of a 50 cent piece. Wounds were covered by the knee immobilizer. (Physician) was notified .will continue to monitor for any changes .Addendum Clarification: MD (physician) intervention was to loosen brace . Medical record review of the Pressure Ulcer Status Record dated 8/29/16 revealed .Date first observed 8/29/16 Location RLE (Right Lower Extremity) (posterior-lateral aspect) stage unstageable 8 (length) x (by) 3.5 (width) cm (centimeters) depth 0 .Necrotic Tissue 100% .drainage small .color serous sanguinous . Medical record review of a physician's orders [REDACTED].New Tx (treatment) .R lower leg-posterior cl (clean)(with) (wound cleanser) apply Iodosorb cover (with) dry dsg (dressing) (change) QOD (every other day) (and) prn (as needed) . Observation with Registered Nurse (RN) #1 on 9/26/16 at 11:00 AM revealed the resident seated in a wheelchair in the resident's room with an immobilizer on the right lower extremity. Interview with the resident's physician on 9/28/16 at 12:05 PM, in the conference room, confirmed the physician expected staff to regularly assess the resident's immobilizer and skin for skin impairment. Interview with the Director of Nursing (DON) on 9/28/16 at 2:10 PM, in the conference room, confirmed the care plan had not been updated for the assessment of the knee immobilizer. The failure to care plan interventions to include assessment of the immobilizer and skin resulted in development of pressure ulcers. Refer to F-314

Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent development of pressure ulcers, failed to provide treatment of [REDACTED].#26) of 3 residents reviewed for pressure ulcers, of 26 residents reviewed, resulting in Harm to the resident. The findings included: Review of the facility policy Treatment Orders dated 2/25/15 revealed .the physician writes a treatment order that includes at least the following .Site of wound .Name of cleanser .Name of ointment .Type of dressing .Number of times to perform the treatment .The physician order is followed . Review of the facility policy Assessment of Wounds dated 2/25/16 revealed .It is the responsibility of a licensed nurse to complete the wound assessment and to document the findings .Include a description of the wound, including its physical characteristics, in the medical record . Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Weekly Skin Integrity Data Collection record dated 8/22/16 revealed no documentation of skin breakdown on the right lower posterior leg. Medical record review of a physical therapy note dated 8/22/16 revealed, .Therapist repositioning R (right) knee immobilized due to downward slipping of immobilizer, and poor positioning. Kne (knee) examined bby (by) both MD (physician) and therapist this date. [MEDICAL CONDITION] (swelling) continues to be present this date. After repositioning and securing of immobilizer . Medical record review of a Nurses Progress Note electronically signed by the nurse on 8/27/16 at 6:21 PM, revealed .pt (patient) was being bathed and 2 new wounds were found on the distal end of the calf. Wounds were approximately the size of a 50 cent piece. Wounds were covered by the knee immobilizer. (Physician) was notified and no new orders were given at this time, will continue to monitor for any changes . Further review revealed an addendum note electronically signed by the nurse on 8/29/16 at 1:36 AM., .Addendum Clarification: MD intervention was to loosen brace, not no new orders. Medical record review of a Rehabilitation Services Multidisciplinary Screening tool completed by the physical therapist on 8/29/16 revealed, Pt (patient) presents (with) wound to post/lat R LE (posterior lateral right lower extremity) measuring 8 x (by) 3.5 x 0 cm (centimeters) (with) 100% eschar to distal end of wound and SDTI (suspected deep tissue injury) to proximal end of wound. Wound is irregularly shaped (with) distinct borders. Minimal serousanguinal drainage noted from distal end of wound (minimal). Dr (name), Dr (name), Nsg (nursing) manager present for screen/assessment. Appears brace (R knee immobilizer) may have contributed to pressure .Advised foam dsg (dressing) can be used to provide padding from brace. Ed (educate) nsg staff & (and) pt/sitter on appropriate fitting of brace to maintain neutral alignment and reduce pressure . Medical record review of the Pressure Ulcer Status Record dated 8/29/16 revealed .Date first observed 8/29/16 (same wound as described in nurse progress notes dated 8/27/16) Location RLE (Right Lower Extremity) (posterior-lateral aspect) stage unstageable 8 (length) x 3.5 (width) cm (centimeters) depth 0 .Necrotic Tissue 100% .drainage small .color serous sanguinous . Medical record review of a physician's note dated 8/29/16 at 3:04 PM revealed, .(Resident #26) has developed a new wound on the lateral R lower leg under the immobilizer .The rigid bar along the side of the immobilizer may be contributing to these wounds. Continue local wound care. Attempt to adjust immobilizer . Medical record review of a Physician's Order dated 8/30/16 revealed .New Tx (treatment) R lower leg-posterior cl (clean) (with) (wound cleanser) apply Iodosorb cover (with) dry dsg (dressing) (change) QOD (every other day) (and) prn (as needed) . Medical record review of a Physician's Order dated 9/20/16 revealed .D/C (Discontinue) all previous tx orders RLE Posterior: cleanse (with) NSS (Normal Saline Solution), pat dry, apply Iodosorb, cover (with) dry dsg. (change) QOD (and) prn . Medical record review of the treatment administration record for September 2016 revealed .RLE Posterior: Cleanse (with) NSS, pat dry. Apply iodosorb, cover (with) dry dsg (change) QOD (and) prn . Continued review revealed the treatment record was initialed on 9/24/16, indicating wound care had been completed. Observation with Registered Nurse (RN) #1 on 9/26/16 at 11:00 AM, revealed the resident seated in a wheelchair in the resident's room. Continued observation revealed a dressing to the right lower extremity dated 9/22/16 (4 days prior). Interview with RN #1 on 9/26/16 at 11:10 AM, at the nursing station, confirmed the dressing was ordered to be changed every other day. Observation of Resident #26's wounds and interview with Licensed Practical Nurse #1 (LPN) on 9/26/16 at 12:15 PM, revealed LPN #1 described the wound on the posterior RLE as 2 areas, both 100% necrotic, with a small amount of brown drainage due to the product applied to the wounds. The wounds measured 3 cm (centimeters) length x 1.2 cm width x 0 cm depth and 3.8 cm width x 3 cm length x 0 cm depth. Medical record review of a nursing note dated 9/26/16 at 7:50 PM revealed, LE (late entry) for 9/24/16: RLE .cleanse and dressing change not done. First attempt, pt was not available and not willing to come into her room to have dressings changed. Second attempt, this nurse talked pt into a dressing change, but was called away to another patient. Interview with the Director of Nursing (DON) on 9/27/16 at 7:45 AM, in the DON's office, confirmed the treatment record was not to be signed prior to providing wound care and the dressing change had not been completed as documented on 9/24/16. Interview with Registered Nurse (RN) #2 (nurse who documented treatment completed on 9/24/16) on 9/27/16 at 2:05 PM, at the Nursing Station, confirmed RN #2 had signed the treatment record as having provided wound care, and had failed to provide treatment to the wound on 9/24/16. Interview with Physical Therapist (PT) #1 on 9/28/16 at 10:05 AM, in the PT department, confirmed the skin breakdown was caused by the knee immoblizer. Interview with the Physician on 9/28/16 at 12:05 PM, in the conference room, confirmed the physician would expect the staff to regularly assess the resident for skin impairment under the knee immobilizer. Interview with the DON on 9/28/16 at 2:10 PM, in the conference room, confirmed an assessment of the wounds on the right lower extremity was not completed to include the stage, size, and characteristics of the wound when identified on 8/27/16. In summary, the facility failed to provide adequate skin assessments and interventions to prevent development of pressure ulcers from Resident #26's knee immobilizer on 8/27/16. Upon discovery of the pressure ulcers, the facility failed to conduct and document a thorough assessment of the pressure ulcers, including stage, size, and character. After development of the pressure ulcers, the facility failed to follow orders for treatment every other day, resulting in a missed wound care treatment on 9/24/16 and the treatment not being done for 4 days.

Based on medical record review, observation, interview, and review of facility policy, the facility failed to ensure complete and accurate documentation in the medical record for 1 (#26) resident of 26 residents reviewed, resulting in Harm to Resident #26. The findings included: Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nurses Progress Note dated 8/27/16 revealed .pt (patient) was being bathed and 2 new wounds were found on the distal end of the calf. Wounds were approximately the size of a 50 cent piece. Wounds were covered by the knee immobilizer . Medical record review of the Pressure Ulcer Status Record dated 8/29/16 revealed .Date first observed 8/29/16 Location RLE (Right Lower Extremity) (posterior-lateral aspect) stage unstageable 8 (length) x 3.5 (width) cm (centimeters) depth 0 .Necrotic Tissue 100% .drainage small .color serous sanguinous . Medical record review of a physician's orders [REDACTED].D/C (Discontinue) all previous tx orders RLE Posterior: cleanse (with) NSS (Normal Saline Solution), pat dry, apply Iodosorb, cover (with) dry dsg (dressing) (change) QOD (every other day) (and) prn (as needed) . Medical record review of the treatment administration record for September 2016 revealed .RLE Posterior: Cleanse (with) NSS, pat dry. Apply iodosorb, cover (with) dry dsg (change) QOD (and) prn . Continued review of the treatment records revealed the treatment record was initialed on 9/24/16, indicating wound care had been completed. Observation with Registered Nurse (RN) #1 on 9/26/16 at 11:00 AM, revealed the resident seated in a wheelchair in the resident's room. Continued observation revealed a dressing to the right lower (RLE) extremity dated 9/22/16. Observation of Resident #26's wounds and interview with Licensed Practical Nurse #1 (LPN) on 9/26/16 at 12:15 PM, revealed LPN #1 described the wound on the posterior RLE as 2 areas, both 100% necrotic, with a small amount of brown drainage due to the product applied to the wounds. The wounds measured 3 cm (centimeters) length x 1.2 cm width x 0 cm depth and 3.8 cm width x 3 cm length x 0 cm depth. Medical record review of a nursing note dated 9/26/16 at 7:50 PM revealed, LE (late entry) for 9/24/16: RLE .cleanse and dressing change not done. First attempt, pt was not available and not willing to come into her room to have dressings changed. Second attempt, this nurse talked pt into a dressing change, but was called away to another patient. Interview with the Director of Nursing (DON) on 9/27/16 at 7:45 AM, in the DON's office, confirmed the treatment record was not accurate and the dressing change had not been completed as documented on 9/24/16. Interview with Registered Nurse (RN) #2 (nurse who documented treatment completed on 9/24/16) on 9/27/16 at 2:05 PM, at the Nursing Station, confirmed the wound care had not been completed on 9/24/16 as documented.

Based on facility policy review, medical record review, and interview, the facility failed to obtain a laboratory test as ordered for 1 resident (#165), of 5 residents reviewed for unnecessary medications, of 26 residents. The findings included: Review of facility policy Diagnostic Services, revised 06/2008, revealed .it is the primary purpose of diagnostic services to provide uniform procedures for obtaining necessary diagnostic services when ordered by the attending physician .all orders for diagnostic services will be promptly carried out as instructed by the physician's orders [REDACTED]. Medical record review revealed Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED].PTT (Partial [MEDICAL CONDITION] time, a blood test that looks at how long it takes for blood to clot) .monthly while on [MEDICATION NAME] (blood thinner) . Medical record review of a Laboratory Administration Record for the month of August 2016, revealed .PTT .monthly while on [MEDICATION NAME] .4th each month . Continued review revealed the administration record was initialed by staff with a completion date of 8/4/16. Medical record review revealed their were no results for the PTT that was documented as obtained 8/4/16. PTT results were available in the medical record for 7/26/16 and 9/1/16. Interview with the Regional Director of Clinical Services on 9/28/16 at 2:15 PM, in the conference room, confirmed the PTT was not completed as ordered by the physician.

Based on facility policy review, observation, and interview, the facility staff failed to wash or sanitize the hands during meal service in 1 of 4 dining areas observed. The findings included: Review of the facility's policy Hand Hygiene, revised 5/1/12, revealed Purpose To decrease the risk of transmission of infection by appropriate hand hygiene .Handwashing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections .If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations . Observation on 9/26/16 at 12:10 PM, of the 100 hall meal service, revealed Certified Nursing Assistant (CNA) #2 delivered a meal tray to a resident's room, adjusted the tray table, touched a wheelchair in the resident's room, exited the resident's room, and without washing the hands or using hand sanitizer, removed a meal tray from the meal cart. CNA #2 then delivered the tray to another resident's room, removed a laptop computer from the tray table, and without washing the hands or using hand sanitizer, removed another meal tray from the meal cart, then used the ice scoop to place ice in a glass, poured tea into the glass, and passed the tray to another staff member for delivery to a resident. Interview with the Director of Nursing on 9/28/16 at 7:50 AM, in the conference room, confirmed hand hygiene was not completed as required and the facility's policy was not followed.

Based on review of Lippincott Manual Nursing Practice, review of facility policy Physician's Orders/Transcription, Maintenance-Nursing, and Monthly Recaps (Physician's Recapitulation Orders), medical record review, review of facility investigation and interview, the facility failed to follow facility policy for transcribing medication orders, and reconciling physician's orders (Physician's Recapitulation Orders) with medication administration records to ensure no medication errors occurred. The facility's failure resulted in a significant medication error and placed 1 resident (#167) of 42 residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for immediate jeopardy. The Administrator, Director of Nursing, and Regional Director of Clinical Services, were informed of the situation which was detrimental to their health, safety, and welfare on 9/16/15 at 10:40 AM, in the Administrator's office. An extended survey was conducted on 9/16/15 through 9/17/15. The findings included: Review of Lippincott Manual of Nursing Practice, Ninth Edition, revealed, .Chapter 2 Standards of Care, Ethical and Legal Issues .Accountability .Maintaining familiarity of relevant, current facility policies, procedures, and regulations as they apply to the nurse's practice and specialty area .Examining the quality (accuracy and completeness) of documentation .Common Departures from the Standards of Nursing Care .failure to .follow physician orders, follow appropriate nursing measures .adhere to facility policy or procedure .administer medications as ordered . Review of facility policy, Physician's Orders/Transcription, revised 10/04 revealed .Proper channels of communication are used to ensure accurate delivery of medications to all residents .by using the Order Sheet, Telephone Order Form, Medication Administration Record (MAR) .Transcribing the orders: Write order .in the appropriate space and complete start order date .if order is for a limited time .enclose that time span in thick pen lines on the medication administration record. Record stop date .sign name and title and write date and time on order sheet indicating orders have been transcribed . Review of facility policy, Maintenance - Nursing, no date revealed .If the physician visits during the month, new orders should be written on telephone order slips in order to allow for a copy to be routed for processing . Review of facility policy, Monthly Recaps, no date revealed .On or about the 23rd of each month, HIM (Health Information Management) staff will input all current orders and medication/treatment administration records for the new month .Physician's orders (Physician's Recapitulation Orders), MARSs .are printed and routed to the nursing staff for review .A licensed nurse reviews and updates orders, MARs .it is important to review all three documents together to ensure accuracy. Reviewing and updating includes: Comparing the newly printed physician orders and current physician orders for updated orders, discontinued orders, or new orders .Comparing the newly printed medication and treatment records to the current records for updated orders, discontinued orders, or new orders. Also review for incorrect time codes or orders routed to the incorrect administration record .Review for old .Inactive orders that are no longer in effect .Comparing the physician orders to the medication records .In all the above, if there are revisions, they are to be made manually on the new month's physician orders or administration records . Medical record review revealed Resident #167 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician Telephone Order dated 7/25/15 at 6:45 PM, revealed .Venous Doppler of RLE (right lower leg) if not available on weekend then x-ray . Medical record review of a Patient Report revealed .Date of Service: 7/26/2015 .Clinical Information .Pain in limb .Procedure .Duplex Scan, Veins, Extremity, Unilat (unilateral)/Limited Study (venous doppler study) .Findings .There are clots noted within the right common femoral and femoral veins. There is decreased flow and compression within these vessels. The great saphenous vein has clot noted as well. No left leg clots are identified .Impressions Right Upper Leg [MEDICAL CONDITIONS]. Right Leg Superficial [MEDICAL CONDITION] .No Left Leg [MEDICAL CONDITION] . Medical record review of a Physician's Telephone Order dated 7/26/15 revealed .Xarelto (blood thinning drug) 15 mg. (milligram) 1 po (per mouth) BID (twice daily) x (times) 21 days then after 21 days begin .Xarelto 20 mg 1 po daily re (related to) R (right) lower ext (extremity) [MEDICAL CONDITION] . Medical record review of the MAR, dated July 2015 revealed .Xarelto 15 mg 1 PO BID x 21 days. After 21 days begin Xarelto 20 mg 1 PO daily re R lower [MEDICAL CONDITION] . Medical record review of the August 2015 Physician Orders (Physician's Recapitulation Orders) dated 7/30/15 and signed by Licensed Practical Nurse (LPN) #5 and LPN #6, revealed the order for Xarelto as written by the physician was transcribed (hand written) on the Recapitulation Orders. Medical record review of the MAR dated August 2015, revealed the Xarelto was listed on the MAR to be administered BID x 21 days with a stop date of 8/16/15. Continued review revealed the Xarelto was administered BID through 8/16/15. Further review revealed the Xarelto 20 mg 1 PO daily was not listed on the MAR to be administered and there was no documentation of the Xarelto 20 mg being administered from 8/17/15-8/31/15 (missing 15 doses). Medical record review of a Progress Note dated 8/3/15 revealed .history of newly diagnosed [MEDICAL CONDITION] of the right lower extremity, diagnosed [DATE] .Currently on Xarelto twice a day for 21 days and then reducing to once a day . Medical record review of a Progress Note dated 8/14/15, revealed .patient requires reevaluation of right lower extremity [MEDICAL CONDITION] for which she was recently started on Xarelto, tolerating it well . Medical record review of a Progress Note dated 8/25/15, revealed .has a right lower extremity [MEDICAL CONDITION] that she developed . Medical record review of the September 2015 Recapitulation Orders dated 8/31/15 signed by LPN #5 and LPN #9, revealed the order for Xarelto had not been transcribed to the Recapitulation Orders or the MAR on 8/31/15. Medical record review of a Physician Telephone Order dated 9/10/15, revealed .Clarification order Xarelto 20 mg 1 PO daily [MEDICAL CONDITION] . Medical record review of the MAR dated September 2015 revealed the Xarelto 20 mg was not listed on the MAR to be administered until 9/11/15. Continued review revealed the Xarelto 20 mg PO daily 1st dose was given on 9/11/15 (missing 10 doses). Medical record review of a Physician Telephone Order dated 9/14/15, revealed .Venous Doppler US (ultra sound) to RLE R/O (rule out) [MEDICAL CONDITION] physical limitations . Medical record review of a Physician Telephone Order dated 9/14/15 revealed .MD (Medical Doctor) notified of [MEDICAL CONDITION] results .Continue Xarelto 20 mg 1 tab (tablet) po daily . Review of facility investigation dated 9/10/15 revealed .Summary of Investigative Facts: pt (patient) didn't receive Xarelto medication was left off MAR. pt denied pain vs (vital signs) assessed stable WNLS (within normal limits) .MD notified no new orders at this time .Recommendations/Actions Taken .Nurse educate (in-serviced) on medication administration with 2 nurses to check during end of month change over .(signed by the Director of Nursing) Follow-Up: pt receive venous doppler study . Review of a Pharmacy Inventory Usage Report dated 7/1/15-9/15/15, revealed the Xarelto 15 mg was delivered to the facility on [DATE] (42 tablets) and Xarelto 20 mg (30 tablets) was delivered to the facility on [DATE] (returned to pharmacy by facility not administered) and 9/10/15 ( not given until 9/11/15). Review of a Witness Statement Form dated 9/16/15 revealed .I looked at the August MAR at Xarelto 15 mg tab 1 Po BID x 21 days that is my writing (signed by LPN #4) . Interview with LPN #5 on 9/15/15 at 8:10 AM, at the 300 Nurse's Station revealed the MD called the facility on 9/10/15 and questioned if the resident was being administered Xarelto. Continued interview revealed at this time the LPN discovered the resident had not received a dose of Xarelto since 8/16/15 and the Xarelto was transcribed to the August 2015 MAR incorrectly. Further interview revealed the Xarelto 15 mg 1 BID for 21 days was administered as ordered, the Xarelto 20 mg 1 daily was not transcribed to the MAR and was not administered until 9/11/15 when the MD questioned the nurse and resulted in the resident missing 25 doses of the Xarelto. Interview with LPN #5 on 9/15/15 at 10:00 AM, at the 300 Nurse's Station confirmed the LPN had been the first check on the August 2015 Physician Recapitulation Orders, had hand written the Xarelto order on the August 2015 Physician Recapitulation Orders and had failed to transcribe the order to the August 2015 MAR. Continued interview confirmed the LPN had also been the 1st check on the September 2015 Physician Recapitulation Orders, failed to discover the Xarelto had not been transcribed correctly on the August MAR, and failed to transcribe the Xarelto to the September 2015 Physician Recapitulation Orders or the September 2015 MAR. Interview with LPN #6 on 9/15/15 at 1:19 PM, in the Conference Room confirmed the LPN had been the 2nd check on the August 2015 Physician Recapitulation Orders and failed to discover the Xarelto had not been transcribed to the August 2015 MAR. Interview with HIM Director on 9/15/15 at 2:45 PM, in the Conference Room confirmed the telephone orders were entered into the system by the HIM department. Continued interview revealed the facility had a non licensed employee in the HIM Department a Certified Nurse Aide (CNA) completing the data entry for telephone orders and the (Director of Nursing )DON had trained the CNA on entering the data in the computer. Further interview revealed the facility does not have a system in place to identify if a telephone order has been entered into the facility's computer system. Interview with the DON on 9/15/15 at 3:00 PM, in the Conference Room revealed HIM picked up the copies of the telephone orders and entered the orders in the computer. The facility employed a CNA to perform data entry for the HIM Department and the data entry training provided to the CNA was performed by the DON. The DON requested HIM to print the monthly orders (Physician's Recapitulation Orders) at a designated time at the end of the month determined by the DON. The Unit Managers received the monthly orders for their individual units and was instructed to follow the Monthly Recap policy. The Monthly Recap policy was as follows: check the new orders with the old orders; compare the old MARS and new MARS; and check for any new orders written since the previous monthly Physician's Recapitulation Orders were printed. The DON would then assign other members of the Nursing Administration Team to provide the 2nd check of the monthly orders and MARS and the Nursing Administration Team was also instructed to follow the Monthly Recap policy. Telephone interview with the Corporate HIM Director on 9/15/15 at 3:25 PM, by telephone confirmed the Xarelto 15 mg BID x 21 days and Xarelto 20 mg daily dated 7/26/15 had not been entered in to the facility's computer system after the telephone order was received. Interview with LPN #9 on 9/15/15 at 4:00 PM, at the Nurse's Station confirmed the LPN had been the 2nd check on the September 2015 Recapitulation Orders and failed to discover the Xarelto had not been transcribed to the August MAR correctly, failed to discover the Xarelto had not been transcribed to the September 2015 Physician Recapitulation Orders or the MAR. Further interview revealed LPN #9 was not part of the Nursing Administration Team and had assisted with the monthly recap orders. Interview with the DON on 9/15/15 at 5:00 PM, confirmed the facility educated LPN #5 and LPN #9 on the Monthly Recap policy and procedure related to the transcription error of the Xarelto that resulted in a significant medication error for Resident #167. Interview with the Medical Director (MD) on 9/16/15 at 8:55 AM, in the Conference Room confirmed the Xarelto error was discovered when the daughter called the MD office and inquired about blood thinner medications. Continued interview revealed the MD telephoned the facility and discovered the medication had been omitted after the resident had received the 42 doses BID of the Xarelto. Further interview confirmed the resident had been placed on the Xarelto for .improve blood flow and ensure no embolic issues . The risk of not receiving the medication for 25 days would be .a clot could go to a lung or other parts of the body wherever it hits and cause problems . Continued interview revealed the MD ordered an ultrasound on 9/10/15 and revealed no changes from previous study and .the blood clot was still there . Interview with LPN #4 on 9/16/15 at 8:15 AM, on the 100 Hall confirmed the LPN transcribed the Xarelto 15 mg 1 po bid x 21 days on the August 2015 MAR. Continued interview revealed the Xarelto order had not been transcribed correctly onto the MAR and the LPN had failed to review the telephone order prior to the transcription of the order onto the MAR on August 1, 2015. Interview with the DON on 9/16/15 at 9:00 AM, in the Conference Room confirmed the Nursing Administration Team was responsible for the Physician's Recapitulation Orders to ensure the correct orders were placed on the Medication Administration Records to prevent medication errors. Continued interview revealed the facility had returned the Xarelto the pharmacy delivered on 8/15/15. In summary, investigation during the annual survey revealed the facility failed to ensure systems and processes were followed to prevent medication errors during transcriptions of the Physician's Telephone Orders and during the monthly recap process which resulted in a medication error and 25 missed doses of Xarelto which placed Resident #167 in Immediate Jeopardy. Review of the facility's medication error investigation dated 9/10/15 revealed the facility had not utilized the data from the investigation to address or to use the data to formulate strategies to prevent transcription errors and medication errors until 9/13/15. Review of the facility's policy revealed: .Maintenance-Nursing .new orders should be written on telephone order slips in order to allow for a copy to be routed for processing .Monthly Recaps .HIM staff will input all current telephone orders that have not been input into .computer .A licensed nurse reviews and updates the orders, MARs and TARs (Treatment Administration Records} .it is important to review all three documents together to ensure accuracy .if there are revisions, they are to be made manually on the new month's physician's orders (Physician's Recapitulation) or administration records (MAR).

Based on review of facility policy, medical record review, review of Pharmacy Inventory Usage Report, review of facility investigation, and interview, the facility failed to prevent a significant medication error. The facility's failure to ensure physician's orders [REDACTED].#167) of 42 residents reviewed of 58 residents sampled for medication errors and transcription errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause injury, harm, impairment of death). The Administrator, Director of Nursing and Regional Director of Clinical Services, were informed of the Immediate Jeopardy on 9/16/15 at 10:40 AM, in the Administrator's Office. The Immediate Jeopardy was effective 8/17/15 and is on going. An extended survey was conducted on 9/16/15 through 9/17/15. Substandard Quality of Care was cited at F309-J and F333-J. The findings included: Review of facility policy, physician's orders [REDACTED].Proper channels of communication are used to ensure accurate delivery of medications to all residents .by using the Order Sheet, Telephone Order Form, Medication Administration Record (MAR) .Transcribing the orders: Write order .in the appropriate space and complete start order date .if order is for a limited time .enclose that time span in thick pen lines on the medication administration record. Record stop date .sign name and title and write date and time on order sheet indicating orders have been transcribed . Review of facility policy, Maintenance - Nursing, no date revealed .If the physician visits during the month, new orders should be written on telephone order slips in order to allow for a copy to be routed for processing . Review of facility policy, Monthly Recaps, no date revealed .On or about the 23rd of each month, HIM (Health Information Management) staff will input all current orders and medication/treatment administration records for the new month .physician's orders [REDACTED].A licensed nurse reviews and updates orders, MARs .it is important to review all three documents together to ensure accuracy. Reviewing and updating includes: Comparing the newly printed physician orders [REDACTED].Comparing the newly printed medication and treatment records to the current records for updated orders, discontinued orders, or new orders. Also review for incorrect time codes or orders routed to the incorrect administration record .Review for old .Inactive orders that are no longer in effect .Comparing the physician orders [REDACTED].In all the above, if there are revisions, they are to be made manually on the new month's physician orders [REDACTED]. Medical record review revealed Resident #167 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician Telephone Order dated 7/25/15 at 6:45 PM, revealed .Venous Doppler of RLE (right lower leg) if not available on weekend then x-ray . Medical record review of a Patient Report revealed .Date of Service: 7/26/2015 .Clinical Information .Pain in limb .Procedure .Duplex Scan, Veins, Extremity, Unilat (unilateral)/Limited Study (venous doppler study) .Findings .There are clots noted within the right common femoral and femoral veins. There is decreased flow and compression within these vessels. The great saphenous vein has clot noted as well. No left leg clots are identified .Impressions Right Upper Leg [MEDICAL CONDITIONS]. Right Leg Superficial [MEDICAL CONDITION] .No Left Leg [MEDICAL CONDITION] . Medical record review of a Physician's Telephone Order dated 7/26/15 revealed .Xarelto (blood thinning drug) 15 mg (milligram) 1 po (per mouth) BID (twice daily) x (times) 21 days then after 21 days begin .Xarelto 20 mg 1 po daily re (related to) R (right) lower ext (extremity) [MEDICAL CONDITION] . Medical record review of the MAR, dated July 2015 revealed .Xarelto 15 mg 1 PO BID x 21 days. After 21 days begin Xarelto 20 mg 1 PO daily re R lower [MEDICAL CONDITION] . Medical record review of the August 2015 Physician's Recapitulation Orders dated 7/30/15 signed by Licensed Practical Nurse (LPN) #5 and LPN #6, revealed the order for Xarelto as written by the physician was transcribed (hand written) to the orders. Medical record review of the MAR dated August 2015 revealed the Xarelto was listed on the MAR to be administered BID x 21 days with a stop date of 8/16/15. Continued review revealed the Xarelto was administered BID through 8/16/15. Further review revealed the Xarelto 20 mg 1 PO daily was not listed on the MAR to be administered and there was no documentation of the Xarelto 20 mg being administered from 8/17/15-8/31/15. Medical record review of a Progress Note dated 8/3/15 revealed .history of newly diagnosed [MEDICAL CONDITION] of the right lower extremity, diagnosed [DATE] .Currently on Xarelto twice a day for 21 days and then reducing to once a day . Medical record review of a Progress Note dated 8/14/15 revealed .patient requires reevaluation of right lower extremity [MEDICAL CONDITION] for which she was recently started on Xarelto, tolerating it well . Medical record review of a Progress Note dated 8/25/15 revealed .has a right lower extremity [MEDICAL CONDITION] that she developed . Medical record review of the September 2015 Physician's Recapitulation Orders dated 8/31/15 signed by LPN #5 and LPN #9, revealed the order for Xarelto 20 mg daily had not been transcribed to the September Physician's Recapitulation Orders or the monthly MAR on 8/31/15. Medical record review of a Physician Telephone Order dated 9/10/15, revealed .Clarification order Xarelto 20 mg 1 PO daily [MEDICAL CONDITION] . Medical record review of the MAR dated September 2015 revealed the Xarelto 20 mg was not listed on the MAR to be administered until 9/11/15. Continued review revealed Xarelto 20 mg PO daily Re: [MEDICAL CONDITION] 1st dose given 9/11/15. Medical record review of a Physician Telephone Order dated 9/14/15 revealed .Venous Doppler US (ultrasound) to RLE R/O (rule out) [MEDICAL CONDITION] physical limitations . Medical record review of a Physician's Telephone Order dated 9/14/15 revealed .MD (Medical Doctor) notified of [MEDICAL CONDITION] results .Continue Xarelto 20 mg 1 tab (tablet) po daily . Review of the facility investigation dated 9/10/15 revealed .Summary of Investigative Facts: pt (patient) didn't receive Xarelto medication was left off MAR. pt denied pain vs (vital signs) assessed stable WNLS (within normal limits) .MD notified no new orders at this time .Recommendations/Actions Taken .Nurse educate on medication administration with 2 nurses to check during end of month change over .(signed by the Director of Nursing) Follow-Up: pt receive venous doppler study . Review of a Pharmacy Inventory Usage Report dated 7/1/15-9/15/15 revealed the Xarelto 15 mg was delivered to the facility on [DATE] (42 tablets) and Xarelto 20 mg (30 tablets) was delivered to the facility on [DATE] (facility returned to the pharmacy not administered) and 9/10/15 (1st dose administered 9/11/15). Review of a facility investigation Witness Statement Form dated 9/16/15, revealed .I looked at the August MAR at Xarelto 15 mg tab 1 Po BID x 21 days that is my writing (signed by LPN #4) . Interview with LPN #5 on 9/15/15 at 8:10 AM, at the 300 Nurse's Station revealed the MD called the facility on 9/10/15 and questioned if the resident was being administered Xarelto. Continued interview revealed the LPN discovered the resident had not received a dose of Xarelto since 8/16/15 and the Xarelto was transcribed to the August 2015 MAR incorrectly (did not include Xarelto 20 mg daily). Further interview revealed the Xarelto 15 mg 1 BID for 21 days was administered as ordered, the Xarelto 20 mg 1 daily was not transcribed to the MAR and was not administered until 9/11/15 when the MD questioned the nurse and resulted in the resident missing 25 doses of the Xarelto. Interview with LPN #5 on 9/15/15 at 10:00 AM, at the 300 Nurse's Station confirmed the LPN had been the first check on the August 2015 Physician's Recapitulation Orders, had hand written the Xarelto order on the August 2015 Physician's Recapitulation Orders and had failed to transcribe the order to the August 2015 MAR. Continued interview confirmed the LPN had also been the 1st check on the September 2015 Physician's Recapitulation Orders, failed to discover the Xarelto had not been transcribed correctly on the August MAR, failed to transcribe the Xarelto to the September 2015 Physician Recapitulation Orders or the September 2015 MAR. Interview with LPN #6 on 9/15/15 at 1:19 PM, in the Conference Room confirmed the LPN had been the 2nd check on the August 2015 Physician's Recapitulation Orders and failed to discover the Xarelto had not been transcribed to the August 2015 MAR. Interview with HIM Director on 9/15/15 at 2:45 PM, in the Conference Room confirmed the telephone orders were entered into the system by the HIM department. Continued interview revealed the facility had a non licensed employee in the HIM Department a Certified Nurse Aide (CNA) completing the data entry for telephone orders and the DON had trained the CNA on entering the data in the computer. Further interview revealed the facility does not have a system in place to identify if a telephone order has been entered into the facility's computer system. Interview with the DON on 9/15/15 at 3:00 PM, in the Conference Room revealed HIM picked up the copies of the telephone orders and entered the orders in the computer. The facility employed a CNA to perform data entry for the HIM Department and the data entry training provided to the CNA was performed by the DON. The DON requested HIM to print the monthly orders (Physician's Recapitulation Orders) at a designated time at the end of the month determined by the DON. The Unit Managers received the monthly orders for their individual units and was instructed to follow the Monthly Recap policy. The Monthly Recap policy was as follows: check the new orders with the old orders; compare the old MARS and new MARS; and check for any new orders written since the previous monthly Physician's Recapitulation Orders were printed. The DON would then assign other members of the Nursing Administration Team to provide the 2nd check of the monthly orders and MARS and the Nursing Administration Team was also instructed to follow the Monthly Recap policy. Telephone interview with the Corporate HIM Director on 9/15/15 at 3:25 PM, by telephone confirmed the Xarelto 15 mg BID x 21 days and Xarelto 20 mg daily dated 7/26/15 had not been entered in to the facility's computer system after the telephone order was received. Interview with LPN #9 on 9/15/15 at 4:00 PM, at the Nurse's Station confirmed the LPN had been the 2nd check on the September 2015 Recapitulation Orders and failed to discover the Xarelto had not been transcribed to the August MAR correctly, failed to discover the Xarelto had not been transcribed to the September 2015 Physician Recapitulation Orders or the MAR. Further interview revealed LPN #9 was not part of the Nursing Administartion Team and assisted with the monthly recap orders. Interview with the DON on 9/15/15 at 5:00 PM, confirmed the facility educated LPN #5 and LPN #9 on the monthly recap policy and procedure related to the transcription error of the Xarelto that resulted in a significant medication error for Resident #167. Interview with the Medical Director (MD) on 9/16/15 at 8:55 AM, in the Conference Room confirmed the Xarelto error was discovered when the daughter called the MD office and inquired about blood thinner medications. Continued interview revealed the MD phoned the facility and discovered the medication had been omitted after the resident had received the 42 doses BID of the Xarelto. Further interview confirmed the resident had been placed on the Xarelto for .improve blood flow and ensure no embolic issues . The risk of not receiving the medication for 25 days would be .a clot could go to a lung or other parts of the body wherever it hits and cause problems . Continued interview revealed the MD ordered an ultrasound on 9/10/15 and it revealed no changes from previous study and .the blood clot was still there . Interview with LPN #4 on 9/16/15 at 8:15 AM, on the 100 Hall confirmed the LPN transcribed the Xarelto 15 mg 1 po bid x 21 days on the August 2015 MAR. Continued interview revealed the Xarelto order had not been transcribed correctly onto the MAR and the LPN had failed to review the telephone order prior to the transcription of the order onto the MAR on August 1, 2015. Interview with the DON on 9/16/15 at 9:00 AM, in the Conference Room, confirmed the Nursing Administration Team was responsible for the Physician's Recapitulation Orders to ensure the correct orders were placed on the medication administration records to prevent medication errors. In summary, investigation during the annual survey revealed the facility failed to ensure systems and processes were followed to prevent medication errors during transcriptions of the Physician's Telephone Orders and during the monthly recap process which resulted in a medication error and 25 missed doses of Xarelto which placed Resident #167 in Immediate Jeopardy. Review of the facility's medication error investigation dated 9/10/15 revealed the facility had not utilized the data from the investigation to address or to use the data to formulate strategies to prevent transcription errors and medication errors until 9/13/15. Review of the facility's policy revealed: .Maintenance-Nursing .new orders should be written on telephone order slips in order to allow for a copy to be routed for processing .Monthly Recaps .HIM staff will input all current telephone orders that have not been input into .computer .A licensed nurse reviews and updates the orders, MARs and TARs (Treatment Administration Records} .it is important to review all three documents together to ensure accuracy .if there are revisions, they are to be made manually on the new month's physician's orders [REDACTED]. Refer to F281-J and F309-J.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to prevent a significant medication error. The facility's failure to ensure physician's orders (Physician's Recapitulation Orders) were transcribed accurately resulted in a significant medication error and the failure of the facility to transcribe orders correctly placed Resident #167 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause injury, harm, impairment of death) and failed to ensure Physician's Orders were followed for 6 resident's (#167, #303, #304, #37, #40, #198) of 42 residents reviewed for medication administration of 58 residents sampled. The Administrator, Director of Nursing, and Regional Director of Clinical Services, were informed of the Immediate Jeopardy on 9/16/15 at 10:40 AM, in the Administrator's office. The Immediate Jeopardy was effective 8/17/15 and is ongoing. Substandard Quality of Care was cited at F309-J. An extended survey was conducted on 9/16/15 and 9/17/15. The findings included: Review of facility policy, Physician's Orders/Transcription, revised 10/04 revealed .Proper channels of communication are used to ensure accurate delivery of medications to all residents .by using the Order Sheet, Telephone Order Form, Medication Administration Record (MAR) .Transcribing the orders: Write order .in the appropriate space and complete start order date .if order is for a limited time .enclose that time span in thick pen lines on the medication administration record. Record stop date .sign name and title and write date and time on order sheet indicating orders have been transcribed . Review of facility policy, Maintenance - Nursing, no date revealed .If the physician visits during the month, new orders should be written on telephone order slips in order to allow for a copy to be routed for processing . Review of facility policy, Monthly Recaps no date revealed .On or about the 23rd of each month, HIM (Health Information Management) staff will input all current orders and medication/treatment administration records for the new month .Physician's orders (Physician's Recapitulation Orders) , MARs .are printed and routed to the nursing staff for review .A licensed nurse reviews and updates orders, MARs .it is important to review all three documents together to ensure accuracy. Reviewing and updating includes: Comparing the newly printed physician orders and current physician orders for updated orders, discontinued orders, or new orders .Comparing the newly printed medication and treatment records to the current records for updated orders, discontinued orders, or new orders. Also review for incorrect time codes or orders routed to the incorrect administration record .Review for old .Inactive orders that are no longer in effect .Comparing the physician orders to the medication records .In all the above, if there are revisions, they are to be made manually on the new month's physician orders or administration records . Review of facility policy, Policies for Medication Administration, last revised on 4/2/13 revealed, All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis. Medical record review revealed Resident #167 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician Telephone Order dated 7/25/15 at 6:45 PM, revealed .Venous Doppler of RLE (right lower leg) if not available on weekend then x-ray . Medical record review of a Patient Report revealed .Date of Service: 7/26/2015 .Clinical Information .Pain in limb .Procedure .Duplex Scan, Veins, Extremity, Unilat (unilateral)/Limited Study (venous doppler study) .Findings .There are clots noted within the right common femoral and femoral veins. There is decreased flow and compression within these vessels. The great saphenous vein has clot noted as well. No left leg clots are identified .Impressions Right Upper Leg [MEDICAL CONDITIONS]. Right Leg Superficial [MEDICAL CONDITION] .No Left Leg [MEDICAL CONDITION] . Medical record review of a Physician's Telephone Order dated 7/26/15 revealed .Xarelto (blood thinning drug) 15 mg. (milligram) 1 po (per mouth) BID (twice daily) x (times) 21 days then after 21 days begin .Xarelto 20 mg 1 po daily re (related to) R (right) lower ext (extremity) [MEDICAL CONDITION] . Medical record review of the MAR, dated July 2015, revealed .Xarelto 15 mg 1 PO BID x 21 days. After 21 days begin Xarelto 20 mg 1 PO daily re R lower [MEDICAL CONDITION] . Medical record review of the August 2015 Recapitulation Orders dated 7/30/15 signed by Licensed Practical Nurse (LPN) #5 and LPN #6, revealed the order for Xarelto as written by the physician was transcribed (hand written) to the orders. Medical record review of the MAR dated August 2015 revealed the Xarelto was listed on the MAR to be administered BID x 21 days with a stop date of 8/16/15. Continued review revealed the Xarelto was administered BID through 8/16/15. Further review revealed the Xarelto 20 mg 1 PO daily was not listed on the MAR to be administered and there was no documentation of the Xarelto 20 mg being administered from 8/17/15-8/31/15 (15 days). Medical record review of a Progress Note dated 8/3/15 revealed .history of newly diagnosed [MEDICAL CONDITION] of the right lower extremity, diagnosed [DATE] .Currently on Xarelto twice a day for 21 days and then reducing to once a day . Medical record review of a Progress Note dated 8/14/15, revealed .patient requires reevaluation of right lower extremity [MEDICAL CONDITION] for which she was recently started on Xarelto, tolerating it well . Medical record review of a Progress Note dated 8/25/15, revealed .has a right lower extremity [MEDICAL CONDITION] that she developed . Medical record review of the September 2015 Recapitulation Orders dated 8/31/15 signed by LPN #5 and LPN #9, revealed the order for Xarelto 20 mg daily had not been transcribed to the Physician's Recapitulation Orders or MAR on 8/31/15. Medical record review of a Physician Telephone Order dated 9/10/15 revealed .Clarification order Xarelto 20 mg 1 PO daily [MEDICAL CONDITION] . Medical record review of the MAR dated September 2015 revealed the Xarelto 20 mg was not listed on the MAR to be administered until 9/11/15. Continued review revealed Xarelto 20 mg PO daily Re: [MEDICAL CONDITION] 1st dose given 9/11/15 (missing 10 doses). Medical record review of a Physician Telephone Order dated 9/14/15 revealed .Venous Doppler US (ultrasound) to RLE R/O (rule out) [MEDICAL CONDITION] physical limitations . Medical record review of a Physician Telephone Order dated 9/14/15 revealed .MD (Medical Doctor) notified of [MEDICAL CONDITION] results .Continue Xarelto 20 mg 1 tab (tablet) po daily . Review of facility investigation dated 9/10/15 revealed .Summary of Investigative Facts: pt (patient) didn't receive Xarelto medication was left off MAR. pt denied pain vs (vital signs) assessed stable WNLS (within normal limits) .MD notified no new orders at this time .Recommendations/Actions Taken .Nurse educate on medication administration with 2 nurses to check during end of month change over .(signed by the Director of Nursing) Follow-Up: pt receive venous doppler study . Review of a Pharmacy Inventory Usage Report dated 7/1/15-9/15/15 revealed the Xarelto 15 mg was delivered to the facility on [DATE] (42 tablets) and Xarelto 20 mg (30 tablets) was delivered to the facility on [DATE] (returned to the pharmacy not administered) and 9/10/15 (administered 1st dose 9/11/15). Review of a Witness Statement Form dated 9/16/15 revealed .I looked at the August MAR at Xarelto 15 mg tab 1 Po BID x 21 days that is my writing (signed by LPN #4) . Interview with LPN #5 on 9/15/15 at 8:10 AM, at the 300 Nurse's Station revealed the MD called on 9/10/15 and questioned if the resident was being administered Xarelto. Continued interview revealed at this time the LPN discovered the resident had not received a dose of Xarelto since 8/16/15 and the Xarelto was transcribed to the August 2015 MAR incorrectly. Further interview revealed the Xarelto 15 mg 1 BID for 21 days was administered as ordered, the Xarelto 20 mg 1 daily was not transcribed to the MAR and was not administered until 9/11/15 when the MD questioned the nurse and resulted in the resident missing 25 doses of the Xarelto. Interview with LPN #5 on 9/15/15 at 10:00 AM, at the 300 Nurse's Station, confirmed the LPN had been the first check on the August 2015 Physician Recapitulation Orders, had hand written the Xarelto order on the August 2015 Physician Recapitulation Orders and had failed to transcribe the order to the August 2015 MAR. Continued interview confirmed the LPN had also been the 1st check on the September 2015 Physician Recapitulation Orders, failed to discover the Xarelto had not been transcribed correctly on the August MAR, failed to transcribe the Xarelto to the September 2015 Physician Recapitulation Orders or the September 2015 MAR. Interview with LPN #6 on 9/15/15 at 1:19 PM, in the Conference Room confirmed the LPN had been the 2nd check on the August 2015 Physician Recapitulation Orders and failed to discover the Xarelto had not been transcribed to the August 2015 MAR. Interview with HIM Director on 9/15/15 at 2:45 PM, in the Conference Room confirmed the telephone orders were entered into the system by the HIM department. Continued interview revealed the facility had a non licensed employee in the HIM Department a Certified Nurse Aide (CNA) completing the data entry for telephone orders and the (Director of Nursing) DON had trained the CNA on entering the data in the computer. Further interview revealed the facility does not have a system in place to identify if a telephone order has been entered into the facility's computer system. Interview with the DON on 9/15/15 at 3:00 PM, in the Conference Room revealed HIM picked up the copies of the telephone orders and entered the orders in the computer. The facility employed a CNA to perform data entry for the HIM Department and the data entry training provided to the CNA was performed by the DON. The DON requested HIM to print the monthly orders (Physician's Recapitulation Orders) at a designated time at the end of the month determined by the DON. The Unit Managers received the monthly orders for their individual units and was instructed to follow the Monthly Recap policy. The Monthly Recap policy was as follows: check the new orders with the old orders; compare the old MARS and new MARS; and check for any new orders written since the previous monthly Physician's Recapitulation Orders were printed. The DON would then assign other members of the Nursing Administration Team to provide the 2nd check of the monthly orders and MARS and the Nursing Administration Team was also instructed to follow the Monthly Recap policy. Telephone interview with the Corporate HIM Director on 9/15/15 at 3:25 PM, by telephone confirmed the Xarelto 15 mg BID x 21 days and Xarelto 20 mg daily dated 7/26/15 had not been entered in to the facility's computer system after the telephone order was received. Interview with LPN #9 on 9/15/15 at 4:00 PM, at the Nurse's Station, confirmed the LPN had been the 2nd check on the September 2015 Recapitulation Orders failed to discover the Xarelto had not been transcribed to the August MAR correctly, and failed to discover the Xarelto had not been transcribed to the September 2015 Physician Recapitulation Orders or the MAR. Interview with the DON on 9/15/15 at 5:00 PM, confirmed the facility educated LPN #5 and LPN #9 on the monthly recap policy and procedure related to the transcription error of the Xarelto. Interview with the Medical Director (MD) on 9/16/15 at 8:55 AM, in the Conference Room confirmed the Xarelto error was discovered when the daughter called the MD office and inquired about blood thinner medications. Continued interview revealed the MD telephoned the facility and discovered the medication had been omitted after the resident had received the 42 doses BID of the Xarelto. Further interview confirmed the resident had been placed on the Xarelto to .improve blood flow and ensure no embolic issues . The risk of not receiving the medication for 25 days would be .a clot could go to a lung or other parts of the body wherever it hits and cause problems . Continue interview revealed the MD ordered an ultrasound on 9/10/15 and it revealed no changes from previous study and .the blood clot was still there . Interview with LPN #4 on 9/16/15 at 8:15 AM, on the 100 Hall, confirmed the LPN transcribed the Xarelto 15 mg 1 po bid x 21 days on the August 2015 MAR. Continued interview revealed the Xarelto 20 mg daily had not been transcribed correctly onto the MAR and the LPN had failed to review the telephone order prior to the transcription of the order onto the MAR on August 1, 2015. Interview with the DON on 9/16/15 at 9:00 AM, in the Conference Room confirmed the Nursing Administration Team was responsible for the Physician's Recapitulation Orders to ensure the correct orders were placed on the Medication Administration Records to prevent medication errors. In summary, investigation during the annual survey revealed the facility failed to ensure systems were in place to prevent medication errors during transcriptions of the physician's telephone orders and during the monthly recap process which resulted in a medication error and 25 missed doses of Xarelto which placed Resident #167 in Immediate Jeopardy. Review of the facility's medication errors investigations prior to this error revealed the facility had not utilized data from the investigations to address or to use the data to formulate strategies to prevent transcription errors and medication errors. Review of the facility's policy revealed: .Maintenace-Nursing .new orders should be written on telephone order slips in order to all for a copy to be routed for processing .Monthly Recaps .HIM staff will input allow current telephone orders that have not been input into .computer .A licensed nurse reviews and updates the orders, MARs and TARs (Treatment Administration Records) .it is important to review all three documents together to ensure accuracy .if there are revisions, they are to be made manually on the new month's physician's orders (Physician's Recapitulation) or administration records (MAR). Medical record review of Resident #167 revealed a Urine Culture dated 7/19/15, revealed the specimen was sensitive to [MEDICATION NAME] (antibiotic), faxed to the facility on [DATE] at 5:18 PM, and signed by the Physician on 7/20/15. Medical record review of a Physician's Order dated 7/20/15 at 10:00 AM, revealed .Cipro 500 mg 1 PO BID x 5 days DX: UTI (urinary tract infection) . Medical record review of the MAR dated 7/2015 revealed the first dose [MEDICATION NAME] given on 7/21/15 at 9:00 AM. Interview with RN #2 on 9/14/15 at 5:15 PM, in the Conference Room confirmed the RN transcribed the order for Resident #167 and stated .I should have started it immediately . Medical record review of a Pharmacy Consultation Report for Resident #167 dated 8/11/15, revealed .Please consider discontinuing Acetaminnophen/[MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) (sleeping aide) .Physician's Response: I accept .8/14/15 . Medical record review of the August 2015 and September 2015 MARs revealed the Acetaminnophen/[MEDICATION NAME] was transcribed on the MARS and had not been discontinued on 8/14/15. Interview with LPN #4 on 9/14/15 at 2:50 PM, on the 300 Hall, confirmed the Acetaminnophen/[MEDICATION NAME] for Resident #167 was transcibed on the September 2015 MAR, no doses had been administered, and the Acetaminnophen/[MEDICATION NAME] was available on the medication cart for resident use. Interview with the DON on 9/14/15 at 5:00 PM, in the Conference Room, confirmed the facility failed to follow the Physician's orders to discontinue the Acetaminnophen/[MEDICATION NAME]. Medical record review revealed Resident #303 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician's Recapitulation Orders dated September 2015 revealed .[MEDICATION NAME] (blood thinner) 150 mg PO BID . Medical record review of the MAR dated September 2015 revealed no dose given on 9/10/15 at 9:00 PM and .No [MEDICATION NAME] available in stock will order . Interview with LPN #5 on 9/16/15 at 7:43 AM, on the 300 Hall confirmed the resident missed 1 dose of the [MEDICATION NAME] 150 mg. Interview with LPN #8 on 9/16/15 at 7:50 AM, on the 300 Hall revealed the medication was on the cart in a box not in a blister pack. Further interview confirmed .I reordered the medication not realizing it was on the cart . Medical record review revealed Resident #304 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the September 2015 Physician's Recapitulations Orders revealed .[MEDICATION NAME] 40 mg .daily . Medical record review of the MAR dated September 2015 revealed the first dose of the [MEDICATION NAME] 40 mg was given on September 14, 2015 (1 day later). Interview with LPN #5 on 9/16/15 at 7:43 AM, at the 300 Hall Nurses Station confirmed the facility failed to administer the [MEDICATION NAME] as ordered and the Resident missed 1 dose. Medical record review revealed Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was diagnosed on [DATE] with a Urinary Tract Infection. Review of the MAR for 4/2015 revealed the facility failed to administer [MEDICATION NAME] (an antibiotic) 500 milligram (mg.) orally once daily, on 4/12/15, 4/13/15, 4/14/15, and 4/15/15. Interview with the Director of Nursing (DON), on 9/16/15 at 5:00 PM, in the DON's office confirmed the facility failed to administer the 4 antibiotic doses. Medical record review revealed Resident #40 was admitted on [DATE] with [DIAGNOSES REDACTED]. He was discharged home on[DATE]. Review of Resident #40's MAR for 5/2015 revealed the facility failed to administer [MEDICATION NAME] (an anticoagulant, to keep blood from clotting) 3 mg. tablet daily, on 5/9/15. Interview with the Director of Nursing (DON), on 9/16/15 at 5:00 PM, in the DON's office, confirmed the facility failed to administer the 1 dose of the anticoagulant. Medical record review revealed Resident #198 was admitted on [DATE] with [DIAGNOSES REDACTED]. She was discharged home on[DATE]. Review of Resident #198's Medication Administration Record (MAR) for 4/2015 revealed the facility failed to administer Eliquis (an anticoagulant, to keep blood from clotting) 2.5 mg orally twice a day, on 4/5/15 and 4/6/15. The second doses of the 4/5/15 and 4/6/15 were not administered due to a transcription error on the MAR. Interview with the Director of Nursing (DON), on 9/16/15 at 5:00 PM, in the DON's office, confirmed the facility failed to transcribe the order accurately to the MAR which resulted in a medication administration error.

Based on medical record review, review of facility investigation, review of Nursing Educational Inservice, and interview, the facility failed to ensure 1 resident (#69) was free from falls resulting in harm of 3 residents reviewed for falls of 59 residents sampled. The findings included: Medical record review revealed Resident #69 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Fall Risk Evaluation dated prior to the fall on 3/27/15 revealed the resident scored a high risk for falls. Medical record review of a 30 day Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and required extensive assist of 1 for bed mobility. Medical record review of a Nursing Note dated 5/23/15 at 3:20 AM, revealed CNA (certified nurse aide) called for nurse and stated client (resident) rolled out of bed . Medical record review of a Physician's Telephone Order dated 5/22/15 revealed .Send to .ER (emergency room ) for evaluation and treatment if necessary . Review of a facility investigation dated 5/23/15 revealed .CNA #2 was providing incontinence care when the CNA turned her back to reach for the brief .pt (patient) rolled to the right side off the bed . Review of facility Nursing Educational Inservice dated 5/26/15 revealed .When providing care to patients (residents) in bed, please gather necessary supplies .prior to providing care and never turn you back or walk away from the resident at any time to ensure that the patient does not roll or fall out of the bed and receive injury . Review of the facility investigation dated 5/28/15 revealed .On 5/23/15 Resident fell from bed onto floor during CNA providing incontinent care; as CNA reached for brief, the resident rolled out of bed resulting in R (right) hip Fx (fracture) . Medical record review of a Progress Note dated 6/9/15 revealed .she fell from her bed and suffered a right hip fracture which required surgical intervention . Telephone interview with CNA #2 on 9/14/15 at 6:40 PM, by telephone revealed the resident was lying on the edge of the bed, on the right side, the CNA turned to get a different brief, took her hand off the resident, the residents feet started to slip off the bed and the resident fell to the floor. Continued interview with CNA #2 confirmed .I was unable to stop the fall . Interview with the resident on 9/15/15 at 8:00 AM, in the resident's room revealed the resident did not recall the fall only what the daughter and others had told her .I know I was very sick and they tried to give up on me but my daughter would not let them and here I am . Interview with DON and the Corporate Nurse on 9/15/15 at 9:05 AM, in the DON office confirmed the resident fell on [DATE] and fractured the right hip. Continued interview revealed CNA #2 was providing incontinence care, turned to get a brief, and the resident fell to the floor resulting in a right hip fracture (harm) requiring hospitalization for surgical intervention. Further interview confirmed the DON stated .the CNA should have had the supplies with her .