The facility identified a census of 46 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to maintain safe and comfortable temperature levels for residents in the facility. On 11/22/24, Administrative Staff B received reports that one of the halls was cold. Administrative Staff B arranged for a maintenance company to assess the problem and a part was required for repair. The part was set to come in on 11/26/24. The facility supplied extra blankets and residents wore their coats inside but reported being extremely cold and experiencing physical discomfort over the weekend and on 11/25/24. On 11/26/24 around 10:00 AM, surveyor observation revealed temperatures on one hall as low as 46.9 degrees Fahrenheit (F.) Multiple temperatures were assessed between 10:10 AM and 10:15 AM with temperatures measuring in the mid to high 40s and low 50's. Multiple residents reported feeling very cold and were unable to go about daily activities due to the cold. No additional heat was provided from 11/22/24 through 12:00 PM on 11/26/24. This failure placed all affected residents in immediate jeopardy. Findings included: - During the initial tour of the facility on 11/26/24 the survey team noted the hall referred to as Long Hall was colder than the rest of the facility. The exit door had a rolled blanket at the base of the door. Both staff and residents reported cold temperatures in the hall. On 11/26/24 at 08:15 AM, Resident (R) 2 sat in his recliner with two blankets pulled up around his neck, and cool air blowing from the ceiling vent. R2 stated he was cold and wished the facility would get the heating fixed. R2 reported his room had been cold for two weeks. On 11/26/24 at 08:33 AM, R1 greeted the surveyor in the hallway as he came from the dining room. R1 reported his room had been cold for two weeks, and stated, You ought to try living with the temperature so cold, and indicated discomfort with the room temperature. R1 stated he reported the room temperature to the maintenance personnel, but the maintenance personnel's employment at the facility ended on 11/15/24. On 11/26/24 at 08:35 AM, R3 rested in bed with blankets pulled up to his neck and stated he was cold. On 11/26/24 at 09:15 AM, R4 sat on her bed watching TV while wearing a jacket. R4 reported her room had been cold for two weeks and she felt ill due to the room being so cold. R4 reported she told numerous staff about the room temperature. R2 also stated the staff used the outside door next to her room which let cold air into the building. On 11/26/24 at 09:45 AM, R5 lay in bed with a winter coat and comforter on. When asked if R5 was cold, she nodded yes. On 11/26/24 at 09:50 AM, R6 reported her room temperature was cold. On 11/26/24 at 09:55 AM, R7 stated she reported her room was cold and the facility did not have enough blankets. R7 stated she remained in bed because it was warmer than sitting in her wheelchair. R7 stated the facility staff reported the heating would be fixed that day. On 11/26/24 at 10:10 AM, the following room temperatures were obtained: R1 and R2's shared room was 46.9 degrees F. R4 and R20's shared room was 48.6 degrees F. R8 and R14's shared room was 49.2 degrees F. R9 and R10's shared room was 54.9 degrees F. R11 and R12's shared room was 55.2 degrees F. On 11/26/24 at 10:15 AM the following room temperatures were obtained: R13 and R21's shared room was 52.7 degrees F. R17 and R22's shared room was 60 degrees F. On 11/26/24 at 12:00 PM, the following temperatures were obtained: R5 and R15's shared room was 60 degrees F. R6 and R7's shared room was 59 degrees F. R23 and R24's shared room was 60 degrees F. The Weather Underground documented the following temperatures from 11/22/24 through 11/26/24 during the timeframes no additional heating was provided by the facility: On 11/22/24, the low was 25 degrees F at 06:00 AM and the high was 49 degrees F at 04:00 PM. On 11/23/24, the low was 28 degrees F at 03:00 PM and the high was 61 degrees F at 03:00 PM. On 11/24/24, the high was 66 degrees F at 04:00 PM and the low was 43 degrees F at 11:50 PM. On 11/25/24, the high was 43 degrees F at 03:30 PM and the low was 22 degrees F at 11:50 PM. On 11/26/24, the temperature was 23 degrees F at 08:00 AM and 36 degrees F at 10:00 AM. On 11/26/24 at 09:20 AM, Certified Medication Aide (CMA) R stated the residents of Long Hall reported being cold. CMA R stated someone came and looked at the heating on 11/22/24 and she thought the heat was scheduled to be repaired today. CMA R reported staff provided the residents with double blankets and left their room doors open to the hallway for warmth. CMA R said staff encouraged the residents to sit near the center of the facility for the warmer temperatures. On 11/26/24 at 10:05 AM, Licensed Nurse (LN) G stated the facility had enough blankets to give extra to the residents who wanted one. LN G stated she heard about the cold temperatures inside the facility at the end of the previous week. On 11/26/24 at 10:20 AM, Administrative Staff B stated the staff reported that Long Hall was cooler than the other halls and she contacted a company to come out and check the problem on Friday, 11/22/24. Administrative Staff B said the contracted company ordered a part and the part would arrive, and the heating problem would be repaired on 11/26/24. Administrative Staff B measured some room temperatures with the surveyor. Administrative Staff B verified the room temperatures in R8 and R14's shared room as 53.7 degrees F, R4 and R20's shared room was 48.6 degrees F, R1 and R2's shared room was 46.9 degrees F, and R13 and R21's shared room was 53.7 degrees F. Administrative Staff B stated the room temperatures were alarming and that she would contact the repair company to have them come and fix the problem as soon as possible. She added that she thought the company would be at the facility by noon that day. The facility's Quality of Life-Homelike Environment policy, dated 10/2009, directed the facility to provide residents with a safe, clean, comfortable, and homelike environment. The policy directed the facility staff and management to maximize, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting which included comfortable temperatures. On 11/26/24 at 01:03 PM, Administrative Staff B received a copy of the Immediate Jeopardy [IJ] template and was informed of the facility's failure to maintain the appropriate required temperatures to ensure a safe and comfortable environment placed the affected residents in IJ. On 11/26/24 at 04:16 PM, the facility submitted an acceptable plan for corrective actions to remove the immediacy. The plan documented the following actions: The facility purchased safe-touch space heaters to provide additional heat. Staff were assigned to monitor the space heaters continuously. The facility audited the number of available blankets and purchased additional blankets to ensure availability to any resident who wanted or needed one. Ambient temperatures were assessed hourly until the temperature reached 71 degrees F. Staff interviewed residents every hour to assess resident comfort and provide additional blankets until residents expressed comfort. The part for the heater was ordered on 11/22/24 and expected to arrive at the facility on 11/27/24. The corrective actions and subsequent temperatures were verified onsite. After the removal of the immediacy, the deficient practice remained at the scope and severity of H to represent the actual physical discomfort as well as the psychosocial impact for the residents unable to self-identify or express their feelings.
Every finding on record at Tanglewood Nursing & Rehabilitation
Topeka, Kansas · CCN 175463
42 findings across 11 inspections, in the inspector's own words, 25 of them at actual harm or above.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Inspection of October 17, 2024
20 findingsThe facility identified a census of 46 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to maintain safe and comfortable temperature levels for residents in the facility. On 11/22/24, Administrative Staff B received reports that one of the halls was cold. Administrative Staff B arranged for a maintenance company to assess the problem and a part was required for repair. The part was set to come in on 11/26/24. The facility supplied extra blankets and residents wore their coats inside but reported being extremely cold and experiencing physical discomfort over the weekend and on 11/25/24. On 11/26/24 around 10:00 AM, surveyor observation revealed temperatures on one hall as low as 46.9 degrees Fahrenheit (F.) Multiple temperatures were assessed between 10:10 AM and 10:15 AM with temperatures measuring in the mid to high 40s and low 50's. Multiple residents reported feeling very cold and were unable to go about daily activities due to the cold. No additional heat was provided from 11/22/24 through 12:00 PM on 11/26/24. This failure placed all affected residents in immediate jeopardy. Findings included: - During the initial tour of the facility on 11/26/24 the survey team noted the hall referred to as Long Hall was colder than the rest of the facility. The exit door had a rolled blanket at the base of the door. Both staff and residents reported cold temperatures in the hall. On 11/26/24 at 08:15 AM, Resident (R) 2 sat in his recliner with two blankets pulled up around his neck, and cool air blowing from the ceiling vent. R2 stated he was cold and wished the facility would get the heating fixed. R2 reported his room had been cold for two weeks. On 11/26/24 at 08:33 AM, R1 greeted the surveyor in the hallway as he came from the dining room. R1 reported his room had been cold for two weeks, and stated, You ought to try living with the temperature so cold, and indicated discomfort with the room temperature. R1 stated he reported the room temperature to the maintenance personnel, but the maintenance personnel's employment at the facility ended on 11/15/24. On 11/26/24 at 08:35 AM, R3 rested in bed with blankets pulled up to his neck and stated he was cold. On 11/26/24 at 09:15 AM, R4 sat on her bed watching TV while wearing a jacket. R4 reported her room had been cold for two weeks and she felt ill due to the room being so cold. R4 reported she told numerous staff about the room temperature. R2 also stated the staff used the outside door next to her room which let cold air into the building. On 11/26/24 at 09:45 AM, R5 lay in bed with a winter coat and comforter on. When asked if R5 was cold, she nodded yes. On 11/26/24 at 09:50 AM, R6 reported her room temperature was cold. On 11/26/24 at 09:55 AM, R7 stated she reported her room was cold and the facility did not have enough blankets. R7 stated she remained in bed because it was warmer than sitting in her wheelchair. R7 stated the facility staff reported the heating would be fixed that day. On 11/26/24 at 10:10 AM, the following room temperatures were obtained: R1 and R2's shared room was 46.9 degrees F. R4 and R20's shared room was 48.6 degrees F. R8 and R14's shared room was 49.2 degrees F. R9 and R10's shared room was 54.9 degrees F. R11 and R12's shared room was 55.2 degrees F. On 11/26/24 at 10:15 AM the following room temperatures were obtained: R13 and R21's shared room was 52.7 degrees F. R17 and R22's shared room was 60 degrees F. On 11/26/24 at 12:00 PM, the following temperatures were obtained: R5 and R15's shared room was 60 degrees F. R6 and R7's shared room was 59 degrees F. R23 and R24's shared room was 60 degrees F. The Weather Underground documented the following temperatures from 11/22/24 through 11/26/24 during the timeframes no additional heating was provided by the facility: On 11/22/24, the low was 25 degrees F at 06:00 AM and the high was 49 degrees F at 04:00 PM. On 11/23/24, the low was 28 degrees F at 03:00 PM and the high was 61 degrees F at 03:00 PM. On 11/24/24, the high was 66 degrees F at 04:00 PM and the low was 43 degrees F at 11:50 PM. On 11/25/24, the high was 43 degrees F at 03:30 PM and the low was 22 degrees F at 11:50 PM. On 11/26/24, the temperature was 23 degrees F at 08:00 AM and 36 degrees F at 10:00 AM. On 11/26/24 at 09:20 AM, Certified Medication Aide (CMA) R stated the residents of Long Hall reported being cold. CMA R stated someone came and looked at the heating on 11/22/24 and she thought the heat was scheduled to be repaired today. CMA R reported staff provided the residents with double blankets and left their room doors open to the hallway for warmth. CMA R said staff encouraged the residents to sit near the center of the facility for the warmer temperatures. On 11/26/24 at 10:05 AM, Licensed Nurse (LN) G stated the facility had enough blankets to give extra to the residents who wanted one. LN G stated she heard about the cold temperatures inside the facility at the end of the previous week. On 11/26/24 at 10:20 AM, Administrative Staff B stated the staff reported that Long Hall was cooler than the other halls and she contacted a company to come out and check the problem on Friday, 11/22/24. Administrative Staff B said the contracted company ordered a part and the part would arrive, and the heating problem would be repaired on 11/26/24. Administrative Staff B measured some room temperatures with the surveyor. Administrative Staff B verified the room temperatures in R8 and R14's shared room as 53.7 degrees F, R4 and R20's shared room was 48.6 degrees F, R1 and R2's shared room was 46.9 degrees F, and R13 and R21's shared room was 53.7 degrees F. Administrative Staff B stated the room temperatures were alarming and that she would contact the repair company to have them come and fix the problem as soon as possible. She added that she thought the company would be at the facility by noon that day. The facility's Quality of Life-Homelike Environment policy, dated 10/2009, directed the facility to provide residents with a safe, clean, comfortable, and homelike environment. The policy directed the facility staff and management to maximize, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting which included comfortable temperatures. On 11/26/24 at 01:03 PM, Administrative Staff B received a copy of the Immediate Jeopardy [IJ] template and was informed of the facility's failure to maintain the appropriate required temperatures to ensure a safe and comfortable environment placed the affected residents in IJ. On 11/26/24 at 04:16 PM, the facility submitted an acceptable plan for corrective actions to remove the immediacy. The plan documented the following actions: The facility purchased safe-touch space heaters to provide additional heat. Staff were assigned to monitor the space heaters continuously. The facility audited the number of available blankets and purchased additional blankets to ensure availability to any resident who wanted or needed one. Ambient temperatures were assessed hourly until the temperature reached 71 degrees F. Staff interviewed residents every hour to assess resident comfort and provide additional blankets until residents expressed comfort. The part for the heater was ordered on 11/22/24 and expected to arrive at the facility on 11/27/24. The corrective actions and subsequent temperatures were verified onsite. After the removal of the immediacy, the deficient practice remained at the scope and severity of H to represent the actual physical discomfort as well as the psychosocial impact for the residents unable to self-identify or express their feelings.
The facility had a census of 49 residents. The sample included 13 residents of which seven were reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure fall prevention interventions, including a floor mat, were utilized for Resident (R) 45. R45 subsequently had a fall, which resulted in a right femur non-displaced femoral (thigh bone) neck fracture. The facility further failed to ensure R17's WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) was in place and functioning. These deficient practices placed the resident at risk of accidents and related injuries. Finding included: - R45's Electronic Medical Record (EMR) documented diagnoses of acute respiratory failure with hypoxia (inadequate supply of oxygen), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), altered mental status, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), other mechanical complication of cystostomy catheter (urinary bladder catheter inserted through the abdomen into the bladder), urinary tract infection, obstructive and reflux uropathy (disorder or urinary tract), a disorder of bone density and structure, muscle weakness, and lack of coordination. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R45 had intact cognition, exhibited no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or behaviors. R45 was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. R45 required partial/moderate assistance with upper body dressing, and substantial/maximal assistance with personal hygiene, bed mobility, standing, and transfers. The MDS further documented R45 had an indwelling catheter and was always incontinent of bowel. R45 received as needed pain medication and had pain that occasionally affected sleep, day-to-day activities, and therapy. R45 had shortness of breath with exertion and lying flat, had oxygen therapy, a non-invasive mechanical ventilator, and speech, occupational, physical, and respiratory therapy. R45 had surgical wound care and received an antidepressant (a class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain) medications in the look back period. R45's Care Plan, dated 07/08/24, documented R45 was at risk for falls related to incontinence. The care plan directed staff to anticipate and meet R45's needs and be sure her call light was within reach. The plan encouraged the resident to use the call light for assistance as needed, directed staff to respond promptly to all requests for assistance, and ensure a safe environment with floors free from spills and clutter, ensure adequate light, ensure the bed in a low position, and ensure personal items were within reach. The Progress Note, dated 07/21/24 at 10:18 AM, documented at 06:15 AM, R45 was yelling and found on her left side, next to her low bed, with her oxygen off. She had blood all over her face and on the ground. It looked like she hit her face on the oxygen concentrator. A towel was placed on the resident's face and vital signs were assessed. Staff called 911 and sent R45 to the hospital. The note further documented that R45's responsible party was notified and the representative asked that a thick pad be placed on the floor. R45's Care Plan documented R45 had a fall on 07/21/24, which resulted in an emergency room transfer for a laceration to the bridge of her nose and required five sutures. The Progress Note dated 07/29/24 at 07:02 PM, documented on 07/27/24 at approximately 06:00 AM, R45 was yelling to get up. The staff informed the resident that help was not available at that time, and they would get more help and then assist the resident to get up. Staff observed R45 scooting onto the floor mat (mattress). The note further documented the writer thought the mattress was care planned but was told it was not. R45's Care Plan documented R45 had a noninjury fall on 07/29/24. A revision dated 07/29/24 directed staff that R45's preference was to get up early in the morning. The Progress Note, dated 08/30/24 at 04:32 AM, documented at approximately 04:00 AM R45 was heard yelling for help. The resident was found lying on her right side. Staff assisted the resident back to bed. Staff notified the responsible party, the Director of Nursing, and the resident's physician. The Progress Note dated 08/30/24 at 08:53 AM, documented staff called R45's responsible party regarding the representative's concerns, and the representative was upset that R45 had fallen from bed. Facility staff assured R45's responsible party the facility would be looking into the fall and placing interventions to prevent future falls and injuries. The Progress Note dated 08/30/24 at 03:06 PM, documented X-ray results showing a right femur non-displaced femoral (thigh bone) neck fracture with angulation at the fracture site. Staff notified the physician and received orders to send R45 to the hospital. On 08/30/24 a Teachable Moment form was used to educate staff to follow the resident's plan of care and fall prevention interventions. The form documented that R45 had a fall, and the fall mat was not in place, leaving a large chance for preventable injuries. A report was made to the State Agency and the facility initiated an investigation into the fall. R45's Care Plan dated 08/30/24, documented R45 fell on [DATE] and the facility provided an in-service to staff to educate them on the need to follow all safety interventions. The care plan further documented the facility changed the fall mat out for a regular mattress next to the bed to reduce the distance if R45 crawled out of bed. The Progress Note dated 09/03/24 at 01:50 PM, documented the facility changed out the resident's fall mat for a full-size mattress, which would decrease the distance that R45 would fall from bed as the facility could not keep R45 from attempting to get up. R45's responsible party stated understanding of the new intervention and agreed with the choice. The Progress Note dated 09/04/24 at 01:42 PM documented R45 readmitted to the facility with a diagnosis of a right hip fracture, R45 was weight bearing as tolerated, and had a surgical incision to the right thigh with nine staples and pain management in place. On 10/15/24 at 02:04 PM an observation revealed R45 sat in her room in a wheelchair. A mattress leaned up against the wall. R45 was working with yarn and a crochet hook. Certified Nurse Aide (CNA) N reported R45 did not lay down during the day, due to breathing issues. CNA N stated the mattress in the room against the wall was to be placed by the bed if the resident wanted to lie down. CNA N reported that R45 was usually up in the wheelchair when she arrived at work in the mornings. On 10/15/24 at 03:31 PM Administrative Staff A reported the facility completed a root cause analysis related to R45's falls, which resulted in the use of a full-sized mattress next to the bed and ensuring the bed was in a low position when the resident was in bed. Administrative Staff A stated staff received in-service regarding safety measures, which needed to be present and implemented. Administrative Staff A provided an investigation for the incident reported to the State Agency. The facility's Fall Clinical Protocol, dated 04/2007, documented as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of serious consequences of falling. If interventions have been successful in preventing falls, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention has been resolved. The facility failed to implement safety interventions for R45 related to falls. Subsequently, R45 fell which resulted in a femoral fracture. This also placed the resident at risk for future falls and injuries. 32360 - The Electronic Medical Record (EMR) for R17 documented diagnoses of heart disease, a need or assistance with personal care, heart failure, atrial fibrillation (rapid, irregular heartbeat), and dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R17 had severely impaired cognition. R17 required substantial assistance with bathing, partial assistance with toileting, and partial assistance with toileting and dressing. R17 received supervision with mobility, transfers, and ambulation. R17 had no behaviors or wandering and had no alarms. The Quarterly MDS, dated [DATE], documented R17 had severely impaired cognition. R17 required substantial assistance with bathing, partial assistance with toileting, and supervision with toileting and dressing. The MDS documented R17 was independent with mobility, transfers, and ambulation. R17 had no behaviors or wandering and had no alarms. The Elopement Risk Assessments, dated 04/01/24, 06/07/24, and 09/07/24, documented R17 was at risk for elopement. R17's Care Plan, dated 09/27/24 and initiated on 06/07/24, documented R17 was an elopement risk and wanderer due to his dementia and directed staff to distract R17 from wandering by offering structured activities, food, conversation, television, and books. R17 was provided with a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) alert bracelet. The Physician's Order, dated 06/07/24, directed staff to check R17's WanderGuard for proper functioning daily, check for proper placement on the right wrist every shift, and replace the WanderGuard as needed upon expiration or not working properly. A review of the R17's Treatment Administration Record TAR including the October 2024 TAR showed staff documented they assessed R17's WanderGuard for placement and function every shift. The Nurses Notes, dated 10/09/2 at 04:26 AM, documented R17 refused to go to sleep and continued to set off door alarms. R17 walked up and down hallways unsafely and was combative with staff. On 10/15/24 at 08:41 AM, observation revealed R17 sat in his recliner taking his medication. Further observation revealed R17 did not have a WanderGuard alert bracelet on. Certified Medication Aide (CMA) R verified R17 did not have a WanderGuard bracelet on and stated she did not know what happened to it. On 10/15/24 at 09:00 AM, Administrative Nurse D stated that R17's family had requested the bracelet be taken off but Administrative Nurse D could not provide documentation for the request. She stated she would have another WanderGuard bracelet put on the resident. On 10/15/24 at 02:30 PM, Licensed Nurse (LN) G stated staff checked R17's WanderGuard every shift for placement. LN G did not know how long R17 had not had his WanderGuard on. The facility's Problematic Behavior Management policy dated 12/08, documented as part of the initial assessment, the staff and physician would identify individuals with a history of impaired cognition, problematic behavior, or mental illness. Nursing staff would document the nature, duration, and associated features of any changes over time in behavior, cognition, or mood and notify the physician. The facility failed to ensure R17's WanderGuard was in place and functioning. These deficient practices placed the resident at risk of accidents and related injuries.
The facility had a census of 49 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who reside at the facility at risk of decreased quality of care. Findings included: - The Payroll-Based Journal [PBJ-a required detail of staffing information submitted by nursing homes) provided by the Centers for Medicare and Medicaid Services (CMS) documented the facility lacked RN eight-hour coverage for the following months: July 2023- five days August 2023- six days September 2023- two days October 2023- five days November 2023- two days December 2023- five days January 2024- seven days February 2024- four days April 2024- seventeen days May 2024- four days On 10/15/24 at 10:00 AM, Administrative Staff A reviewed the dates provided and verified the facility lacked RN eight-hour coverage for those dates. Upon request a policy for staffing was not provided by the facility. The facility failed to provide RN coverage eight consecutive hours a day, seven days a week. This placed all residents who reside at the facility at risk of decreased quality of care.
The facility identified a census of 49 residents. The facility had one main kitchen and one main dining area. Based on observation, record review, and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 10/14/24 at 08:16 AM Dietary BB stated she had not taken her test to get her dietary manager certification, but she had begun her courses to get the certification. Dietary BB stated that Administrative Staff A did have a CDM certification. Dietary BB stated that the registered dietician came to the facility twice a month to review the resident's diets. On 10/15/24 at 12:27 PM Administrative Staff A stated she had a CDM certification but did not actively use it. Administrative Staff stated Dietary BB had been taking the courses to get certified and was overseen by the dietician who came to the facility twice monthly. The Food Services Manager policy documented: The daily functions of the Food Services Department are under the supervision of a qualified Food Services Manager. The Food Services Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement storage, handling, preparation, and delivery. The Food Services Manager was responsible for the daily functions of the Food Services Department in accordance with the facility ' s department policies and procedures. Additional responsibilities of the Food Services Manager included supervision, training, and scheduling of kitchen supervisors; and assisting the dietitian and the nursing services department. The facility failed to ensure the director of food and nutrition services had the required qualifications of a CDM. This placed residents at risk for unmet dietary and nutritional needs.
The facility identified a census of 49 residents. The facility had one main kitchen. Based on observation and interview, the facility failed to ensure staff stored food items in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination (the transfer of harmful substances to food). Findings included: - Upon the initial tour of the main kitchen on 10/14/24 at 08:16 AM observation in the refrigerator revealed a block of cheese wrapped in plastic wrap that lacked a label or a date. There was a sealed bag of ham slices with no label or date. There were several brown-tinged towels on the floor under the stove. In the dry storage room, there were opened bags of potato chips, tortilla chips, and gravy mix that were not in a sealed and labeled bag. Dietary Staff BB stated on 10/14/24 at 08:25 AM that the food items all should be placed in a sealed bag and then labeled and dated. Dietary BB stated she had been working hard on training staff to ensure that any time a food was opened it must be placed in a sealed bag and labeled and dated. The Food Receiving and Storage policy revised in December 2008 documented that dry foods that are stored in bins will be removed from their original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in - first out system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded. The facility failed to ensure dietary staff stored food items in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination.
The facility had a census of 49 residents. Based on interviews and record review, the facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter (Q) 2 indicated no licensed nurse coverage on eight days. The PBJ for FY 2024 Q2 recorded no licensed nurse coverage on the following dates: 02/11/24, 02/17/24, 02/24/24, 03/09/24, 03/16/24, 03/24/24, 03/30/24 and 03/31/24. Review of the facility licensed nurse payroll data for the dates listed above revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 10/15/24 at 10:00 AM, Administrative Staff A stated the information for the PBJ was submitted from someone off campus and the error was probably due to agency staff not accounted for. Administrative Staff A stated there was always a licensed nurse in the building and that there were more registered nurses than there used to be. Upon request a policy for Payroll-Based Journal was not provided by the facility. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.
The facility had a census of 49 residents. The sample had 13 residents, with four reviewed for bathing. Based on observation record review, and interview, the facility failed to provide consistent bathing for fResident (R) 17, R24, R44, and R45. This placed the residents at risk for poor hygiene and related complications. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of heart disease, a need or assistance with personal care, heart failure, atrial fibrillation (rapid, irregular heartbeat), and dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R17 had severely impaired cognition. R17 required substantial assistance with bathing, partial assistance with toileting, and partial assistance with toileting and dressing. The Quarterly MDS, dated [DATE], documented R17 had severely impaired cognition and required substantial assistance with bathing. R17's Care Plan, dated 09/27/24 and initiated on 04/12/24, documented that R17 required supervision assistance of one staff member for bathing, and directed staff to provide a bath per schedule, allow the resident time to complete tasks, and praise him for all his efforts made. The August 2024 Bathing Record documented R17 requested showers on Monday and Thursday dayshift and documented R17 had not received a bath or shower the following days: 08/01/14- 08/14/24 (14 days) 08/23/24- 08/31/24 (9 days) The EMR documented R17 refused a shower on 08/05/24, 08/26/24, and 08/29/24. The October 2024 Bathing Record documented R17 requested showers on Monday and Thursday dayshift and documented R17 had not received a bath or shower the following days: 10/01/24- 10/17/24 (17 days) The EMR documented R17 refused a shower on 10/03/24 and 10/10/24. On 10/15/25 at 08:41 AM, observation revealed R17 was unshaven and had dried liquid stains on his jeans. On 10/17/24 at 08:26 AM, Certified Nurse Aide (CNA) M stated when R17 refused his bath, staff documented the refusals on a shower sheet that was given to the Director of Nursing. CNA M stated that sometimes it took two staff to give R17 a shower. On 10/17/24 at 09:30 AM Licensed Nurse (LN) H stated R17 did refuse showers but staff tried to offer at different times and days. On 10/17/24 at 11:45 AM, Administrative Staff A stated the facility did use shower sheets along with documentation in the EMR but the shower sheets have been thrown away. The facility's Shower/Tub Bath policy, dated 10/09, documented that staff are to promote cleanliness, provide comfort to the resident, and observe the condition of the skin. After a resident received his or her shower, staff document the date and time the shower/tub was performed, who assisted the resident with the shower/bath, and if there were any reddened areas or sores. If the resident refused the shower/tub bath, staff document the reasons why and what interventions were initiated, Staff notify the supervisor, and report any other information in accordance with facility policy and professional standards taken. The facility failed to provide R17 with consistent bathing. This placed him at risk for poor hygiene. - The Electronic Medical Record (EMR) for R24 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type 2, hypertension (high blood pressure), and atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R24 had intact cognition. R24 required partial assistance with showers. R24's Care Plan, dated 08/29/24 and initiated on 11/24/23, documented R24 required limited staff participation with bathing. Staff were to inspect her skin for open areas and redness, assist the resident with clothing, and stand by assistance with transfers. The August 2024 Bathing Record documented R24 requested showers on Tuesday and Friday dayshift and documented R24 had not received a bath or shower the following days: 08/01/24- 08/26/24 (26 days) The EMR documented R24 refused a shower on 08/02/24, 08/06/24, and 08/20/24. The September 2024 Bathing Record documented R24 requested showers on Tuesday and Friday dayshift and documented R24 had not received a bath or shower the following days: 09/11/24- 09/30/24 (20 days) The EMR documented R24 refused a shower on 09/13/24, 09/17/24, and 09/20/24. The October 2024 Bathing Record documented R24 requested showers on Tuesday and Friday dayshift and documented R24 had not received a bath or shower the following days: 10/09/24-09/17/24 (9 days) On 10/14/24 at 10:50 AM, observation revealed R24's hair was disheveled and greasy. On 10/17/24 at 08:26 AM, Certified Nurse Aide (CNA) M stated if R24 refused her showers, staff documented the refusals on a shower sheet that was given to the Director of Nursing. On 10/17/24 at 09:30 AM, Licensed Nurse (LN) H stated she was unsure whether R24 refused her showers but if she did, staff would inform the charge nurse and document it on the shower sheet which was turned in to administration. On 10/17/24 at 11:45 AM, Administrative Staff A stated the facility did use shower sheets along with documentation in the EMR but the shower sheets have been thrown away. The facility's Shower/Tub Bath policy, dated 10/09, documented that staff are to promote cleanliness, provide comfort to the resident, and observe the condition of the skin. After a resident received his or her shower, staff document the date and time the shower/tub was performed, who assisted the resident with the shower/bath, and if there were any reddened areas or sores. If the resident refused the shower/tub bath, staff document the reasons why and what interventions were initiated, Staff notify the supervisor, and report any other information in accordance with facility policy and professional standards taken. The facility failed to provide R24 with consistent bathing. This placed her at risk for poor hygiene. - The Electronic Medical Record (EMR) for R44 documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary tract infection (UTI-an infection in any part of the urinary system), and lymphedema (swelling caused by accumulation of lymph fluid). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R44 had intact cognition. R44 required substantial assistance from staff for eating, toileting, bathing, mobility, and transfers. R44's Care Plan, dated 09/05/24, directed staff to assist R44 with bathing and provide her bath as scheduled. The care plan directed staff to provide assistance with dressing and getting garments from the closet or drawer and praise residents for all efforts made. The September 2024 Bathing Record documented R44 received daily bed baths and documented R44 had not received a bed bath or shower the following days: 09/22/24- 09/30/24 (9 days) The EMR lacked documentation R44 refused any baths or showers. The October 2024 Bathing Record documented R44 received bed baths and documented R44 had not received a bed bath or shower the following days: 10/03/24- 10/09/24 (7 days) The EMR lacked documentation R44 refused any baths or showers. On 10/14/24 at 08:40 AM, observation revealed R44 sat up in bed, and her hair was disheveled. R44 reported she was nauseated and had vomited several times in the past few days. On 10/17/24 at 08:55 AM, Certified Nurse Aide (CNA) M stated R44 did not refuse the bed bath or shower and she could decide which one she wanted. On 10/17/24 at 09:30 AM Licensed Nurse (LN) H stated she was unsure if R44 refused her showers but if she did, staff would inform the charge nurse and document it on the shower sheet which was turned in to administration. On 10/17/24 at 11:45 AM, Administrative Staff A stated the facility did use shower sheets along with documentation in the EMR but the shower sheets have been thrown away. The facility's Shower/Tub Bath policy, dated 10/09, documented that staff are to promote cleanliness, provide comfort to the resident, and observe the condition of the skin. After a resident received his or her shower, staff document the date and time the shower/tub was performed, who assisted the resident with the shower/bath, and if there were any reddened areas or sores. If the resident refused the shower/tub bath, staff document the reasons why and what interventions were initiated, Staff notify the supervisor, and report any other information in accordance with facility policy and professional standards taken. The facility failed to provide R44 with consistent bathing. This placed her at risk for poor hygiene. 37450 - R45's Electronic Medical Record (EMR) documented diagnoses of acute respiratory failure with hypoxia (inadequate supply of oxygen), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), altered mental status, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), other mechanical complication of cystostomy catheter (urinary bladder catheter inserted through the abdomen into the bladder), urinary tract infection, obstructive and reflux uropathy (disorder or urinary tract), a disorder of bone density and structure, muscle weakness, and lack of coordination. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R45 had intact cognition, exhibited no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or behaviors. R45 was dependent on toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. R45 required partial/moderate assistance with upper body dressing, and substantial/maximal assistance with personal hygiene, bed mobility, standing, and transfers. The MDS further documented R45 had an indwelling catheter and was always incontinent of bowel. R45 received as-needed pain medication and had pain that occasionally affected sleep, day-to-day activities, and therapy. R45 had shortness of breath with exertion and lying flat, had oxygen therapy, a non-invasive mechanical ventilator, and speech, occupational, physical, and respiratory therapy. R45 had surgical wound care and received an antidepressant (a class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain). R45's Care Plan dated 09/05/24, documented the resident exhibited activities of daily living (ADL) self-care performance deficit and required assistance of substantial to maximal assistance due to limited mobility. The plan documented that R45 required substantial to maximal assistance of one staff for bathing, toileting, and transfers. The Progress Note dated 09/07/24 at 01:42 PM, documented that R45 had been readmitted to the facility with a diagnosis of right hip fracture, weight bearing as tolerated; R45 used a wheelchair for mobility propelled by staff. A review of R45's EMR revealed R45 had not received bathing for a 27-day period between September 2024 and October 15, 2024. On 10/15/24 at 02:04 PM, observation revealed R45 sat in a wheelchair in her room, working with yarn and a crochet hook. Certified Nurse Aide (CNA) N was present in the room and reported this to be the third day she worked at the facility; she said she was not aware of the bathing schedule for R45. On 10/17/24 at 02:55 PM, Administrative Nurse D reported staffing a bath aide to complete bathing and the facility had been documenting bathes on paper to monitor bathing schedules, but the bathing records had been thrown away and not recorded in the EMR. Administrative Nurse D stated residents should be bathed more frequently than every 27 days. The facility's Shower/Tub Bath policy, dated 10/09, documented that staff are to promote cleanliness, provide comfort to the resident, and observe the condition of the skin. After a resident received his or her shower, staff document the date and time the shower/tub was performed, who assisted the resident with the shower/bath, and if there were any reddened areas or sores. If the resident refused the shower/tub bath, staff document the reasons why and what interventions were initiated, Staff notify the supervisor, and report any other information in accordance with facility policy and professional standards taken. The facility filed to provide R45 assistance with bathing, which placed the resident at risk for poor hygiene.
The facility identified a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure accurate reconciliation of controlled medications (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed. This placed residents at risk of medication misappropriation and diversion. Findings included: - A review of the Tanglewood Narcotics Shift Count Sheet from 08/01/24 to 10/15/24 revealed 44 missed opportunities for staff signature verifying completion of the narcotic reconciliation by the on-coming and off-going nurse. On 10/15/24 at 08:03 AM Licensed Nurse (LN) G stated the narcotics shift count sheet should be signed by the on-coming and the off-going nurse at each shift after the count has been completed. On 10/17/24 at 08:15 AM Administrative Nurse D stated she expected the nurses at the end of their shift and the on-coming nurse to each sign the narcotic sign-off sheet after the count of the narcotics and exchanging of the medication cart keys each shift. Administrative Nurse D stated she would re-educate the nurses to ensure this was completed each shift. The Controlled Substances policy documented Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. The Director of Nursing Services will identify staff members who are authorized to handle controlled substances. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. If the count is correct, an individual resident-controlled substance record must be made for each resident who will be receiving a controlled substance. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. The charge nurse on duty would maintain the keys to controlled substance containers. The Director of Nursing Services (DON) would maintain a set of backup keys for all medication storage areas including keys to controlled substance containers. Unless otherwise instructed by the DON, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given), the medication shall be destroyed (witnessed by 2 Licensed Nurses) and may not be returned to the container. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the DON. The facility failed to ensure accurate reconciliation of controlled medications was completed consistently. This placed residents at risk of medication misappropriation and diversion.
The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 45's indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), R7's gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) care, and R43's wound care. The facility failed to ensure R33's eye medication was administered using adequate infection control standards and failed to ensure R7's oxygen equipment was changed and stored in a sanitary manner. This placed the residents at risk for infectious processes. Findings included: - On 10/14/24 at 02:44 PM, observation revealed R43's door to her room had a personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) caddy hanging on it that only had face masks in it; there were no gowns in her room. On 10/15/24 at 07:45 AM, observation revealed that R30's oxygen tubing and cannula were wrapped around an oxygen tank, unbagged. On 10/15/24 at 08:30 AM, observation revealed R43's PPE caddy on her door had masks and gloves but no gowns. On 10/15/24 at 09:16 AM, Certified Nurse Aide (CNA) O pushed R43 into the bathroom, donned clean gloves but not a gown, assisted R43 to stand up, and pulled down R43's pants. CNA O pulled off part of the dressing that was on R43's right buttock wound. The wound bed was yellow, with redness to the skin surrounding the wound and there was no drainage apparent. On 10/15/24 at 01:30 PM, R7 lay on his bed. Licensed Nurse (LN) G knocked on his door and announced herself and stated she was going to be giving him his Glucerna. LN G donned gloves but no gown and flushed R7's G-tube with 150 ml of water prior to pouring the Glucerna into the syringe attached to the G-tube. LN G then poured the bolus of Glucerna into the syringe until all was emptied through the tube. LN G then poured an additional 30 cc of water into the tube to flush. LN G said she was unsure if R7 required EBP. On 10/15/24 at 02:04 PM, observation revealed CNA N emptying R45's catheter. R45's room lacked signage for EBP. CNA N explained to R45 that she was going to empty the catheter bag. CNA N placed gloves on and retrieved the measuring cylinder from the bathroom, gathered an incontinent wipe from a package on the overbed table, unhooked the drainage bag from the underside of the resident's wheelchair, drained the collection bag, wiped the drainage spicket with an incontinent wipe, then laid the drainage bag directly on the floor, smoothed it out flat, then placed the drainage back to the underside of the wheelchair. CNA N did not wear a gown during the procedure. On 10/17/24 at 08:00 AM, observation revealed R30's oxygen tubing and cannula were wrapped around the back of the oxygen concentrator unbagged. On 10/17/24 at 09:07 AM, observation revealed Certified Medication Aide (CMA) S administering eye drops to R33. CMA S verified the medication order with the electronic record, retrieved the medication from the medication cart, entered R33's room, and announced she would administer the resident's eye drop. CMA S did not place gloves on her hands, instructed R33 to look upwards and CMA S rested her hand on the forehead of R33 while administering a drop of medication into R33's right eye. CMA S stated it was her usual practice not to use gloves when administering eye drops for R33. On 10/17/24 at 08:25 AM, CNA M stated she thought R43 had something on her door that had gowns, gloves, and masks to wear when staff assisted R43 but did not know why. She stated R30 wore his oxygen off and on and stated when he did not have it on, the tubing should be stored in a bag. On 10/15/24 at 08:52 AM, Administrative Nurse D said that when not in use, oxygen tubing and cannula are to be stored in a bag. On 10/17/24 at 09:04 AM Licensed Nurse (LN) H stated CNA N should not have placed the catheter bag directly on the floor. LN H also verified that R45 should be on EBP related to the indwelling catheter and should wear a gown and gloves during catheter care. LN H verified that R45 did not have signage or a supply of PPE available in the room or near the room. On 10/17/24 at 09:56 AM, LN H stated R43 was on EBP due to her pressure ulcer and staff wear gowns and gloves when staff provide care. On 10/17/24 at 11:00 AM, Administrative Nurse D stated staff should wear gloves when administering eye drops. On 1/17/24 at 12:15 PM, Administrative Nurse D stated that R43's door caddy should have had the necessary PPE for staff to use when providing care and that the care plan should have her EBP status on it. On 10/17/24 at 03:00 PM, Administrative Nurse D reported catheter bags should not be laid directly on the ground and that staff should implement EBP during care for residents with catheters. The facility's Enhanced Barrier Precautions policy, dated 04/01/24, documented that Enhanced Barrier Precautions are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organism (MDRO)'s to staff hands and clothing. EBP is indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Facilities should ensure PPE and alcohol-based hand rubs are readily accessible to staff. The facility's Oxygen Use policy, dated 03/04, documented, for safe oxygen administration, verified that there was a physician's order for oxygen use, and reviewed the care plan for any special needs of the resident. Check the tubing connected to the oxygen cylinder to ensure that it is free of kinks and turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. The facility's Instillation of Eye Drops policy, dated 01/2014, directed staff to put on gloves, administer the eye drops, remove gloves, and discard them into a designated container. The facility failed to ensure staff followed EBP for three residents, and failed to use standard infection control practices during eye drop administration and for sanitary storage of respiratory tubing. This placed the resident sat risk for increased infections.
The facility identified a census of 49 residents. The sample included 13 residents with three sampled residents reviewed for hospitalization . Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 7's transfer or discharge was documented in the resident ' s medical record and appropriate information was communicated to the receiving healthcare institution or provider. This placed R7 at risk for delayed treatment and impaired continuity of care. Findings included: - The electronic medical record (EMR) for R7 documented diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), respiratory failure (a condition where your blood does not have enough oxygen), dysphagia (swallowing difficulty), aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R7's Discharge MDS dated [DATE] documented an unplanned discharge to an acute hospital with a return anticipated. R7's Entry MDS dated [DATE] documented a reentry after a short-term acute hospital stay. R7's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 had a swallowing disorder and required a feeding tube for nutrition. R7 was at risk of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R7's Nutritional Care Area Assessment (CAA) dated 10/01/24 documented he had a potential nutrition risk related to a medical history of cerebral infarction, dysphagia, and COPD and received nothing by mouth (NPO); he was dependent on enteral nutrition support to meet all estimated nutrient needs. R7's Care Plan documented a resolved care area dated 02/06/24 directing staff to provide written instruction as required to ensure care continuity post-discharge. The care plan last revised on 10/14/24 lacked staff direction regarding discharge. A review of R7's Progress Notes from 05/21/24 revealed he was sent out to the hospital after a coughing episode after attempting to swallow food. R7's Progress Reports reviewed from 09/13/24 to 09/19/24 lacked any documentation related to R7 ' s change in status and transfer to an acute hospital. R7's clinical record tab lacked any change of condition assessment related to R7's change of condition on 09/13/24 including physician notification, mode of transport, and destimation. The record lacked evidence the appropriate health information was communicated to the receiving provider or healthcare destination. A late entry Physician Progress Note dated 09/24/24 at 10:05 AM documented that R7 was admitted to the hospital on 09/13/24 after a seizure. R7 had bitten his tongue. R7 had a full seizure in the emergency room . R7 was discharged back to the facility on [DATE]. On 10/15/24 at 09:00 AM R7 lay on his bed with his blanket over his head. On 10/17/24 at 09:15 PM Administrative Nurse D stated that the nurses initiate the discharges and should complete a discharge summary in the EMR. Administrative Nurse D stated that she expected nursing staff to document any change in the condition of a resident including when a resident would need to be sent to the hospital. The facility did not provide a policy related to discharge preparation. The facility failed to ensure that R7's transfer or discharge was documented in the resident ' s medical record and appropriate information was communicated to the receiving healthcare institution or provider. This placed R7 at risk for delayed treatment and impaired continuity of care.
The facility identified a census of 49 residents. The sample included 13 residents with three sampled residents reviewed for hospitalization . Based on observation, record review, and interviews, the facility failed to provide written notification of transfer to Resident (R) 33 and R44 or their representatives for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and impaired rights for R33 and R44. Findings included: - R33's Electronic Medical Record (EMR) documented diagnoses of fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), epilepsy (brain disorder characterized by repeated seizures), hypertension (HTN-elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic respiratory failure with hypoxia (inadequate supply of oxygen), major depressive disorder (major mood disorder that causes persistent feelings of sadness), muscle wasting and atrophy, need for assistance with personal care, unsteady on feet and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Minimum Data Set (MDS), dated [DATE], documented a quarterly assessment and a discharge from the facility, with a return anticipated. The MDS, dated [DATE], documented an entry into the facility. The MDS, dated [DATE], documented a discharge with a return anticipated. The MDS, dated [DATE], documented an entry into the facility. The MDS, dated [DATE], documented a discharge with a return anticipated. The MDS, dated [DATE], documented an entry into the facility. The Progress Note dated 07/10/24 at 09:01 PM, documented a change in R33's condition. The primary care provider ordered the resident to be sent to the emergency room for evaluation and treatment. The Progress Note dated 07/12/24 at 01:55 PM documented R33 returned to the facility. The Progress Note dated 07/20/24 at 09:42 PM documented a change in R33's condition. The primary care provider ordered the resident to be sent to the emergency room for evaluation and treatment. The Progress Note dated 07/24/24 at 02:45 PM, documented R33 returned to the facility. The Progress Note dated 07/29/24 at 05:35 PM, documented R33 seen by the practitioner and was sent to the emergency room at a different hospital. The Admit/Readmit Screener, dated 08/02/24, recorded R33 readmitted to the facility. R33's clinical record lacked evidence the resident was provided a written notice when she was transferred to the hospital. The facility was unable to provide evidence as requested. On 10/15/24 at 09:44 AM, R33 was observed going outside to smoke with a jacket on. R33 was able to get in and out of the door unassisted. On 10/17/24 at 10:00 AM Administrative Staff A stated that the facility did provide the Notice of Transfer/Discharge form to the ombudsman and the resident ' s representative would be called to be notified of the transfer, but the notice of transfer was not mailed to the representative that she was aware of. The facility's Readmission to the Facility policy, dated 11/28/17, documented that residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident or the resident representative written notice specifying the duration of the bed-hold policy, and the opportunity to pay the bed-hold if allowed by the State Plan. At the time of admission, the resident or the resident representative will be provided with the facility's bed hold policy. The facility will provide the second notice of bed-hold at the time of transfer, or in cases of emergency transfer, within 24 hours. The facility will document the attempts to reach the resident's representative in situations where unable to notify the resident or representative. The facility notice will provide information that explains the duration of the bed-hold and the bed-hold payment policy. Also, the notice will include permitting the return of residents to the next available bed. The facility failed to provide the resident or resident representative written notification of the facility-initiated transfer. This placed R33 at risk of impaired rights. 32360 - The Electronic Medical Record (EMR) for R44 documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary tract infection (UTI-an infection in any part of the urinary system), and lymphedema (swelling caused by accumulation of lymph fluid). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R44 had intact cognition and required substantial assistance from staff for eating, toileting, bathing, mobility, and transfers. R44 received insulin (medications used to help reduce the amount of sugar present in the blood) and diuretic (a medication to promote the formation and excretion of urine) medications. R44's Care Plan, dated 09/05/24, documented that R44 had the potential for fluid volume deficit and directed staff to instruct R44 and their family on the importance of fluid intake, monitor weight as ordered, observe urine output for signs of dehydration and strong odor. The care plan directed staff to check for incontinence during rounds, assist R44 as needed with the use of a bedpan, check and change with rounds, and establish voiding patterns. The care plan directed staff to obtain an Accu-check (blood glucose monitoring test) with sliding scale coverage as ordered, administer diabetes medication as physician ordered, dietary consult for nutritional regimen, and discuss with R44 the importance of compliance with dietary restrictions. The Progress Notes, dated 10/14/24 at 02:33 PM, documented that R44 was admitted to the hospital due to vomiting coffee grounds. R44's clinical record lacked evidence the resident was provided a written notice when she was transferred to the hospital. On 10/14/24 at 08:40 AM, observation revealed R44 was in bed and had a plastic bag on her lap, R44 stated she was nauseated and had vomited multiple days. R44 stated she had been given medication for the nausea and had thought that it was from the weight loss injections she had been given. R44 started to vomit into the plastic bag and this Surveyor went and got the nurse. On 10/17/24 at 10:00 AM Administrative Staff A stated that the facility did provide the Notice of Transfer/Discharge form to the ombudsman and the resident ' s representative would be called to be notified of the transfer, but the notice of transfer was not mailed to the representative that she was aware of. The facility's Readmission to the Facility policy, dated 11/28/17, documented that residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident or the resident representative written notice specifying the duration of the bed-hold policy, and the opportunity to pay the bed-hold if allowed by the State Plan. At the time of admission, the resident or the resident representative will be provided with the facility's bed hold policy. The facility will provide the second notice of bed-hold at the time of transfer, or in cases of emergency transfer, within 24 hours. The facility will document the attempts to reach the resident's representative in situations where unable to notify the resident or representative. The facility notice will provide information that explains the duration of the bed-hold and the bed-hold payment policy. Also, the notice will include permitting the return of residents to the next available bed. The facility failed to provide the resident or resident representative written notification of the facility-initiated transfer. This placed R44 at risk of impaired rights.
The facility had a census of 49 residents. The sample included 13 residents of which three residents were reviewed for transfer and/or discharge. Based on record review and interview, the facility failed to provide Resident (R) 33 and R44 with the appropriate bed hold policy as required. This placed the residents at risk of being uninformed of bed-hold requirements. Findings included: - R33's Electronic Medical Record (EMR) documented diagnoses of fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), epilepsy (brain disorder characterized by repeated seizures), hypertension (HTN-elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic respiratory failure with hypoxia (inadequate supply of oxygen), major depressive disorder (major mood disorder that causes persistent feelings of sadness), muscle wasting and atrophy, need for assistance with personal care, unsteady on feet and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Minimum Data Set (MDS), dated [DATE], documented a quarterly assessment and a discharge from the facility, with a return anticipated. The MDS, dated [DATE], documented an entry into the facility. The MDS, dated [DATE], documented a discharge with a return anticipated. The MDS, dated [DATE], documented an entry into the facility. The MDS, dated [DATE], documented a discharge with a return anticipated. The MDS, dated [DATE], documented an entry into the facility. The Progress Note dated 07/10/24 at 09:01 PM, documented a change in R33's condition. The primary care provider ordered the resident to be sent to the emergency room for evaluation and treatment. The Progress Note dated 07/12/24 at 01:55 PM documented R33 returned to the facility. The Progress Note dated 07/20/24 at 09:42 PM documented a change in R33's condition. The primary care provider ordered the resident to be sent to the emergency room for evaluation and treatment. The Progress Note dated 07/24/24 at 02:45 PM, documented R33 returned to the facility. The Progress Note dated 07/29/24 at 05:35 PM, documented R33 seen by the practitioner and was sent to the emergency room at a different hospital. The Admit/Readmit Screener, dated 08/02/24, recorded R33 readmitted to the facility. R33's clinical record lacked evidence the resident and/or representative received a copy of the bed hold notice at the time of transfer or discharge. The facility was unable to provide evidence as requested. On 10/15/24 at 09:44 AM, R33 was observed going outside to smoke with a jacket on. R33 was able to get in and out of the door unassisted. On 10/15/24 at 02:00 PM, Administrative Staff A stated that R33's representative was called related to the discharge of the resident at each discharge. Admin Staff A verified the facility had not provided the bed hold notice to R33's representative. The facility's Readmission to the Facility policy, dated 11/28/17, documented that residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident or the resident representative written notice specifying the duration of the bed-hold policy, and the opportunity to pay the bed-hold if allowed by the State Plan. At the time of admission, the resident or the resident representative will be provided with the facility's bed hold policy. The facility will provide the second notice of bed-hold at the time of transfer, or in cases of emergency transfer, within 24 hours. The facility will document the attempts to reach the resident's representative in situations where unable to notify the resident or representative. The facility notice will provide information that explains the duration of the bed-hold and the bed-hold payment policy. Also, the notice will include permitting the return of residents to the next available bed. The facility failed to provide R33 with a bed-hold policy which placed the resident at risk of being uninformed choices and impaired ability to return to the same room. 32360 - The Electronic Medical Record (EMR) for R44 documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary tract infection (UTI-an infection in any part of the urinary system), and lymphedema (swelling caused by accumulation of lymph fluid). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R44 had intact cognition and required substantial assistance from staff for eating, toileting, bathing, mobility, and transfers. R44 received insulin (medications used to help reduce the amount of sugar present in the blood) and diuretic (a medication to promote the formation and excretion of urine) medications. R44's Care Plan, dated 09/05/24, documented that R44 had the potential for fluid volume deficit and directed staff to instruct R44 and their family on the importance of fluid intake, monitor weight as ordered, observe urine output for signs of dehydration and strong odor. The care plan directed staff to check for incontinence during rounds, assist R44 as needed with the use of a bedpan, check and change with rounds, and establish voiding patterns. The care plan directed staff to obtain an Accu-check (blood glucose monitoring test) with sliding scale coverage as ordered, administer diabetes medication as physician ordered, dietary consult for nutritional regimen, and discuss with R44 the importance of compliance with dietary restrictions. The Progress Notes, dated 10/14/24 at 02:33 PM, documented that R44 was admitted to the hospital due to vomiting coffee grounds. R44's clinical record lacked evidence the resident and/or representative received a copy of the bed hold notice at the time of transfer or discharge. The facility was unable to provide evidence as requested. On 10/14/24 at 08:40 AM, observation revealed R44 was in bed and had a plastic bag on her lap, R44 stated she was nauseated and had vomited multiple days. R44 stated she had been given medication for the nausea and had thought that it was from the weight loss injections she had been given. R44 started to vomit into the plastic bag and this Surveyor went and got the nurse. On 10/15/24 at 02:20 PM, Administrative Staff A stated she had not discussed bed hold with the family but would call them at some point, fill out discharge paperwork, and put it into R44's file. The facility's Readmission to the Facility policy, dated 11/28/17, documented that residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident or the resident representative written notice specifying the duration of the bed-hold policy, and the opportunity to pay the bed-hold if allowed by the State Plan. At the time of admission, the resident or the resident representative will be provided with the facility's bed hold policy. The facility will provide the second notice of bed-hold at the time of transfer, or in cases of emergency transfer, within 24 hours. The facility will document the attempts to reach the resident's representative in situations where unable to notify the resident or representative. The facility notice will provide information that explains the duration of the bed-hold and the bed-hold payment policy. Also, the notice will include permitting the return of residents to the next available bed. The facility failed to provide R44 with a bed hold notice which specifies the duration of the bed hold when she was transferred to the hospital. This placed R44 at risk of not being permitted to return and resume residence in the facility.
The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to accurately assess and document that Resident (R) 30 had a terminal condition on the Minimum Data Set (MDS) assessment. This placed the resident at risk for an inaccurate care plan and unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R30 documented diagnoses of stomach cancer, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), heart failure, and hypertension (high blood pressure). The Admission Minimum Data Set (MDS), dated [DATE], documented R30 had intact cognition and required set-up assistance with toileting, and upper body dressing. R30 was independent with personal hygiene, mobility, transfers, and ambulation. The MDS noted R30 had no behaviors and received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), and antianxiety (a class of medications that calm and relax people) medication. The assessment lacked documentation R30 had a terminal condition and was on hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. R30's Care Plan, dated 08/14/24, initiated on 09/10/24, documented R30 had a terminal prognosis related to gastric (stomach) cancer and directed staff to consult with the physician to have hospice care for R30. The care plan documented encouraged R30 to express feelings, listen with non-judgmental acceptance, observe for signs of pain, administer pain medications as ordered, and notify the physician immediately if there was breakthrough pain. Staff were to refer to a psychiatric or psychologist consult if needed, review R30's living will and ensure it was followed, and work with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. The Nurse's Note, dated 08/19/24 at 08:32 PM, documented R30 was evaluated and admitted into hospice services. On 104/24 at 02:41 PM, observation revealed R30 sat in his wheelchair and had his head lying on his bed. On 10/17/24 at 12:1 PM, Administrative Nurse D stated MDS assessments were completed offsite. Administrative Nurse D said she would pass on the information to the person completing the MDS that R30 received hospice services and that it should have been on the MDS assessment. The facility's Resident Assessment Instruments policy, dated 12/10, documented a comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. The Assessment Coordinator was responsible for ensuring that the Interdisciplinary Assessment Team conducts timely resident assessments and reviews according to the following schedule. The purpose of the assessment was to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Information derived from the comprehensive assessments helped the staff to plan care that allowed the resident to reach his/her highest practicable level of functioning. The facility failed to accurately assess and record R30's terminal condition on his 08/26/24 comprehensive MDS. This placed the resident at risk for an inaccurate care plan and unmet care needs.
The facility identified a census of 49 residents. The sample included 13 residents with two residents reviewed for treatment of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure Resident (R) 7 received appropriate prompt treatment to promote healing and prevent worsening of a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers. The facility also failed to ensure R43 had nutritional measures and a pressure reducing device for her wheelchair in place. This placed R7 and R43 at risk for delayed healing and or increased risk for pressure ulcers. Findings included: - The electronic medical record (EMR) for R7 documented diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), respiratory failure (a condition where your blood does not have enough oxygen), dysphagia (swallowing difficulty), aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit), Stage 2 pressure wound, and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R7's Entry Minimum Data Set (MDS) dated [DATE] documented a reentry after a short-term acute hospital stay. R7's Significant Change MDS, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 had a swallowing disorder and required a feeding tube for nutrition. R7 was at risk of pressure ulcers. R7's Significant Change MDS lacked documentation that R7 had a Stage 2 pressure ulcer. R7's Nutritional Care Area Assessment (CAA) dated 10/01/24 documented he had a potential nutrition risk related to a medical history of cerebral infarction, dysphagia, and COPD and received nothing by mouth (NPO); he was dependent on enteral nutrition support to meet all estimated nutrient needs. R7's Care Plan last revised on 10/14/24 documented he had the potential for pressure ulcer development and directed staff to do weekly skin assessments. Staff was directed to assist with turning and repositioning during rounds. R7 had a Stage 2 pressure injury to the left buttock. Staff was directed to administer treatments as ordered and monitor their effectiveness. Staff was directed to document wound appearance, color, wound healing, wound size, and stage. Staff was directed to provide a pressure relieving device in his bed. A Physician Progress Note dated 09/24/24 documented R7 was seen for re-admit after hospitalization . R7 was admitted to the hospital on 09/13/24 after a seizure (violent involuntary series of contractions of a group of muscles). He had a diagnosis of a pressure injury of the right heel, left buttock, and sacral (large triangular bone/area between the two hip bones) region Stage 2 that was added on 09/17/24. R7 was discharged back to the facility on [DATE]. A physical exam of the skin revealed R7's skin was warm and dry but did not include further documentation or examination of R7's sacral wound. A Weekly Skin Review Report dated 09/28/24 documented four Stage 2 pressure wounds to R7's left buttock. Wound One measured 1.2 centimeters (cm) in length by 1.0 cm in width; Wound Two measured 2.2 cm in length by a 1.5 cm width; Wound Three measured 0.7 cm in length by 0.3 cm in width; and Wound Four measured 0.4 cm length by 0.1 cm width. The wound beds were red with scant exudate (a fluid that leaks out of body vessels and tissues). A pressure-relieving device was in place (low air loss mattress). The primary provider and resident's responsible party were notified. A Physician Progress Note dated 10/03/24 documented R7 was seen for a new wound, R7 had a coccyx (tailbone the last bone at the base of your spine) wound that staff found yesterday. R7 also has a new wound on his right heel. Examination revealed a shallow ulcer in the coccyx, and the wound bed was beefy red. The diagnosis and orders for this visit include Stage 2 pressure ulcer of the coccyx region. The plan is to clean the coccyx wound with wound cleanser and apply zinc oxide twice daily and as needed. Under the Orders tab of the EMR documented a physician order dated 10/03/24 for wound healing to clean with normal saline and apply zinc twice daily. R7's EMR lacked documentation for a wound treatment before the 10/03/24 order. On 10/15/24 at 01:30 PM, R7 lay on his bed with the cover over his head as staff entered his room and prepared him for his wound treatment. On 10/17/24 at 11:46 PM Administrative Nurse E stated via telephone that after R7 returned from the hospital she believed they got him the low air loss mattress and she believed a foam dressing was put in place. Administrative Nurse D stated she was not sure why there was a delay in R7 being treated for his pressure wounds after his return from the hospital. Administrative Nurse D stated that R7's physician had orders in place, and she assessed the wound weekly. The Prevention of Pressure Ulcers policy documented that once a pressure ulcer develops it could be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. The facility should have a system to ensure assessments are timely and appropriate and changes in condition are recognized, evaluated, and reported to the practitioner, physician, and family, and addressed. The facility failed to monitor and treat R7's Stage 2 pressure ulcer to his left buttocks promptly which resulted in a delay of treatment. This placed R7 at risk for complications related to skin breakdown and pressure ulcers. 32360 - The Electronic Medical Record (EMR) for R43 documented diagnoses of traumatic brain injury (TBI-an injury to the brain caused by external forces), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), abnormalities of gait and mobility, mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time) and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Admission Minimum Data Set (MDS), dated [DATE], documented R43 had moderately impaired cognition. R43 was dependent on staff for toileting, bathing, dressing, and personal hygiene and required substantial assistance for mobility and transfers. The MDS documented R43 had functional impairment on both lower extremities. R43 had an unhealed Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer and had a pressure relieving device for her chair and received pressure ulcer dressings. The Braden Scale Assessment, (a formal assessment for predicting pressure ulcer risk) dated 10/01/24 documented that R43 was at low risk for breakdown. The assessments dated 10/08/24 and 10/15/24 documented R43 had no risk for skin breakdown. R43's Interim Care Plan, dated 10/01/24, directed staff to provide R43 with a pressure device for her bed and chair, inspect her skin according to facility protocol, treat the pressure ulcer according to the physician's orders, and document. R43's Care Plan, dated 10/14/24, documented R43 had a Stage 2 pressure injury to her right buttock (either of the two round fleshy parts that form the lower rear area of a human trunk) and directed staff to administer treatment as ordered and monitor effectiveness. The plan directed staff to check for incontinence during rounds and provide care as needed, document wound appearance, color, wound healing, signs and symptoms of infection, and wound size. The care plan directed staff to keep the bed as flat as tolerated to reduce shear, notify the family of any new area of skin breakdown, notify the nurse of any new areas of breakdown, obtain lab and diagnostic work as ordered, and report the results to the physician and follow-up as needed. Staff were to provide wound healing supplements as ordered, refer to the dietician to follow recommendations, and serve R43's diet as ordered. The Physician's Order, dated 10/01/24, directed staff to cleanse the wound to the right buttock with wound cleanser, pat it dry with a 4 x 4 gauze pad, apply Medihoney (medical-grade honey used to aid wound healing) to the wound bed, nickel thick, and cover with a dry dressing every three days on day shift. This order was discontinued on 10/10/24. The Physician's Order, dated 10/10/24, directed staff to cleanse the wound to the right buttock with wound cleanser, pat it dry with a 4 x 4, apply Medihoney to the wound bed, nickel thick, and cover with a dry dressing every Monday, Wednesday, and Friday. The Weekly Skin Review, dated 10/01/24, documented R43 had a Stage 2 pressure injury on her right buttock that measured 4.1 centimeters (cm) x 6.2 cm x 0.1 cm. The Weekly Skin Review, dated 10/10/24, documented R43 had a Stage 2 pressure injury on her right buttock that measured 4.1 cm x 6.2 cm x 0.1 cm. The wound had 100 percent (%) slough (dead tissue, usually cream or yellow), had shown no improvement, and documented an appointment with the wound clinic would be scheduled. The Nurse's Note, dated 10/16/24, documented R43's right buttock wound measured 3.3 cm x 2.6 cm x less than 0.1 cm and documented the wound was yellow-greenish in color. R43's clinical record lacked evidence there the Registered Dietician evaluated R43's nutritional status to promote wound healing. On 10/14/24 at 02:44 PM, observation revealed that R43's room contained a bed and no other chair or recliner. R43 sat in her wheelchair in her room. Observation revealed there was no cushion in her wheelchair. On 10/15/24 at 09:00 AM, observation revealed R43 sat in her wheelchair in her room with no cushion in her wheelchair. On 10/15/24 at 09:16 AM, Certified Nurse Aide (CNA) O pushed R43 into the bathroom, donned clean gloves but not a gown, assisted R43 to stand up, and pulled down R43's pants. CNA O pulled off part of the dressing that was on R43's right buttock wound. The wound bed was yellow, with redness to the skin surrounding the wound and there was no drainage apparent. On 10/17/24 at 08:25 AM, CNA M stated R43 sat in her wheelchair most of the time. CNA M did not remember R43 ever having had a cushion in her wheelchair. On 10/15/24 at 10:29 AM, Administrative Nurse D stated R43 should have a cushion in her wheelchair and verified R43 had not had a nutritional assessment completed with recommendations from the Registered Dietician. Administrative Nurse D verified there were no supplements for wound healing ordered for R43. Administrative Nurse D stated she would contact the physician and dietician to obtain orders for R43. The facility's Prevention of Pressure Ulcers policy, dated 03/2005, directed staff to review the resident's care plan to assess for any special needs of the resident and see the policy and procedure for specific tasks such as bathing, incontinence care, and repositioning. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. The facility should have a system/procedure to ensure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Identify risk factors for pressure ulcer development, for a person in a chair change position at least every hour, and use foam, gel, or air cushion as indicated to relieve pressure. The Dietitian would assess nutrition and hydration and make recommendations based on the individual resident's assessment. The facility failed to provide a pressure-reducing wheelchair cushion and nutritional support to promote healing for R43 who had a Stage 2 pressure ulcer upon admission. This placed R43 at risk for further breakdown and delayed healing.
The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 45 with sanitary indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) care. This placed the resident at risk for urinary tract infections (UTI-an infection in any part of the urinary system) and other catheter-related complications. Findings included: - R45's Electronic Medical Record (EMR) documented diagnoses of acute respiratory failure with hypoxia (inadequate supply of oxygen), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), altered mental status, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), other mechanical complication of cystostomy catheter (urinary bladder catheter inserted through the abdomen into the bladder), urinary tract infection, obstructive and reflux uropathy (disorder or urinary tract), a disorder of bone density and structure, muscle weakness, and lack of coordination. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R45 had intact cognition, exhibited no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or behaviors. R45 was dependent on toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. R45 required partial/moderate assistance with upper body dressing, and substantial/maximal assistance with personal hygiene, bed mobility, standing, and transfers. The MDS further documented R45 had an indwelling catheter and was always incontinent of bowel. R45 received as-needed pain medication and had pain that occasionally affected sleep, day-to-day activities, and therapy. R45 had shortness of breath with exertion and lying flat, had oxygen therapy, a non-invasive mechanical ventilator, and speech, occupational, physical, and respiratory therapy. R45 had surgical wound care and received an antidepressant (a class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain). R45's Care Plan dated 07/08/24, documented an indwelling catheter for obstructive uropathy. The plan directed staff to change the catheter as ordered, check for patency and urinary output each shift, observe for pain and discomfort due to the catheter, observe and report signs and symptoms to the physician, and position the catheter bag and tubing below the level of the bladder. The Physician Orders dated 09/04/24, documented R45 had an indwelling catheter size 16 French (FR) with 10 cubic centimeters (cc) balloon to bedside drainage; provide catheter care every shift and as needed, and record catheter output every shift. The Progress Note dated 09/25/24 at 10:49 PM, documented the nurse placed a urinary catheter which remained in place, and draining. R45 had no concerns, complaints, pain, or discomfort at that time. The Progress Note dated 10/07/24 at 02:18 PM, documented that R45's family member thought R45 may had a UTI and the physician was notified. The Progress Note dated 10/10/24 at 01:28 PM, documented R45 was seen by the physician who ordered phenazopyridine (a medication used to relieve symptoms caused by UTIs) 200 milligrams (mg) three times a day for three days and Gemtesa 75 mg (a medication used to treat overactive bladder) daily. On 10/15/24 at 02:04 PM, observation revealed Certified Nurse Aide (CNA) N providing catheter emptying task. CNA N explained to R45 that she was going to empty the catheter bag. CNA N placed gloves on and retrieved the measuring cylinder from the bathroom, gathered an incontinent wipe from a package on the overbed table, unhooked the drainage bag from the underside of the resident's wheelchair, drained the collection bag, wiped the drainage spicket with an incontinent wipe, then laid the drainage bag directly on the floor, smoothed it out flat, then placed the drainage back to the underside of the wheelchair. On 10/17/24 at 09:04 AM Licensed Nurse (LN) H stated CNA N should not have placed the catheter bag directly on the floor. On 10/17/24 at 03:00 PM, Administrative Nurse D reported catheter bags should not be laid directly on the ground. The facility's Urinary Catheter Care dated 03/31/16, documented the purpose of this procedure is to prevent catheter-associated urinary tract infections. Use standard precautions when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor. The facility failed to provide R45 with sanitary indwelling urinary catheter care which placed the resident at risk for urinary tract infections.
The facility identified a census of 49 residents. The sample included 13 residents with one resident reviewed for enteral feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) management. Based on observation, record review, and interview the facility failed to ensure that Resident (R) 7 had a flush order for pre and post-bolus (a method of tube feeding that involves giving a patient a large amount of liquid formula through a feeding tube all at once) via gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). This placed R7 at risk of G-tube complications and adverse reactions including dehydration (not enough fluids) and fluid overload. Findings included: - The electronic medical record (EMR) for R7 documented diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), respiratory failure (a condition where your blood does not have enough oxygen), dysphagia (swallowing difficulty), aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R7's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 had a swallowing disorder and required a feeding tube for nutrition. R7 was at risk of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R7's Nutritional Care Area Assessment (CAA) dated 10/01/24 documented he had a potential nutrition risk related to a medical history of cerebral infarction, dysphagia, and COPD and received nothing by mouth (NPO); he was dependent on enteral nutrition support to meet all estimated nutrient needs. R7's Care Plan last revised 08/08/24, directed staff to flush the G-tube with 150 cubic centimeters (cc) of water before and after feedings four times a day for water flush. R7's Orders tab of the EMR documented an order dated 05/08/24 for a G-tube flush with 150 cc of water four times a day. This order was discontinued on 09/19/24. R7's Order Summary Report documented an order dated 09/19/24 for a bolus of Glucerna (a nutritional supplement with low carbohydrate content) 1.5 to give 250 milliliters (ml) one time a day for supplement. R7's Order Summary Report documented an order dated 09/19/24 for G-tube a bolus of Glucerna 1.5 to give 250 ml two times a day for a supplement. R7's Order Summary Report documented an order dated 09/19/24 for G-tube a bolus of Glucerna 1.5 to give 250 ml at bedtime for a supplement. R7's Order Summary Report documented an order dated 09/19/24 for G-tube flush with 250 ml of water every day and night shift for a supplement. R7's Order Summary Report documented an order dated 09/19/24 for G-tube flush with 30 ml of water before and after meds and flush with 10 cc of water between each medication. R7's Orders tab lacked an order specifying the amount for G-tube flush prior to and after administration of the Glucerna bolus. On 10/15/24 at 01:30 PM, R7 lay on his bed. Licensed Nurse (LN) G knocked on his door and announced herself and stated she was going to be giving him his Glucerna. LN G flushed R7's G-tube with 150 ml of water prior to pouring the Glucerna into the syringe attached to the G-tube. LN G then poured the bolus of Glucerna into the syringe until all was emptied through the tube. LN G then poured an additional 30 cc of water into the tube to flush. On 10/15/24 at 01:45 PM LN G stated that R7's orders say to flush with 30 ccs of water before and after medications so she just assumed that was the amount that was to be used to flush the G-tube when giving the Glucerna. On 10/17/24 at 08:15 AM Administrative Nurse D stated that R7's G-tube should be flushed with 150 ml of water prior to and after his bolus of Glucerna. Administrative Nurse D stated the prior order must have been omitted upon his return from the hospital on 09/19/24. The undated Enteral Nutrition policy documented that fluids to be provided beyond free fluid in the product would be calculated by the dietitian and referred to the physician for an order. The dietitian would recommend bolus fluid flushes, with consideration of the fluid content of the feeding product, resident weight, diagnosis, fluid, electrolyte, and nutritional status. The facility failed to ensure R7 had an order for a flush prior to and after administration of his enteral bolus feeding. This placed R7 at risk of G-tube complications and adverse effects including dehydration or fluid overload.
The facility had a census of 49 residents. The sample included 13 residents, with three reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30 had physician orders for oxygen therapy and failed to provide direction to staff for the cleaning, storage, and dispensing of oxygen. The facility failed to ensure R7 had a physician's order for his oxygen and further failed to store R7's and R45's respiratory equipment in a sanitary manner. This placed the residents at risk for increased respiratory infections and other related complications. Findings included: - The Electronic Medical Record (EMR) for R30 documented diagnoses of stomach cancer, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), heart failure, hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Admission Minimum Data Set (MDS), dated [DATE], documented R30 had intact cognition and required set-up assistance with toileting, and upper body dressing. R30 was independent with personal hygiene, mobility, transfers, and ambulation The MDS noted R30 had shortness of breath with exertion, resting, lying flat, and was on oxygen. R30's Care Plan, dated 08/14/24, documented R30 had oxygen therapy and directed staff to administer oxygen via nasal cannula at two liters continuously; observe for respiratory distress, and report to the physician as needed. R30's EMR lacked a physician order for the oxygen use. On 10/15/24 at 07:45 AM, observation revealed that R30's oxygen tubing and cannula were wrapped around an oxygen tank, unbagged. On 10/15/24 at 08:35 AM, R30 stated he used his oxygen every night and sometimes during the day. R30 stated when he used it during the day, he used an oxygen tank if he was out of his room. On 10/17/24 at 08:00 AM, observation revealed R30's oxygen tubing and cannula were wrapped around the back of the oxygen concentrator unbagged. On 10/15/24 at 08:52 AM, Administrative Nurse D verified R30 did not have a doctor's order for oxygen use. Administrative Nurse D said that when not in use, oxygen tubing and cannula are to be stored in a bag. On 10/17/24 at 08:28 AM, Certified Nurse Aide (CNA) M stated R30 wore his oxygen off and on, and stated when he did not have it on, the tubing should be stored in a bag. On 10/17/24 at 10:05 AM, Licensed Nurse (LN) H stated she did not think he used his oxygen but the tubing and cannula should be stored in a bag when not in use. The facility's Oxygen Use policy, dated 03/04, documented, for safe oxygen administration, verified that there was a physician's order for oxygen use, and reviewed the care plan for any special needs of the resident. Check the tubing connected to the oxygen cylinder to ensure that it is free of kinks, and turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. The facility failed to obtain physician orders prior to administering R30's supplemental oxygen and failed to store the oxygen tubing and cannula in a sanitary manner when not in use. This placed the resident at risk for respiratory complications and physical decline. 41713 - The electronic medical record (EMR) for R7 documented diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), respiratory failure (a condition where your blood does not have enough oxygen), dysphagia (swallowing difficulty), aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R7's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 required moderate to maximal staff assistance with his functional abilities. R7 had a swallowing disorder and required a feeding tube for nutrition. R7 was at risk of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The MDS lacked documentation that R7 was on oxygen therapy. R7's Nutritional Care Area Assessment (CAA) dated 10/01/24 documented he had a potential nutrition risk related to a medical history of cerebral infarction, dysphagia, and COPD and received nothing by mouth (NPO); he was dependent on enteral nutrition support to meet all estimated nutrient needs. R7's Care Plan last revised on 10/14/24 directed staff to give nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) treatment and oxygen therapy as ordered. The care plan lacked staff direction for care and storage of the nebulizer and oxygen therapy equipment. A review of R7's Order Summary Report dated 10/17/24 revealed an order dated 09/19/24 for albuterol sulfate (a class of medication used to prevent and treat wheezing and shortness of breath caused by breathing problems inhalation nebulization solution one vial four times a day for shortness of air. R7's Order Summary Report lacked a physician's order for oxygen therapy. R7's Treatment Administration Record (TAR) lacked directions for staff to clean or change the nebulizer and oxygen tubing and how frequently. On 10/15/24 at 01:30 PM R7's laid in bed, his nebulizer mask and tubing laid on top of the table stand. The nebulizer tubing was dated 10/05/24. R7's supplemental oxygen machine was turned on and his nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was lying on his bed. On 10/15/24 at 01:40 PM, Licensed Nurse (LN) G stated the tubing and mask should be placed in a plastic bag when not in use. LN G stated she believed that the tubing was changed out weekly on Sundays by the night shift staff. On 10/17/24 at 08:15 AM Administrative Nurse D stated all residents that received oxygen should have a physician's order for use. Administrative Nurse D stated the new masks and tubing should be changed out every Sunday night by staff. Administrative Nurse D stated the tubing and masks or cannulas should be stored in a dated bag when not in use. The Oxygen Administration policy documented: Verify that there was a physician's order for this procedure. Review the physician's order for facility protocol for oxygen administration. Document the following information in the resident's medical record: the date and time, the rate of oxygen flow, the route, and the rationale. The facility failed to ensure R7 had a physician's order in place for supplemental oxygen use. The facility failed to ensure staff appropriately changed, stored, and labeled R7's nebulizer mask, oxygen tubing, and cannula when not in use. This placed R7 at risk of respiratory complications and infection. 37450 - R45's Electronic Medical Record (EMR) documented diagnoses of acute respiratory failure with hypoxia (inadequate supply of oxygen), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), altered mental status, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), other mechanical complication of cystostomy catheter (urinary bladder catheter inserted through the abdomen into the bladder), urinary tract infection, obstructive and reflux uropathy (disorder or urinary tract), a disorder of bone density and structure, muscle weakness, and lack of coordination. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R45 had intact cognition, exhibited no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or behaviors. R45 was dependent on toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. R45 required partial/moderate assistance with upper body dressing, and substantial/maximal assistance with personal hygiene, bed mobility, standing, and transfers. The MDS further documented R45 had an indwelling catheter and was always incontinent of bowel. R45 received as-needed pain medication and had pain that occasionally affected sleep, day-to-day activities, and therapy. R45 had shortness of breath with exertion and lying flat, had oxygen therapy, a non-invasive mechanical ventilator, and speech, occupational, physical, and respiratory therapy. R45 had surgical wound care and received an antidepressant (a class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain). R45's Care Plan, dated 10/14/24, documented that R45 had oxygen therapy related to ineffective gas exchange. The plan noted that R45 removed the oxygen and continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep)at times, and at times did not want nebulizer treatments. The plan directed staff to observe R45 for signs and symptoms of respiratory distress and report to the physician. The oxygen setting for oxygen via nasal cannula/mask was at three liters continuously. The Physician Order, dated 09/08/24, directed staff to clean and label the bilevel positive airway pressure (BiPAP- a noninvasive ventilator that helps to breathe) and nebulizer masks, nasal cannula, tubing, filters, and water canisters weekly. On 10/15/24 at 11:32 AM, observation revealed R45 was not in her room, though the oxygen concentrator was on and set at two litters. The tubing was draped over the concentrator and the nasal cannula was lying on the floor behind the concentrator without a date or label. The nebulizer treatment equipment stored in a clear plastic bag had a date of 10/05/25. The CPAP mask and tubing lying on the bedside table were not covered and also lacked a date label. On 10/17/24 at 07:56 AM, observation revealed R45 in the dining room eating her meal. She wore oxygen per nasal cannula and had an oxygen canister on the back of the wheelchair. Observation of the R45's room revealed the oxygen tubing was draped over the top of the bed, over the pillow, and the nasal cannula lay on the bed. The date label remained 10/05/24. On 10/15/24 at 03:00 PM, Administrative Nurse D stated the oxygen tubing should be stored in a bag while not in use. Administrative Nurse D verified the oxygen equipment should be changed and labeled on a weekly basis. The facility's Oxygen Administration policy, dated 03/2004, lacked instructions related to changing and maintaining infection control practices of the oxygen and other equipment used. The facility failed to maintain, change, and label respiratory equipment for R45 which placed the resident at risk for respiratory infections.
The facility identified a census of 49 residents. The sample included 13 residents with Resident (R) 19 reviewed for pain management. Based on observation, record review, and interview, the facility failed to ensure R19 had her physician ordered Norco (a combination pain medication of opioid pain reliever hydrocodone and non-opioid pain reliever acetaminophen) medication available for administration as scheduled for pain management, which resulted in R19 missing a scheduled dialysis (a procedure where impurities or wastes are removed from the blood) appointment. This placed R19 at risk of complications related to unmanaged pain. Findings included: - R19's Electronic Medical Record (EMR) documented diagnosis of hypertension (HTN- elevated blood pressure), end-stage renal disease (ESRD-a terminal disease of the kidneys), and type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R19's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R19 utilized a wheelchair for mobility and required moderate to maximal assistance from staff for functional abilities. R19 took pain medications for pain management. R19 was on dialysis. R19's Skin Care Area Assessment (CAA) dated 07/07/24 documented she had the potential for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as result of pressure, or pressure in combination with shear and/or friction) development related to immobility, incontinence, and ESRD. R19's Care Plan last revised on 07/07/24 directed staff to administer medications as directed. R19's Orders tab of the EMR documented a physician's order dated 09/17/24 for Norco tablet 10-325 milligrams (mg) one tablet by mouth three times daily for pain. A review of R19's October 2024 Medication Administration Record (MAR) revealed on 10/13/24 at 11:00 PM the Norco was unavailable for administration. On 10/15/24 at 08:03 AM R19 stated that she had missed her dialysis appointment yesterday (10/14/24) due to her being in pain and that her Norco pain medication had not been available for almost 24 hours. R19 stated she did not receive her Norco on Sunday 10/13/24 at 05:00 PM or at 11:00 PM. R19 stated the nurse had told her that the Norco had been ordered before the weekend but had not been received yet. On 10/15/24 at 08:05 AM Licensed Nurse (LN) G stated that the facility had ordered R19's pain medication, but it had not been received by the pharmacy until last night. LN G stated the facility did have an emergency kit, but as an agency nurse, she did not have access to the kit. On 10/17/24 at 08:15 AM Administrative Nurse D stated that the facility had been having some issues with the pharmacy service saying they had not received a refill request so there had been a delay. Administrative Nurse D stated that the medication aides and nurses have all been educated on ensuring that pain medication was sent for refill request five days prior to running out. Administrative Nurse D stated that the facility also had an emergency kit for medications in the medication room, the nurse or medication aide would just have to call her or the assistant director of nursing (ADON) when a medication was needed. The Pain - Clinical Protocol policy documented: The physician and staff will identify individuals who have pain or who are at risk for having pain. This included a review of each person's known diagnoses and conditions that commonly cause or predispose to pain; It also included a review of any treatments that the resident currently was receiving for pain, including complementary (non-pharmacologic) treatments. The nursing staff would assess each individual for pain upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was an onset of new pain or worsening of existing pain. The staff and physician would identify the nature and severity of the pain. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The staff would observe the resident (during rest and movement) for evidence of pain. The facility failed to ensure R19 had her physician-ordered Norco available for administration as scheduled for pain management, which resulted in unmanaged pain. This placed R19 at risk of complications related to unmanaged pain.
The facility identified a census of 49 residents. The sample included 13 residents with one resident reviewed for dialysis for dialysis (a procedure where impurities or wastes were removed from the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services regarding Resident (R) 19's health status with each procedure. This deficient practice placed R19 at risk for complications related to dialysis. Findings included: - R19's Electronic Medical Record (EMR) documented diagnosis of hypertension (HTN- elevated blood pressure), end-stage renal disease (ESRD-a terminal disease of the kidneys), and type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R19's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R19 utilized a wheelchair for mobility and required moderate to maximal assistance from staff for functional abilities. R19 took pain medications for pain management. R19 was on dialysis. R19's Skin Care Area Assessment (CAA) dated 07/07/24 documented she had the potential for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as result of pressure, or pressure in combination with shear and/or friction) development related to immobility, incontinence, and ESRD. R19's Care Plan last revised on 07/07/24 directed staff to ensure R19 goes to dialysis as scheduled on Monday, Wednesday, and Friday. The staff was directed to educate the resident on the importance of dialysis and provide educational material if needed. R19's Orders tab of the EMR documented an order dated 07/19/24 for dialysis three times a week on Monday, Wednesday, and Friday. Chair time is at 06:40 AM. A review of R19's Dialysis Communication Sheets revealed the facility lacked sheets from 03/25/24 to 08/21/24. On 10/15/24 at 08:03 AM R19 sat on her bed in her room. R19 stated she missed her dialysis appointment due to being in quite a bit of pain. R19 stated that the facility would send the communication sheet with her to her dialysis appointment, but she did not always return with the paper. On 10/15/24 at 08:05 AM Licensed Nurse (LN) G stated that the dialysis communication sheet was completed by facility staff prior to R19 being taken to dialysis. LN G stated the communication sheet was sent with R19 on her scheduled day, but the sheet did not always come back with the resident. LN G stated she had not ever called the dialysis clinic to request the communication sheet or the health information when the sheet had not come back with R19. On 10/17/24 at 10:15 AM Administrative Nurse D provided all the dialysis sheets she could find. Administrative Nurse D stated the facility had not had a medical records person for a while so the dialysis sheets that had not been scanned yet could be waiting to be scanned in. Administrative Nurse D stated that the nurse should be obtaining vital signs and completing the communication sheets prior to R19 going for her scheduled appointments. Administrative Nurse D stated that staff nurses should be calling the dialysis clinic to have them fax the sheet to the facility. The End-Stage Renal Disease, Care of a Resident policy documented the following. Agreements between this facility and the contracted ESRD facility included all aspects of how the resident's care would be managed including how the care plan would be developed and implemented; and how information would be exchanged between the facilities. The resident's comprehensive care plan would reflect the resident's needs related to ESRD and dialysis care. The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services regarding R19's health status with each procedure. This deficient practice placed R19 at risk for complications related to dialysis.
Inspection of June 17, 2024
1 findingThe facility identified a census of 43 residents. The sample included five residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 received care consistent with the standards of practice when staff failed to notify and obtain physician involvement regarding R1's multiple medication refusals including medications used to control seizures (violent involuntary series of contractions of a group of muscles). R1 refused all morning doses for his twice-daily Keppra (medication used to treat seizures) from [DATE] through [DATE]. R1's clinical record lacked evidence the staff reported the refusals to the physician for medical evaluation. On [DATE] at 04:02 PM, R1 sat in the dining room, talking to staff, when his legs began to shake and extend outward. He received Ativan (medication used to treat seizures and anxiety [mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear]) 0.5 milligrams (mg) orally at 04:05 PM. At 04:07 PM, his full body stiffened, and staff took him to his room and assisted him into bed. At 04:10 PM, Consultant GG arrived at the facility and ordered an Ativan 2 mg injection for the seizure, which staff administered At 04:15 PM, staff administered an Ativan 4 mg injection for the ongoing seizure. At 04:16 PM, staff called Emergency Medical Services (EMS) and administered another dose of Ativan 2 mg via injection for the seizure. EMS arrived and transported R1 to the hospital. R1 admitted to the hospital and later died on [DATE]. The facility's failure to provide nursing care within the standards of practice including notification and involvement for medical oversight for repeated and ongoing seizure medication refusals placed R1 in immediate jeopardy. Findings included: - R1's clinical record documented a diagnosis of seizures and anxiety disorder. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. R1 had wandering behavior that occurred one to three days in the assessment period. R1 was independent with transfers; required set-up or clean-up assistance with eating, toileting hygiene, upper and lower body dressing, and putting on/taking off shoes; required supervision with oral hygiene; and required partial to moderate assistance with bathing and personal hygiene. R1's Care Plan dated [DATE], documented R1 had a seizure disorder and directed staff to administer seizure medications as ordered by the doctor, notify the nurse immediately if seizure activity occurred, and obtained labs as ordered and reported results to the doctor. The Orders tab of R1's EMR documented an order with a start date of [DATE] for Keppra 1000 mg 1.5 tablets two times a day for seizures. Review of R1's Medication Administration Record (MAR) for [DATE] to [DATE] revealed R1 refused his Keppra medication the following scheduled morning doses: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. R1's MAR documented he spit out meds for his morning Keppra dose on [DATE] and [DATE]. R1's clinical record lacked evidence that staff notified the physician of R1's Keppra refusals from [DATE] to [DATE]. R1's clinical record revealed a progress note from Consultant GG for [DATE] that documented R1 was seen for a seizure. Nursing staff reported R1 was having tremors around 04:00 PM and he was given oral Ativan 0.5 mg. R1 went into full status epilepticus (a seizure that occurs continuously for much longer than usual or seizures that occur in quick succession with no time between the seizures for the person to recover) and Consultant GG gave an order for a 2 mg Ativan injection with no change in his seizure. The Ativan was repeated every 15 minutes until R1 was transferred to the emergency room by ambulance. Upon request, the facility provided Emergency Department (ED) Provider Notes for R1. The ED Provider Notes, dated [DATE], documented R1 presented from a nursing facility with concerns of seizures for the last hour and 15 minutes. R1's seizure activity apparently started around 04:00 PM. He was treated with oral lorazepam (Ativan) as well as lorazepam injections without improvement to seizure-like activity. EMS arrived at the facility and R1 continued to have seizure-like activity. EMS gave 4 mg intravenous (through a vein) lorazepam then phoned in indicating a code red patient was coming into the ED. Upon R1's arrival to the ED, he was nonresponsive and not responding to pain or verbal stimuli. The decision was made to intubate (tube inserted into a trachea [wind pipe] to assist with breathing) R1. On [DATE] at 12:56 PM, Certified Medication Aide (CMA) R stated if a resident refused a medication, she tried three more times then asked the nurse to try. She stated if a medication was refused a couple of days in a row, she let the nurse know. On [DATE] at 12:58 PM, Licensed Nurse (LN) G stated if a resident refused a medication, she tried to give it again, but it was their right to refuse. She stated the physician was notified daily if a resident refused medications or the provider was notified when they did rounds on Thursdays. LN G stated the physician notification was documented in medication notes which showed up with the progress notes. She stated she had not received any notification from any CMAs that R1 refused his Keppra medication. LN G stated she expected CMAs to notify the nurse if the resident refused any medications. On [DATE] at 01:09 PM, Administrative Nurse D stated on [DATE], R1 was in the dining room for an activity before dinner when she heard staff yelled for help; R1 looked like he was having a seizure. She stated the right side of R1's body was jerking but he was still talking. Consultant GG came in and ordered Ativan then staff took R1 to his room where he started seizing again and kept seizing. Administrative Nurse D stated Consultant GG ordered more Ativan for R1 and told staff to send him to the ER. She stated the Ativan was not working but when the ambulance arrived, R1 stopped presenting as seizing at that point and he left with EMS. Administrative Nurse D stated nobody had reported to her that R1 refused his Keppra and R1 did have a history of seizures. She stated she did not review R1's MAR. Administrative Nurse D stated if a resident refused a medication, staff were to let the nurse know so the nurse could notify the physician. She expected the nurse to notify the physician after every missed dose and the physician notification should be documented in the progress notes. After reviewing R1's [DATE] MAR,, Administrative Nurse D stated the missed morning doses of Keppra were not good. On [DATE] at 01:20 PM, CMA S stated R1 constantly refused his medications and if he refused medications, she told the nurse and charted it. She stated she charted it by using the refused option in the MAR and sometimes she put the nurse notification in the notes. CMA S stated she followed up with the nurse if a resident missed a couple of doses. She stated she did not remember the period of [DATE] to [DATE] and if R1 refused his Keppra. On [DATE] at 02:55 PM, Administrative Staff A stated she expected the CMA to notify the nurse if a resident refused a medication and for the nurse to notify the physician then chart the notification in the progress notes. On [DATE] at 03:00 PM, Consultant GG stated on [DATE] she came into the facility and was asked for an order for Ativan. She stated she went to R1's room within five minutes and he was still seizing. She stated she told staff to call 911. Consultant GG stated Ativan was given every 15 minutes, but the seizure did not stop. She stated she had been told several times on and off that R1 refused medications, but she was not aware that he had not taken his Keppra from [DATE] to [DATE]. Consultant GG stated she was usually notified of refused medications and if a resident refused two doses, she expected to be notified. The facility's Change in a Resident's Condition or Status, dated [DATE], directed the nurse notified the resident's attending physician or physician on call when there had been a refusal of treatment or medications. The policy directed the nurse recorded in the resident's medical record information related to changes in the resident's medical or mental condition or status. The facility failed to ensure R1 received care consistent with the standards of practice when staff failed to notify and obtain physician involvement regarding R1's multiple medication refusals including medications used to control seizures. R1 refused all morning doses for his twice-daily Keppra from [DATE] through [DATE]. R1's clinical record lacked evidence the staff reported the refusals to the physician for medical evaluation. On [DATE], R1 experienced a seizure that required medical intervention including emergency transportation to the hospital for evaluation. He was transferred to another hospital where he was admitted and died on [DATE]. The facility's failure to provide nursing care within the standards of practice including notification and involvement for medical oversight for repeated and ongoing seizure medication refusals placed R1 in immediate jeopardy. On [DATE] at 03:15 PM, Administrative Staff A received a copy of the Immediate Jeopardy Template and was informed of the facility failure to notify and obtain physician involvement regarding R1's multiple medication refusals for Keppra leading up to a seizure on [DATE], that required emergent medical intervention and admission to the hospital, placed R1 in immediate jeopardy. On [DATE], the facility completed the following corrective actions: The facility educated the CMA and nurses in the facility on medication refusals and notifications following medication refusals. The facility completed an audit of all missed medications for [DATE] and the physician was notified during the Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting on [DATE]. The surveyor verified removal of the immediacy on [DATE] at 04:49 PM. The deficient practice remained at the scope and severity of a G.
Inspection of May 18, 2016
1 findingThe facility identified a census of 41 residents. The sample included 3 residents. Based on observation, interview, and record review, the facility failed to develop and implement effective interventions to identify and prevent the development of an avoidable pressure ulcer, without the facility knowledge, for resident (#1), which required hospitalization due to the development [MEDICAL CONDITION] (potentially life-threatening complication of an infection) and gangrene (death of tissue). The ulcer required multiple surgical debridements (the removal unhealthy tissue from a wound to promote healing), and placement of a [MEDICAL CONDITION] (surgical creation of an artificial opening on the stomach/abdominal wall to excrete feces from the body). This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1 had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of (15), which indicated intact cognition. The resident was independent with all activities of daily living except he/she required extensive assistance with bathing. Staff performed formal and clinical skin assessments and identified the resident at risk for development of pressure ulcers and had a pressure reduction device for his/her bed. The MDS lacked evidence of a turning and repositioning plan. The quarterly MDS dated [DATE] recorded the resident with a BIMS score of (13), which indicated intact cognition. The resident required supervision/set-up with bed mobility and locomotion in his/her wheelchair. The resident required limited assistance from one staff with dressing, personal hygiene and transfers and required extensive assistance from 1 staff member with toileting, and did not bathe during the assessment period. The resident had a suprapubic urinary catheter (urinary bladder catheter inserted through the skin) and was always incontinent of bowel. Staff performed formal and scheduled clinical skin assessments and documented the resident was not at risk for pressure ulcer development. The resident required no pressure relieving devices and had a [MEDICAL CONDITION]. The MDS lacked evidence of a turning and repositioning plan. The Braden scale assessment for predicting pressure sore risk dated 9/4/15 and 3/15/16 documented a score of (16) and recorded the resident at low risk for developing pressure ulcers. A Braden scale assessment dated [DATE], documented a score of (17), a low risk for development of pressure ulcers. The assessment documented the resident was chair fast, had occasionally moist skin, no impairment in skin sensory, had slightly limited mobility, and received adequate nutrition. The resident had a potential for friction or sheer, moved feebly (physically weak) or required minimum assistance. The care plan for activities of daily living and limited physical mobility updated 3/7/16 documented the resident with left sided weakness. The resident required a wheelchair for locomotion. Staff observed, documented, and reported to the physician any signs of increased immobility and skin breakdown. The resident required one staff with transfers, dressing, personal hygiene, and toileting. The resident required extensive assistance of one staff with two baths/showers per week. The resident was able to turn from side to side, however, required assistance of one staff to pull him/herself up in bed, and move from a lying position to a sitting position on the side of the bed. The undated direct care staff Kardex (paper cheat sheet reference for nursing staff with documentation of a summary of the resident's care needs) identified the resident with a suprapubic catheter, and bowel incontinence. The resident required assistance of one staff, and staff offered to toilet the resident for a bowel movement in the morning, before and after meals, before bed and on repositioning rounds (which was in conflict with staff interviews). The resident required assistance of one staff with dressing and grooming, provided two showers each week, and he/she required a wheelchair for locomotion due to left arm and leg weakness. The resident turned and repositioned him/herself. The care plan for impaired skin integrity dated 3/8/16 documented the resident with the [DIAGNOSES REDACTED]. On 2/16/16, the consultant wound physician discussed the non-compliance issues with the resident which included lying down for rest periods with feet elevated and adequate nutrition to improve wound healing. The resident had a pressure reducing mattress on his/her bed, frequently refused to sleep in bed, and slept sitting up in his/her wheelchair. The care plan for potential for pressure ulcer development revised 4/4/16, documented the resident's risk factors of obesity and chronic progressive disease. The care plan directed staff to notify the nurse immediately of any signs of skin breakdown, redness, blisters, bruises, and discoloration observed during baths or daily care. The resident's care plan for sleep preference dated 4/19/16, documented the resident slept in a recliner instead of a bed. Staff assisted the resident with repositioning in the recliner as frequently as needed and the resident was able to turn side to side, but required assistance to pull him/herself up. Staff made sure the resident understood how to work the controls in his/her recliner and that the control pad was within his/her reach before leaving the room. The care plan lacked evidence of any intervention of a pressure reduction device for a recliner or wheelchair. The initial skin note dated 9/4/15 at 6:13 P.M., documented the resident with [MEDICATION NAME] (brand of protective foam dressing) to the coccyx (small triangular bone at the base of the spine) area and upon removal staff found no impaired skin to that area. Staff notified the physician and received an order to discontinue any treatment listed for coccyx at this time. Nursing note (NN) dated 2/14/16 at 1:25 A.M. documented the resident continued to refuse to lay in bed. He/she chose to stay up in his/her wheelchair and lay his/her head and arms on the bed, and sleep in this position. Staff attempts to encourage the resident to lay in bed were not effective and attempts to educate the resident of pressure related risks were not effective. NN on 3/12/16 at 2:31 A.M., documented the resident had some weeping (clear fluid leaking from [MEDICAL CONDITION]) to his/her bilateral lower extremities, and staff continued to encourage the resident to lie in bed and elevate his/her legs. At this time, the resident chose to sleep in his/her electric wheel chair. Staff educated the resident, that by doing this, he/she placed him/herself at risk for pressure related issues and continued [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues). A quarterly nursing assessment note dated 4/13/16 documented the resident required limited assistance of one staff with toileting and required staff assistance with personal hygiene after a bowel movement. Review of direct care staff bathing sheets documented: On 4/18/16, the resident had no new skin issues. On 4/21/16, the resident had no new skin issues. On 4/25/16, the bath sheet lacked documentation evidence staff assessed the resident's skin. On 4/28/16, the bath sheet lacked documentation evidence staff assessed the resident's skin. On 5/2/16, the resident refused a shower and staff offered the resident a bed bath. The bath sheet lacked evidence the resident accepted or declined a bed bath. The bath sheet lacked documentation of evidence staff assessed the resident's skin. The weekly skin assessment dated [DATE], documented a wound area to the resident's right foot with a treatment in place. Staff assessed the resident with dry areas to bilateral shins and no other skin impairment issues. NN on 5/3/16 at 11:35 P.M., documented at approximately 8:50 P.M., the resident stated he/she wanted to go to the hospital. The resident said, I ' m sick I ' m sick. The resident could not verbalize if he/she was having pain, dizziness, or any details. Nursing staff assessed the resident was warm, clammy, unable to grip hands, and was running his/her electric wheelchair all over banging into things in his/her room. Staff turned the wheelchair off for safety. The resident slurred his/her words, was unable to answer most questions appropriately, barely kept his/her eyes open, and was only alert for a small amount of time. A physician telephone order dated 5/3/16 at 11:53 P.M. directed staff to send the resident to an acute care hospital for evaluation and treatment related to change in mental status and to rule out [MEDICAL CONDITION] (rapid, irregular heartbeat). Review of hospital emergency room records dated 5/3/16 timed 10:24 P.M. documented the hospital admitted the resident to the ICU (intensive care unit) with the [DIAGNOSES REDACTED]. A hospital consultation note dated 5/5/16 time 12:18 A.M. documented the resident with septic shock and necrotic buttock decubitus (pressure ulcer with dead tissue which resulted from lack of blood flow) with evidence of Fournier's gangrene (a horrendous infection of the genitalia that causes severe pain in the genital area and progresses from [DIAGNOSES REDACTED] (redness) to necrosis (death) of tissue). A hospital operative report dated 5/11/16 timed 6:36 A.M. documented findings of a necrotic ulceration involving the left buttock, hip and perineal region. Edges of the wound had putrid pus and gas bubbles consistent the Fournier's gangrene. Some of the wound edges extended to the (scrotum) and perineum. The resulting defect after the sharp excisional debridement measured 25 centimeters (cm) by 15 cm with exposed muscle. The surgeon created a diversion [MEDICAL CONDITION] because the wound was right to the anus and perineum and the entire left buttock, to prevent fecal contamination of the wound. Observation on 5/10/16 at 1:00 P.M. revealed the resident lay in bed in an acute care hospital intensive care unit, in isolation. The resident received supplemental oxygen by bi-pap (bi-level positive airway pressure, a non-invasive form of oxygen therapy to treat sleep apnea). On 5/10/16 at 1:45 P.M. observation revealed the resident's electric wheelchair in his/her facility room with a pillow type cushion on the hard surface seat. The semi-private room lacked a bed in the resident's area and had a recliner against the wall. On 5/10/16 at 10 A.M., licensed nursing staff H reported the wound nurse did all the skin assessments and treatments. On 5/10/16 at 10:08 A.M. licensed nursing staff G reported he/she knew about the resident's foot ulcer from diabetes and heard about the other wounds when the resident admitted to the hospital. Interview with consultant hospital nurse KK on 5/10/16 at 1:25 P.M. revealed the hospital admitted the resident to the intensive care unit [MEDICAL CONDITIONS] in a large sacral decubitus in the left buttock. The resident was septic when admitted to the hospital, had black necrotic tissue over the ulcer, foul odor and Fournier's gangrene. The surgeon debrided the pressure ulcer on the left buttock to measure 13 cm by 9 cm by 1.5 cm. The resident also had redness in the peri-area when he/she admitted to the hospital, which was not from urine as the resident had a suprapubic catheter which was not leaking. On 5/10/16 2:10 P.M., direct care staff Q reported the resident stayed in his/her wheelchair and staff took the bed out because he/she wanted to sleep in the wheelchair. The resident asked for incontinence products and he/she never assisted the resident in the bathroom. On 5/10/16 at 2:30 P.M. administrative nursing staff D reported the staff performed weekly skin assessments on all residents. On 5/10/16 at 2:35 P.M. licensed nursing staff G revealed staff performed weekly skin assessments on the residents. On 5/10/16 at 4:10 P.M., direct care staff O reported the resident transferred him/herself to the toilet. Most of the time the resident called for help in the bathroom and needed staff to help with personal care for bowel incontinence. Staff would report any change of skin to the charge nurse. On 5/10/16 at 4:25 P.M., direct care staff N reported the resident did his/her own cares. At times the resident had bowel incontinence, would not tell staff, and when he/she found the resident that way, he/she would assist to clean the resident. The resident slept reclined in his/her wheelchair with a blanket and staff had to encourage the resident and follow up with getting showers. Staff observed the resident's skin during care, showers, charted any findings, and reported to the nurse. On 5/10/16 at 5:15 P.M. administrative nursing staff F reported he/she did skin assessments with the resident lying in bed to look at all the skin, and the resident had a bed, up to 4/15/16. The resident required assistance with positioning. The resident's skin had been okay, except for the diabetic ulcer on his/her foot, and the wound nurse performed a skin assessment on 4/28/16 before the resident went to the hospital. Administrative nursing staff F reported the hospital found a pressure ulcer. On 5/10/16 at 5:20 P.M. licensed nursing staff G revealed he/she performed the resident's full skin assessment on 4/28/16 while the resident was in the shower and seated on a shower chair. Licensed nursing staff G reported the resident could not stand, and he/she looked up under the shower chair through the hole and could visualized all the resident's skin except where the shower chair ring was under the resident. Licensed nursing staff G reported he/she did not see any pressure ulcers. On 5/11/16 at 9:40 A.M. direct care staff P revealed the resident took him/herself to the bathroom, needed help with wiping and called for staff. The resident rarely used the call light for assistance and only slept in his/her electric wheelchair, reclined. On 5/11/16 at 3:40 P.M., administrative nursing staff D reported licensed nursing staff could perform the resident's skin assessments in the shower or in their room in bed, it depended on the resident's preference. He/she expected nursing staff to be sure to inspect all the resident's skin for any changes. On 5/12/16 at 10:05 A.M. physician consultant FF revealed, the gangrene was a very rare type and could sometimes come from deep, deep infection that rose to the surface, and the way this originated was probable infection from deep inside, and gangrene occurred within hours. Physician consultant FF reported staff could do a better skin assessment, than on the shower chair. The facility provided policy Pressure Ulcer Risk Assessment Prevention dated March 2005, directed staff assessed residents skin for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. The facility policy Prevention of Pressure Ulcers dated March 2005, documented interventions for the risk factor chair-fast included change position at least every hour, and use foam, gel or air cushion as indicated. The facility failed to develop and implement effective interventions for one resident #1, to prevent the development of an avoidable pressure ulcer which developed without the facility knowledge, and required hospitalization due to the development [MEDICAL CONDITION] and gangrene. The ulcer required two surgical debridements and placement of a [MEDICAL CONDITION]. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 5/13/16 at 2:00 P.M. when: 1) Licensed nursing staff completed a skin evaluation on all current residents to ensure identification, assessment and appropriate treatment for [REDACTED]. 2) The facility developed a procedural addendum for prevention of pressure ulcers which addressed skin observations performed during routine shower/tub baths, routine weekly skin evaluations by the licensed nurse, and a procedure for resident refusal of skin evaluation during routine showers or weekly skin evaluations by the licensed nurse. 3) The facility trained licensed nurses on wound identification, assessments, and treatments. 4) The facility trained nursing assistants on conducting skin observations during routine care and the time of the INTERACT (Interventions to Reduce Acute Care Transfers) Stop and Watch to communicate findings to the licensed nurse. 5) The facility provided on-going monitoring for compliance with routine weekly skin checks, scheduled Braden assessments, weekly wound documentation, compliance with scheduled showers/baths and skin observations. 6) The facility reviewed and monitored the audits reported to the Quality Assurance/Performance Improvement Committee for compliance. The deficient practice remained at the scope a severity of a G.
Inspection of June 15, 2015
2 findingsThe facility identified a census of 48 residents. Based on observation, interview, and record review, the facility failed to provide preventive treatments and effective interventions to prevent the development of avoidable pressure ulcers for 3 of 4 dependent residents reviewed (#1, #2, and #6). Findings included: - The clinical face sheet documented the facility readmitted resident #1 on 12/24/14 with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment dated [DATE] recorded the resident with short and long term memory impairment, moderately impaired decision-making skills, and required extensive assistance for activities of daily living. The resident received all nutrition from tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube). This MDS documented the resident was at risk for pressure ulcers and had a surgical wound on his/her hip. This MDS lacked evidence of any pressure relieving devices, turning/repositioning program. The Care Area Assessment for pressure ulcers dated 12/30/14 documented the resident was at risk for pressure ulcers related to bowel and bladder incontinence, impaired mobility, and received all nutrition through a feeding tube (a tube for introducing high calorie fluids into the stomach); and had a surgical wound on his/her right hip. A significant change MDS dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment, required extensive assistance from staff for all activities of daily living. This same MDS recorded the resident with one unstageable pressure ulcer covered with slough (dead tissue, usually cream or yellow in color) or eschar (dead tissue) that measured 1.0 by 2.0 by 0 centimeters and slough. Staff performed turning/repositioning; applied ointments and dressings to the resident ' s skin; and provided pressure relief device for the bed. The Care Area Assessment for pressure ulcers dated 3/13/15 documented the resident with pressure ulcer related to end stage [MEDICAL CONDITION]. Review of the quarterly MDS assessment dated [DATE] recorded the resident with short and long term memory impairment, severely impaired decision-making skills, required extensive assistance from staff for all activities of daily living and total assistance with nutrition from a tube feeding, always incontinent of bowel and bladder and received supplement oxygen therapy. This same MDS recorded the resident at risk for pressure ulcers, received clinical and formal skin assessments, and documented the resident with one unstageable pressure ulcer covered with slough and one pressure ulcer suspected with deep tissue injury covered with eschar, and one stage 3 pressure ulcer not present on the previous assessment. Staff provided turning/repositioning, pressure relief device for the bed, application of dressings and ointments to the skin. Review of the Braden scale assessment for predicting pressure sore risk dated 11/7/14 recorded a score (18), low risk for pressure ulcers. The next completed Braden assessment dated [DATE] recorded a score of (11), which placed the resident at high risk for pressure ulcers. Review of a nutritional assessment dated [DATE] recorded the resident readmitted following a [MEDICAL CONDITION] and received nutritional by way of a tube feeding due dysphagia (swallowing difficulty). The resident had intact skin and received therapy. Review of the plan of care for pressure ulcers dated 3/18/15 recorded interventions dated 1/2/15 that directed to provide devices for proper body alignment as indicated, monitor labs and report to the physician. Interventions added on 3/18/15 documented a deep tissue injury pressure ulcer per consulting physician, right hip bony prominence. Perform treatment per physician orders [REDACTED]. Encourage oral and fluid intake. Keep family and physician informed of wound progress. Assist the resident with turning/repositioning every 2 hours throughout shift. Use padding between pressure areas and positioning. Provide pressure relieving devices for the resident ' s bed and wheelchair and dietary consultation for nutrition. Undated documentation recorded a left heel unstageable, with necrotic tissue. The plan of care for incontinence of bowel and bladder directed staff to perform cares every two hours. The physician orders [REDACTED]. Nursing note dated 12/24/14 at 1:40 P.M. recorded a hospital report which documented the resident experienced a right [MEDICAL CONDITION] (at home), received surgical repair on 12/15/14 with a large surgical stapled incision. Bruises over entire body, incontinent of bowel and bladder and a red groin area. Nursing note dated 1/22/15 at 1:38 P.M. documented the podiatrist (doctor that specialized in foot care) trimmed the resident ' s toenails and recorded no new orders. This documentation lacked anything regarding pressure ulcers on the resident ' s feet or any impairment of the resident ' s skin. A skilled nursing note dated 1/26/15 timed 8 A.M. recorded the resident was dependent on staff for all activities of daily living and left the skin condition assessment blank. Nursing note on 1/27/15 at 8:41 A.M. recorded therapy required nursing to assess the resident ' s left heel. Staff documented the resident ' s left heel with a necrotic like area underneath skin of left heel with some peeling noted over area. Therapy reported the area was not observed last week. Nursing staff requested the wound consultant physician to evaluate and assess the resident ' s heel on rounds today. Nursing note dated 1/27/15 at 6:41 P.M. recorded the resident ' s left heel with necrotic tissue (unstageable) pressure ulcer. The initial wound encounter measurements were 3 centimeter (cm) length by 3 cm width; right heel was suspected deep tissue injury pressure ulcer with measurements of 1.3 cm length by 1.6 cm width. The physician ordered heel cut out boots (provided by therapy), and off-loading of the areas. Nursing note dated 2/3/15 at 11:26 A.M. recorded a wound care consultant visit and assessment of the resident ' pressure ulcers to his/her heels. The left heel with necrotic unstageable tissue measured 1.4 cm length by 2.5 cm width; right heel with suspected deep tissue injury pressure ulcer measured 1.2 cm length by 1.6 cm width. The physician ordered to continue skin prep, heel cut out boots when in bed, and off-loading the heels. A bathing skin assessment dated [DATE] recorded the resident with no impaired skin issues. Nursing note dated 2/17/15 at 2:24 P.M. documented the wound care consultant debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) the left heel and ordered treatment of [REDACTED]. Nursing note dated 2/24/15 at 2:34 P.M. documented the wound care consultant assessed the residents left heel pressure ulcer which measured 0.9 cm length by 2 cm width, moderate amount of serosanguineous (semi-thick reddish drainage) drainage and the right heel wound resolved. The clinical record lacked evidence of the weekly skin assessment for 3/4/15. Nursing note dated 3/10/15 at 12:50 P.M. documented the wound care consultant assessed the resident with a new wound to the right hip bony prominence observed with a pink bordered foam covering the area. The wound care consultant removed the dressing and reported the right hip area was a suspected deep tissue pressure ulcer initial wound that measured 4 cm length by 3.2 cm width, a moderate amount of serosanguineous drainage. The wound bed was 26 to 50% [MEDICATION NAME] (healing), 51 to 75% dry, black eschar. New treatment orders documented to cleanse the wound with normal saline. Protect the periwound with skin prep, cover the wound with bordered foam, and change the dressing every 72 hours and as needed for soiling and/or saturation. The weekly skin assessment dated [DATE] recorded the resident's right hip pressure ulcer measured 3.6 x 2.8 cm, black eschar covered with bordered foam. The weekly skin assessment dated [DATE] documented the resident ' s right hip pressure ulcer measured 3.4 cm by 1.9 cm. Nursing note dated 4/1/15 at 9:46 A.M., documented the wound care consultant assessed the resident on 3/31/15 to ensure proper wound healing per physician orders. The resident ' s right hip pressure ulcer measured 3.4 cm length by 1.9 cm width, moderate amount of serosanguineous drainage and left heel pressure ulcer measured 0.9 cm length by 1.6 cm width. Nursing notes dated 4/2/15 at 7:28 A.M. documented staff observed the resident lying on his/her right side in bed, soaked with multiple layers of yellowish rings and clothing saturated. Physician orders [REDACTED]. Clean the right hip pressure ulcer with normal saline, apply Alginate to the wound bed over the Santyl, cover the wound with bordered gauze/foam, and change daily and as needed for soiling and/or saturation. Nursing note dated 4/16/15 at 2:44 P.M. recorded the wound care consultant performed the resident ' s skin assessment. Nursing note dated 4/21/15 at 3:55 P.M. documented the wound care consultant performed the resident ' s skin assessment and inquired about the macerated wound edges. Nursing staff informed the wound care consultant on 4/20/15 another Duoderm was found on resident's right hip with a heavy amount of serosanguineous drainage. The wound consultant reported this was contraindicated for optimal healing. The wound care consultant ordered if the wound dressing came off, had strike through or soiled; to place a new dressing. Physician orders [REDACTED]. Nursing note dated 4/23/15 at 12:51 P.M. recorded a physician order [REDACTED]. Nursing note dated 4/23/15 at 1:55 P.M. documented the eschar/slough plug came off with removal of the hip dressing. The dressing revealed extra heavy serosanguineous drainage and mild odor. The wound care consultant ordered a new treatment with alginate packing in the open wound and to continue other orders for the right hip pressure ulcer. Nursing note dated 4/28/15 at 9:04 A.M. documented the resident's right hip pressure ulcer revealed copious wound drainage and odor. The clinical record lacked the wound culture results, lab results with culture and sensitivity obtained on 4/27/15. Nursing staff obtained the results from the laboratory website and notified the primary care physician and the wound care consultant. The computerized clinical record lacked evidence of the wound culture results or the physician order [REDACTED].>During an interview on 5/19/15 at 11:00 A.M., administrative nursing staff F reported that staff should record all physician orders [REDACTED]. On 5/19/15 at 11:35 A.M. administrative nursing staff E reported staff recorded physician orders [REDACTED]. Nursing note dated 5/1/15 at 5:04 P.M. documented the resident received an antibiotic for a wound infection. Staff turned the resident to keep of his/her right hip pressure ulcer. Review of the resident ' s May 2015 treatment administration record documented the 5/13/15 skin assessment. The computerized clinical record lacked evidence of any electronic documentation for skin or wound assessments. Observation of wound care on 5/15/15 at 2:10 P.M. revealed the resident lay on his/her back in bed with an alternating air mattress. Licensed nursing staff I assisted the resident to position on his/her left side and removed the dressing that covered the right hip pressure ulcer. Licensed nursing staff I cleansed the wound with normal saline, inserted one and one-half 4 by 4 gauze into the circular wound that measured approximately 3.5 cm in diameter, with extensive tunneling and covered the wound with bordered foam dressing. Licensed nursing staff I revealed he/she had requested and received new treatment orders for the resident's pressure ulcer. Review of the resident's computerized clinical record lacked evidence of the physician order [REDACTED]. Observation on 5/19/15 at 1:30 P.M. revealed the resident with a scabbed area approximately 0.5 centimeter in diameter on the scalp at the top of the resident's ear behind the oxygen tubing. The oxygen tubing lacked any cushion and the resident's ear lacked any dressing. Review of the resident'ss clinical record lacked evidence of any treatment or monitoring of the area behind the resident ' s left ear. On 5/19/15 at 1:30 P.M., licensed nursing staff I reported staff just monitored the area behind the resident ' s left ear without any current treatment. On 5/20/15 continuous observation at 9:05 A.M., 9:15 A.M., 9:30 A.M., 9:45 A.M., 10:00 A.M., 10:15 A.M., 10:30 A.M., 10:45 A.M., 11 A.M., 11:15 A.M., 11:30 A.M., 11:45 A.M. At 12:00 noon, direct care staff Q pushed the resident in his/her wheelchair from the television room to the dining room where the resident remained until 12:50 P.M. when direct care staff Q pushed the resident back to the television room in his/her wheelchair. Observation revealed the resident remained in the wheelchair without incontinence care or repositioning for (3 hours and 50 minutes). An interview with licensed nursing staff H on 5/15/15 at 8:50 A.M. revealed the resident had some wounds; however, he/she did not know what wound treatments were ordered for today. Licensed nursing staff H revealed the assistant director of nursing would provide a list if any treatments needed provided today. On 5/15/15 at 1:50 P.M., direct care staff N revealed staff checked and changed for incontinence every 2 hours. On 5/15/15 at 2:15 P.M., licensed nursing staff I reported the resident ' s pressure ulcer had tunneling under all sides of the open area that previously required four 4 by 4 gauze pads to fill. Licensed nursing staff I reported the wound care plan and treatment orders were kept in the treatment book and recorded wound and skin assessments on the paper record and not in the computer. On 5/20/15 at 1:20 P.M. direct care staff O reported staff checked and changed residents for incontinence every 2 hours at a minimum. On 5/20/15 at 10:07 A.M., licensed nursing staff J reported the resident had a wound to his/her right hip. On 5/20/15 at 3:25 P.M. direct care staff P reported the resident required total care from staff, transferred with a mechanical lift and staff kept the resident positioned off the right hip pressure area. The facility policy Prevention of Pressure Ulcers dated March 2005 recorded pressure ulcers were usually formed when a resident remained in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. For a person in a chair, change position at least every hour. Routinely assess and document the condition of the resident ' s skin per the facility wound and skin care program for any signs and symptoms of irritation or breakdown. Place a resident on a minimum of every 2-hour check and change program for incontinence. Change position of a bedfast resident at least every 2 hours and more frequently as needed. Staff should document in the resident ' s medical record any condition of the resident ' s skin to include size, location of any red or tender areas. The facility failed to ensure appropriate interventions in the prevention and treatment for [REDACTED]. - The electronic health records for resident #2 documented [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident with short- and long-term memory loss, moderately impaired decision-making and required extensive assistance for all activities of daily living except eating. The resident used a wheelchair for mobility. Staff performed formal and clinical skin assessments and the resident did not have any pressure ulcers now or on the prior assessment. The Care Area Assessment for pressure ulcers dated 11/13/14 documented the resident with the potential for impaired skin due to episodes of incontinence, required staff assistance with repositioning, transfers and the inability to express him/herself and understand others at times. The quarterly MDS dated [DATE] documented the resident with moisture associated skin damage and staff applied ointments for skin protection. The quarterly MDS dated [DATE] documented the resident required extensive assistance for bed mobility, and total staff assistance for transfers, dressing, toileting, personal hygiene, and bathing. The resident had no pressure ulcers and staff applied ointments for skin protection. Review of the quarterly MDS dated [DATE] recorded the resident always incontinent of bowel and bladder, at risk for pressure ulcers and no pressure ulcers on the prior assessment. The resident had one stage 3 pressure ulcer, two unstageable pressure ulcers, and one of the unstageable pressure ulcers revealed slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue). The largest unhealed pressure ulcer at stage 3/4 recorded measurements of 0.9 centimeter (cm) by 0.1 cm, and the most severe pressure ulcer revealed eschar tissue. Staff performed formal and clinical assessments, pressure reduction for bed, turning/repositioning program, nutrition/hydration, and pressure ulcer application of dressings and medications. Review of the Braden scale assessment for predicting pressure sore risk revealed: on 11/12/14 and on 1/19/15 a total score of (15); and on 4/17/15 a total score of (16), which indicated the resident was at low risk for pressure ulcers. The comprehensive plan of care dated 11/12/14 for bowel and bladder incontinence directed staff to provide perineal care and moisture barrier after each incontinence episode and the resident was on a check and change program every two hours and PRN (as needed). The plan of care for the resident ' s alteration in skin dated 11/13/14 documented the resident experienced incontinence episodes and required extra assistance with bed mobility/repositioning. The care plan directed staff to keep the resident ' s skin clean and dry with consistent bathing twice weekly, monitor the resident ' s skin during bathing and cares for red/open areas, rashes and report to the nurse. Staff offloaded the resident ' s heels when in bed with pillows or boots, provided nutritional supplements, and mechanical soft diet as ordered and offered fluids during hydration rounds. Staff checked and changed the resident for incontinence, provided perineal care and moisture barrier after each incontinence episode every 2 hours and PRN. Additional intervention added on 11/29/14 recorded due to an open area identified on the resident ' s right lower buttocks to provide treatment as ordered, encouraged, and provided the resident assistance to lie down between meals. Staff performed a new voiding trial and provided a low air loss mattress. Staff provided extensive assistance with transfers/repositioning at least every 2 hours and handled the resident gently to reduce skin tears to thin fragile skin and avoid bruising. Added on 4/13/15, staff performed Braden assessments quarterly. Added on 4/21/15, the resident experienced episodes of incontinence and was on a scheduled toileting program every 2 hours at night and PRN. The plan of care for the resident ' s activities of daily living dated 11/12/14 documented the resident with a self-care deficit, dementia, and required extensive assist to complete daily cares. The care plan directed staff to provide extensive assistance with repositioning every 2 hours, provide skin inspections: observe for redness, open areas, scratches, cuts, bruises and report to charge nurse, and provide weekly skin assessments per facility protocol. The resident had limited physical mobility related to weakness and was totally dependent on staff for locomotion in the wheelchair. Additional interventions added on 3/18/15 recorded a right knee scab and directed staff to perform treatments per physician orders. If no improvement in two weeks, report to the physician. Monitor for increase breakdown, signs, and symptoms of infection, and report to the physician. Monitor the resident for pain and relief, encourage oral and fluid intake. Staff to keep the physician and responsible party informed of progress. Assess the skin weekly and record clinical findings. Physician orders [REDACTED]. physician progress notes [REDACTED]. physician progress notes [REDACTED]. Nursing note dated 2/27/15 at 11:53 A.M. recorded an alteration in resident ' s skin integrity. Assessment revealed skin shearing with beginning wound in center base to his/her left inner thigh 6 cm by 1.8 cm, with edges intact. The surrounding tissue reddened, blanched easily, no drainage noted on pants, no odor. A second area noted to the resident ' s left pre-tibial (below the knee) round 1.0 cm circumference open sore with black necrotic center. Wound consultant note dated 3/3/15 documented assessment of left inner thigh and knee wound, of unknown origin but based on the history, likely a coffee burn. The area started as more of a whitish area, then darkened to grey. It sounded like the wound converted such that there was grey and yellow slough on the wound now. The left knee wound traumatic, was present over a bony prominence. Resident has dementia and contractures (abnormal permanent fixation of a joint). Wound #1Right (should be left) medial upper thigh was a full thickness burn with initial measurements of 1.3 cm by 6.2 cm. The wound bed presented with 76-100% adherent yellow slough. Wound #2 Right knee was an eschar covered trauma wound with initial measurement 0.9 cm length by 1 cm width it had no drainage with 76-100% black eschar. The wound appeared with superficial eschar, but directly over bony prominence. The knee wound, over bony prominence but a location where pressure would necessarily be a factor, appears more traumatic (hit lift?). Burn debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) 100% from slough and necrotic tissue and post debridement measured 1.4 cm long by 6.3 cm width. Orders to apply Santyl (sterile enzymatic [MEDICATION NAME]) to wound bed. Okay to use hydrogel (a water based gel which donates moisture and aids autolytic debridement) until obtain Santyl. Nursing notes dated 3/11/15 at 8:38 A.M. recorded the wound care consultant report for the 3/10/15 assessment. The resident ' s left medial thigh wound base was slough and minimally debrided at 100% with post debridement measurements of 1.5 cm length by 6 cm width by 0.2 cm depth. The left knee eschar covered wound measured 0.8 cm length by 0.8 cm width. A physician recertification form dated 3/17/15 documented the resident with a stage 2 partial thickness ulcer and a pressure ulcer. Nursing note dated 3/18/15 at 2:45 P.M. recorded the wound care consultant report for the 3/17/15 assessment. The resident ' s left medial upper thigh area was a full thickness burn, wound bed continued with slough and partial debridement performed with a post debridement wound measurement of 1.1 cm length by 6.2 cm width. Nursing note dated 3/18/15 at 3:02 P.M., recorded the left knee wound covered with eschar measured 0.5 cm by 0.6 cm. Wound consultant note dated 3/24/15 documented the resident ' s left medial thigh/upper leg burn, debride and Santyl dressing. Left knee trauma wound, stable with scab/eschar. A new pressure ulcer to the left knee found 5 days ago, dressed with foam. Staff attempts to keep the resident ' s knees apart were limited by the patient who wiggled until cushions were out of position. Wound measurements as follows: Wound #1: left medial upper leg/thigh initially measured 0.6 cm by 5.4 cm initially with 25% [MEDICATION NAME], 51-75% adherent yellow slough, and 25% bright red granulation tissue. Wound #2: left knee, eschar covered with measurements of 0.4 cm by 0.4 cm, with 76-100% black eschar. Wound #3: left medial knee, stage 3 pressure ulcer initially measured 1.3 cm long by 1.5 cm wide by 0.1 cm deep and moderate drainage. Wound #1: debrided with post measurements 0.7 cm long by 5.4 cm width by 0.1 cm deep. Wound #3: debrided and recorded a stage 3 wound. Physician orders [REDACTED]. Wound consultant note dated 3/31/15 documented the resident' s left upper leg/thigh burn with Santyl/xeroform dressing and left medial knee pressure ulcer, with collagen/foam, but found with bordered gauze (non adherent pad). The staff was supposed to be offloading the resident ' s knee by keeping the knees separated for left knee trauma eschar. Wound #1: left medial upper leg/thigh, measured 0.2 cm by 0.3 cm by 0.1 cm with the wound bed 76-100% [MEDICATION NAME] tissue, and 25% bright red granulation tissue. Wound #2: left knee, eschar covered, measured 0.3 cm by 0.3 cm with the wound bed 76-100% dry, black eschar tissue. Wound #3: left medial knee, stage 3 wound measured 1.3 cm by 1.3 cm with moderate serous drainage, the wound bed 76-100% yellow slough. Previously treatment order to cleanse with saline, protect periwound with skin prep, and apply collagen to wound bed, cover with bordered foam, and change every 72 hours, prn and if soiled/saturated. The left medial knee pressure ulcer with slough now, debrided and measured 1.3 cm length by 1.4 cm width by 0.1 cm depth. New order to start Santyl and pressure needs to be off loaded. The plan of care discussed with facility staff: do not use the bordered gauze (nonadhesive, [MEDICATION NAME] like pad with border) Nursing note dated 4/7/15 at 11:02 P.M. recorded the wound care consultant assessment of the left medial upper leg/thigh a full thickness burn that measured 0.5 cm length by 3.5 cm in width and 0.1 cm depth, healing. The left knee eschar covered trauma wound measured 0.3 cm length by 0.3 cm width. The left medial knee, a stage 3 pressure ulcer, measured 0.9 cm length by 1.2 cm width, healing. New treatment orders to protect periwound with skin prep, apply [MEDICATION NAME] to wound bed, and change every 72 hours. The annual physician history and physical dated 4/7/15, recorded the resident with burns, pressure ulcers, received wound specialist treatments improving, vitamin C, multi-vitamin, and zinc. Wound consultant note dated 4/14/15 documented the resident ' s left medial thigh/upper leg burn, originally healed, but now with a new open area, no dressing, which was supposed to be [MEDICATION NAME]. Unsure if this caused the wound to reopen or a recurrent trauma. The left anterior knee stable scab/eschar. The left medial knee stage 3 pressure ulcer supposed to be dressed with [MEDICATION NAME], offloaded with pillow between knees. Wound #1: left medial upper leg/thigh, full thickness burn, consequently encountered to measure 1 cm by 1.5 cm by 0.1 cm deep, wound bed 76-100% bright red granulation tissue. As a general note, the wound reopened and was originally a healed area. Wound #2: left knee was eschar covered, measured 0.5 cm by 0.4 cm with the wound bed 76-100% dry black eschar tissue. Wound #3: left medical knee stage 3 pressure ulcer measured 0.4 cm by 0.9 cm by 0.1cm with the wound bed 76-100% [MEDICATION NAME] tissue. Wound consultant note dated 4/21/15 recorded a new open area to the resident ' s right hip. The area appeared as a pressure ulcer given shape and size and it was unknown if any treatment had been instituted. Wound #1: left medial upper leg/thigh was a burn and resolved. Wound #2: left knee, eschar covered wound measured 0.4 cm by 0.3 cm, dry black eschar tissue. Wound #3: left medial knee stage 3 pressure ulcer measured 0.5 cm by 0.9 cm by 0.1cm deep with the wound bed 76-100% [MEDICATION NAME] tissue. Wound #4: Right hip stage 3 pressure ulcer measured 3 cm by 2.5 cm by 0.1 cm with the wound bed 75-100% [MEDICATION NAME], 25% bright red granulation tissue, and a shallow stage 3 pressure ulcer. Order to cleanse the wound with normal saline, protect the periwound with skin prep, apply [MEDICATION NAME] dressing to the wound bed, and change every 72 hours or PRN soiling. Additional orders directed the facility pressure ulcer prevention policy, protocol. Turn resident side to side every 2 to 3 hours, check to make sure his/her knees were separated or repositioned every 2 to 3 hours, pressure relieving mattress, wheelchair cushion, and offload heels per facility policy. A nutritional risk note dated 4/21/15 at 9:27 A.M. documented the resident had multiple skin issues. Staff provided a mechanical soft diet with ice cream at all meals. The resident ' s weight declined from 180 pounds six months ago to 173 pounds, which reflected a gradual weight loss. The resident received multivitamin, vitamin C, and zinc for healing. The pharmacist requested to discontinue of the vitamin C and zinc, however, the physician refused. The resident received iron twice daily. Recommended to change ice cream back to magic cups for more calories. Nursing note dated 4/21/15 documented the new pressure area on the resident ' s right hip bony prominence that was new from the assessment on 4/17/15. Wound consultant note dated 4/28/15 recorded the [MEDICATION NAME] dressing on the residents right hip lacked a date to determine the date the dressing was placed. The resident had limited ability to offload himself and with contractures. Wound #2: left knee trauma resolved now with only a superficial scab. Wound #3: left medial knee, stage 3 pressure ulcer measured 0.4 cm by 0.4 cm by 0.1 cm with 76-100% [MEDICATION NAME] tissue. Keep protected with [MEDICATION NAME] dressing and offloading. Wound #4: right hip stage 3 pressure area worse due to maceration of periwound, measured 3.8 cm by 3.2 cm by 0.1 cm, with a small amount of serous drainage. Orders to cover the wound with foam dressing and offload the right hip. A skin assessment dated [DATE] recorded the residents le
The facility identified a census of 48 residents with 3 residents sampled for accidents. Based on observation, interview, and record review, the facility failed to ensure supervision and assistive devices to 2 of 3 sampled dependent residents (#2 and #6). Resident #2 experienced repeated unwitnessed falls and an unwitnessed burn that required treatment by a physician when staff failed to have a lid in place for the resident ' s coffee. Resident #6 also experienced unwitnessed falls. Findings included: - The electronic health records for resident #2 documented [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident with short- and long-term memory loss, moderately impaired decision-making skills and required extensive assistance for all activities of daily living (adls) except eating. The resident used a wheelchair for mobility. Staff performed formal and clinical skin assessments. The resident had unsteady balance and only able to stabilize with staff assistance and had no falls since the previous assessment. The Care Area Assessment for falls dated 11/13/14 documented the resident with a history of falls, unsteady gait without assistance, had a bed and chair alarm in place. The resident had short and long-term memory deficit and at times when addressed, would just look at staff and not respond. Staff provided all assistance with transfers, ensured alarms were in place, and monitored the resident for safety. Review of the Quarterly MDS dated [DATE] recorded the resident required extensive assistance from staff for all adls except for eating, total assistance from staff for bathing, had unsteady balance, and only able to stabilize with staff assistance. This MDS recorded the resident with a fall since the previous assessment. Review of the Fall risk assessments revealed: 12/19/14 a total score of (21), which indicated high risk for falls; 12/24/14 a total score of (22) high risk for falls; 1/19/15 a total score of (19) high risk for falls; 2/5/15 (18) high risk for falls; and 4/12/15 a total score of (19), high risk for falls. The plan of care for the resident ' s alteration in skin dated 11/13/14 documented the resident experienced incontinence episodes and required extra assistance with bed mobility/repositioning. The care plan directed staff to keep the resident ' s skin clean and dry with consistent bathing twice weekly, monitor the residents skin during bathing and cares for red/open areas, rashes and report to the nurse. Staff provided extensive assist with transfers/repositioning at least every 2 hours and handled the resident gently to reduce skin tears to thin fragile skin and avoid bruising. An addition dated 4/13/15 revealed staff would perform Braden assessments quarterly. The plan of care for the resident ' s activities of daily living dated 11/12/14 documented the resident with a self-care deficit, dementia, and required extensive assist to complete daily cares. The care plan directed staff to offer a cup with lid for all hot liquids, provide extensive assistance with repositioning every 2 hours, provide skin inspections: observe for redness, open areas, scratches, cuts, bruises and report to charge nurse, and provide weekly skin assessments per facility protocol. The resident had limited physical mobility related to weakness and was totally dependent on staff for locomotion in the wheelchair. The plan of care for falls dated 11/12/14 documented the resident with a history of falls and gait/balance problems. The care plan documented falls on: 12/16/14 a non-injury fall, the resident fell between bed and wall, and maintenance provided locks on the bed. 12/19/14 a non-injury fall, the resident attempted to transfer him/herself to regular chair in the dining room. The intervention directed staff to transfer the resident to a regular chair at meals if he/she allowed. 12/24/14 a non-injury fall, with the intervention for an alarm audit, educate staff on rounds, and the resident currently worked with therapy. 4/23/15 a non-witnessed fall, with a minor injury a bloody nose. The care plan directed staff to anticipate the resident ' s needs, assist to bed around 8:00 P.M., and be sure the call light is within reach and encourage him/her to use it for assistance. Staff needed to promptly respond to all requests for assistance. Bed/chair alarm in place, floor mat in place at all times when the resident was in bed. Ensure the resident wore appropriate footwear when ambulating or mobilizing in wheelchair. The resident required a safe environment; even floors free from spills and/or clutter, adequate glare free light, a working and reachable call light, the bed in low position at night, items within reach. Keep adjustable bed in low position, and keep wheelchair locked for safe transfers. Provide extensive assist of one with all transfers. Review information on past falls and attempt to determine cause of falls. Record possible root causes. After/remove any potential causes if possible. Education of resident/family/caregivers/interdisciplinary team as to causes of the fall. The resident used a wheelchair for mobility. Nursing note dated 12/24/15 timed 6:15 P.M. documented staff found the resident seated on the floor mat against the bed. The facility provided fall investigation dated 12/24/15 documented staff assessed the resident with a healing bruise on the right deltoid that measured 6 centimeter (cm) by 2 cm. The facility investigation revealed the resident's safety alarm was not plugged in, and night shift left without doing rounds. The root cause analysis of the investigation recorded the resident was incontinent, needed changed and the bed alarm was unplugged. The plan recorded to make sure the resident was checked, night shift was educated on 2-hour rounds and make sure the bed alarm was plugged in and working. Nursing note dated 2/5/15 timed 3:45 P.M. documented staff found the resident out of bed on the fall mat, wrapped in his/her blanket and incontinent of bowel. Staff documented the residents call light was in reach and not activated, the bed was in the lowest position, and the sensor alarm was in place and sounding. The facility investigation documented staff needed to check on the resident more frequently for toileting. Nursing note dated 4/23/15 timed 8 P.M. documented staff found the resident on his/her left side on the fall mat next to the bed. The resident had blood on his/her face and apparently hit his/her face on the air inflator for his/her bed (air mattress). The facility fall investigation worksheet dated 4/23/15 timed 9:46 P.M. recorded the unwitnessed fall with the resident ' s bloody nose and abrasion to the face and determined the root cause was the resident was on a low air mattress which was very slick. The clinical record revealed the next nursing note dated 4/29/15 and timed 8:50 A.M. recorded the resident with left periorbital (tissue around the eye) with dark purple bruising. The clinical record lacked evidence of 72-hour nursing assessments and charting after the residents fall. The bathing record dated 5/4/15 documented the resident with a chest bruise and revealed staff notified the charge nurse and the assistant director of nursing. The bathing record dated 5/11/15 documented the resident with an alteration in skin on the chest area. Nursing note dated 5/14/15 time 9:39 A.M. documented direct care staff reported to nursing staff residents chest was purple and nursing assessed the resident. The assessment revealed the resident ' s chest from right below the neck to his/her lower abdomen all the way across was dark purple in color. Between the breasts was light in color. The left breast was edematous (swollen); approximately three times the size of the right breast. The charge nurse reported staff reported the bruising last week. The resident was non-verbal most of the time. A physician progress notes [REDACTED]. Nursing note dated 12/25/14 at 9:27 P.M. documented the resident spilled coffee during breakfast and his/her assessment of his/her left inner thigh was red with no blisters. The note lacked documentation that the resident ' s coffee had a lid on it. The bathing record documentation recorded an inner thigh dressing on 2/23/15 and on 2/26/15 inner thigh redness. The clinical record lacked evidence of any other documented assessment for the resident ' s left inner thigh redness until the physician note on 2/27/15. Physician note dated 2/27/15 documented staff reported a 10 cm by 4 cm linear blister half-way up the resident ' s inner left thigh, some subcutaneous tissue seen in the middle and ordered staff to dress the wound with Bactroban (antibiotic ointment), four by four gauze and obtain a wound care consultation. Nursing note dated 2/27/15 at 11:53 A.M. recorded an alteration in resident ' s skin integrity. Assessment revealed skin shearing with beginning wound in center base to his/her left inner thigh 6 centimeter (cm) by 1.8 cm, with intact edges. Wound consultant note dated 3/3/15 documented the assessment of left inner thigh wound, of unknown origin but based on the history, likely a coffee burn. The area started as more of a whitish area, then darkened to grey. It sounded like the wound converted such that there was 76-100% grey and adherent yellow slough on the wound now. Resident had dementia and contractures (abnormal permanent fixation of a joint). The physician recorded the wound as a full thickness burn, which initially measured 1.3 cm by 6.2 cm. Surgical debridement of the burn (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) from 100% from slough and necrotic tissue and post debridement measured 1.4 cm long by 6.3 cm width. New physician orders [REDACTED]. Okay to use hydrogel (a water based gel which donates moisture and aids autolytic debridement) until obtain Santyl. The clinical record revealed wound care consultant care on 3/17/15, 3/24/15, 3/13/15, 4/7/15, and 4/14/15. On 5/15/15 at 10:00 A.M. direct care staff O transferred the resident with sit to stand to his/her bed and positioned the resident on his/her right side in the bed on the alternating air mattress. Observation revealed the resident required total assistance from staff for bed mobility. The resident ' s chest presented with bruising across the entire upper chest with varied colors from greenish-yellow to dark purple under the left underarm. On 5/15/15 at 11:30 A.M. observation revealed, the resident sat in his/her wheelchair slowly moving the wheelchair in the hallway of the facility. Observation on 5/15/15 at 1:40 P.M. revealed direct care staff N and licensed nursing staff I placed a gait belt on the resident and provided extensive assistance to transfer the resident from his/her wheelchair to the bed. At this time staff reported trouble with the pressure pad alarm and direct care staff N reported the battery was low. Observation on 5/19/15 at 8:30 A.M. administrative nursing staff D and F repositioned the resident in bed and reported trouble with the pressure pad alarm not working. At this time direct care staff S reported the battery was bad and the alarm needed a new 9-volt battery. Observation revealed from Friday 5/15/15 until Tuesday 5/19/15 staff had not replaced the faulty battery to ensure the pressure pad alarm worked to prevent the resident ' s falls. On 5/20/15 at 1:15 P.M. direct care staff O and R placed the lift transfer belt around the resident ' s chest and transferred the resident with the sit-to-stand lift from his/her wheelchair to the bed. Staff positioned a pillow between the resident ' s knees and positioned the resident on his/her right side. Observation revealed the resident required total assistance from staff for bed mobility. On 5/15/15 at 10:00 A.M. direct care staff O reported the resident had a low bed, fall mat, and alarm for fall risk. On 5/15/15 at 1:50 P.M. direct care staff N reported staff checked and changed incontinent residents every 2 hours and report any skin conditions to the nurse. On 5/15/15 at 1:31 P.M. licensed nursing staff I reported he/she assessed the resident yesterday and changed the Duoderm (moisture resistant cover) dressing twice. Staff performed weekly skin assessments on half the residents Monday and the other half of residents on Wednesday. Licensed nursing staff I reported he/she completed the resident ' s weekly skin assessment on the 13th, however, did not look at the resident ' s skin under his/her shirt at the bruising. On 5/15/15 at 3:00 P.M. a discussion with administrative staff A and wound consultant EE revealed nursing staff reported to him/her that the area on the resident ' s left thigh was probably a result of a coffee burn. Administrative staff A reported there was some discussion of the resident ' s burn but we could not tell if it was a burn or how it happened. The resident does drink coffee. On 5/20/15 at 10:07 A.M. licensed nursing staff J reported the resident had bruising to his/her chest and staff checked the resident at least every 2 hours. The resident was a fall risk and interventions included a low bed, floor mat, and an alarm. The facility protocol for falls and incidents included assessments range of motion, skin red areas, and bruising. Staff reassessed the resident for three days (72 hours) on each shift. Staff notified the responsible party and the physician with any incident and did an investigation. On 5/20/15 at 12:50 P.M. direct care staff M reported staff documented any changes in a resident ' s skin during bathing and gave the sheets to the assistant direct of nursing. The facility ' s undated policy Incident/Accident Program/System recorded staff completed incident report forms with all falls (changes of elevation) and injuries. The director of nursing or designee would ensure that for all falls (change on elevation) staff would complete an incident/accident report, fall investigation worksheet, witness statements, fall risk assessment, and care plan updated, with dated new interventions for every fall. The director of nursing or designee would ensure that for all injuries, including those of unknown origin staff would complete incident/accident report, witness statements going back at least 24 hours for all injuries of unknown origin, investigation follow up, care plan with dated intervention and summary of findings and reasonable cause was documented on the investigation follow up form. All incident/accidents were discussed at the daily clinical meeting, all falls referred to therapy for screening, and staff ensured all proper interventions were in place. This policy further recorded staff documented in the resident ' s medical record every shift for 72 hours if the resident did not sustain an injury and if an actual injury, until the injury was resolved. Staff documented in the care plan with dated interventions after each fall or incident. The facility failed to provide supervision, assistive devices, and effective intervention for this dependent resident with repeated unwitnessed falls, extensive bruising, and burns that required treatment by a wound care specialist. - The clinical face sheet documented the facility admitted resident #6 on 3/17/15 with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) score of 13, independent with all activities of daily living, intact skin with formal and clinical skin assessments, pressure relieving device for bed and experienced a fall prior to admission. The Care Area Assessment (CAA) dated 3/31/15 falls was not completed. The CAAs lacked evidence of causes and contributing factors of the residents risk for experiencing falls. A significant change MDS dated [DATE] documented the resident with a BIMS score of 0, totally dependent on staff for all activities of daily living, and two or more recent falls since the previous assessment. The CAA dated 4/23/15 for pressure ulcers and falls were not completed. The CAAs lacked evidence of causes and contributing factors of the residents risk to experience falls. The fall risk assessment dated [DATE] recorded a total score of (5), which indicated low risk for falls and a fall risk assessment dated [DATE] that recorded a total score of (17) at high risk for falls. The plan of care for falls dated 3/24/14 documented to continue interventions on the at risk plan (not located in the resident ' s clinical record). Staff observed, documented, and reported to the physician as needed for signs/symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation. Added to the care plan on 4/13/15, the resident had an actual fall after admission related to a [DIAGNOSES REDACTED]. Intervention added on 4/13/15, for no apparent acute injury, determine, and address causatives factors of the fall. Intervention added on 4/20/15, provide a bed alarm, and chair alarm for safety due to falls. The resident has a low bed and mat. The care plan identified the resident with falls on 4/12/15 and 4/18/15. Nursing note dated 3/18/15 at 6:20 P.M. recorded the resident stated he/she had a fall prior to going into the hospital. Nursing notes dated 4/12/15 at 8:25 A.M. documented at 6:27 A.M. staff found the resident lethargic, unable to lift or move his/her left arm and the right side of his/her face was swollen with eyelid swollen and fluid filled pocked. The resident leaned over the wheelchair to the right side. Nursing note on 4/12/15 at 6:50 A.M. revealed staff obtained a physician order [REDACTED]. Review of a hospital transfer sheet dated 4/12/15 recorded the resident with very slow respirations, his/her arm laying back and behind and could not move the arm. The right side of the resident ' s face was swollen with the right eyelid with a fluid filled pocket, looked like the resident had been beat up . Nursing note dated 4/12/15 at 3:11 P.M. documented the resident returned from the hospital, not responding well, looked confused, and the right side of his/her face was swollen around the eye. The resident ' s responsible party pointed out a red area in the center of resident ' s chest with an indention noted. Where this came from was uncertain. A weekly skin note dated 4/13/15 at 5:11 P.M. recorded the resident with a small superficial redness to his/her left chest wall and chest abrasion 2 centimeters by 2.4 centimeters. The facility failed to provide an investigation for the 4/12/15 assessment of puffy eye and face or the chest indentation/abrasion. The resident ' s plan of care documented the resident with a fall on 4/12/15. Review of a fall assessment dated [DATE] documented at noon, staff found the resident lying on his/her back next to his/her wheelchair that was parked next to his/her bed. The resident reported he/she just slipped out of the chair. Staff documented the resident with weakness, a recent change in medical condition, increased confusion and no witnesses to the incident. The fall investigation recorded the resident required supervision, did not call for assistance, increased confusion, and need for assistance with adls. The resident had bowel and bladder incontinence, however did not need toileting. The fall investigation lacked a root cause to determine the reason for the resident ' s fall. Observation on 5/19/15 at 8:25 A.M. revealed the resident sat in a Broda ( specialized wheelchair with the ability to tilt and recline) at the dining table as direct care staff fed the resident breakfast. On 5/20/15 at 10:07 A.M. licensed nursing staff J reported the resident had been non-verbal for the last month and was unable to use a call light. With any falls or incidents, staff assessed the resident, completed a fall report, have all staff working do a witness statement and continue to assess and chart on the resident ' s condition each shift for 72 hours. On 5/20/15 at 5:30 P.M. administrative nursing staff F revealed on 4/12/15 the resident went out with family for the day and when brought back, the family left the resident in the bathroom and staff found the resident on the floor. Administrative nursing staff F then reported he/she was not sure if this was 4/12/15 or 4/18/15, however, when the resident returned from the hospital, he/she was total care and not walking any longer. Review of the clinical record lacked any documentation of the resident out of the facility with family since admission. The facility provided undated policy Incident/Accident Program/System recorded staff completed incident report forms with all falls (changes of elevation) and injuries. The director of nursing or designee would ensure that for all falls (change on elevation) staff would complete an incident/accident report, fall investigation worksheet, witness statements, fall risk assessment, and care plan updated, with dated new interventions for every fall. The director of nursing or designee would ensure that for all injuries, including those of unknown origin staff would complete incident/accident report, witness statements going back at least 24 hours for all injuries of unknown origin, investigation follow up, care plan with dated intervention and summary of findings and reasonable cause was documented on the investigation follow up form. The facility provided policy Reporting Abuse to Facility Management dated April 2010 documented that an injury that was not observed by any person or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or location of the injury was immediately reported to the director of nursing services and to the nursing supervisor on duty. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing. The facility failed to thoroughly investigate unwitnessed falls for this resident with a [DIAGNOSES REDACTED] and a history of falls.
Inspection of October 7, 2014
2 findingsThe facility identified a census of 48 residents. The sample size included 18 residents. Based on observation, record review and interview the facility failed to develop and implement effective interventions to prevent worsening an promote healing of an ulcer on a resident's foot for 1 of 1 resident sampled for skin conditions. (#13) Findings included: - Resident #13's admission Minimum Data Set ((MDS) dated [DATE] identified the resident scored 13 (cognition intact) on the Brief Interview for Mental Status (BIMS), required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toilet use, and personal hygiene, and the activity of walking did not occur. The MDS identified the resident utilized a wheelchair. The resident's quarterly MDS dated [DATE] identified the resident scored 14 (cognition intact) on the BIMS, had no behavior, required extensive staff assistance with bed mobility, locomotion on/off the unit, dressing, personal hygiene, totally dependent upon staff for transfers and toilet use, and the activity of walking in the room/corridor did not occur. The MDS identified the resident had a functional impairment of both sides of his/her lower extremity and utilized a wheelchair. The resident was at risk for the development of pressure ulcers, had surgical wounds and received application of ointment/medication other than to the feet and application of dressing to the feet. The resident's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 6/27/14 included the resident required extensive staff assistance with all ADLs, did not walk, and utilized a wheelchair for mobility with staff assistance, and required assistance of 2 staff with repositioning and transfers. Review of the resident's care plan with a print date of 9/26/14 on 9/29/14 at 1:00 P.M. included the following interventions in place since 6/26/14: the resident required extensive staff assistance with all ADLs, the facility provided extensive assistance of two with the stand up lift for all transfers required extensive staff with repositioning, and the resident utilized a wheelchair with staff assistance for mobility. The care plan included staff would ensure the resident wore proper footwear, the resident handled the resident gently to reduce skin tear to the resident's thin, fragile skin and to avoid bruising. The care plan included on 7/29/14 the facility washed and dried the resident's great toe, applied TAO (Triple Antibiotic Ointment) and dressed the resident's great toe on a daily basis. An entry dated 8/27/14 included a Doppler study (noninvasive test used to estimate blood flow through blood vessels) of the resident's bilateral lower legs suggested mild outflow obstruction (reduction of blood flow) and multifocal [MEDICAL CONDITION] calcification (condition where the arteries become narrowed and hardened due to an excessive build up of plaque around the artery wall). An entry dated 9/5/14 included the resident 2nd toe was amputated (removal of a limb). An entry dated 9/22/14 included the resident started [MEDICATION NAME](an antibiotic) twice a day (BID) for 7 days due [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus - a resistant infection) in his/her left foot. Review of the resident's care plan provided to the surveyor on 10/1/14 at 3:30 P.M. included an extra page (without a print date) and not included in the resident's care plan reviewed on 9/29/14 at 1:00 P.M. included on 7/29/14 staff washed, dried and applied TAO to the resident's left great and 2nd toe daily until healed, staff provided the resident with socks, monitored the resident's extremities during transfers, and padded the bar on the resident's tray table. The resident's care plan did not include interventions as to how staff was to minimize the resident bumping his/her toes other than monitoring the resident during transfers and padding of the resident's tray table. The resident's clinical record did not support staff monitored the resident during transfers. The resident's care plan did not include if the resident was to wear socks and slippers or just socks although the resident received new slippers on 8/19/14. A nurse's note dated 7/29/14 and timed 1:30 P.M. included direct care staff reported to licensed nurse the resident's toe was bleeding. The resident's left great toe had a 0.3 centimeter (cm) by 0.5 cm abrasion and the resident's 2nd toe had a 0.9 cm by 0.5 cm abrasion. The resident stated he/she did not know how it happened but that he/she was always banging up his/her toes. The facility received a physician's orders [REDACTED]. Review of the facility's investigation report regarding the abrasion noted on the resident's great and 2nd toe observed on 7/29/14 as noted in the nurse's note included the date of the incident on/about 7/27/14 (2 days prior to the nurse's note) included staff assessed and noted the resident to have abrasions on his/her left great toe that measured 0.3 cm by 0.5 cm and the abrasion on the resident's 2nd toe measured 0.9 cm by 0.5 cm. The resident stated he/she did not know how it happened but he/she was always banging his/her toes. The facility completed a root cause analysis, the resident had boots on, and the resident's toes were against his/her bedside table. Corrective actions included staff assessed the resident, notified the resident's family and physician, received a physician order, staff performed an environmental check, completed a root cause analysis and noted the resident sat with his/her toes against a bedside table, revised and reviewed the resident's care plan and padded the resident's bedside table. The investigation did not include statements from staff nor education provided to staff regarding proper transfers for this resident that required extensive to total dependence upon staff for bed mobility, transfers and locomotion. The resident's wound sheet dated 7/30/14 included staff observed an abrasion on the resident's left great and 2nd toe, the abrasion on the resident's great toe measured 0.3 cm by 0.5 cm by 0.1 cm, the wound bed contained dark pink/red tissue. The abrasion on the resident's 2nd toe measured 0.9 cm by 0.5 cm by 0.1 cm and the wound bed contained dark pink/red tissue. The resident's wound sheet included staff provided the resident with new slippers on 8/19/14. A wound care physician's note dated 8/5/14 included the trauma wound on the resident's great toe was eschar (dead tissue) covered and measured 0.1 cm by 0.1 cm; the trauma wound on the resident's 2nd toe was eschar covered and measured 0.5 cm by 0.4 cm. A wound care physician's note dated 8/12/14 included the resident's left great toe and 2nd toe were trauma wounds, the wounds had skin prep and band-aid on them, the resident's left great toe was eschar and measured 0.8 cm by 1.1 cm and the resident's left 2nd toe was eschar covered and measured 0.8 cm by 1.3 cm. The wound care physician was unable to determine how the trauma wounds started; where the resident bumped them. Review of the resident's clinical record lacked evidence the facility communicated to the resident's wound care physician the result of the root cause analysis to ensure the facility implemented interventions to minimize the bumping of the resident's toes, worsening of the abrasion and prevention of infection in the resident's toe abrasions. A wound care physician's note dated 8/26/14 included the resident's left great toe was an eschar covered trauma wound that measured 0.5 cm by 1.2 cm and the resident's left second toe was a full thickness trauma wound that measured 2.0 cm by 1.4 cm and the bone, joint, and tendon was exposed. The resident's primary care physician referred the resident to a surgeon. A physician's consultation history and physical dated 8/28/14 included the resident had limited mobility, at most he/she stood up to transfer, the resident had significant hip surgery on his/her left leg and stated he/she could not really use that leg very well. The resident developed an ulcer on the top of his/her second toe and the resident stated he/she had hit his/her second toe several times. The history and physical included the resident's second toe had obvious osteo[DIAGNOSES REDACTED] (infection of the bone), the joint was not intact in that location and the bone was exposed. Recommendations included the resident was to undergo a left second toe amputation. On 9/29/14 at 10:55 A.M. the resident laid on a low air loss mattress in bed on his/her left side. On 9/29/14 at 12:25 A.M. the resident was in bed on his/her right side and pillows on his/her left side. On 10/1/14 at 5:00 A.M. licensed nurse I stated the resident was tall and he/she was not sure the resident's bed accommodated the resident's height to minimize the resident's bumping of his/her feet. On 10/1/14 at 2:25 P.M. administrative nursing staff D stated the abrasions on the feet were injuries of unknown origin. Administrative nursing staff D stated staff transferred the resident via a stand up lift, and due to positioning due the transfer the resident toes hit the lift which caused the abrasions on the resident's left toes. Administrative nursing staff D stated after the development of the abrasions, staff used a mechanical lift versus the stand-up lift to transfer the resident. On 10/2/14 at approximately 11:30 A.M., the resident's physician was contacted with a message left and no returned call as of 10/6/14 at 11:00 A.M. The facility failed to implement interventions to minimize the worsening of the abrasions, infection in the resident's second toe which led to the amputation of the resident's 2nd toe for this resident that required extensive staff assistance with bed mobility, transfers, locomotion and bed mobility, which resulted in the resident's 2nd toe amputation.
The facility had a census of 48 residents. The sample included 18 residents. Based upon record review and interviews the facility failed to provide services and treatment to prevent the development of pressure ulcers and to promote the healing of healing pressure ulcers for 1 (#13) of 1 residents sampled for pressure ulcers. Findings included: - Residents #13's admission Minimum Data Set ((MDS) dated [DATE] identified the resident scored 13 (cognition intact) on the Brief Interview for Mental Status (BIMS), required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toilet use, and personal hygiene, and the activity of walking did not occur. The MDS identified the resident was at risk for the development of pressure ulcers, had (1) unstageable pressure ulcer due to slough(non-viable tissue)/eschar(dead tissue) present upon admission, had a pressure relieving device in his/her chair and on his/her bed, received pressure ulcer care, application of ointments/medications other than to the feet and applications of dressings to the feet. The resident's quarterly MDS dated [DATE] identified the resident scored 14 (cognition intact) on the BIMS, had no behavior, required extensive staff assistance with bed mobility, locomotion on/off the unit, dressing, personal hygiene, totally dependent upon staff for transfers and toilet use, and the activity of walking in the room/corridor did not occur. The MDS identified the resident had a functional impairment of both sides of his/her lower extremity, utilized a wheelchair, had an indwelling catheter,and occasionally incontinent of bowel. The MDS identified the resident weighed 215 pounds, had not experienced a weight loss, was at risk for the development of pressure ulcers, had (1) Stage 3 pressure ulcer present upon admission that measured 1.8 centimeter (cm) by 2.1 cm by 0.2 cm, had surgical wounds, utilized a pressure relieving device on his/her bed and in his/her chair, received pressure ulcer care, application of ointment/medication other than to the feet and application of dressing to the feet. The resident's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 6/27/14 included the resident required extensive staff assistance with all ADLs, did not walk, and utilized a wheelchair for mobility with staff assistance. The CAA documented the resident received a regular diet and at times need staff assistance with eating and fluids, had an indwelling catheter, was incontinent of bowel and at times requested to use the bathroom and required assistance of 2 staff with repositioning and transfers. The resident's Nutritional Status CAA dated 6/27/14 included the resident received double protein portions. The resident's pressure ulcer CAA dated 6/27/14 included the resident admitted with eschar to his/her left and right heel, was at further risk for the development of pressure ulcers due to requiring extensive staff assistance with bed mobility and repositioning. The resident required extensive assistance with transfers on/off the toilet, clothing adjustment and perineal care. The resident's care plan dated 9/26/14 included the following interventions in place since 6/26/14: the resident required extensive staff assistance with all ADLs, had an indwelling catheter and was occasionally incontinent of bowel. Staff monitored the resident's skin ADL care, applied moisture barrier to the resident's skin after incontinent episodes, and required extensive staff assistance of 2 or stand up lift for all transfers. The resident required extensive staff assistance with repositioning at least every 2 hours. Staff performed skin assessment per facility protocol, utilized a wheelchair for mobility with staff assistance, and received a mechanical soft diet with honey thickened liquids as physician ordered with double protein portions. Staff monitored the the percentage of food and fluids consumed at each meal. The resident was admitted with eschar to both heels and was at risk for further issues due to bed mobility and non-compliance with repositioning. Staff checked the resident frequently for incontinence, avoided restrictive footwear, staff discussed/reinforced the importance of proper pressure redistribution, the resident utilized a low air loss pressure relieving mattress. On 7/1/14 staff provided boots for the resident to wear at all times, the resident was non-complaint with repositioning, staff turned the resident from side to side and the resident would often go on his/her back. Staff educated the resident on risks, continued to educate and provided assistance. On 7/15/14 staff noted an area under the resident's bilateral legs, was non-complaint with repositioning preferred to use the wedge under his/her legs. Staff removed the wedge from the resident's room and treatments were in place for the area. A Registered Dietician (RD) note dated 7/2/14 included the resident had no swallowing difficulties, received a regular diet, double portions, a multivitamin for healing, extra protein for healing from Ensure three times a day (TID), and the resident stated he/she would like the Ensure if it had ice cream. The resident weighed 226 pounds and the resident's serum [MEDICATION NAME] level (test to determine the amount of protein in the body) suggested severe visceral protein status. A RD note dated 8/15/14 documented the resident had multiple skin issues, received double portions of meat and 1 egg but usually did not eat that amount. The resident did not accept the Ensure (supplement used to provide extra protein and calories) very well and recommended to discontinue the Ensure and provide Magic Cups (used to provide extra protein and calories) with lunch and dinner. A RD note dated 9/17/14 included the RD recommended for the resident to receive 30 cubic centimeters (cc) of liquid protein twice a day (BID) for healing, the resident consumed 50 percent (%) or greater of meals, weighed 213 pound which reflected significant weight loss greater than 5% loss in 1 month. The resident was recently placed on house supplements TID, ate independently, received magic cup BID and double meal entrees which also provided extra protein for healing. A RD note dated 9/29/14 included the resident received house supplements three times a day, magic cups BID and double entrees. The resident [MEDICATION NAME] level was decreased at 15 grams/deciliter, and the resident's primary care physician did not want to start the resident on the liquid protein. A laboratory report dated 9/24/14 recorded the resident's [MEDICATION NAME] level at 15 milligrams/deciliter (mg/dl), normal reference range 18 to 45 mg/dl. A laboratory report dated 8/5/14 recorded the resident's total protein level at 5.4 grams/deciliter (gm/dl), normal reference range 6.5 to 8.2 gm/dl. The report recorded the resident's serum [MEDICATION NAME] level at 2.5 gm/dl, normal reference range 3.5 to 4.8 grams/dl. A Mini In-Service Form dated 7/2/14 and located in the resident's clinical record included staff education on positioning the resident in bed: please use boots to keep the resident's heels off of the bed, do not place the wedge under the resident's legs because it was causing skin breakdown. Use the wedge for repositioning the resident on either side placing the wedge under the resident's back/buttock and to place pillows between the resident's knees. A wound care progress note dated 7/8/14 included the resident's left heel was split into 2 areas superior (upper) and inferior (lower) and staff treated the area with Santyl. The pressure ulcer on the inferior aspect of the resident's left heel was unstageable and measured 1.4 cm by 1.1 cm by 0.1 cm. The superior wound was unstageable and measured 1.2 cm by 0.4 cm. The pressure ulcer on the resident's left improved after debridement wad was now a Stage 3 pressure ulcer with 100% healthy granulation. The resident was found offloaded today with the large wedge which should have been discontinued due to it being too high and placed pressure on posterior (back) aspect of the resident's calves. Staff continued Santyl (ointment used to remove dead tissue from wounds) and offloading and the physician discussed with the facility nurse proper offloading and the large wedge really needed to be discontinued, there was visible indentation on the resident's calves from resting on the wedge. The facility was to offload the resident's heels per facility policy/protocol, the physician preferred cut out boots and did not use the large wedge. A wound care physician's note dated 7/15/14 included the resident developed unstageable pressure ulcers on his/her posterior calves from the use of large wedge. Staff was unable to convince the resident to stop using the wedge until this past week. The unstageable pressure ulcer on the posterior aspect of the resident's left calf measured 3.9 cm by 0.9 cm. The unstageable pressure ulcer on the resident's right lateral posterior calf measured 1.6 cm by 1.7 cm. The Stage 3 pressure ulcer on the resident's left inferior heel measured 1.1 cm by 0.7 cm, and the Stage 3 pressure ulcer on the aspect of the resident's left superior heel measured 1 cm by 0.1 cm. Use heel cut out boots and do not use the large wedge. A wound care physician's note dated 7/22/14 included the resident was offloaded somewhat but would not remain on his/her side even with repositioning and no longer used the large wedge which caused the calves pressure ulcer. A wound care physician note dated 7/29/14 included he/she observed the resident in a recliner, the resident's heels were barely offloaded, had no boots on and pressure was on that ulcer as well. Staff treated the resident's left upper heel pressure ulcer with Santyl but now appeared to have formed eschar/scab, measured 1.6 cm by 1.5 cm, the pressure ulcer on the resident's left superior heel was necrotic and unstageable and measured 0.7 cm by 0.3 cm. The physician documented offloading was most important. A wound care physician's note dated 8/12/14 included the left posterior calf pressure ulcer resolved. According to the facility's wound log the left posterior calf pressure ulcer resolved on 8/12/14. A wound care physician's note dated 8/19/14 included the pressure ulcer on the resident's left superior heel resolved. The facility's wound log identified on 9/25/14 the Stage 3 pressure ulcer on the resident's left inferior heel measured 1.8 cm by 2.1 cm by 0.2 cm. A nurse's note dated 7/16/14 and timed 8:00 AM included the wound care physician saw the resident on 7/15/14, the resident insisted on using the large wedge cushion under his/her legs for positioning and offloading of his/her heels. The licensed nurse and physician educated the resident on the wedge cushion causing pressure to his/her lower legs. Direct care staff reported the resident continued to insist on using the wedge even after told of possible pressure issues. Staff explained the new wounds to the resident and it was agreed by nursing staff and the resident, staff would remove the wedge from the resident's room, position the resident's legs and offload his/her heels with pillows, and staff applied pressure relieving boots bilaterally. Review of the resident's clinical record did not support the facility assessed the posterior aspect of the resident's calves until 7/15/14. The resident's clinical record did not support the facility educated the resident on the negative aspect of the wedge until the nurse's note dated 7/16/14. The resident's care plan did not address the use of the wedge cushion until 7/15/14 (after the development of the unstageable pressure ulcer on the posterior aspect of the resident's calves. Review of the resident's July 2014 Medication Administration Record [REDACTED]. Further review revealed staff did not document the percentage of the supplement the resident consumed. Review of the resident's August MAR/TAR documented the resident received a Magic Cup at lunch and dinner starting on 8/19/14, and the resident continued to receive the Ensure TID. Further review revealed staff did not document the percentage of the supplements (Ensure and Magic Cup) the resident consumed. Review of the resident's August MAR/TAR identified the resident wore a heel cut out boot since 7/29/14. During interview with therapy consultant AA on 10/1/14 at 9:00 A.M. he/she started the heel cut out boot was not placed until 2 to 3 weeks ago. He/she stated staff should have placed the wedge under the resident's sides and not under his/her legs. Review of the resident's August 2014 Food Acceptance Record did not support staff offered the Magic Cup at lunch and dinner as physician ordered. The record did not reveal any documentation for the lunch meal on 8/21/14, 8/22/14, 8/28/14 and 8/30/14 and for the dinner meal from 8/25/14 to 8/30/14. On 9/29/14 at 10:55 A.M. the resident laid on a low air loss mattress in bed on his/her left side. On 9/29/14 at 12:25 A.M. the resident was in bed on his/her right side and pillows on his/her left side. On 9/29/14 at approximately 1:30 P.M. the facility transferred the resident to the hospital and he/she admitted to the hospital. On 9/30/14 at 4:13 P.M. direct care staff O stated staff repositioned the resident every 2 hours,the resident utilized heel boots and pillows under his/her feet. Direct care staff O stated the resident had a wedge under his/her feet to keep the resident's heels and feet off of the mattress, the resident did not like the wedge and always asked staff to take it out. Direct care staff O stated staff discontinued the wedge and the facility implemented the pillows and boots. Direct care staff O stated the resident was uncomfortable when positioned on his/her side, the resident sometimes moved the pillows after repositioning. The resident was not able to remove the wedge because he/she could not move his/her legs but the resident could push the pillows with his/her hands when positioned on his/her side. On 10/1/14 at 5:00 A.M. licensed nurse I stated the resident had pressure ulcers, due to right hip pain, the resident did not like staff positioning him/her on his/her sides. Licensed nurse I stated staff used a wedge under the resident's legs to elevate his/her feet, the resident preferred the boots to the wedge, the resident was not admitted with the wedge and the wedge belonged to the facility. On 10/1/14 at 6:05 A.M. direct care staff P stated the resident had utilized a wedge, the resident did not like the wedge and repeatedly asked staff to remove the wedge. On 10/1/14 at 8:45 A.M. dietary staff DD stated staff should record the percentage of supplements consumed on the intake record if the supplement was received with meals. Dietary staff DD stated nursing staff recorded the percentage of the Ensure received TID. Dietary staff confirmed the facility did not consistently document the percentage of the Magic Cup received with meals and also confirmed the resident's August and July MAR indicated [REDACTED]. On 10/1/14 at 9:30 A.M. licensed nurse H stated the resident refused to give up the wedge until 7/15/14. Licensed nurse H stated the resident's refusal should have been on the resident's care plan or documented in the resident's nurse's notes. Licensed nurse H reviewed the resident's nurse's notes and care plan and confirmed the resident's clinical record lacked evidence the resident requested staff not discontinue the wedge and lacked evidence to support staff educated the resident regarding the wedge until the nurse's note dated 7/16/14. Licensed nurse H stated the wedge belonged to the facility and not the resident. On 10/1/14 at 2:25 P.M. administrative nursing staff D stated staff should record the percentage of the the Ensure and Magic Cups. On 10/2/14 at approximately 11:30 A.M., the resident's physician was contacted with a message left and no returned call as of 10/6/14 at 11:00 A.M. The facility failed to document the percentage of supplements as care planned, failed to educate the resident on the use of the wedge prior to the development of the unstageable pressure ulcer on the posterior aspect of the resident's calves, failed to use the boots as care planned on 7/1/14 and failed to ensure offloading per physician and therapy recommendation for this resident admitted with heel pressure ulcers and developed (2) facility acquired pressure ulcers due to the use of a wedge.
Inspection of April 23, 2014
1 findingThe facility had a census of 48 residents. Based upon observation, record review and interviews the facility failed to maintain/restore urinary function for 2 (#11, #12) of 3 residents sampled for urinary incontinence. Findings included: - Resident #12's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, was independent with bed mobility, transfers, walking in the room/corridor and locomotion on/off the unit, dressing, eating, toilet use and personal hygiene. The MDS recorded the resident was always continent of urine and bowel, was not at risk for the development of pressure ulcers, did not have a pressure relieving device on his/her bed or chair and was not on a turning/repositioning program. The resident's significant change MDS dated [DATE] identified the resident scored 99 (resident was unable to complete the Brief Interview for Mental Status Interview) and staff assessed the resident had moderately impaired cognition and without behaviors. The MDS identified the resident required extensive staff assistance with bed mobility, transfers, locomotion on/off unit, dressing, eating, toilet use, did not walk in room/corridor, limited staff assistance with personal hygiene and utilized a wheelchair. The MDS identified the resident was occasionally incontinent of urine and bowel, was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, had a pressure relieving device on his/her bed, no pressure relieving device on his/her chair and was not on a turning/repositioning program. The resident's Activity for Daily Living (ADL) Functional Status/Rehabilitation Potential Care Area Assessment (CAA) dated 3/24/14 documented the resident required total staff assistance with all ADL's, no longer walked, and needed extensive staff assistance with wheelchair mobility. The resident had episodes of incontinence, wore a brief and required staff assistance with toileting. The above represented the resident had a decline in his/her urinary function. The resident's Urinary Incontinence/Indwelling Catheter CAA dated 3/24/14 documented the resident was incontinent of bowel and bladder and required staff assistance with incontinent care. The resident wore incontinent briefs for dignity and protection and a voiding trial was out to determine the resident's targeted toileting times. The resident's Bowel/Bladder assessment dated [DATE] documented the resident was continent of urine. The resident's Bowel and Bladder assessment dated [DATE] included the resident was incontinent during the day and night. Review of the resident's clinical record lacked evidence to support the facility conducted a bladder assessment after 12/28/12. The resident's care plan dated 4/15/14 included the resident required extensive staff assistance with activities of daily living. The resident had a potential for alteration in skin integrity, staff kept the resident's skin clean and dry and monitored the resident for skin changes. Interventions in place 3/24/14 included the resident was incontinent of urine, staff applied incontinent care and a moisture barrier after each incontinent episode. A 3 day voiding trial was out to determine the resident's toileting times. Staff checked and changed the resident during the hours of 7 to 8 A.M., 10 to 11 A.M., 1 to 2 P.M., 4 to 5 P.M., 7 to 8 P.M., every 2 hours during the night as as needed. A nurse's note dated 3/4/14 and timed 11:35 A.M. included the facility received a physician's orders [REDACTED]. A physician progress notes [REDACTED]. The resident's March 2014 Medication Administration Record [REDACTED]. Review of the resident's 3 day voiding pattern/voiding record for 1/8/14 to 1/10/14 documented the resident toileted himself/herself. The record did not identify the resident was incontinent of urine. The resident's 3 day voiding pattern/voiding record for 3/11/14 to 3/13/4 was incomplete because the resident was in the hospital on [DATE]. The resident's 3 day voiding pattern/voiding record for 3/25/14 to 3/27/14 lacked incomplete documentation. For example the facility did not record the resident's voiding/pattern on 3/26/14 from 3:00 P.M. to 9:00 P.M. and from 2:00 P.M. to 9:00 P.M. on 3/27/14. The bottom of the record contained a handwritten entry that documented check and change program during the hours of 7 to 8 A.M., 10 to 11 A.M., 1 to 2 P.M., 4 to 5 P.M., 7 to 8 P.M., every 2 hours and as needed at night due to a change in the resident's condition. Further review did not include an analysis of how the facility determined this toileting schedule for the resident. Further review also revealed no analysis as to the type of the resident's incontinence. Review of the resident's 3 day voiding pattern/voiding record for 4/15/14 to 4/17/14 on 4/17/14 at 4:17 P.M. lacked any documentation on 4/17/14. On 4/16/14 at 9:44 A.M. the resident sat on the toilet in his/her room. During interview with direct care staff R at that time, he/she stated the resident was not incontinent of urine when he/she placed the resident on the toilet. Direct care staff R stated staff toileted the resident every 2 hours and as needed per resident request. On 4/16/14 at 1:32 P.M. the resident sat on the toilet in his/her room. At that time direct care staff R (staff that transferred the resident to the toilet) stated the resident was not incontinent of urine. At 2:00 P.M., 2:15 P.M., and 2:30 P.M. the resident sat in his/her wheelchair in the day room (by the nurse's station). At 2:54 A.M., 3:15 P.M., and 3:24 P.M. the resident sat in a regular chair in the day room. At 3:50 P.M., 4:00 P.M., 4:15 P.M. and 4:20 P.M. the resident sat in his/her wheelchair in the day room. At 4:20 P.M. the resident propelled himself/herself to the dining room. At 4:30 P.M., 4:45 P.M., 5:00 P.M. and 5:15 P.M. the resident sat in his/her wheelchair at a dining room table. Observation revealed staff did not toilet the resident during the hour of 4 to 5 P.M. On 4/17/14 at 7:33 A.M. the resident laid in bed and direct care staff S entered the resident's room to assist the resident with the A.M. care. Observation revealed the resident had on an incontinent brief and the brief and resident's gown was saturated with urine. On 4/17/14 at 4:16 P.M. administrative nursing staff F stated the facility only performed a 3 day voiding trial and did not perform the bowel/bladder evaluations. Administrative nursing staff F stated administrative nursing staff E performed the analysis of the data and noted the resident's toileting schedule on the voiding trial. Administrative nursing staff F stated the facility started a 3 day voiding trial for the resident on 4/15/14 and it would be completed on 4/17/14. Administrative nursing staff F confirmed the resident's voiding trial did not contain any documentation for 4/17/14. On 4/17/14 at 3:22 P.M. licensed nurse I stated staff toileted the resident every 2 hours. On 4/17/14 at 4:00 P.M. licensed nurse J stated staff toileted the resident every 2 hours. On 4/17/14 at 4:4:42 P.M. direct care staff T stated staff toileted the resident every hour and as needed. The facility's Urinary Continence and Incontinence-Assessment and Management policy revised August 2006 included the staff and practitioner appropriately screened residents and managed residents with urinary incontinence. The physician and staff provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The facility failed to complete a 3 day voiding trial of this resident's urinary pattern to determine an individualized toileting program and also failed to toilet this resident as planned and who experienced a decline in his/her urinary status. - Resident #11's quarterly Minimum Data Set (MDS) 3.0 dated 2/14/14 identified the resident scored 11(moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with bed mobility, walking in the room/corridor and locomotion off the unit, required extensive staff assistance with transfers, locomotion on the unit, dressing, toilet use and personal hygiene. The MDS identified the resident was occasionally incontinent of urine and was at risk for the development of pressure ulcers. The resident's Significant Change MDS dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with bed mobility, transfers, walking in the room/corridor, personal hygiene, and locomotion on/off the unit, required extensive staff assistance with dressing and toilet use. The resident was frequently incontinent of urine. The MDS identified the resident was at risk for pressure ulcers. The resident's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 3/31/14 documented the resident had episodes of incontinence, a 3 day voiding trial was "out" to determine the resident's targeted scheduling times. The resident wore incontinent briefs for dignity and protection, needed extensive staff assistance with transfers on/off the toilet, clothing adjustment, and perineal care. The resident used the urinal at times. The resident's care plan dated 3/31/14 included the resident was incontinent of urine and interventions as of 3/31/14 included staff provided perineal care and applied a moisture barrier after each incontinent episode. An entry dated 4/1/14 documented staff toileted the resident during the hours of 6 to 7 A.M., 9 to 10 A.M., 12 to 1 P.M., 3-4 P.M., 6-7 P.M. and checked and changed the resident every 2 hours and as needed. The resident's Bowel and Bladder assessment dated [DATE] included the resident was independent with toileting and was continent of urine. Review of the resident's clinical record lacked evidence the facility completed a Bowel and Bladder assessment since 7/1/11. A three day voiding pattern dated 3/25/14 to 3/27/14 contained incomplete data. For example, there was no documentation from 2:00 P.M. to 10:00 P.M. on 3/26/14 and from 12:00 P.M. to 10:00 P.M. on 3/27/14. A handwritten entry at the bottom included staff toileted the resident at targeted times during the day during the hours of 6 to 7 A.M., 9 to 10 A.M., 12 to 1 P.M., 3 to 4 P.M., 6 to 7 P.M., checked and changed the resident every 2 hours during the night, and as needed. On 4/17/14 at 4:16 P.M. administrative nursing staff F stated the facility did not perform bladder assessments. Administrative nursing staff F stated the facility conducted a 3 day voiding trial and administrative licensed nurse staff performed an analysis of the voiding pattern and documented the resident's toileting program on the 3 day voiding trial record. Administrative nursing staff F confirmed the clinical record lacked evidence the facility had performed a bladder assessment for this resident since 7/1/11. On 4/16/14 at 7:55 A.M. the resident sat on the side of his/her bed. Observation revealed the resident's pants saturated with a liquid. During interview with the resident at that time, he/she stated he/she was wet with urine and needed changed. On 4/16/14 at 8:05 A.M. the resident sat on the side of his/her bed and ate the breakfast meal. Observation revealed the resident still had on the same pants and the pants continued to be wet. On 4/16/14 at 8:20 A.M. the resident laid in bed. During interview with the resident at that time, he /she stated he/she was wet with urine and needed change. At that time the surveyor reported the above to administrative nursing staff D. Administrative nursing staff D asked direct care staff R to assist the resident. Direct care staff R entered the resident's room and assisted the resident. Observation revealed the resident's incontinent brief, pants and bed linens saturated with urine. Direct care staff R performed incontinent care and changed the resident's clothes. Direct care staff R confirmed the resident's brief and urine saturated with urine. Direct care staff R stated staff checked and changed the resident every 2 hours. On 4/17/14 at 6:50 A.M. the resident laid in bed and with a strong urine odor noted. Observation revealed the handle of the resident's empty urinal rested on the side of the trash can. On 4/17/14 at 7:17 A.M. direct care staff S entered the resident's room to assist the resident with A.M. care. Observation revealed the resident's incontinent brief, pants and blanket saturated with urine. Direct care staff assisted the resident to ambulate to the bathroom. Observation revealed the back of the resident's pants were wet. During interview with direct care staff at that time he/she stated staff checked and changed the resident at least every 2 hours. On 4/17/14 at 3:22 P.M. licensed nurse I stated staff toileted the resident every 2 hours. On 4/17/14 at 4:00 P.M. licensed nurse J stated staff toileted the resident every 2 hours. On 4/17/14 at 4:42 P.M. direct care staff T stated staff toileted the resident every hour and as needed. During the findings meeting on 4/17/14 between 5:15 P.M. and 5:40 P.M. administrative staff A (not a licensed nursing staff or certified staff) stated he/she checked on the resident at 6:00 A.M. on 4/17/14, the resident was not incontinent of urine and he/she emptied the resident's urinal. Administrative staff A did not state whether staff toileted the resident at that time. The facility's Urinary Continence and Incontinence-Assessment and Management policy revised August 2006 included the staff and practitioner appropriately screened residents and managed residents with urinary incontinence. The physician and staff provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The facility failed to complete a 3 day voiding trial of this resident's urinary pattern to determine an individualized toileting program and failed to provide timely toileting for this resident that experienced a decline in bladder function.
Inspection of April 21, 2014
2 findingsThe facility had a census of 48 residents. Based upon observation, record review and interviews the facility failed to prevent the development of avoidable pressure ulcers, and/or provide services to promote healing of pressure ulcers for 3 (#12,#11,#15) of 3 sampled residents. Findings included: - Resident # 12's Physician order [REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, was independent with bed mobility, transfers, walking in the room/corridor and locomotion on/off the unit, dressing, eating, toilet use and personal hygiene. The MDS recorded the resident was always continent of urine and bowel, weighed 147 pounds and had experienced a weight loss. The MDS identified the resident was not at risk for the development of pressure ulcers, did not have a pressure relieving device on his/her bed or chair and was not on a turning/repositioning program. The resident's significant change MDS dated [DATE] identified the resident scored 99 (resident was unable to complete the Brief Interview for Mental Status Interview) and staff assessed the resident had moderately impaired cognition and without behaviors. The MDS identified the resident required extensive staff assistance with bed mobility, transfers, locomotion on/off unit, dressing, eating, toilet use, did not walk in room/corridor, limited staff assistance with personal hygiene and utilized a wheelchair. The MDS identified the resident was occasionally incontinent of urine and bowel, weighed 136 pounds and had experienced a weight loss of 5 percent (%) or more in the last month or 10% in the last 6 months and was not on physician prescribed weight loss regimen. The MDS identified the resident was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, had a pressure relieving device on his/her bed, no pressure relieving device on his/her chair and was not on a turning/repositioning program. The resident's Activity for Daily Living (ADL) Functional Status/Rehabilitation Potential Care Area Assessment (CAA) dated 3/24/14 documented the resident required total staff assistance with all ADL's, no longer walked, and needed extensive staff assistance with wheelchair mobility. The resident had episodes of incontinence, wore a brief and required staff assistance with toileting. The resident received a mechanical soft diet, attempted to feed himself/herself and needed extensive staff assistance with meals. The resident's Braden Scale (scale used to predict the development of pressure ulcers) dated 1/22/14 identified the resident scored 22 (not at risk for the development of pressure ulcers) and on 3/24/14 and 3/27/14 the resident's score was 12 (high risk for the development of pressure ulcers). The resident's care plan dated 4/15/14 included the resident required extensive staff assistance with activities of daily living. The resident had a potential for alteration in skin integrity, staff kept the resident's skin clean and dry, monitored the resident for skin changes, and provided a low air loss mattress (pressure relieving) to the resident's bed. The resident utilized a wheelchair for mobility and staff repositioned the resident at least every 60 to 90 minutes. Staff provided perineal care after each incontinent episode. Staff monitored the percentage of food and fluids the resident consumed at each meal. The resident received a Magic Cup at lunch and dinner. An entry dated 4/9/14 included the resident had open areas on his/her buttock and staff applied Duoderm (a dressing used to cover wounds and skin conditions) and change the dressing daily and as needed. The 4/15/14 care plan did not include interventions regarding the development of pressure ulcers on bony prominences. A laboratory report dated 3/13/14 documented the resident's [MEDICATION NAME] level at 3.1 grams/deciliter (g/dL), normal reference range 3.4-4.8 g/dL. A laboratory report dated 3/28/14 recorded the resident's [MEDICATION NAME] level at 2.9 g/dL, normal reference range 3.0-5.5 g/dL. A physician's orders [REDACTED]. A pressure ulcer communication form to the resident's physician dated 4/8/14 included the resident had a Stage 2 pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction, the topmost layer of skin is broken, creating a shallow open sore and the second layer of skin may also be broken), on his/her right buttock that measured 0.8 centimeters (cm) by 0.5 cm with no depth. A Stage 2 pressure ulcer on his/her left buttock that measured 2.5 cm by 0.5 cm with no depth. The communication form included the resident weighed 131 pounds. A physician's orders [REDACTED]. The resident's weight log revealed the following weights: 1/2014: 147 pounds 2/2014: 143 pounds 3/2014: 141 pounds 3/26/14: 131 pounds (16 pounds or 22% of his/her body weight in 2 months; and 10 pounds or 7.09% in 1 month) A Registered Dietician's (RD) note dated 3/7/14 included the resident's March weight was stable at 141 pounds and the resident stated he/she noticed his/her weight and intake dropped a little. A RD note dated 3/27/14 documented the resident weighed 131 pounds on 3/26/14 and the resident had lost approximately 10 pounds since the first of the month. The resident typically did not eat breakfast. The resident's [MEDICATION NAME] level drawn at the hospital suggested moderate to mild visceral protein depletion. The Ensure plus and Magic Cups provided more calories and protein and if the resident consumed 1 Ensure Plus and Magic Cup each day the resident would meet 40 percent (%) of his/her daily caloric needs. The resident's March 2014 Medication Administration Record [REDACTED].M. and at 12:00 P.M. on 3/31/14. The resident's March 2014 MAR indicated [REDACTED].M. and 5:00 P.M. The resident's April 2014 MAR indicated [REDACTED].M. on 4/5, 4/6 and 4/12/2014 and at 5:00 P.M. on 4/4, 4/5, 4/6, 4/13, and 4/14/2014. The resident's April 2014 MAR indicated [REDACTED].M. Further review of the resident's April MAR indicated [REDACTED]. Review of the resident's 3/1/2014 to 4/17/2014 meal intake exception log revealed the facility did not consistently document the percentage of meals the resident consumed. The facility's Skin/Wound Log dated 4/9/14 included the resident had a facility acquired Stage 2 pressure ulcer on his/her left buttock that measured 1.0 cm by 1.2 cm with a depth of 0.1 cm. A facility acquired Stage 2 pressure ulcer on his/her right buttock that measured 1.0 cm by 0.8 cm with a depth of 0.1 cm. The facility's Skin/Wound Log dated 4/16/14 documented the Stage 2 pressure ulcers on the resident's left and right buttock resolved. The facility's Skin/Wound Log with week ending 4/18/14 included the word resolved whiten out and written in "next pg." Review of the next page included the resident had a Stage 2 pressure ulcer on his/her left buttock that measured 0.9 cm by 0.4 cm with a depth of less than 0.1 cm. The Stage 2 pressure ulcer on the resident's right buttock measured 0.5 cm by 0.5 cm with a depth of less than 0.1 cm. The above represented the areas on the resident's right and left buttock healed sometime between 4/9/14 and 4/16/14 and reopened between 4/16/14 and 4/17/14 at 10:25 A.M. On 4/16/14 the resident sat in his/her wheelchair at 8:44 A.M., 9:00 A.M. 9:15 A.M., and 9:30 A.M. At 9:44 A.M. the resident sat on the toilet in his/her room. At 9:50 A.M., 10:00 A.M., 10:10 A.M., 10:15 A.M., and 10:30 A.M. the resident sat in the wheelchair in his/her room. At 10:43 A.M., 10:50 A.M., 11:00 A.M., 11:11 A.M., and 11:20 A.M., the resident sat in his/her wheelchair in the television area of the facility. At 11:32 A.M. the resident sat in the wheelchair of his/her room and received a breathing treatment. At 11:42 A.M. direct care staff R propelled the resident from his/her room to a dining room table, without repositioning or toileting the resident. The resident sat in his/her wheelchair at the dining room table at 11:49 A.M., 11:55 A.M., 12:06 P.M., 12:15 P.M. and 12:30 P.M. (duration of 2 hours and 40 minutes, instead of the planned 60 to 90 minute repositioning). Observations revealed the resident had a pressure relieving device in his/her wheelchair. On 4/16/14 at 12:15 P.M. the resident ate the lunch meal which consisted of a polish sausage, macaroni salad, mixed vegetables, a container of yogurt, a Magic Cup, a bowl of fruit, pudding and a empty glass with with a brown substance. During interview with the resident at that time the resident stated the glass had contained Ensure. The resident pointed to the unopened container of Magic Cup and stated he/she did not know why staff brought him/her that because he/she did not like it. Observation revealed the resident consumed all the yogurt, and 25% of the other foods. On 4/16/14 the resident sat in the wheelchair of his/her room at 1:00 P.M., and 1:15 P.M. At 1:32 P.M. the resident sat on the toilet in his/her room. At 2:00 P.M., 2:15 P.M., and 2:30 P.M. the resident sat in his/her wheelchair in the day room (by the nurse's station). At 2:54 A.M., 3:15 P.M., and 3:24 P.M. the resident sat in a regular chair in the day room. At 3:50 P.M., 4:00 P.M., 4:15 P.M. and 4:20 P.M. the resident sat in his/her wheelchair in the day room. At 4:20 P.M. the resident propelled himself/herself to the dining room. At 4:30 P.M., 4:45 P.M., 5:00 P.M. and 5:15 P.M. the resident sat in his/her wheelchair at a dining room table. On 4/16/14 at 5:05 P.M. the resident ate his/her dinner meal that consisted of baked chicken, tater tots, yogurt, pudding and chocolate ensure. Observation did not reveal the resident received a Magic Cup. At 5:15 P.M. the resident consumed all the yogurt and Ensure and none of the tater tots or chicken. On 4/17/14 at 7:33 A.M. the resident laid in bed and direct care staff S entered the resident's room to assist the resident with the A.M. care. Observation revealed the resident had on an incontinent brief and the brief and resident's gown was saturated with urine. Further observation revealed the resident did not have on heel protectors, the resident's heels were not floated and staff had not placed devices between the resident's legs to prevent skin on skin contact. On 4/17/14 at 8:00 A.M., 8:15 A.M., 8:30 A.M., 8:45 A.M. and 8:52 A.M. the resident sat in his/her wheelchair in the dining room. On 4/17/14 at 9:20 A.M. 9:30 A.M., 9:45 A.M. and 10:00 A.M. the resident sat in the wheelchair in his/her room. On 4/17/14 at 10:17 A.M. administrative licensed practical nurse F and licensed practical nurse H entered the resident's room to perform the pressure ulcer treatment on the resident's buttock. As staff waited for direct care S to assist with the transfer the resident stated he/she sat all the time and his/her buttock "really hurts." At 10:25 A.M. direct care staff S transferred the resident from the wheelchair to the bed. At that time licensed registered nurse I entered the resident's room. Observation revealed the inner aspect of the resident's right buttock had a Stage 2 pressure ulcer that measured approximately 1.0 cm by 1.0 cm and a Stage 2 pressure ulcer on the inner aspect of his/her left buttock that measured approximately 0.5 cm by 0.5 cm. Further observation revealed no dressing on the resident's pressure ulcers. On 4/17/14 at 9:20 A.M. the resident stated he/she had an open area on his/her buttock. The resident stated he/she sat for long periods of times which caused the open area on his/her buttock. The resident stated staff did not reposition him/her and he/she wished they did. The resident was unable to state how long the cushion had been in his/her wheelchair but stated he/she was glad it was there. On 4/17/14 at 11:10 A.M. licensed registered nurse I stated the areas on the resident's left and right buttock were Stage 2 pressure ulcers. On 4/17/14 at 11:20 AM licensed practical nurse F confirmed the pressure ulcers on the resident's right and left buttock. On 4/17/14 at 1:18 P.M. direct care staff S stated staff repositioned the resident every 2 hours. On 4/17/14 at 4:00 P.M. licensed nurse J stated staff repositioned the resident every hour. On 4/17/14 at 4:42 P.M. direct care staff T stated staff repositioned the resident every hour. The 2009 International Guidelines for Pressure Ulcer Treatment stated to limit the time an individual spent in a chair without pressure relief. The facility's Wound and Skin Care Policy and Protocols updated 4/9/14 included staff repositioned residents unable to reposition himself/herself. The facility failed to provide the Magic Cup and Ensure Plus as planned and physician ordered, failed to ensure the resident's repositioning program was sufficient to prevent additional pressure ulcers and failed to develop a care plan that included interventions to prevent the development of new pressure ulcers on the resident's other bony prominences, and to promote healing for this resident who developed 2 facility acquired pressure ulcers. - Review of resident #15 (a closed record) nurse's notes revealed the resident admitted to the facility on [DATE]. The resident's discharge not return anticipated Minimum Data Set (MDS) 3.0 dated 4/8/14 identified the resident had modified independence in cognitive skills for daily decision making skills, no behaviors, required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toilet use, and personal hygiene, did not walk in the room/corridor, and was totally dependent upon staff for eating. The MDS identified the resident was frequently incontinent of urine and bowel. The MDS identified the resident had (4) Stage 2 pressure ulcers, and (2) unstageable pressure ulcers with suspected deep tissue injury in evolution not present at time of admission/entry or reentry. The resident's Braden Scale (scale used to predict the development of pressure ulcers) dated 3/30/14 identified the resident scored 7 (a total score of less than 9 represented the resident was at severe risk for the development of pressure ulcers). The resident's initial care plan dated 3/30/14 included the resident required total care with all activities of daily living, was at risk for skin breakdown and staff repositioned the resident every 1 to 2 hours. The resident had a pressure relieving device on his/her bed and wheelchair and staff offloaded the resident's heels with pillows. The initial care plan did not include the Sage boots (device used to minimize pressure on the heels) or interventions regarding how to position the resident to minimize pressure on the pressure ulcers. A Discharge Referral from a local hospital with a discharge date of [DATE] included [MEDICATION NAME] (foam dressing used to treat wounds) to the SDTI (suspected deep tissue injury-Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or sheer) pressure ulcer on the resident's right back, change weekly and as needed, left heel pressure ulcer, open to air (OTA), right heel SDTI pressure ulcer, OTA and Sage boots. A hospital's Wound Management Pressure Ulcer note dated 3/28/14 and timed 10:37 AM included the resident's perineal [MEDICAL CONDITION] (irritation of skin due to exposure of moisture) resolved and the resident now had a Stage 2 pressure ulcer to his/her right buttock and recommended use of Zinc cream (barrier) with [MEDICATION NAME] (anti-fungal medication). The Resident-Data Collection Assessment with an admission date of [DATE] at 2:40 P.M. included the resident had a left back fecal management system (device use to collect liquid or semi-liquid stool), a Stage 2 pressure ulcer on his/her left buttock (no measurements) and the resident's heels were soft bilaterally (no description of the resident's heels). A nurse's note dated 3/29/14 and timed 5:00 P.M. included the resident's rectal tube came out, staff noted a large amount of stool and staff telephoned the resident's physician regarding the rectal tube coming out. A nurse's note dated 3/31/14 and timed 4:50 P.M. included the resident's physician gave orders to leave the fecal tube out. An occupational therapist note dated 4/2/14 documented nursing was notified of the pressure ulcers on the resident's buttock region and bilateral heels. A physical therapy assistance note co-signed by a physical therapist on 4/2/14 included the therapist and assistant physical therapist noted sacral wounds with possible tunneling. The therapist informed the wound nurse who examined the area and applied ointment and dressing. The therapist also noted the resident had pressure wounds on his/her heels bilaterally, more severe on the right, applied heel protectors and positioned the resident in partial side-lying position with a pillow positioned between the resident's lower extremities and two pillows behind the resident's back. The therapist educated nursing staff of the importance of avoiding to lay the resident directly on his/her back secondary to breakdown. The facility's Skin/Wound Log dated 4/2/14 included the resident admitted with wounds on 3/28/14. On 4/2/14 (day staff measured the resident's pressure ulcers) the resident had (3) Stage 2 pressure ulcers on his/her left buttock. The facility admitted the resident with only 1 pressure ulcer of the left buttock. One Stage 2 pressure ulcer measured 3.0 centimeters (cm) by 1.6 cm by 0.3 cm, another one measured 2.5 cm by 1.0 cm by 0.2 cm and another one measured 3.4 cm by 1.5 cm with no depth. The facility acquired Stage 2 on the resident's right buttock measured 3.4 cm by 1.5 cm with no depth and the resident had a SDTI pressure ulcer on his/her right and left heel, not noted by the facility on admission, and staff was unable to determine the depth. The wound log did not include an assessment of the resident's back. The April Treatment Administration Record from 4/1 to 4/7/14 included [MEDICATION NAME] to right back, SDTI, change one time weekly and as needed. Staff initialed on 4/1 to 4/6 and on 4/7/14; however there was no documentation regarding whether staff changed the [MEDICATION NAME] or checked to ensure it was in place. The resident's clinical record did not contain documentation regarding the description of the resident's right back. The resident's clinical record did not support the facility measured and/or performed a thorough skin assessment on the resident from 3/28/14 to 4/2/14 (duration of 5 days). A Nutrition Assessment signed by a Registered Dietician on 4/2/14 documented the resident had diarrhea, multiple skin issues and received multivitamins for healing. The resident's Physician order [REDACTED]. back, staff should change one time weekly and as needed, and the resident wore Sage boots. An Interdisciplinary (ID) note dated 4/8/14 documented the resident was admitted to a local hospital. On 4/17/14 at approximately 3:45 P.M. administrative nursing staff D stated he/she did not know if the resident had wounds upon admission or upon discharge. The surveyor and administrative nursing staff D reviewed the resident's clinical record and administrative nursing staff acknowledged the facility did not measure the resident's wounds until 4/2/14 and failed to perform a thorough assessment of the resident's skin. Administrative nursing staff D acknowledged the Discharge MDS identified the resident had (4) Stage 2 at time of discharge and (2) SDTI pressure ulcers. Administrative nursing staff D acknowledged the resident's initial care plan did not include the Sage boots or how staff was to position the resident off the pressure ulcers. The facility's Wound and Skin Care Policy and Protocols updated 4/9/14 included staff repositioned residents unable to reposition himself/herself. The facility failed to thoroughly assess the resident's skin for a duration of 4 days after the resident was admitted to the facility. The facility failed to develop an initial care plan that included the interventions for heel protectors and how staff was to position the resident off the pressure ulcers for this resident admitted with one pressure ulcer and developed five pressure ulcers after admission. - Review of the physician's orders [REDACTED].#16 revealed a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 revealed he/she had long and short term memory impairment, moderate impairment for cognitive skills for daily decision making, and exhibited inattentive and wandering behaviors. The resident had moderate hearing difficulty, unclear speech, usually could be understood by others and usually understood others. The resident required extensive assist of 2 people for transfers and toileting, extensive assist of one staff for bed mobility, dressing, and personal hygiene, and supervision of one person for eating. The resident was not steady for moving from seated to stand position, moving on and off the toilet and surface to surface transfer. The resident was incontinent of bladder and bowel and was on a toileting program. The resident had a stage II pressure ulcer since 12/26/13 with granulation tissue (the new tissue formed in repair of wounds). The resident had a pressure relieving device for the bed, and received pressure ulcer care with ointments and a dressing. The resident received an antipsychotic 7 of 7 days of the look back period. Review of the cognitive Care Area Assessment (CAA) dated 11/14/13 revealed the resident had a [DIAGNOSES REDACTED]. Review of the Activities of Daily Living (ADL) CAA dated 11/14/13 revealed the resident required extensive assistance with all ADLs, mobility, transfers, toileting, hygiene, and bathing, wandered throughout the facility with a wanderguard on his/her wheelchair, and wore briefs for dignity for incontinence of bladder and bowel. The resident received a regular diet with set up assistance in the main dining room. Review of the urinary incontinence CAA dated 11/14/13 revealed the resident was incontinent and required extensive assist with transfers, clothing adjustment, and perineal care. The resident wore a brief for dignity and protection, and was on a scheduled toileting program with targeted times. Review of the nutritional CAA dated 11/14/13 revealed the resident was on a regular diet, ate in the main dining room with set up assistance and received ice cream three times a day with meals. Review of the pressure ulcer CAA dated 11/14/13 revealed the resident was at risk for pressure ulcers due to incontinence episodes and required extensive assist with repositioning and bed mobility. The resident required extensive assist with toileting needs, transfers, clothing adjustment and perineal care. Review of the ADL care plan dated 2/11/14 revealed the staff were to monitor for skin changes during ADL care, keep skin clean and dry, and apply moisture barrier to the skin after each incontinent episode. Review of the urinary incontinence care plan dated 2/11/14 revealed the resident had adult briefs and pads to protect skin and clothing and for dignity. The staff were to provide perineal care and apply moisture barrier to the skin after each incontinent episode. The staff were to provide extensive assist with transfers, clothing adjustments and personal hygiene. The resident was on a scheduled toilet prompting at 7 to 8 A.M., 10 to 11 A.M., 1 to 2 P.M., 4 to 5 P.M., 7 to 8 P.M. and every 2 hours at night and as necessary, Review of the nutritional care plan dated 2/11/14 revealed the staff were to provide set up assistance with meals, and the resident ate in the large dining room, Review of the dental care plan dated 2/11/14 revealed the staff were to assist with oral care twice a day and as necessary, and a regular diet. Review of altered skin integrity care plan dated 2/11/14 with revised date of 3/26/14 revealed the staff were to do a Braden scale (assessment tool for predicting pressure sore risk) quarterly, apply moisture barrier after each incontinent episode, return the resident to bed after meals, turn side to side every 60 to 90 minutes, the resident was not to sit in the wheelchair for more than 60 to 90 minutes without changing body position, and perineal care after each incontinent episode. The resident was seen by the wound clinic for left buttock/ischium and the staff were to continue with the current wound care of Duoderm (a gel dressing used for wounds with drainage), reposition the resident off the pressure ulcer, and continue the low air loss mattress. Review of the Braden Scale dated 3/27/14 revealed a score of 16 which indicated the resident was at high risk for pressure ulcers. Review of the Skin/wound log dated 4/17/14 at 8:30 A.M. revealed the resident had a facility acquired stage 2 pressure ulcer on the left gluteal fold with measurements of 0.8 centimeters (cm) by 0.8 cm with a depth of less than 0.1 cm, and had an air loss mattress. The staff were to position the resident by using pillows, on a turning positioning program, received nutrition/hydration interventions, application of dressing, and had a dietary intervention. Review of the Wound Evaluation Flowsheet revealed the resident developed a stage I red area on 12/26/13 with measurements of 1.8 (cm) by 1 cm on the left buttocks. On 1/5/14 the measurements were 2.5 cm by 1.5 cm and were listed as a stage II, staff were to apply Duoderm and change every 3 days. On 1/22/14 the measurements were 1.8 cm by 2.0 cm by 0.2 cm depth with granulation tissue, Staff to apply Duoderm every 3 days, provide a supplement, and position the resident by using pillows. On 1/30/14 the measurements were 2.6 cm by 3.2 cm by 0.2 cm with granulation tissue. Staff to apply Duoderm every 3 days, frequent reposition the resident, lay the resident in bed between meals, provide a multivitamin daily, Vitamin C 500 mg twice a day and to place the resident on an incontinence program. On 2/5/14 the measurements were 2.0 cm by 2.5 cm by 0.1 cm with granulation tissue. The interventions were unchanged. On 2/12/14 the measurements and interventions were unchanged. On 2/19/14 the measurements were 2.0 cm by 2.0 cm by 0.1 cm with granulation tissue. The interventions were unchanged. On 2/28/14 the measurements and interventions were unchanged. On 3/5/14 the measurements and interventions were unchanged. On 3/12/14 the measurements were 1.4 cm by 1.2 cm by 0.2 cm with granulation tissue. The interventions were unchanged. On 3/19/14 the measurements were 1 cm by 0.8 cm by 0.1 cm with granulation tissue, staff were to cleanse the wound area, apply skin prep and [MEDICATION NAME] (a gel dressing used for wounds with drainage) dressing every 3 days and as necessary. On 3/27/14 the measurements were 1.2 cm by 1.0 cm by 0.1 cm. The resident was sent to the wound clinic on 3/26/14. Staff interventions were to continue the previous interventions, and to start a wheelchair cushion, a low air loss mattress, Zinc Sulfate 220 mg per day, and Vitamin A units per day. On 4/2/14 the measurements were 1.2 cm by 1.0 cm by 0.2 cm with granulation tissue. Staff interventions were unchanged. On 4/9/14 the measurements were 0.8 cm by 0.2 cm by less than 0.1 cm with granulation tissue. Staff interventions were unchanged. On 4/17/14 the measurements were 0.5 cm by 0.4 cm by less than 0.1 cm with granulation tissue. Staff interventions were unchanged. Observation on 4/16/14 at 7:35 A.M. the resident sat in his/her wheelchair in the main dining room. At 8:00 A.M. the resident remained in the dining room. At 8:05 A.M. staff provided scrambled eggs, toast, corn flakes, and a chocolate magic cup. The resident fed him/herself. At 8:40 A.M. the resident consumed 100 percent of food except the toast and remained in the wheelchair in front of the nursing station. At 8:44 A.M. the resident sat in the wheelchair and self-propelled his/her wheelchair toward the resident's room. Observation on 4/16/17 at 8:59 A.M. revealed the resident lay in bed on his/her left side, with heel protectors on and elevated on pillows. Observation on 4/16/14 at 11:20 A.M. the resident sat in the wheelchair in the north hallway. At 12:06 P.M. the resident sat in the wheelchair in the dining room and fed him/herself lunch. Staff provided a polish sausage, mixed vegetable, macaroni salad, and 2 magic cups. At 12:30 P.M. the resident consumed ? polish sausage and 2 magic cups. Observation on 4/16/14 at 4:15 P.M. direct care staff O performed a brief check on the resident and the resident was incontinent of bowel and bladder. The staff did perineal care and the left buttock wound did not have a dressing and was approximately dime size. No barrier cream was applied to the perineal area. A pressure relieving pad was in the wheelchair. Interview on 4/16/14 at 4:15 P.M. direct care staff O stated the resident was always incontinent and did not attempt to get out of bed. The pressure ulcer did not have a dressing in place. Observation on 4/16/14 at 5:00 P.M. the staff provided a tortilla, 2 magic cups and the resident initiated feeding him/herself. At 5:25 P.M. the resident consumed 100 percent. Observation on 4/17/14 at 7:03 A.M. the resident sat in the wheelchair and self-propelled to the dining room. At 7:45 A.M. the resident sat in the wheelchair at the dining room table. At 8:00 A.M. the staff provided 2 slices of bacon eggs, toast and coffee. At 8:15 A.M. the resident was feeding self. At 8:30 A.M. the resident consumed 100 percent and 2 magic cups. Observation on 4/17/14 at 8:50 A.M. direct care staff P transferred the resident to bed. The resident was incontinent of urine, perineal care was performed and no moisture barrier was applied. The staff positioned the resident supine in bed. Interview on 4/17/14 at 9:05 A.M. direct care staff P stated the resident was always incontinent and required staff to change his/her brief. No dressing was on the pressure wound because the resident had received a shower earlier today. Observation on 4/17/14 at 11:15 A.M. administrative licensed staff D used cleansing spray to clean the left coccyx wound, measured the wound and applied Duoderm and positioned the resident on his/her left side. Interview on 4/17/14 at 11:15 A.M. administrative licensed staff D stated the Duoderm was in place but was removed for wound measurements. Interview on 4/17/14 at 11:20 A.M. administrative licensed staff F stated he/she had applied a Duoderm to the open wound at approximately 9:30 A.M., the resident received a shower and it was not reported to him/her so he/she could apply a dressing. Interview on 4/17/14 at 1:20 P.M. licensed staff E confirmed he/she did not apply barrier cream
The facility had a census of 48 residents. Based upon observation, record review and interviews the facility failed to maintain/restore urinary function for 2 (#11, #12) of 3 residents sampled for urinary incontinence. Findings included: - Resident #12's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, was independent with bed mobility, transfers, walking in the room/corridor and locomotion on/off the unit, dressing, eating, toilet use and personal hygiene. The MDS recorded the resident was always continent of urine and bowel, was not at risk for the development of pressure ulcers, did not have a pressure relieving device on his/her bed or chair and was not on a turning/repositioning program. The resident's significant change MDS dated [DATE] identified the resident scored 99 (resident was unable to complete the Brief Interview for Mental Status Interview) and staff assessed the resident had moderately impaired cognition and without behaviors. The MDS identified the resident required extensive staff assistance with bed mobility, transfers, locomotion on/off unit, dressing, eating, toilet use, did not walk in room/corridor, limited staff assistance with personal hygiene and utilized a wheelchair. The MDS identified the resident was occasionally incontinent of urine and bowel, was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, had a pressure relieving device on his/her bed, no pressure relieving device on his/her chair and was not on a turning/repositioning program. The resident's Activity for Daily Living (ADL) Functional Status/Rehabilitation Potential Care Area Assessment (CAA) dated 3/24/14 documented the resident required total staff assistance with all ADL's, no longer walked, and needed extensive staff assistance with wheelchair mobility. The resident had episodes of incontinence, wore a brief and required staff assistance with toileting. The above represented the resident had a decline in his/her urinary function. The resident's Urinary Incontinence/Indwelling Catheter CAA dated 3/24/14 documented the resident was incontinent of bowel and bladder and required staff assistance with incontinent care. The resident wore incontinent briefs for dignity and protection and a voiding trial was out to determine the resident's targeted toileting times. The resident's Bowel/Bladder assessment dated [DATE] documented the resident was continent of urine. The resident's Bowel and Bladder assessment dated [DATE] included the resident was incontinent during the day and night. Review of the resident's clinical record lacked evidence to support the facility conducted a bladder assessment after 12/28/12. The resident's care plan dated 4/15/14 included the resident required extensive staff assistance with activities of daily living. The resident had a potential for alteration in skin integrity, staff kept the resident's skin clean and dry and monitored the resident for skin changes. Interventions in place 3/24/14 included the resident was incontinent of urine, staff applied incontinent care and a moisture barrier after each incontinent episode. A 3 day voiding trial was out to determine the resident's toileting times. Staff checked and changed the resident during the hours of 7 to 8 A.M., 10 to 11 A.M., 1 to 2 P.M., 4 to 5 P.M., 7 to 8 P.M., every 2 hours during the night as as needed. A nurse's note dated 3/4/14 and timed 11:35 A.M. included the facility received a physician's orders [REDACTED]. A physician progress notes [REDACTED]. The resident's March 2014 Medication Administration Record [REDACTED]. Review of the resident's 3 day voiding pattern/voiding record for 1/8/14 to 1/10/14 documented the resident toileted himself/herself. The record did not identify the resident was incontinent of urine. The resident's 3 day voiding pattern/voiding record for 3/11/14 to 3/13/4 was incomplete because the resident was in the hospital on [DATE]. The resident's 3 day voiding pattern/voiding record for 3/25/14 to 3/27/14 lacked incomplete documentation. For example the facility did not record the resident's voiding/pattern on 3/26/14 from 3:00 P.M. to 9:00 P.M. and from 2:00 P.M. to 9:00 P.M. on 3/27/14. The bottom of the record contained a handwritten entry that documented check and change program during the hours of 7 to 8 A.M., 10 to 11 A.M., 1 to 2 P.M., 4 to 5 P.M., 7 to 8 P.M., every 2 hours and as needed at night due to a change in the resident's condition. Further review did not include an analysis of how the facility determined this toileting schedule for the resident. Further review also revealed no analysis as to the type of the resident's incontinence. Review of the resident's 3 day voiding pattern/voiding record for 4/15/14 to 4/17/14 on 4/17/14 at 4:17 P.M. lacked any documentation on 4/17/14. On 4/16/14 at 9:44 A.M. the resident sat on the toilet in his/her room. During interview with direct care staff R at that time, he/she stated the resident was not incontinent of urine when he/she placed the resident on the toilet. Direct care staff R stated staff toileted the resident every 2 hours and as needed per resident request. On 4/16/14 at 1:32 P.M. the resident sat on the toilet in his/her room. At that time direct care staff R (staff that transferred the resident to the toilet) stated the resident was not incontinent of urine. At 2:00 P.M., 2:15 P.M., and 2:30 P.M. the resident sat in his/her wheelchair in the day room (by the nurse's station). At 2:54 A.M., 3:15 P.M., and 3:24 P.M. the resident sat in a regular chair in the day room. At 3:50 P.M., 4:00 P.M., 4:15 P.M. and 4:20 P.M. the resident sat in his/her wheelchair in the day room. At 4:20 P.M. the resident propelled himself/herself to the dining room. At 4:30 P.M., 4:45 P.M., 5:00 P.M. and 5:15 P.M. the resident sat in his/her wheelchair at a dining room table. Observation revealed staff did not toilet the resident during the hour of 4 to 5 P.M. On 4/17/14 at 7:33 A.M. the resident laid in bed and direct care staff S entered the resident's room to assist the resident with the A.M. care. Observation revealed the resident had on an incontinent brief and the brief and resident's gown was saturated with urine. On 4/17/14 at 4:16 P.M. administrative nursing staff F stated the facility only performed a 3 day voiding trial and did not perform the bowel/bladder evaluations. Administrative nursing staff F stated administrative nursing staff E performed the analysis of the data and noted the resident's toileting schedule on the voiding trial. Administrative nursing staff F stated the facility started a 3 day voiding trial for the resident on 4/15/14 and it would be completed on 4/17/14. Administrative nursing staff F confirmed the resident's voiding trial did not contain any documentation for 4/17/14. On 4/17/14 at 3:22 P.M. licensed nurse I stated staff toileted the resident every 2 hours. On 4/17/14 at 4:00 P.M. licensed nurse J stated staff toileted the resident every 2 hours. On 4/17/14 at 4:4:42 P.M. direct care staff T stated staff toileted the resident every hour and as needed. The facility's Urinary Continence and Incontinence-Assessment and Management policy revised August 2006 included the staff and practitioner appropriately screened residents and managed residents with urinary incontinence. The physician and staff provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The facility failed to complete a 3 day voiding trial of this resident's urinary pattern to determine an individualized toileting program and also failed to toilet this resident as planned and who experienced a decline in his/her urinary status. - Resident #11's quarterly Minimum Data Set (MDS) 3.0 dated 2/14/14 identified the resident scored 11(moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with bed mobility, walking in the room/corridor and locomotion off the unit, required extensive staff assistance with transfers, locomotion on the unit, dressing, toilet use and personal hygiene. The MDS identified the resident was occasionally incontinent of urine and was at risk for the development of pressure ulcers. The resident's Significant Change MDS dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with bed mobility, transfers, walking in the room/corridor, personal hygiene, and locomotion on/off the unit, required extensive staff assistance with dressing and toilet use. The resident was frequently incontinent of urine. The MDS identified the resident was at risk for pressure ulcers. The resident's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 3/31/14 documented the resident had episodes of incontinence, a 3 day voiding trial was "out" to determine the resident's targeted scheduling times. The resident wore incontinent briefs for dignity and protection, needed extensive staff assistance with transfers on/off the toilet, clothing adjustment, and perineal care. The resident used the urinal at times. The resident's care plan dated 3/31/14 included the resident was incontinent of urine and interventions as of 3/31/14 included staff provided perineal care and applied a moisture barrier after each incontinent episode. An entry dated 4/1/14 documented staff toileted the resident during the hours of 6 to 7 A.M., 9 to 10 A.M., 12 to 1 P.M., 3-4 P.M., 6-7 P.M. and checked and changed the resident every 2 hours and as needed. The resident's Bowel and Bladder assessment dated [DATE] included the resident was independent with toileting and was continent of urine. Review of the resident's clinical record lacked evidence the facility completed a Bowel and Bladder assessment since 7/1/11. A three day voiding pattern dated 3/25/14 to 3/27/14 contained incomplete data. For example, there was no documentation from 2:00 P.M. to 10:00 P.M. on 3/26/14 and from 12:00 P.M. to 10:00 P.M. on 3/27/14. A handwritten entry at the bottom included staff toileted the resident at targeted times during the day during the hours of 6 to 7 A.M., 9 to 10 A.M., 12 to 1 P.M., 3 to 4 P.M., 6 to 7 P.M., checked and changed the resident every 2 hours during the night, and as needed. On 4/17/14 at 4:16 P.M. administrative nursing staff F stated the facility did not perform bladder assessments. Administrative nursing staff F stated the facility conducted a 3 day voiding trial and administrative licensed nurse staff performed an analysis of the voiding pattern and documented the resident's toileting program on the 3 day voiding trial record. Administrative nursing staff F confirmed the clinical record lacked evidence the facility had performed a bladder assessment for this resident since 7/1/11. On 4/16/14 at 7:55 A.M. the resident sat on the side of his/her bed. Observation revealed the resident's pants saturated with a liquid. During interview with the resident at that time, he/she stated he/she was wet with urine and needed changed. On 4/16/14 at 8:05 A.M. the resident sat on the side of his/her bed and ate the breakfast meal. Observation revealed the resident still had on the same pants and the pants continued to be wet. On 4/16/14 at 8:20 A.M. the resident laid in bed. During interview with the resident at that time, he /she stated he/she was wet with urine and needed change. At that time the surveyor reported the above to administrative nursing staff D. Administrative nursing staff D asked direct care staff R to assist the resident. Direct care staff R entered the resident's room and assisted the resident. Observation revealed the resident's incontinent brief, pants and bed linens saturated with urine. Direct care staff R performed incontinent care and changed the resident's clothes. Direct care staff R confirmed the resident's brief and urine saturated with urine. Direct care staff R stated staff checked and changed the resident every 2 hours. On 4/17/14 at 6:50 A.M. the resident laid in bed and with a strong urine odor noted. Observation revealed the handle of the resident's empty urinal rested on the side of the trash can. On 4/17/14 at 7:17 A.M. direct care staff S entered the resident's room to assist the resident with A.M. care. Observation revealed the resident's incontinent brief, pants and blanket saturated with urine. Direct care staff assisted the resident to ambulate to the bathroom. Observation revealed the back of the resident's pants were wet. During interview with direct care staff at that time he/she stated staff checked and changed the resident at least every 2 hours. On 4/17/14 at 3:22 P.M. licensed nurse I stated staff toileted the resident every 2 hours. On 4/17/14 at 4:00 P.M. licensed nurse J stated staff toileted the resident every 2 hours. On 4/17/14 at 4:42 P.M. direct care staff T stated staff toileted the resident every hour and as needed. During the findings meeting on 4/17/14 between 5:15 P.M. and 5:40 P.M. administrative staff A (not a licensed nursing staff or certified staff) stated he/she checked on the resident at 6:00 A.M. on 4/17/14, the resident was not incontinent of urine and he/she emptied the resident's urinal. Administrative staff A did not state whether staff toileted the resident at that time. The facility's Urinary Continence and Incontinence-Assessment and Management policy revised August 2006 included the staff and practitioner appropriately screened residents and managed residents with urinary incontinence. The physician and staff provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The facility failed to complete a 3 day voiding trial of this resident's urinary pattern to determine an individualized toileting program and failed to provide timely toileting for this resident that experienced a decline in bladder function.
Inspection of March 24, 2014
6 findingsThe facility had a census of 47 residents. The sample included residents. Based upon record review and interview the facility failed to perform Cardiopulmonary Resuscitation (CPR) for 1 (#2) of 1 residents that was a full code status (resident's directive to undergo CPR if his/her heart stopped or he/she stopped breathing). The resident passed away at the facility when he/she did not receive CPR. This practice placed this resident in immediate jeopardy. Findings included: - Review of resident #2's (a closed record) interdisciplinary discharge summary revealed the resident admitted to the facility on [DATE] and expired at the facility on [DATE]. The resident's face sheet did not identify the resident was a DNR (resident's directive to not undergo CPR if his/her heart stopped or he/she stopped breathing). Due to the resident's length of stay at the facility (less than 14 days) the facility did not conduct a Minimum Data Set 3.0. The resident's clinical record did not support the facility completed a temporary care plan for the resident. An admission History and Physical signed and dated by a physician on [DATE] documented the resident was a full code. An Interdisciplinary progress note dated [DATE] documented the resident admitted to the facility on [DATE], upon admission the resident was a full code and was not interested in changing his/her code status at that time. Review of the resident's February 2014 treatment administration revealed on [DATE] at 8:00 A.M. staff checked the resident's blood glucose level (amount of glucose in the blood) via a glucometer (device used to measure the glucose) and the resident's blood glucose level was 300. Documentation included staff did not administer the resident's insulin per sliding scale because the resident had not eaten breakfast. A nurse's note dated [DATE] and timed 9:00 A.M. documented (2) licensed nurses entered the resident's room after a direct care staff reported the resident's skin color was gray. Upon entering the resident's room the resident's skin was cold to touch, the resident's extremities were purple, the resident's body was limp, and the resident was without respirations, blood pressure and pulse. A nurse's note dated [DATE] and timed 9:15 A.M. documented staff notified the resident's physician nurse practitioner of the resident's status and obtained an order to transfer the resident to a funeral home per the resident's family choice. A nurse's note dated [DATE] timed 9:30 A.M. documented at 9:25 A.M. the facility left a message for the resident's family to contact the facility and a family member returned the facility's telephone call at 9:30 A.M. and staff informed the family member the resident had expired. A nurse's note dated [DATE] and timed 9:00 A.M. documented 2 licensed nurses started CPR on the resident and was unable to revive the resident. The resident's skin color was gray and his/her body was limp. Staff did not telephone 911 and the resident was without a blood pressure, pulse or respirations. Review of the nurse's notes did not support staff documented how much time lapsed from the time the direct care staff observed the resident and summoned licensed nurse M to the resident's room. The nurse's notes did not support licensed nurse M documented the time he/she entered the resident's room, the amount of time he/she spent assessing the resident for vital signs or the appearance of the resident or the temperature in the resident's room when he/she entered the resident's room. The nurse's note did not support staff documented how much time lapsed before licensed nurse L entered the resident's room. The Centers for Medicare and Medicaid Survey and Certification Letter dated [DATE] included facility policy should specifically direct staff to initiate CPR when [MEDICAL CONDITION] (heart stopped) occurs for residents who have requested CPR in their advance directives (written instructions that a person gives that specify what actions should be taken for his/her health, if they are no longer able to make decisions); who have not formulated an advance directive; who do not have a valid DNR order; or who do not show AHA (American Heart Association) signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC). CPR certified staff must be available at all times to perform CPR when needed. According to the AHA, reversal of clinical death is among the goals of ECC since brain death begins four to six minutes following [MEDICAL CONDITION] if CPR is not administered during that time. AHA guidelines urge " ...all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place; 2) obvious signs of clinical death (for example, rigor mortis (stiffness that occurs after death), dependent lividity (settling of the blood in the lower portion of the body, causing a purplish red discoloration of the skin), decapitation(separation of the head from the body), transection(cut across), or decomposition (rotting) are present; or 3) initiating CPR could cause injury or peril to the rescuer." On [DATE] at 12:50 P.M. administrative staff provided a list of staff CPR certified. Review of the list revealed the facility employed 38 nursing staff. Further review revealed 2 direct care staff and 1 licensed practical nurse was CPR certified. On [DATE] at 1:05 P.M. licensed nurse L stated he/she performed the resident's blood glucose level at 8:30 A.M., did not administer the resident's insulin because the resident had not eaten his/her breakfast. Licensed nurse L stated he/she asked a direct care staff to perform the resident's A.M. care so the resident could eat breakfast. Licensed nurse stated that around 9:00 A.M. the direct care staff summoned him/her to the resident's room. Licensed nurse L stated he/she and licensed nurse M entered the resident's room and he/she observed the resident had expired, due to his/her years of nursing experience the resident could not be resuscitated; therefore staff did not perform CPR. When asked about the discrepancies in the nurse's notes, licensed nurse L stated he/she was going to start CPR but did not based on the above. Licensed nurse L stated the resident was a full code. Licensed nurse L stated he/she was not CPR certified. On [DATE] at 1:45 P.M. licensed nurse M stated on [DATE] at approximately 9:00 A.M. he/she performed treatments down the long hall and a direct care staff approached him/her and asked him/her to check on the resident. Licensed nurse M stated he/she entered the resident's room and checked the resident's for a pulse (rate at which the heart beats). Licensed nurse M stated the resident was cold and was not breathing. Licensed nurse M stated he/she asked the direct care staff to summon the charge nurse. Licensed nurse M stated licensed nurse L entered the resident's room and confirmed the resident was not breathing. He/she asked licensed nurse L if the resident was a DNR and licensed nurse L stated yes; therefore staff did not perform CPR. Licensed nurse M stated he/she was not certified in CPR. On [DATE] at 3:20 P.M. administrative nursing staff D stated he/she was not in the facility at the time of the incident. Administrative nursing staff D stated staff informed him/her the resident had expired and did not perform CPR because the resident's extremities were purple which indicated the resident could not be resuscitated. On [DATE] at 3:25 P.M. social service staff H stated prior to admission, he/she spoke with residents and/or their legal representative regarding his/her code status. Social service staff H stated he/she communicated to nursing staff the resident's status via a sticker placed on the inside of the resident's chart. Social service staff H stated the resident's chart was placed at the nursing station prior to the resident arriving at the facility. On [DATE] at 1:30 P.M. administrative staff A stated nursing staff was informed of resident's code status prior to admission via a sticker placed on the inside of the resident's chart. Administrative staff A stated none of the staff on duty at the time of the incident was CPR certified. On [DATE] at 12:45 P.M. administrative nursing staff D stated the facility did not review the AHA guidelines with staff regarding when CPR should not be performed. Administrative nursing staff D stated when staff attended CPR classes the guidelines were reviewed. Administrative nursing staff D confirmed at the time of the incident none of the staff was CPR certified. The facility's Cardiopulmonary Resuscitation and Basic Life Support (BLS) policy and procedure dated [DATE] included key clinical staff members who would direct BLS/CPR, including non-licensed personnel would obtain and/or maintain American Red Cross or AHA certification in BLS/CPR ...if an individual (resident, visitor, staff) was found unresponsive and without a pulse, a licensed staff person would initiate CPR unless it was known a DNR order that specifically prohibited CPR and/or external defibrillation existed for the individual; or there were obvious signs of irreversible death (for example rigor mortis). The facility failed to perform CPR for this resident was a full code status and no documentation to support the resident had obvious signs of irreversible death when staff first observed the resident without a pulse. The facility also failed to have a staff on duty that was CPR certified. This practice placed this resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 12:00 P.M. when: The facility reviewed the policy and procedure for CPR and Advance Directives. Initiated the procedure for all residents with a DNR to have a red star on the outside of their room door on the resident's chart. Social service director reviewed and verified all resident's code status. A list of residents that were a code was placed at the nurses' station in a yellow folder. The Social service director will updated the list with new admission, discharges, or any other change in orders. Training on CPR policy and procedure for code status completed with all staff on [DATE] at 4:00 P.M. CPR training completed for staff on [DATE] at 12:00 P.M. The Quality Assessment and Assurance committee with discuss and provide interventions as needed. The deficiency will remain at a scope and severity of a D.
The facility identified a census of 47 residents. Sample included 11 residents of which 3 were reviewed for supervision to prevent accidents. Based on observation, record review, and interview, the facility failed to accurately assess and provide supervision to prevent the elopement of 1 (#1) resident that placed him/her in Immediate Jeopardy, and failed to provide timely and effective interventions for the preventions of falls for 1 (#3) resident that received a fracture. Findings included: - Resident #1's Physician order [REDACTED].). The POS included the resident utilized a walker and wheelchair for mobility. The quarterly Minimum Data Set (MDS) 3.0 dated 12/2/13 indicated the resident had short and long term memory problems, moderately impaired cognition (decisions poor; cues/supervision required). The MDS coded the resident had trouble concentrating on things such as reading the newspaper or watching television and rejected care 1 to 3 days of the 7 day assessment period and did not wander. The MDS identified the resident required limited staff assistance with bed mobility, transfers, dressing, toilet use and personal hygiene, the activity of walking in the room/corridor occurred only once or twice, the resident was independent with locomotion on/off the unit. The MDS coded the resident was not steady but was able to stabilize without human assistance when moved from seated to standing position, walking, turning around, moving on/off toilet, surface-to surface transfer, no functional limitation in range of motion and utilized a walker and wheelchair. The MDS coded the resident fell in the last 2-6 months prior to admission, no falls since admission and received an antianxiety medication 4 days during the 7 day assessment period. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 8/21/13 documented the resident had a [DIAGNOSES REDACTED]. The resident had short and long term memory deficit, was unable to recall the day, month or year, did recall some staff names and location of his/her room. At times the resident was easily agitated and had inattention problems and disorganized thinking. The resident's Activity of Daily Living (ADLs) CAA dated 8/21/13 documented the resident needed extensive staff assistance with all ADLs, was able to walk short distances in his/her room and in the hallway but often declined and did not walk in the 7 day look back period and used a wheelchair for mobility. The resident's Fall CAA dated 8/21/13 documented the resident had a history of [REDACTED]. The resident's Psychotropic Drug Use CAA dated 8/21/13 documented the resident received a daily antipsychotic, at times was easily agitated, yelled out or had outbursts. The resident's Fall Risk assessment dated [DATE] and 11/29/13 identified the resident scored 11. The resident's Fall Risk assessment dated [DATE] and 12/27/13 identified the resident scored 10. According to the legend a score of 10 or greater identified the resident was at high risk for falls. The resident's Elopement Risk assessment dated [DATE] identified the resident scored 9 (no risk of elopement). Review of the resident's elopement risk assessment revealed the resident did not ambulate independently. Further review revealed if the facility had taken into account the resident was independent with locomotion when in his/her wheelchair the resident would have scored 12 (minimal risk for elopement). Further review revealed the facility reassessed the resident's elopement risk assessment on 12/4/13 and documented on the form the resident was not at risk for elopement. The assessment did not include a score identifying the resident's risk. The resident's Elopement Risk assessment dated [DATE] identified the resident scored 4 (low risk for elopement). Further review revealed the assessment included the resident's mobility status. A score of 0 represented the resident was non-ambulatory. However, the resident would have scored an additional 4 points on the mobility section if the facility had taken into account the resident was ambulatory, independent with wheelchair. Further review revealed the facility reassessed the resident's elopement risk assessment on 12/4/13 and documented on the form the resident was not at risk for elopement. The assessment did not include a score identifying the resident's risk. The above represents the facility used 2 different elopement risk assessments and the forms scoring criteria differed as to whether residents were at risk for elopement. The assessments did not take into account the resident had a history of [REDACTED]. The resident's care plan dated 1/13/14 with interventions in place since 8/21/13 included staff re-directed the resident's reality orientation during waking hours, and did not support the resident's confusion. Staff observed the resident for a decline in his/her cognitive function and monitored the resident for adverse effects of medications. If the resident was agitated staff allowed the resident time and space and returned at another time with a pleasant attitude and attempted to redirect the resident or provide care. Staff monitored the resident for signs/symptoms of frustration or increased anxiety, and ensured the resident understood. Staff encouraged/assisted the resident to make slow position changes and provided extensive assistance with transfers and bed mobility. The resident was able to walk but chose not to very often and used a wheelchair for mobility. The resident had a history of [REDACTED]. The resident had a [DIAGNOSES REDACTED]. Staff ensured the resident's call light was within reach and ensured the resident's pathway was free and clear of any objects. Staff monitored the resident for dizziness, faintness, fatigue or shortness of breath with activity or increased anxiety. Staff attempted to redirect the resident when he/she had behaviors occurred and informed him/her the behavior was not appropriate and encouraged him/her to express himself/herself appropriately. The resident's care plan dated 3/4/14 included the resident was exit seeking, would not leave the facility unattended, staff placed a wander guard (device that alerted staff if the resident attempted to leave the facility unattended) and staff checked the functioning and placement of the wander guard each shift. A nurse's note dated 3/3/14 and timed 2:30 P.M. documented the facility received a telephone call from a nurse at a local hospitals emergency department asking why the resident was at the hospital's emergency department. The facility's licensed nurse responded the resident should not be at the hospital and facility staff would come and pick up the resident. The note included the facility staff checked the entire facility to ensure the resident was not in the facility. The nursing supervisor stated he/she saw the resident in the facility at approximately 1:30 P.M. to 1:45 P.M. A nurse's note dated 3/3/14 and timed 3:45 P.M. documented the resident returned to the facility, with no apparent injuries or distress. The note did not include how the resident was dressed. A hospital emergency department nurse's note dared 3/3/14 and timed 2:43 P.M. documented a hospital's security guard presented the resident to the hospitals' emergency department. The resident was unable to give any information as to why he/she was at the hospital or how he/she arrived at the hospital. The resident verbalized his/her name and date of birth. The resident arrived in a wheelchair and the resident's clothes were dirty with dried food. The resident had no obvious injuries and denied pain. A hospital emergency department nurse's note dated 3/3/14 and timed 3:50 P.M. documented the hospital's nurse spoke with 2 nurses at the nursing facility where the resident resided. The nursing facility staff was unaware the resident was at the hospital and did not need to be evaluated. The nursing facility staff stated the resident eloped from the facility and would send transportation personnel to pick up the resident. A physician's orders [REDACTED]. According to www.wunderground.com <http://www.wunderground.com at 1:53 P.M. on 3/3/14 the temperature in Topeka, Kansas was 17.1 degrees Fahrenheit (F); the wind chill temperature was 8.7 degrees F with southeast winds at 5.8 miles per hour. Review of the facility's daily inspection log for 2/14 revealed on 2/28/14 facility staff replaced the door closure on the front door of the facility. Review of the facility's daily inspection log for 3/14 revealed on 3/3/14 staff readjusted the front door closure. On 3/6/14 at 7:55 A.M. the resident sat in his/her wheelchair in the television area of the facility. Observation revealed the wheelchair had a wander guard device and the name on the wheelchair did not correspond to the resident's name. The resident proceeded to stand, took a few steps and transferred him/herself without staff assistance to the couch and continued to watch television. On 3/6/14 at approximately 8:20 A.M. revealed the distance from the facility to the hospital's emergency department was 5.3 miles. On 3/11/14 at approximately 1:20 P.M. observation revealed the front door of the facility with a wandering monitoring device and a 15 second delay. Observation revealed when the front door release bar was pressed, an alarm sounded, after 15 seconds the door opened and staff had to manually reset the alarm. Observation revealed a key pad located next to the door with a code posted that read enter month, year and the number sign (#) to exit the door with a format of XX XX #. Observation further revealed if one entered the code the door open and no alarm sounded. If one did not immediately close the door, and held the door open an alarm sounded 40 seconds later which alerted staff the door remained open. On 3/13/14 at approximately 5:45 PM. revealed no posted speed limits on the street where the facility was located until 0.10 miles east of the facility. Observation at that time revealed a road sign indicating a curve and a speed limit of 25 miles per hour. Further observation revealed the area was a residential area and sidewalks present in some areas. Observation revealed there were 6 side streets with a distance of 0.10 to 0.20 miles that led to a heavily traveled 4 lane street with a speed limit of 40 miles per hour. On 3/11/14 at approximately 1:00 P.M. administrative nursing staff D stated he/she received a telephone call on 3/3/14 at approximately 2:30 P.M. from a nurse at the local hospital's informing him/her the resident was at the hospital's emergency department and inquired as to why the resident was at the hospital. Administrative nursing staff D stated he/she informed the hospital's nurse the resident should not be at the hospital and the facility would send transportation staff to pick up the resident. Administrative nursing staff D stated the nursing supervisor saw the resident between 1:30 P.M. and 1:45 P.M. on 3/3/14. Administrative nursing staff stated the resident ambulated independently in his/her wheelchair, all of the facility's exit doors were padlocked and the resident would have left the facility via the facility's front door. Administrative nursing staff D stated due to the resident's cognition the resident would not have been able to enter the code on the keypad to exit the facility and he/she did not know how the resident left the facility without staff knowledge. Administrative nursing staff D stated due to the time frame when the nursing supervisor saw the resident in the facility between 1:30 P.M. and 1:45 P.M. and the time the hospital notified the facility at 2:30 P.M. due to the distance from the hospital to the facility the resident would have to have arrived to the hospital via a vehicle and he/she did not know who transported the resident to the hospital. Administrative nursing staff D stated based on the resident's elopement risk assessment the resident was not an elopement risk. Administrative nursing staff D stated he/she assessed the resident upon his return to the facility and the resident could not or would not say how he/she left the facility. Administrative nursing staff D stated he/she did not recall how the resident was dressed when he/she returned to the facility. On 3/11/14 at 1:30 P.M. an alert and oriented resident stated he/she sat in the foyer of the facility by the front door of the facility on the date the resident left the facility unattended by staff and he/she saw the resident exiting the facility. The resident stated the front door of the facility did not function properly due to snow and the cold temperature. The resident sated the front door was three-fourth open and the resident wheeled himself/herself out of the front door and headed east (toward the residential area). The resident stated he/she wheeled his/her motorized wheelchair to the end of the hall, looked for staff to alert them the resident had left the building and he/she could not find staff to alert them the resident had left the facility. On 3/11/14 at approximately 1:35 P.M. maintenance staff X stated on 2/28/14 he/she replaced the closure on the front door. Maintenance staff X stated the door was hard to open but properly functioned. Maintenance staff X stated on 3/314 he/she readjusted the closing time on the front door after the resident left the facility unattended. Maintenance staff X stated adjusting the closing time of the door allowed the door to close faster in case the resident caught the door with his/her foot after someone went out. An alert and oriented resident on 3/13/14 at 12:06 P.M. stated for a couple of weeks when he/she went out he front door, the door did not close all the way. The resident stated recently the staff fixed the door and the front door now closed. An alert and oriented resident on 3/17/14 at 1:30 P.M. stated within the last week or so the staff fixed the front door to make sure it closed. This resident stated for a couple of weeks the front door did not close all the way. On 3/11/14 at 1:49 P.M. administrative staff A stated he/she was not in the facility on the day the resident eloped from the facility. Administrative staff A stated administrative nursing D telephoned him/her on 3/3/14 and informed him/her the resident left the facility unattended. Administrative staff A stated a resident stated he/she observed the resident exiting the facility. Administrative staff A stated resident #1 told him/her he/she did not feel well, was going to the hospital and received a ride from someone he/she did not know. Administrative staff A stated the resident had never tried to elope or leave the facility before. Administrative staff A stated maintenance staff X checked the door on a daily basis and the door alarms functioned properly. Administrative staff A stated the facility replaced the door closer because the door was hard to open, the cover on of the closure fell and staff could not retrieve the cover, and due to the weather the door closure needed to be covered but did not affect the functioning of the door. On 3/11/14 at approximately 2:30 P.M. licensed nurse J stated the resident did not walk but propelled his/her wheelchair independently. Licensed nurse J stated the elopement risk assessment included ambulation which he/she interpreted to mean walk so he/she did assess the resident to be independent with ambulation. On 3/11/14 at approximately 3:00 P.M. nursing administrative staff F stated he/she reviewed the previous scoring on the resident's elopement risk assessment but did not re-score the assessment. Administrative nursing staff F stated the resident did not walk independently but independently propelled his/her wheelchair. Nursing administrative staff F stated since the resident independently propelled his/her wheelchair it would indicate the resident ambulated independently; therefore the locomotion/ambulation was coded properly the resident would have been at risk for elopement. Nursing administrative staff F stated the facility used 2 different elopement risk assessments and the scoring criteria differed among the 2 assessments. The Missing Elder/Elopement Policy revised on 3/5/14 included it was the policy of the facility to provide a safe and secure environment for all residents. The facility failed to assess and provide supervision to prevent this cognitively impaired resident at a risk for falls from exiting the building which placed him/her at risk for immediate jeopardy. The facility abated this immediate jeopardy on 3/13/14 at 4:00 P.M. when: The administrator and Director of Nursing reviewed and trained all staff on the elopement policy, missing resident protocol, door alarm policy, elopement risk policy, and the policy on checking wanderguards completed on 3/13/14 at 4:00 P.M. All residents were re-assessed for risk of elopement with their care plan reviewed and new interventions added as needed. Will complete elopement drills two times a month. Residents at risk for elopement would be discussed during morning meetings and weekly risk care meetings. A list of residents at risk for elopement would be kept at the nurses' station and the MDS coordinator would update the elopement risk book as needed. Residents identified at risk for elopement would have a Wanderguard in place and staff would check placement and functioning every shift. Maintenance would complete door alarm checks during daily rounds with results documented on the maintenance log. ad additional sign was placed at the front door, yellow in color, that stated, do not hold open door for anyone without checking with a member of the nursing staff. Quality Assessment and Assurance will discuss and place interventions as needed. - Resident #3's Physician order [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 11 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with bed mobility, walking in the room/corridor, locomotion off the unit and required extensive staff assistance with transfers, locomotion on the unit, dressing, toilet use and personal hygiene. The MDS identified the resident was tot steady, was only able to stabilize with human assistance when moved from seated to standing position, walking, turning around, moving on/off the toilet, and surface to surface transfer. The MDS coded the resident sustained [REDACTED]. The resident's Activity of Daily Living (ADL) Care Area Assessment Care Area assessment dated [DATE] documented the resident was independent with most ADLs, required extensive staff assistance with dressing in the A.M. The Fall CAA did not trigger. The resident's Fall Risk Assessment identified the resident scored 11 on the assessment dated [DATE] and 15 on the fall risk assessment dated [DATE]. According to the legend a score of 10 or greater represented the resident was at high risk for falls. The resident's care plan dated 1/31/14 included the resident was at risk for falls and the resident's gait was unsteady at times. Interventions in place since 8/5/13 included staff assessed the resident for pain, ensured/encouraged the resident wore proper footwear. The resident liked to wear just socks and staff documented the resident to wear some kind of shoe. Staff encouraged/assisted the resident to make slow position changes, ensured the resident's call light was within reach, performed a fall risk assessment on a quarterly basis and kept the resident's pathway free and clear of objects. The resident utilized a walker, at times walked to the doorway to converse with staff without his/her walker and staff reminded the resident to use his/her walker. On 1/25/14 the resident had a non-injury fall and staff was to assist the resident with putting his/her clothing in the closet and monitored daily during rounds the resident's clothing was hung up. On 1/27/14 the resident had a non- injury fall and staff rearranged the resident's room. On 2/5/14 the resident fell and sustained bruising and the facility evaluated the resident's medications. An entry dated 2/11/14 included the resident fell , sustained a laceration, and fracture of his/her right fourth metacarpal (fracture of the fourth finger) and the facility placed a bed/chair alarm. Licensed nurses checked the functioning and placement of the resident's bed/chair alarm each shift. Handwritten in and not dated included staff provided the resident with non-skid socks or house slippers during transfers and when the resident ambulated, staff ensured the resident's call light was attached to his/her recliner, staff placed non-skid strips in front of the resident's bed and recliner and monitored to ensure the strips were in place. A nurse's note dated 1/25/14 and timed 10:30 A.M. documented the resident was on the floor in his/her room and the left side of the resident's head was against his/her wheelchair. The resident stated he/she attempted to hang up his/her clothes and fell . A nurse's note dated 1/27/14 and timed 3:45 P.M. included the resident laid on his/her back on the floor in his/her room and the left side of the resident's head was against his/her dresser. A nurse's note dated 2/5/14 and timed 9:30 A.M. documented the resident was on the floor in his/her bathroom and staff observed the resident had a skin tear on his/her right hand. Staff received a physician order [REDACTED]. A late entry note for 2/11/14 documented at 5:15 A.M. the resident attempted to rise, the resident's walker got away from him/her , the resident fell on his/her hands and knees causing a skin tear 0.5 inches by 1.5 inches. An X-ray report dated 2/11/14 documented the resident's hand had an oblique non-displaced fracture of the 4th metacarpal. The 2/11/14 care plan listed the intervention for a splint placed on the right 4th finger. On 3/12/14 at 10:40 A.M. observation revealed the resident was in bed, had on socks without a non-skid bottom. Further observation revealed the resident's house slippers were not within his/her reach. On 3/13/14 at 10:50 A.M. observation revealed the resident sat in his/her recliner without shoes and socks that were not non-skid. Observation revealed the resident's right hand wrapped with a bandage. During interview with the resident at that time the resident stated he/she rolled out bed and hurt his/her right hand. On 3/13/14 at 3:00 P.M. the resident sat in his/her recliner in his/her room. Observation revealed the resident without shoes, regular socks that were not non-skid. At 3:20 P.M. the resident's chair alarm sounded. Observation revealed the resident faced the front of his/her recliner, the resident had on socks that were not non-skid and wore no shoes. Further observation revealed 2 licensed staff in proximity when the alarm sounded but did not respond to the resident's chair alarm. Further observation revealed direct care staff P responded to the resident's chair alarm at 3:21 P.M. (1 minute after the alarm sounded). On 3/17/14 at 2:45 P.M. administrative nursing staff G stated the resident was at risk for falls and sustained a fracture of his/her 4th right finger as a result of the fall. Administrative nursing staff G stated the resident had alarms on his/her bed and chair and staff rearranged the resident's room to minimize his/her falls. On 3/17/14 at 3:31 P.M. direct care staff Q stated the resident was at risk for falls and staff checked on the resident frequently. Direct care staff Q stated the facility placed alarms on the resident's chair and bed in the last month. The facility's undated Fall protocol included staff notified the facility's interdisciplinary team per facility protocol after a resident fell and the interdisciplinary team performed a team huddle to discuss the resident's fall and causal factors. The facility failed to implement timely effective interventions for this resident with a history of falls who sustained a fracture of his/her right fourth finger. This deficiency remains at a scope and severity of a G.
The facility had a census of 47 residents. The sampled included 11 residents. Based upon observation, record review and interview the facility failed to provide adequate treatment for 1 (#3) of 1 residents sampled with a diabetic ulcer. Findings included: - Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 11 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with bed mobility, walking in the room/corridor, and locomotion off the unit and required extensive staff assistance with transfers, locomotion on the unit, dressing, toilet use and personal hygiene. The MDS recorded the resident was occasionally incontinent of urine, weighed 166 pounds and had not experienced a weight loss and was at risk for the development of pressure ulcers. The MDS coded the resident did not have a pressure relieving device for his/her bed or chair, was not on a turning/repositioning program, had a skin tear and no pressure, arterial or venous ulcers. The resident's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 5/14/13 documented the resident was independent with most ADLs, required extensive staff assistance with dressing in the A.M. The CAA included the resident was continent of bowel and bladder, independent with toilet use and staff assisted the resident with toileting per his/her request. The CAA included the resident received a regular diet, and ate most meals in the dining room with set up assistance. The resident's Nutritional Status CAA dated 5/14/13 included the resident received ice cream three times a day. A pressure ulcer CAA for 5/14/13, did not trigger. The resident's care plan up-dated 1/31/14 included the resident was at risk for skin breakdown due to a [DIAGNOSES REDACTED]. Staff ensured the resident avoided restricted footwear, staff provided preventive skin care as needed and bathed/showered the resident 3 times a week. Staff monitored the resident's food and fluid intake and encouraged/assisted the resident with repositioning at least every 2 hours. Staff offered the resident ice cream three times a day, the resident often refused but staff continued to offer the ice cream as physician ordered. The resident received a sugar free nutritional supplement once a day with the lunch meal. The care plan did not include the resident had an open lesion on the second toe of his/her left foot. The resident's care plan up-dated 2/17/14 included the interventions in place since 9/21/13 that included staff ensured the resident avoided restrictive footwear, the resident liked to wear just socks and staff encouraged some type of shoe. Staff provided preventive skin care as needed, kept the resident's skin clean and dry, and monitored the resident's skin during bathing/showers three times a week. The resident was continent of bowel and bladder, but staff needed to check and change at night. The resident received a regular diet and sugar free ice cream at meals if the resident wanted it. Staff monitored the resident's food/fluid intake. The resident required limited to extensive staff assistance with repositioning at least every 2 hours for pressure redistribution. An entry dated 2/21/14 included the resident received 1 scoop of protein powder mixed with mashed potatoes when he/she ordered mashed potatoes and the resident received sugar free ice cream with the lunch meal. An entry dated 2/25/14 included the resident had a right (should be left) toe wound and staff applied [MEDICATION NAME] (an antibiotic ointment) topically over the area and secured with a dressing on a daily basis until healed. An entry dated 3/11/14 documented the resident had an appointment at a wound clinic on 3/11/14. An entry dated 3/12/14 included staff elevated the resident's legs to the level of his/her heart or above for 30 minutes 3 times per day and attempted to keep pressure off the area of concern. A physician's orders [REDACTED]. The order included for staff to cleanse the area, pat dry, apply Santyl (agent used to debride wounds), cover and secure with a dressing and to change daily as needed. A Registered Dietician's (RD) note dated 2/19/14 documented the resident complained of lack of appetite, he/she offered the resident house shakes, the resident stated you know they are not real shakes, the resident said ice cream was okay but he/she did not really care. The note included the resident had an area on his/her toe and received a multivitamin for healing. The RD recommended the resident receive ice cream with one meal per day and 1 scoop of protein powder (used to increase the amount of protein) in mashed potatoes when the resident ordered mashed potatoes. The facility had tried a juice supplement but the resident did not like it. The resident's consumption of food was down but the resident stated he/she ate food out of his/her refrigerator at times which contained cheese, bologna, grapes and soda. The resident was a diabetic but he/she did not recommend a diabetic diet due to the resident's poor food intake. The resident's [MEDICATION NAME] suggested adequate visceral protein status. The resident's weight would be maintained at 166 pounds and the resident would not experience a significant weight loss. Review of the facility's menu from 3/1/14 to 3/29/14 revealed the facility served mashed potatoes on 3/1/14 and 3/29/14. Review of the resident's weight log revealed the following weights: Week 1 of 1/14 the resident weighed 167 pounds Week 4 of 2/14 the resident weighed 164 pounds 3/14 the resident weighed 160 pounds The above represented the resident lost 7 pounds in 3 months or 4.19 percent of his/her body weight. An undated physician progress notes [REDACTED]. A physician's progress note dated 3/11/14 included the resident related about 3 weeks ago he/she developed a sore on his/her left second toe and denied history of any specific precipitating cause such as injury or activity. The resident had a deep ulcer on his/her left second toe with bone and joint exposed. The physician referred the resident to a physician for surgical interventions with an eye toward metatarsophalangeal disarticulation (amputation of the toe). The resident had a diabetic ulcer (open ulcer in people with [DIAGNOSES REDACTED]. The lesion on the dorsum aspect of the resident's left second toe appeared eburnated (conversion of bone into a hard, ivory-like mass) in the depths and measured 1.0 centimeter (cm) by 1.5 cm. Physician's recommendations included for staff to elevate the resident's legs to the level of his/her heart or above for 30 minutes 3 times per day and attempt to keep pressure off the area of concern. The facility's wound log dated 12/25/13 included the resident had an open lesion on his/her 2nd left toe that measured 0.6 cm by 0.8 cm. The facility's wound log dated 1/23/14 documented the resident was admitted to the facility with a Stage 2 pressure ulcer on his/her left second toe that measured 1.0 cm by 1.2 cm and staff was unable to determine the depth of the Stage 2 pressure ulcer. The facility's wound log dated 2/28/14 documented the area on the resident's left second toe measured 0.8 cm by 0.5 cm and staff was unable to determine the depth of the pressure ulcer. Documentation included the wound bed had 100 percent (%) slough (non-viable tissue) and staff offloaded the area. The facility's wound log dated 3/5/14 documented the pressure ulcer on the resident's second left toe measured 0.8 cm by 0.5 cm and staff was unable to determine the depth of the wound. The wound bed contained 100% yellow tan slough, was tender to touch, and had a red exudate (drainage). The facility's wound log dated 3/12/14 documented the pressure ulcer on the resident's second toe measured 1.0 cm by 1.2 cm and staff was unable to determine the depth of the wound. The wound bed a dark area which covered 100% of the wound bed and the edges of the wound were indurated (firm or hard). On 3/12/14 at 10:15 A.M. administrative nursing staff G performed the treatment on the resident's left second toe. Administrative nursing staff G stated he/she had administered pain medication prior to the treatment because the resident complained of pain to the area. Administrative nursing staff G stated when he/she removed the sock from the resident's left foot the pain lessened. Observation at that time revealed the resident sat in the recliner in his/her room, the foot of the recliner was elevated, the resident's right foot crossed over the resident's left foot and in direct contact with the open area on the resident's left foot. Administrative nursing staff measured the area and reported the open area on the resident's left second toe measured 1 cm by 1.2 cm. On 3/12/14 at 10:40 A.M. the resident laid in bed on his/her back and observation revealed the resident had socks on both of his/her feet. Further observation revealed no devices between the resident's legs to prevent skin to skin pressure and the resident's feet not off loaded. On 3/12/14 at approximately 12:30 P.M. the resident stated he/she was not hungry, ate a snack of Cheetos and a pop earlier and was not going to eat lunch. Observation revealed the resident did not have a lunch meal in his/her room and no ice cream was present in the resident's room. During interview with direct care staff V at that time, he/she stated the resident often times refused meals. Direct staff V stated the resident had a refrigerator in his/her room and the resident ate food from the refrigerator, therefore the resident often times refused meals. On 3/13/14 at 7:15 A.M. the resident laid in bed. Observation revealed the resident had on socks, the resident's feet not off loaded, had no heel protectors on, and no devices between the resident's legs to prevent skin to skin pressure. On 3/13/14 at 8:00 A.M. direct care staff W assisted the resident from the bed to his/her recliner. Observation revealed the resident had on socks, required extensive staff assistance with dressing. Further observation revealed direct care staff elevated the foot of the recliner, did not elevate or off load the resident's feet, the resident's socks in direct contact with the foot of the recliner and no devices between the resident's legs to prevent skin to skin pressure. Observation revealed the resident crossed his/her legs and the resident's right foot was in direct contact with his/her left foot, placing pressure on the ulcer. On 3/13/14 at 9:20 A.M. observation revealed the resident laid in bed. Observation revealed the resident had on socks, the resident's feet were not off loaded, had no heel protectors on, and no devices between the resident's legs to prevent skin to skin pressure. At that time the resident stated he/she was not feeling well and did not eat breakfast. The resident complained of discomfort in his/her left second toe. The resident stated when staff removed his/her socks, the left toe felt better. On 3/13/14 at 10:50 A.M. the resident sat in his/her wheelchair with socks on and no foot rest on the wheelchair. Observation revealed the resident's feet in direct contact with the floor as a family member propelled the resident in the wheelchair. On 3/13/14 at 12:15 A.M. the resident sat in his/her recliner and ate the lunch meal which consisted of a ham sandwich. Observation revealed no ice cream on the resident's lunch tray. On 3/13/14 at 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M., and 3:09 P.M. observation revealed the resident sat in his/her recliner, had on socks, the foot of the recliner was elevated, the resident's feet were not off loaded, did not have heel protectors on, the resident's legs crossed, the resident's left foot in direct contact with his/her right foot, and no devices between the resident's legs to prevent skin to skin pressure. On 3/13/14 at 3:30 P.M. the resident laid in bed with socks on, the resident's feet were not off loaded, no heel protectors on, and no devices between the resident's legs to prevent skin to skin pressure. On 3/13/14 at 5:10 P.M. the resident laid in bed with socks on, the resident's feet were not off loaded, no heel protectors on, and no devices between the resident's legs to prevent skin to skin pressure. During interview with the resident at that time, he/she stated he/she was not hungry and was not going to eat supper. The resident complained of pain in his/her left second toe and stated the toe felt better when staff removed the sock from his/her foot. On 3/17/14 at 10:15 A.M. administrative nursing staff G stated the facility had treated the area on the resident's left second toe since 12/25/13. Administrative nursing staff G stated from 12/25/13 to approximately 2/25/14 the facility identified the area as an open lesion. Administrative nursing staff G stated on/around 2/25/14 the resident's primary care physician or his/her designee identified the area as a pressure ulcer. Administrative nursing staff G stated from 2/25/14 until 3/11/14 the facility identified the area as a pressure ulcer. Administrative nursing staff G stated on 3/11/14 the resident saw a physician at the wound clinic and the physician identified the area as a diabetic ulcer. Administrative nursing staff G stated the resident was to see a surgeon to have the toe amputated. On 3/17/14 at 10:30 A.M. administrative nursing staff F stated the resident had a callous on and off on his/her left second toe and the callous opened. Administrative nursing staff F confirmed the resident's care plan did not address the area on the resident's left second toe until 2/25/14. Administrative nursing staff F confirmed the resident's care plan did not include how staff was to minimize the pressure off the resident's left second toe nor did the resident's care plan address how staff was to prevent the development of other diabetic ulcers. On 3/7/14 at 2:45 P.M. licensed nurse J stated the resident had an open area on his/her left second toe and the resident was scheduled to see a surgeon regarding amputation of the toe. Licensed nurse J stated the resident wore socks and at times house slippers. Licensed nurse J stated staff did not elevate or off load the resident's extremities. Nursing administrative staff G present during the interview stated the facility had not attempted alternative footwear for the resident. On 3/17/14 at 3:23 P.M. licensed nurse K stated the resident had an open area on his/her left second toe and staff did not off load or elevate the resident's extremities. Licensed nurse K stated the resident wore socks and to his/her knowledge the facility had not attempted alternative foot wear for the resident. On 3/17/14 at 3:31 P.M. direct care staff Q stated staff did not elevate or offload the resident's extremities. On 3/17/14 at 4:00 P.M. dietary staff Y stated the facility served mashed potatoes 2 to 3 times a week. Dietary staff Y stated on the days the facility served mashed potatoes staff placed Promod (a protein supplement) in the resident's mashed potatoes and the resident consumed the potatoes. Dietary staff Y stated staff was to include ice cream on the resident's lunch tray but the resident did not like ice cream; therefore he/she did not eat the ice cream. According to International Best Practice Guidelines: Wound Management in [MEDICAL CONDITION]. Wound International, 2013 treatment and prevention of diabetic ulcers included pressure offloading. Staff should examine footwear and the aim should be to provide a pressure device or to adapt existing footwear to accommodate pressure. The facility's undated Wound and Skin Care Policy and Protocol included the facility promoted a systematic approach and monitoring process for the care of residents with existing wounds and for those at risk for skin breakdown. The facility failed to provide interventions to prevent the deterioration of the diabetic ulcer. The facility failed to develop a care plan that included interventions for pressure offloading, failed to attempt alternative footwear, and failed to implement alternative nutritional supplements for this resident with a diabetic ulcer.
The facility had a census of 47 residents. The sample included 11 residents. Based upon observation, record review and interview the facility failed to prevent the development of an avoidable pressure ulcer and failed to provide treatment that promoted healing for 1 (#4) of 3 residents sampled for pressure ulcers. Findings included: - Review of resident #4's Physician order [REDACTED]. The POS included staff cleansed the area on the resident's left hip, applied Duoderm and changed the dressing every 3 days and as needed. The POS included the resident received Therapy M (vitamin supplement) with Beta [MEDICATION NAME] (a multivitamin) 9 mg (milligrams) - 400 mg tablet daily and Vitamin C (vitamin supplement) 500 mg twice daily for wound healing since 1/8/14. The resident's quarterly Minimum Data Set (MDS) 3.0 dated 2/10/14 identified the resident had short and long term memory problems and moderately impaired cognition. The MDS identified the resident required extensive staff assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and did not walk in the room/corridor. The MDS coded the resident required limited staff assistance with locomotion on/off the unit and eating, was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS identified the resident weighed 167 pounds, not experienced a weight loss and was at risk for the development of pressure ulcers. The MDS recorded the resident had one Stage 2 pressure ulcer not present upon admission/readmission and the date of the oldest Stage 2 was 12/26/13. The resident had a pressure relieving device on his/her bed, no pressure relieving device on his/her chair, was not on a turning/repositioning program and received pressure ulcer care. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/14/13 included the resident had short and long term memory deficits. The resident's Activity of Daily Living (ADL) -Functional Status/Rehabilitation Potential CAA dated 11/14/13 documented the resident required extensive staff assistance with all ADLs, mobility, transfers, toileting, personal hygiene and bathing and he/she utilized a wheelchair for mobility. The resident was incontinent of bowel and bladder and was on a scheduled toileting program. The resident's Urinary Incontinence and Indwelling Catheter CAA dated 11/14/13 documented the resident was incontinent of urine, required extensive staff assistance with transfers, clothing adjustment, personal care, wore an incontinent brief for dignity and was on a scheduled toileting program at targeted times. The resident's Nutritional Status CAA dated 11/14/13 documented the resident received a regular diet and received ice cream three times a day with meals. The resident's Pressure Ulcer CAA dated 11/14/13 documented the resident was at risk for pressure ulcer due to episodes of incontinence and required extensive staff assistance with repositioning and bed mobility. The resident's care plan dated 2/11/14, documented the resident had a potential for alteration in skin integrity with the interventions in place since 11/14/13 included, staff monitored the resident for skin changes during ADL care, staff kept the resident's skin clean and dry and consistently bathed the resident 3 times per week. Staff repositioned the resident at least every 2 hours. Staff discussed /reinforced the importance of proper pressure redistribution and hygiene with the (cognitively impaired) resident and monitored the resident for skin changes and notified the resident's physician of complications or no response to treatments. The resident had a low loss mattress on his/her bed. On 12/21/13 an entry included the resident liked to spend a lot of time in his/her wheelchair and was not always compliant with repositioning or lying down and staff continued to attempt to educate the (cognitively impaired) resident. An entry dated 12/24/13 included the resident had an area on his/her left buttock, staff provided treatment as physician ordered and consulted therapy regarding a new wheelchair cushion. An entry dated 12/24/13 documented therapy provided the resident with a Roho (pressure reliving device) cushion. An entry dated 1/9/14 included staff received a physician's orders [REDACTED]. An entry dated 2/4/14 documented the resident had an area on his/her right hip, staff cleansed the area, applied Duoderm and changed the Duoderm every 72 hours and as needed. Staff provided extra pillows, encouraged the resident to lie down throughout the day, and repositioned the resident at least every 2 hours. The resident was non-complaint and staff continued to educate the (cognitively impaired) resident. An entry dated 2/12/14 documented the area on the resident's right hip healed on 2/12/14. The resident's care plan did not include interventions regarding how staff were to protect the resident's bony prominences to prevent the development of new pressure ulcers. The resident's care plan/clinical record lacked evidence the facility performed a tissue tolerance test to ensure the resident had an individualized turning/repositioned program. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Registered Dietician's (RD) note dated 1/7/14 documented the resident's weight was stable at 173 pounds and the resident had an open area on his/her left buttock. The resident received a regular diet with ice cream and received a multivitamin with mineral daily and Vitamin C 500 mg twice daily per wound protocol. A RD note dated 2/19/14 included the resident had skin issues, received ice cream at all meals, consumed 50 to 75 percent (%) of meals, received a multivitamin with minerals and Vitamin C for wound healing. The resident's laboratory values as of 12/12/13 were within normal limits and the resident's weight was stable at 176 pounds. The resident's Wound Evaluation Flow Sheet documented the following measurements on the resident's Stage 2 pressure ulcer on his/her left coccyx/buttock/gluteal fold as follows: 12/26/13: 1.8 centimeters (cm) by 1.0 cm by 0.1 cm 01/05/14: 2.5 cm by 1.5 cm by 0.1 cm 01/22/14: 1.8 cm by 2.0 cm by 0.2 cm 01/30/14: 2.6 cm by 3.2 cm by 0.2 cm 02/05/14: 2.0 cm by 2.5 cm by 0.1 cm 02/12/14: 2.0 cm by 2.5 cm by 0.1 cm 02/19/14: 2.0 cm by 2.0 cm by 0.1 cm 02/28/14: 2.0 cm by 2.0 cm by 0.1 cm 03/05/14: 2.0 cm by 2.0 cm by 0.1 cm 03/12/14: 1.2 cm by 1.4 cm by 0.2 cm The wound evaluation included from 12/26/13 to 1/22/14 the treatment included [MEDICATION NAME] (dressing used for wound care) to the resident's left coccyx/gluteal fold, staff changed the dressing on a daily basis, and on 1/22/14 the treatment was changed to apply Duoderm and change every 3 days and as needed. On 3/12/14 at 11:00 A.M. observation revealed the resident sat in his/her wheelchair in front of the nursing station. At 11:15 A.M. the resident self- propelled his/her wheelchair toward the dining room. At 11:30 A.M. the resident sat in his/her wheelchair at a dining room table. At 11:45 A.M. , 12:00 P.M., 12:15 P.M., 12:25 P.M., 12:35 P.M., 12:40 P.M., 12:54 P.M. the resident sat in the dining room in his/her wheelchair. At 1:00 P.M. the resident wheeled himself from the dining room and headed toward the nursing station. At 1:14 P.M. the resident sat in his/her wheelchair, staff was in his/her room and stated they were going to transfer the resident to his/her bed. The resident sat in his/her wheelchair without a change of position for duration of 2 hours and 14 minutes. At 2:00 P.M. administrative nursing staff G performed the treatment on the resident's left gluteal fold. Observation revealed the resident laid in bed on his/her right side, was incontinent of bowel and the Duoderm dressing was not in place on the resident's Stage 2 pressure ulcer on his/her left gluteal fold. Further observation revealed the resident wore socks, the resident's feet were not off loaded and the resident did not have on heel protectors. Observation revealed there were no devices between the resident's knees/legs to prevent skin on skin contact. As staff repositioned the resident observation revealed the inner aspect of the resident's left knee had a red area. Administrative nursing staff G confirmed the Duoderm was not in place. Administrative nursing staff G measured the pressure area on the resident's left gluteal fold, stated the pressure area was a Stage 2 and measured 1.2 cm by 1.4 cm. Direct care staff R assisted administrative nursing staff G. Observation revealed the resident's heels/feet were without pressure ulcers. After completing the treatment staff repositioned the resident on his/her left side, did not off load the resident's heels/feet nor did staff place devices between the resident's legs/knees to prevent skin to skin contact. Administrative nursing staff stated the resident had previously had a Stage 2 pressure ulcer on his/her right hip that recently healed. Observation revealed the resident had a low air loss mattress on his/her bed and a pressure relieving device in his/her wheelchair. On 3/13/14 at 10:00 A.M. and 10:29 A.M. the resident laid in bed on his/her back. Observations revealed the resident's heels/feet were not off loaded and were in direct contact with the sheet. Further observations revealed there were no devices between the resident's legs/knees to prevent skin to skin pressure. On 3/13/14 at 10:50 A.M. observation revealed staff propelled the resident from his/her room. At 11:00 A.M., 11:15 A.M., 11:30 A.M. and 11:45 A.M. the resident sat in his/her wheelchair at a dining room table. At 12:00 P.M. observation revealed the resident sat at the same table but had moved to the location of the table where he/she sat during meals. The resident sat at the dining room table in his/her wheelchair at 12:05 P.M., 12:12 P.M., 12:15 P.M., 12:30 P.M., 12:40 P.M., and 1:00 P.M. At 1:03 P.M. the resident wheeled his/her wheelchair from the dining room toward the nurse's station. At 1:15 P.M. the resident sat in his/her wheelchair in his/her room. The resident sat in his/her wheelchair without a change in position for duration of 2 hours and 25 minutes. On 3/13/14 at 1:30 P.M. the resident laid in bed on his/her back. Observation revealed the resident's heels/feet were not off loaded and the resident's feet were in direct contact with the sheet. Observation also revealed there were no devices between the resident's legs/knees to prevent skin to skin pressure. On 3/13/14 at 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M. and at 3:09 P.M. observation revealed the resident laid in bed on his/her left side. Further observation revealed the resident's heels/feet were not offloaded and there were no devices between the resident's legs/knees to prevent skin to skin pressure. On 3/17/14 at 3:07 P.M. licensed nurse J stated the resident had a Stage 2 pressure ulcer on his/her left gluteal fold, utilized a pressure relieving mattress on his/her bed and wheelchair. Licensed nurse J stated staff encouraged this cognitively impaired resident to lay down throughout the day and explained the importance as to why he/she should lie down. Licensed nurse J stated staff encouraged this cognitively impaired resident to allow staff to off load his/her heels/feet and if staff observed red areas on the resident's skin staff attempted to reposition the resident. Licensed nurse J stated the resident's care plan should include interventions staff attempted to prevent the development of new pressure ulcers. On 3/17/14 at 3:23 P.M. licensed nurse K stated staff repositioned the resident at least every 2 hours and did not off load the resident's heels/feet when the resident was in bed. Licensed nurse K stated staff did not place assistive devices between the resident's legs/knees to prevent skin to skin contact. On 3/17/14 direct care staff Q stated the resident had a pressure ulcer, staff repositioned the resident every 2 hours, did not float the resident's heels/feet when he/she was in bed and did not place assistive devices between the resident's legs/knees to prevent skin to skin pressure. According to the European Pressure Ulcer National Panel and National Pressure Advisor Panel Pressure Ulcer Treatment Quick Reference Guide dated 2009 included individuals should show signs of healing in most individuals within 2 weeks. Reassess the individual if the ulcer did not show some signs of healing as expected despite adequate local wound care, pressure redistribution and nutrition. Do not position the individual directly on a pressure ulcer. Establish turning frequency on the characteristics of the support surface and the individual's response. Use pillows or other positioning devices to prevent skin-on-skin pressure. The facility's undated Wound and Skin Care Policy and Protocol included staff prevented pressure ulcer formation by identifying residents at risk for pressure ulcer development and developed appropriate interventions. The facility failed to develop a care plan that included interventions to prevent the development of new pressure ulcers, failed to perform a tissue tolerance test to ensure the resident's repositioning program of every 2 hours was sufficient, failed to change the pressure ulcer treatment after 2 weeks of not showing signs of improvement and failed to reposition the resident every 2 hours as care planned for this resident with a Stage 2 pressure ulcer and a history of pressure ulcers.
The facility had a census of 48 residents. Based upon observation, record review and interviews the facility failed to prevent the development of avoidable pressure ulcers, and/or provide services to promote healing of pressure ulcers for 3 (#12, #16, #15) of 3 sampled residents. Findings included: - Resident #12's Physician order [REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, was independent with bed mobility, transfers, walking in the room/corridor and locomotion on/off the unit, dressing, eating, toilet use and personal hygiene. The MDS recorded the resident was always continent of urine and bowel, weighed 147 pounds and had experienced a weight loss. The MDS identified the resident was not at risk for the development of pressure ulcers, did not have a pressure relieving device on his/her bed or chair and was not on a turning/repositioning program. The resident's significant change MDS dated [DATE] identified the resident scored 99 (resident was unable to complete the Brief Interview for Mental Status Interview) and staff assessed the resident had moderately impaired cognition and without behaviors. The MDS identified the resident required extensive staff assistance with bed mobility, transfers, locomotion on/off unit, dressing, eating, toilet use, did not walk in room/corridor, limited staff assistance with personal hygiene and utilized a wheelchair. The MDS identified the resident was occasionally incontinent of urine and bowel, weighed 136 pounds and had experienced a weight loss of 5 percent (%) or more in the last month or 10% in the last 6 months and was not on physician prescribed weight loss regimen. The MDS identified the resident was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, had a pressure relieving device on his/her bed, no pressure relieving device on his/her chair and was not on a turning/repositioning program. The resident's Activity for Daily Living (ADL) Functional Status/Rehabilitation Potential Care Area Assessment (CAA) dated 3/24/14 documented the resident required total staff assistance with all ADL's, no longer walked, and needed extensive staff assistance with wheelchair mobility. The resident had episodes of incontinence, wore a brief and required staff assistance with toileting. The resident received a mechanical soft diet, attempted to feed himself/herself and needed extensive staff assistance with meals. The resident's Braden Scale (scale used to predict the development of pressure ulcers) dated 1/22/14 identified the resident scored 22 (not at risk for the development of pressure ulcers) and on 3/24/14 and 3/27/14 the resident's score was 12 (high risk for the development of pressure ulcers). The resident's care plan dated 4/15/14 included the resident required extensive staff assistance with activities of daily living. The resident had a potential for alteration in skin integrity, staff kept the resident's skin clean and dry, monitored the resident for skin changes, and provided a low air loss mattress (pressure relieving) to the resident's bed. The resident utilized a wheelchair for mobility and staff repositioned the resident at least every 60 to 90 minutes. Staff provided perineal care after each incontinent episode. Staff monitored the percentage of food and fluids the resident consumed at each meal. The resident received a Magic Cup at lunch and dinner. An entry dated 4/9/14 included the resident had open areas on his/her buttock and staff applied Duoderm (a dressing used to cover wounds and skin conditions) and change the dressing daily and as needed. The 4/15/14 care plan did not include interventions regarding the development of pressure ulcers on bony prominences. A laboratory report dated 3/13/14 documented the resident's [MEDICATION NAME] level at 3.1 grams/deciliter (g/dL), normal reference range 3.4-4.8 g/dL. A laboratory report dated 3/28/14 recorded the resident's [MEDICATION NAME] level at 2.9 g/dL, normal reference range 3.0-5.5 g/dL. A physician's orders [REDACTED]. A pressure ulcer communication form to the resident's physician dated 4/8/14 included the resident had a Stage 2 pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction, the topmost layer of skin is broken, creating a shallow open sore and the second layer of skin may also be broken), on his/her right buttock that measured 0.8 centimeters (cm) by 0.5 cm with no depth. A Stage 2 pressure ulcer on his/her left buttock that measured 2.5 cm by 0.5 cm with no depth. The communication form included the resident weighed 131 pounds. A physician's orders [REDACTED]. The resident's weight log revealed the following weights: 1/2014: 147 pounds 2/2014: 143 pounds 3/2014: 141 pounds 3/26/14: 131 pounds (16 pounds or 22% of his/her body weight in 2 months; and 10 pounds or 7.09% in 1 month) A Registered Dietician's (RD) note dated 3/7/14 included the resident's March weight was stable at 141 pounds and the resident stated he/she noticed his/her weight and intake dropped a little. A RD note dated 3/27/14 documented the resident weighed 131 pounds on 3/26/14 and the resident had lost approximately 10 pounds since the first of the month. The resident typically did not eat breakfast. The resident's [MEDICATION NAME] level drawn at the hospital suggested moderate to mild visceral protein depletion. The Ensure plus and Magic Cups provided more calories and protein and if the resident consumed 1 Ensure Plus and Magic Cup each day the resident would meet 40 percent (%) of his/her daily caloric needs. The resident's March 2014 Medication Administration Record [REDACTED].M. and at 12:00 P.M. on 3/31/14. The resident's March 2014 MAR indicated [REDACTED].M. and 5:00 P.M. The resident's April 2014 MAR indicated [REDACTED].M. on 4/5, 4/6 and 4/12/2014 and at 5:00 P.M. on 4/4, 4/5, 4/6, 4/13, and 4/14/2014. The resident's April 2014 MAR indicated [REDACTED].M. Further review of the resident's April MAR indicated [REDACTED]. Review of the resident's 3/1/2014 to 4/17/2014 meal intake exception log revealed the facility did not consistently document the percentage of meals the resident consumed. The facility's Skin/Wound Log dated 4/9/14 included the resident had a facility acquired Stage 2 pressure ulcer on his/her left buttock that measured 1.0 cm by 1.2 cm with a depth of 0.1 cm. A facility acquired Stage 2 pressure ulcer on his/her right buttock that measured 1.0 cm by 0.8 cm with a depth of 0.1 cm. The facility's Skin/Wound Log dated 4/16/14 documented the Stage 2 pressure ulcers on the resident's left and right buttock resolved. The facility's Skin/Wound Log with week ending 4/18/14 included the word resolved whiten out and written in "next pg." Review of the next page included the resident had a Stage 2 pressure ulcer on his/her left buttock that measured 0.9 cm by 0.4 cm with a depth of less than 0.1 cm. The Stage 2 pressure ulcer on the resident's right buttock measured 0.5 cm by 0.5 cm with a depth of less than 0.1 cm. The above represented the areas on the resident's right and left buttock healed sometime between 4/9/14 and 4/16/14 and reopened between 4/16/14 and 4/17/14 at 10:25 A.M. On 4/16/14 the resident sat in his/her wheelchair at 8:44 A.M., 9:00 A.M. 9:15 A.M., and 9:30 A.M. At 9:44 A.M. the resident sat on the toilet in his/her room. At 9:50 A.M., 10:00 A.M., 10:10 A.M., 10:15 A.M., and 10:30 A.M. the resident sat in the wheelchair in his/her room. At 10:43 A.M., 10:50 A.M., 11:00 A.M., 11:11 A.M., and 11:20 A.M., the resident sat in his/her wheelchair in the television area of the facility. At 11:32 A.M. the resident sat in the wheelchair of his/her room and received a breathing treatment. At 11:42 A.M. direct care staff R propelled the resident from his/her room to a dining room table, without repositioning or toileting the resident. The resident sat in his/her wheelchair at the dining room table at 11:49 A.M., 11:55 A.M., 12:06 P.M., 12:15 P.M. and 12:30 P.M. (duration of 2 hours and 40 minutes, instead of the planned 60 to 90 minute repositioning). Observations revealed the resident had a pressure relieving device in his/her wheelchair. On 4/16/14 at 12:15 P.M. the resident ate the lunch meal which consisted of a polish sausage, macaroni salad, mixed vegetables, a container of yogurt, a Magic Cup, a bowl of fruit, pudding and a empty glass with with a brown substance. During interview with the resident at that time the resident stated the glass had contained Ensure. The resident pointed to the unopened container of Magic Cup and stated he/she did not know why staff brought him/her that because he/she did not like it. Observation revealed the resident consumed all the yogurt, and 25% of the other foods. On 4/16/14 the resident sat in the wheelchair of his/her room at 1:00 P.M., and 1:15 P.M. At 1:32 P.M. the resident sat on the toilet in his/her room. At 2:00 P.M., 2:15 P.M., and 2:30 P.M. the resident sat in his/her wheelchair in the day room (by the nurse's station). At 2:54 A.M., 3:15 P.M., and 3:24 P.M. the resident sat in a regular chair in the day room. At 3:50 P.M., 4:00 P.M., 4:15 P.M. and 4:20 P.M. the resident sat in his/her wheelchair in the day room. At 4:20 P.M. the resident propelled himself/herself to the dining room. At 4:30 P.M., 4:45 P.M., 5:00 P.M. and 5:15 P.M. the resident sat in his/her wheelchair at a dining room table. On 4/16/14 at 5:05 P.M. the resident ate his/her dinner meal that consisted of baked chicken, tater tots, yogurt, pudding and chocolate ensure. Observation did not reveal the resident received a Magic Cup. At 5:15 P.M. the resident consumed all the yogurt and Ensure and none of the tater tots or chicken. On 4/17/14 at 7:33 A.M. the resident laid in bed and direct care staff S entered the resident's room to assist the resident with the A.M. care. Observation revealed the resident had on an incontinent brief and the brief and resident's gown was saturated with urine. Further observation revealed the resident did not have on heel protectors, the resident's heels were not floated and staff had not placed devices between the resident's legs to prevent skin on skin contact. On 4/17/14 at 8:00 A.M., 8:15 A.M., 8:30 A.M., 8:45 A.M. and 8:52 A.M. the resident sat in his/her wheelchair in the dining room. On 4/17/14 at 9:20 A.M. 9:30 A.M., 9:45 A.M. and 10:00 A.M. the resident sat in the wheelchair in his/her room. On 4/17/14 at 10:17 A.M. administrative licensed practical nurse F and licensed practical nurse H entered the resident's room to perform the pressure ulcer treatment on the resident's buttock. As staff waited for direct care S to assist with the transfer the resident stated he/she sat all the time and his/her buttock "really hurts." At 10:25 A.M. direct care staff S transferred the resident from the wheelchair to the bed. At that time licensed registered nurse I entered the resident's room. Observation revealed the inner aspect of the resident's right buttock had a Stage 2 pressure ulcer that measured approximately 1.0 cm by 1.0 cm and a Stage 2 pressure ulcer on the inner aspect of his/her left buttock that measured approximately 0.5 cm by 0.5 cm. Further observation revealed no dressing on the resident's pressure ulcers. On 4/17/14 at 9:20 A.M. the resident stated he/she had an open area on his/her buttock. The resident stated he/she sat for long periods of times which caused the open area on his/her buttock. The resident stated staff did not reposition him/her and he/she wished they did. The resident was unable to state how long the cushion had been in his/her wheelchair but stated he/she was glad it was there. On 4/17/14 at 11:10 A.M. licensed registered nurse I stated the areas on the resident's left and right buttock were Stage 2 pressure ulcers. On 4/17/14 at 11:20 AM licensed practical nurse F confirmed the pressure ulcers on the resident's right and left buttock. On 4/17/14 at 1:18 P.M. direct care staff S stated staff repositioned the resident every 2 hours. On 4/17/14 at 4:00 P.M. licensed nurse J stated staff repositioned the resident every hour. On 4/17/14 at 4:42 P.M. direct care staff T stated staff repositioned the resident every hour. The 2009 International Guidelines for Pressure Ulcer Treatment stated to limit the time an individual spent in a chair without pressure relief. The facility's Wound and Skin Care Policy and Protocols updated 4/9/14 included staff repositioned residents unable to reposition himself/herself. The facility failed to provide the Magic Cup and Ensure Plus as planned and physician ordered, failed to ensure the resident's repositioning program was sufficient to prevent additional pressure ulcers and failed to develop a care plan that included interventions to prevent the development of new pressure ulcers on the resident's other bony prominences, and to promote healing for this resident who developed 2 facility acquired pressure ulcers. - Review of resident #15 (a closed record) nurse's notes revealed the resident admitted to the facility on [DATE]. The resident's discharge not return anticipated Minimum Data Set (MDS) 3.0 dated 4/8/14 identified the resident had modified independence in cognitive skills for daily decision making skills, no behaviors, required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toilet use, and personal hygiene, did not walk in the room/corridor, and was totally dependent upon staff for eating. The MDS identified the resident was frequently incontinent of urine and bowel. The MDS identified the resident had (4) Stage 2 pressure ulcers, and (2) unstageable pressure ulcers with suspected deep tissue injury in evolution not present at time of admission/entry or reentry. The resident's Braden Scale (scale used to predict the development of pressure ulcers) dated 3/30/14 identified the resident scored 7 (a total score of less than 9 represented the resident was at severe risk for the development of pressure ulcers). The resident's initial care plan dated 3/30/14 included the resident required total care with all activities of daily living, was at risk for skin breakdown and staff repositioned the resident every 1 to 2 hours. The resident had a pressure relieving device on his/her bed and wheelchair and staff offloaded the resident's heels with pillows. The initial care plan did not include the Sage boots (device used to minimize pressure on the heels) or interventions regarding how to position the resident to minimize pressure on the pressure ulcers. A Discharge Referral from a local hospital with a discharge date of [DATE] included [MEDICATION NAME] (foam dressing used to treat wounds) to the SDTI (suspected deep tissue injury-Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or sheer) pressure ulcer on the resident's right back, change weekly and as needed, left heel pressure ulcer, open to air (OTA), right heel SDTI pressure ulcer, OTA and Sage boots. A hospital's Wound Management Pressure Ulcer note dated 3/28/14 and timed 10:37 AM included the resident's perineal [MEDICAL CONDITION] (irritation of skin due to exposure of moisture) resolved and the resident now had a Stage 2 pressure ulcer to his/her right buttock and recommended use of Zinc cream (barrier) with [MEDICATION NAME] (anti-fungal medication). The Resident-Data Collection Assessment with an admission date of [DATE] at 2:40 P.M. included the resident had a left back fecal management system (device use to collect liquid or semi-liquid stool), a Stage 2 pressure ulcer on his/her left buttock (no measurements) and the resident's heels were soft bilaterally (no description of the resident's heels). A nurse's note dated 3/29/14 and timed 5:00 P.M. included the resident's rectal tube came out, staff noted a large amount of stool and staff telephoned the resident's physician regarding the rectal tube coming out. A nurse's note dated 3/31/14 and timed 4:50 P.M. included the resident's physician gave orders to leave the fecal tube out. An occupational therapist note dated 4/2/14 documented nursing was notified of the pressure ulcers on the resident's buttock region and bilateral heels. A physical therapy assistance note co-signed by a physical therapist on 4/2/14 included the therapist and assistant physical therapist noted sacral wounds with possible tunneling. The therapist informed the wound nurse who examined the area and applied ointment and dressing. The therapist also noted the resident had pressure wounds on his/her heels bilaterally, more severe on the right, applied heel protectors and positioned the resident in partial side-lying position with a pillow positioned between the resident's lower extremities and two pillows behind the resident's back. The therapist educated nursing staff of the importance of avoiding to lay the resident directly on his/her back secondary to breakdown. The facility's Skin/Wound Log dated 4/2/14 included the resident admitted with wounds on 3/28/14. On 4/2/14 (day staff measured the resident's pressure ulcers) the resident had (3) Stage 2 pressure ulcers on his/her left buttock. The facility admitted the resident with only 1 pressure ulcer of the left buttock. One Stage 2 pressure ulcer measured 3.0 centimeters (cm) by 1.6 cm by 0.3 cm, another one measured 2.5 cm by 1.0 cm by 0.2 cm and another one measured 3.4 cm by 1.5 cm with no depth. The facility acquired Stage 2 on the resident's right buttock measured 3.4 cm by 1.5 cm with no depth and the resident had a SDTI pressure ulcer on his/her right and left heel, not noted by the facility on admission, and staff was unable to determine the depth. The wound log did not include an assessment of the resident's back. The April Treatment Administration Record from 4/1 to 4/7/14 included [MEDICATION NAME] to right back, SDTI, change one time weekly and as needed. Staff initialed on 4/1 to 4/6 and on 4/7/14; however there was no documentation regarding whether staff changed the [MEDICATION NAME] or checked to ensure it was in place. The resident's clinical record did not contain documentation regarding the description of the resident's right back. The resident's clinical record did not support the facility measured and/or performed a thorough skin assessment on the resident from 3/28/14 to 4/2/14 (duration of 5 days). A Nutrition Assessment signed by a Registered Dietician on 4/2/14 documented the resident had diarrhea, multiple skin issues and received multivitamins for healing. The resident's Physician order [REDACTED]. back, staff should change one time weekly and as needed, and the resident wore Sage boots. An Interdisciplinary (ID) note dated 4/8/14 documented the resident was admitted to a local hospital. On 4/17/14 at approximately 3:45 P.M. administrative nursing staff D stated he/she did not know if the resident had wounds upon admission or upon discharge. The surveyor and administrative nursing staff D reviewed the resident's clinical record and administrative nursing staff acknowledged the facility did not measure the resident's wounds until 4/2/14 and failed to perform a thorough assessment of the resident's skin. Administrative nursing staff D acknowledged the Discharge MDS identified the resident had (4) Stage 2 at time of discharge and (2) SDTI pressure ulcers. Administrative nursing staff D acknowledged the resident's initial care plan did not include the Sage boots or how staff was to position the resident off the pressure ulcers. The facility's Wound and Skin Care Policy and Protocols updated 4/9/14 included staff repositioned residents unable to reposition himself/herself. The facility failed to thoroughly assess the resident's skin for a duration of 4 days after the resident was admitted to the facility. The facility failed to develop an initial care plan that included the interventions for heel protectors and how staff was to position the resident off the pressure ulcers for this resident admitted with one pressure ulcer and developed five pressure ulcers after admission. - Review of the physician's orders [REDACTED].#16 revealed a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 revealed he/she had long and short term memory impairment, moderate impairment for cognitive skills for daily decision making, and exhibited inattentive and wandering behaviors. The resident had moderate hearing difficulty, unclear speech, usually could be understood by others and usually understood others. The resident required extensive assist of 2 people for transfers and toileting, extensive assist of one staff for bed mobility, dressing, and personal hygiene, and supervision of one person for eating. The resident was not steady for moving from seated to stand position, moving on and off the toilet and surface to surface transfer. The resident was incontinent of bladder and bowel and was on a toileting program. The resident had a stage II pressure ulcer since 12/26/13 with granulation tissue (the new tissue formed in repair of wounds). The resident had a pressure relieving device for the bed, and received pressure ulcer care with ointments and a dressing. The resident received an antipsychotic 7 of 7 days of the look back period. Review of the cognitive Care Area Assessment (CAA) dated 11/14/13 revealed the resident had a [DIAGNOSES REDACTED]. Review of the Activities of Daily Living (ADL) CAA dated 11/14/13 revealed the resident required extensive assistance with all ADLs, mobility, transfers, toileting, hygiene, and bathing, wandered throughout the facility with a wanderguard on his/her wheelchair, and wore briefs for dignity for incontinence of bladder and bowel. The resident received a regular diet with set up assistance in the main dining room. Review of the urinary incontinence CAA dated 11/14/13 revealed the resident was incontinent and required extensive assist with transfers, clothing adjustment, and perineal care. The resident wore a brief for dignity and protection, and was on a scheduled toileting program with targeted times. Review of the nutritional CAA dated 11/14/13 revealed the resident was on a regular diet, ate in the main dining room with set up assistance and received ice cream three times a day with meals. Review of the pressure ulcer CAA dated 11/14/13 revealed the resident was at risk for pressure ulcers due to incontinence episodes and required extensive assist with repositioning and bed mobility. The resident required extensive assist with toileting needs, transfers, clothing adjustment and perineal care. Review of the ADL care plan dated 2/11/14 revealed the staff were to monitor for skin changes during ADL care, keep skin clean and dry, and apply moisture barrier to the skin after each incontinent episode. Review of the urinary incontinence care plan dated 2/11/14 revealed the resident had adult briefs and pads to protect skin and clothing and for dignity. The staff were to provide perineal care and apply moisture barrier to the skin after each incontinent episode. The staff were to provide extensive assist with transfers, clothing adjustments and personal hygiene. The resident was on a scheduled toilet prompting at 7 to 8 A.M., 10 to 11 A.M., 1 to 2 P.M., 4 to 5 P.M., 7 to 8 P.M. and every 2 hours at night and as necessary, Review of the nutritional care plan dated 2/11/14 revealed the staff were to provide set up assistance with meals, and the resident ate in the large dining room, Review of the dental care plan dated 2/11/14 revealed the staff were to assist with oral care twice a day and as necessary, and a regular diet. Review of altered skin integrity care plan dated 2/11/14 with revised date of 3/26/14 revealed the staff were to do a Braden scale (assessment tool for predicting pressure sore risk) quarterly, apply moisture barrier after each incontinent episode, return the resident to bed after meals, turn side to side every 60 to 90 minutes, the resident was not to sit in the wheelchair for more than 60 to 90 minutes without changing body position, and perineal care after each incontinent episode. The resident was seen by the wound clinic for left buttock/ischium and the staff were to continue with the current wound care of Duoderm (a gel dressing used for wounds with drainage), reposition the resident off the pressure ulcer, and continue the low air loss mattress. Review of the Braden Scale dated 3/27/14 revealed a score of 16 which indicated the resident was at high risk for pressure ulcers. Review of the Skin/wound log dated 4/17/14 at 8:30 A.M. revealed the resident had a facility acquired stage 2 pressure ulcer on the left gluteal fold with measurements of 0.8 centimeters (cm) by 0.8 cm with a depth of less than 0.1 cm, and had an air loss mattress. The staff were to position the resident by using pillows, on a turning positioning program, received nutrition/hydration interventions, application of dressing, and had a dietary intervention. Review of the Wound Evaluation Flowsheet revealed the resident developed a stage I red area on 12/26/13 with measurements of 1.8 (cm) by 1 cm on the left buttocks. On 1/5/14 the measurements were 2.5 cm by 1.5 cm and were listed as a stage II, staff were to apply Duoderm and change every 3 days. On 1/22/14 the measurements were 1.8 cm by 2.0 cm by 0.2 cm depth with granulation tissue, Staff to apply Duoderm every 3 days, provide a supplement, and position the resident by using pillows. On 1/30/14 the measurements were 2.6 cm by 3.2 cm by 0.2 cm with granulation tissue. Staff to apply Duoderm every 3 days, frequent reposition the resident, lay the resident in bed between meals, provide a multivitamin daily, Vitamin C 500 mg twice a day and to place the resident on an incontinence program. On 2/5/14 the measurements were 2.0 cm by 2.5 cm by 0.1 cm with granulation tissue. The interventions were unchanged. On 2/12/14 the measurements and interventions were unchanged. On 2/19/14 the measurements were 2.0 cm by 2.0 cm by 0.1 cm with granulation tissue. The interventions were unchanged. On 2/28/14 the measurements and interventions were unchanged. On 3/5/14 the measurements and interventions were unchanged. On 3/12/14 the measurements were 1.4 cm by 1.2 cm by 0.2 cm with granulation tissue. The interventions were unchanged. On 3/19/14 the measurements were 1 cm by 0.8 cm by 0.1 cm with granulation tissue, staff were to cleanse the wound area, apply skin prep and [MEDICATION NAME] (a gel dressing used for wounds with drainage) dressing every 3 days and as necessary. On 3/27/14 the measurements were 1.2 cm by 1.0 cm by 0.1 cm. The resident was sent to the wound clinic on 3/26/14. Staff interventions were to continue the previous interventions, and to start a wheelchair cushion, a low air loss mattress, Zinc Sulfate 220 mg per day, and Vitamin A units per day. On 4/2/14 the measurements were 1.2 cm by 1.0 cm by 0.2 cm with granulation tissue. Staff interventions were unchanged. On 4/9/14 the measurements were 0.8 cm by 0.2 cm by less than 0.1 cm with granulation tissue. Staff interventions were unchanged. On 4/17/14 the measurements were 0.5 cm by 0.4 cm by less than 0.1 cm with granulation tissue. Staff interventions were unchanged. Observation on 4/16/14 at 7:35 A.M. the resident sat in his/her wheelchair in the main dining room. At 8:00 A.M. the resident remained in the dining room. At 8:05 A.M. staff provided scrambled eggs, toast, corn flakes, and a chocolate magic cup. The resident fed him/herself. At 8:40 A.M. the resident consumed 100 percent of food except the toast and remained in the wheelchair in front of the nursing station. At 8:44 A.M. the resident sat in the wheelchair and self-propelled his/her wheelchair toward the resident's room. Observation on 4/16/17 at 8:59 A.M. revealed the resident lay in bed on his/her left side, with heel protectors on and elevated on pillows. Observation on 4/16/14 at 11:20 A.M. the resident sat in the wheelchair in the north hallway. At 12:06 P.M. the resident sat in the wheelchair in the dining room and fed him/herself lunch. Staff provided a polish sausage, mixed vegetable, macaroni salad, and 2 magic cups. At 12:30 P.M. the resident consumed ? polish sausage and 2 magic cups. Observation on 4/16/14 at 4:15 P.M. direct care staff O performed a brief check on the resident and the resident was incontinent of bowel and bladder. The staff did perineal care and the left buttock wound did not have a dressing and was approximately dime size. No barrier cream was applied to the perineal area. A pressure relieving pad was in the wheelchair. Interview on 4/16/14 at 4:15 P.M. direct care staff O stated the resident was always incontinent and did not attempt to get out of bed. The pressure ulcer did not have a dressing in place. Observation on 4/16/14 at 5:00 P.M. the staff provided a tortilla, 2 magic cups and the resident initiated feeding him/herself. At 5:25 P.M. the resident consumed 100 percent. Observation on 4/17/14 at 7:03 A.M. the resident sat in the wheelchair and self-propelled to the dining room. At 7:45 A.M. the resident sat in the wheelchair at the dining room table. At 8:00 A.M. the staff provided 2 slices of bacon eggs, toast and coffee. At 8:15 A.M. the resident was feeding self. At 8:30 A.M. the resident consumed 100 percent and 2 magic cups. Observation on 4/17/14 at 8:50 A.M. direct care staff P transferred the resident to bed. The resident was incontinent of urine, perineal care was performed and no moisture barrier was applied. The staff positioned the resident supine in bed. Interview on 4/17/14 at 9:05 A.M. direct care staff P stated the resident was always incontinent and required staff to change his/her brief. No dressing was on the pressure wound because the resident had received a shower earlier today. Observation on 4/17/14 at 11:15 A.M. administrative licensed staff D used cleansing spray to clean the left coccyx wound, measured the wound and applied Duoderm and positioned the resident on his/her left side. Interview on 4/17/14 at 11:15 A.M. administrative licensed staff D stated the Duoderm was in place but was removed for wound measurements. Interview on 4/17/14 at 11:20 A.M. administrative licensed staff F stated he/she had applied a Duoderm to the open wound at approximately 9:30 A.M., the resident received a shower and it was not reported to him/her so he/she could apply a dressing. Interview on 4/17/14 at 1:20 P.M. licensed staff E conf
2 The facility had a census of 48 residents. Based upon observation, record review and interviews the facility failed to maintain/restore urinary function for 2 (#11, #12) of 3 residents sampled for urinary incontinence. Findings included: - Resident #12's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, was independent with bed mobility, transfers, walking in the room/corridor and locomotion on/off the unit, dressing, eating, toilet use and personal hygiene. The MDS recorded the resident was always continent of urine and bowel, was not at risk for the development of pressure ulcers, did not have a pressure relieving device on his/her bed or chair and was not on a turning/repositioning program. The resident's significant change MDS dated [DATE] identified the resident scored 99 (resident was unable to complete the Brief Interview for Mental Status Interview) and staff assessed the resident had moderately impaired cognition and without behaviors. The MDS identified the resident required extensive staff assistance with bed mobility, transfers, locomotion on/off unit, dressing, eating, toilet use, did not walk in room/corridor, limited staff assistance with personal hygiene and utilized a wheelchair. The MDS identified the resident was occasionally incontinent of urine and bowel, was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, had a pressure relieving device on his/her bed, no pressure relieving device on his/her chair and was not on a turning/repositioning program. The resident's Activity for Daily Living (ADL) Functional Status/Rehabilitation Potential Care Area Assessment (CAA) dated 3/24/14 documented the resident required total staff assistance with all ADL's, no longer walked, and needed extensive staff assistance with wheelchair mobility. The resident had episodes of incontinence, wore a brief and required staff assistance with toileting. The above represented the resident had a decline in his/her urinary function. The resident's Urinary Incontinence/Indwelling Catheter CAA dated 3/24/14 documented the resident was incontinent of bowel and bladder and required staff assistance with incontinent care. The resident wore incontinent briefs for dignity and protection and a voiding trial was out to determine the resident's targeted toileting times. The resident's Bowel/Bladder assessment dated [DATE] documented the resident was continent of urine. The resident's Bowel and Bladder assessment dated [DATE] included the resident was incontinent during the day and night. Review of the resident's clinical record lacked evidence to support the facility conducted a bladder assessment after 12/28/12. The resident's care plan dated 4/15/14 included the resident required extensive staff assistance with activities of daily living. The resident had a potential for alteration in skin integrity, staff kept the resident's skin clean and dry and monitored the resident for skin changes. Interventions in place 3/24/14 included the resident was incontinent of urine, staff applied incontinent care and a moisture barrier after each incontinent episode. A 3 day voiding trial was out to determine the resident's toileting times. Staff checked and changed the resident during the hours of 7 to 8 A.M., 10 to 11 A.M., 1 to 2 P.M., 4 to 5 P.M., 7 to 8 P.M., every 2 hours during the night as as needed. A nurse's note dated 3/4/14 and timed 11:35 A.M. included the facility received a physician's orders [REDACTED]. A physician progress notes [REDACTED]. The resident's March 2014 Medication Administration Record [REDACTED]. Review of the resident's 3 day voiding pattern/voiding record for 1/8/14 to 1/10/14 documented the resident toileted himself/herself. The record did not identify the resident was incontinent of urine. The resident's 3 day voiding pattern/voiding record for 3/11/14 to 3/13/4 was incomplete because the resident was in the hospital on [DATE]. The resident's 3 day voiding pattern/voiding record for 3/25/14 to 3/27/14 lacked incomplete documentation. For example the facility did not record the resident's voiding/pattern on 3/26/14 from 3:00 P.M. to 9:00 P.M. and from 2:00 P.M. to 9:00 P.M. on 3/27/14. The bottom of the record contained a handwritten entry that documented check and change program during the hours of 7 to 8 A.M., 10 to 11 A.M., 1 to 2 P.M., 4 to 5 P.M., 7 to 8 P.M., every 2 hours and as needed at night due to a change in the resident's condition. Further review did not include an analysis of how the facility determined this toileting schedule for the resident. Further review also revealed no analysis as to the type of the resident's incontinence. Review of the resident's 3 day voiding pattern/voiding record for 4/15/14 to 4/17/14 on 4/17/14 at 4:17 P.M. lacked any documentation on 4/17/14. On 4/16/14 at 9:44 A.M. the resident sat on the toilet in his/her room. During interview with direct care staff R at that time, he/she stated the resident was not incontinent of urine when he/she placed the resident on the toilet. Direct care staff R stated staff toileted the resident every 2 hours and as needed per resident request. On 4/16/14 at 1:32 P.M. the resident sat on the toilet in his/her room. At that time direct care staff R (staff that transferred the resident to the toilet) stated the resident was not incontinent of urine. At 2:00 P.M., 2:15 P.M., and 2:30 P.M. the resident sat in his/her wheelchair in the day room (by the nurse's station). At 2:54 A.M., 3:15 P.M., and 3:24 P.M. the resident sat in a regular chair in the day room. At 3:50 P.M., 4:00 P.M., 4:15 P.M. and 4:20 P.M. the resident sat in his/her wheelchair in the day room. At 4:20 P.M. the resident propelled himself/herself to the dining room. At 4:30 P.M., 4:45 P.M., 5:00 P.M. and 5:15 P.M. the resident sat in his/her wheelchair at a dining room table. Observation revealed staff did not toilet the resident during the hour of 4 to 5 P.M. On 4/17/14 at 7:33 A.M. the resident laid in bed and direct care staff S entered the resident's room to assist the resident with the A.M. care. Observation revealed the resident had on an incontinent brief and the brief and resident's gown was saturated with urine. On 4/17/14 at 4:16 P.M. administrative nursing staff F stated the facility only performed a 3 day voiding trial and did not perform the bowel/bladder evaluations. Administrative nursing staff F stated administrative nursing staff E performed the analysis of the data and noted the resident's toileting schedule on the voiding trial. Administrative nursing staff F stated the facility started a 3 day voiding trial for the resident on 4/15/14 and it would be completed on 4/17/14. Administrative nursing staff F confirmed the resident's voiding trial did not contain any documentation for 4/17/14. On 4/17/14 at 3:22 P.M. licensed nurse I stated staff toileted the resident every 2 hours. On 4/17/14 at 4:00 P.M. licensed nurse J stated staff toileted the resident every 2 hours. On 4/17/14 at 4:4:42 P.M. direct care staff T stated staff toileted the resident every hour and as needed. The facility's Urinary Continence and Incontinence-Assessment and Management policy revised August 2006 included the staff and practitioner appropriately screened residents and managed residents with urinary incontinence. The physician and staff provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The facility failed to complete a 3 day voiding trial of this resident's urinary pattern to determine an individualized toileting program and also failed to toilet this resident as planned and who experienced a decline in his/her urinary status. - Resident #11's quarterly Minimum Data Set (MDS) 3.0 dated 2/14/14 identified the resident scored 11(moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with bed mobility, walking in the room/corridor and locomotion off the unit, required extensive staff assistance with transfers, locomotion on the unit, dressing, toilet use and personal hygiene. The MDS identified the resident was occasionally incontinent of urine and was at risk for the development of pressure ulcers. The resident's Significant Change MDS dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with bed mobility, transfers, walking in the room/corridor, personal hygiene, and locomotion on/off the unit, required extensive staff assistance with dressing and toilet use. The resident was frequently incontinent of urine. The MDS identified the resident was at risk for pressure ulcers. The resident's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 3/31/14 documented the resident had episodes of incontinence, a 3 day voiding trial was out to determine the resident's targeted scheduling times. The resident wore incontinent briefs for dignity and protection, needed extensive staff assistance with transfers on/off the toilet, clothing adjustment, and perineal care. The resident used the urinal at times. The resident's care plan dated 3/31/14 included the resident was incontinent of urine and interventions as of 3/31/14 included staff provided perineal care and applied a moisture barrier after each incontinent episode. An entry dated 4/1/14 documented staff toileted the resident during the hours of 6 to 7 A.M., 9 to 10 A.M., 12 to 1 P.M., 3-4 P.M., 6-7 P.M. and checked and changed the resident every 2 hours and as needed. The resident's Bowel and Bladder assessment dated [DATE] included the resident was independent with toileting and was continent of urine. Review of the resident's clinical record lacked evidence the facility completed a Bowel and Bladder assessment since 7/1/11. A three day voiding pattern dated 3/25/14 to 3/27/14 contained incomplete data. For example, there was no documentation from 2:00 P.M. to 10:00 P.M. on 3/26/14 and from 12:00 P.M. to 10:00 P.M. on 3/27/14. A handwritten entry at the bottom included staff toileted the resident at targeted times during the day during the hours of 6 to 7 A.M., 9 to 10 A.M., 12 to 1 P.M., 3 to 4 P.M., 6 to 7 P.M., checked and changed the resident every 2 hours during the night, and as needed. On 4/17/14 at 4:16 P.M. administrative nursing staff F stated the facility did not perform bladder assessments. Administrative nursing staff F stated the facility conducted a 3 day voiding trial and administrative licensed nurse staff performed an analysis of the voiding pattern and documented the resident's toileting program on the 3 day voiding trial record. Administrative nursing staff F confirmed the clinical record lacked evidence the facility had performed a bladder assessment for this resident since 7/1/11. On 4/16/14 at 7:55 A.M. the resident sat on the side of his/her bed. Observation revealed the resident's pants saturated with a liquid. During interview with the resident at that time, he/she stated he/she was wet with urine and needed changed. On 4/16/14 at 8:05 A.M. the resident sat on the side of his/her bed and ate the breakfast meal. Observation revealed the resident still had on the same pants and the pants continued to be wet. On 4/16/14 at 8:20 A.M. the resident laid in bed. During interview with the resident at that time, he /she stated he/she was wet with urine and needed change. At that time the surveyor reported the above to administrative nursing staff D. Administrative nursing staff D asked direct care staff R to assist the resident. Direct care staff R entered the resident's room and assisted the resident. Observation revealed the resident's incontinent brief, pants and bed linens saturated with urine. Direct care staff R performed incontinent care and changed the resident's clothes. Direct care staff R confirmed the resident's brief and urine saturated with urine. Direct care staff R stated staff checked and changed the resident every 2 hours. On 4/17/14 at 6:50 A.M. the resident laid in bed and with a strong urine odor noted. Observation revealed the handle of the resident's empty urinal rested on the side of the trash can. On 4/17/14 at 7:17 A.M. direct care staff S entered the resident's room to assist the resident with A.M. care. Observation revealed the resident's incontinent brief, pants and blanket saturated with urine. Direct care staff assisted the resident to ambulate to the bathroom. Observation revealed the back of the resident's pants were wet. During interview with direct care staff at that time he/she stated staff checked and changed the resident at least every 2 hours. On 4/17/14 at 3:22 P.M. licensed nurse I stated staff toileted the resident every 2 hours. On 4/17/14 at 4:00 P.M. licensed nurse J stated staff toileted the resident every 2 hours. On 4/17/14 at 4:42 P.M. direct care staff T stated staff toileted the resident every hour and as needed. During the findings meeting on 4/17/14 between 5:15 P.M. and 5:40 P.M. administrative staff A (not a licensed nursing staff or certified staff) stated he/she checked on the resident at 6:00 A.M. on 4/17/14, the resident was not incontinent of urine and he/she emptied the resident's urinal. Administrative staff A did not state whether staff toileted the resident at that time. The facility's Urinary Continence and Incontinence-Assessment and Management policy revised August 2006 included the staff and practitioner appropriately screened residents and managed residents with urinary incontinence. The physician and staff provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The facility failed to complete a 3 day voiding trial of this resident's urinary pattern to determine an individualized toileting program and failed to provide timely toileting for this resident that experienced a decline in bladder function.
Inspection of July 2, 2013
4 findingsThe facility identified a census of 52 residents. The sample included 22 residents. Based on observation, record review, and staff interview, the facility failed to provide a safe resident environment for 2 of 4 sampled residents (#25 and #45) and in 1 of 2 common bathing areas. Findings included: - Observation during the environmental tour on 6/24/13 from 2:10 P.M. until 4:00 P.M. revealed the handrail beside the toilet in the main hall bathing room was loose with the screws exposed. Interview on 6/24/13 at 3:00 P.M. with maintenance staff X stated he/she was not aware the handrail needed repaired. The facility policy "General Maintenance Inspections" revealed staff should complete maintenance inspections weekly. The facility failed to provide documented maintenance inspections. The facility failed to ensure the handrail was secure and without an accident hazzard. - Observation during the environmental tour on 6/24/13 from 2:10 P.M. until 4:00 P.M. revealed the shower in the main common bathing area lacked anti-slip strips, and the drain cover was loose, warped, and not aligned with the drain. Interview on 6/24/13 at 3:00 P.M. with maintenance staff X stated he/she was not aware the drain cover needed repaired, nor was he/she aware the anti-slip strips were missing. The facility policy "General Maintenance Inspections" revealed staff should complete maintenance inspections weekly. The facility failed to provide documented maintenance inspections. The facility failed to provide a safe resident environment. - Resident #25's Minimum Data Set (MDS) 3.0 dated 5/22/2013 documented the resident had short and long term memory problems. The resident required extensive assistance with bed mobility, transfers, dressing, and toileting,and he/she did not have falls since the last assessment. The Care Area Assessment (CAA) for activities of daily living dated 10/12/12 documented the resident had dementia (cognitive problems) and was forgetful. He/She attempted to do self care and had falls due to that. He/she needed limited to extensive assistance with activities of daily living. The resident was unsteady with transfers and ambulation and was occasionally incontinent. The 11/7/11 care plan for incontinence directed resident required extensive assistance to toilet and was incontinent of bladder and directed staff to provide perineal care for incontinence. On 10/23/11 staff added an intervention to toilet the resident at 12:00 P.M., 2:00 P.M. to 3:00 P.M., 7:00 P.M. and as needed. The care plan for urinary incontinence dated as revised on 5/30/13 documented the resident was incontinent of bladder and directed staff to provide extensive assistance with toileting, perineal care for incontinence episodes, apply a moisture barrier, and incontinent brief, and dress the resident in clothing that was easily removed. Staff to assess the resident for signs of urinary tract infection and for regularity of bowel movements. On 3/28/13 staff added a new intervention that directed staff to provide prompted toileting at targeted times from 7:00 A.M. to 8:00 A.M., 11:00 P.M. to toilet at12:00 P.M., 2:00 P.M. to 3:00 P.M., 6:00 P.M. to 7:00 P.M. and as needed. The fall care plan dated 10/4/2012 directed staff to ensure the resident's bed alarm was functioning, assist with transfers and ambulation, ensure the call light was within reach, assure the resident wore proper footwear, encourage him/her to make slow position changes, monitor him/her for pain, assure there was adequate lighting, keep the resident's pathway free and clear of any objects, monitor for wet/slippery floors, and monitor for urinary tract infection symptoms. Staff added the following interventions to the resident's care plan: 2/6/13 the resident fell , add alarm audit. 2/14/13 the resident fell , add a new alarm and offer non-skid socks. 3/11/13 the resident fell and had recent medication change, add a medication evaluation. 3/13/13 the resident slid from bed. 3/15/12 the resident fell , add a new voiding trial and X-ray. 3/17/13 the resident fell and was sent to the emergency room and make an audiologist appointment. 4/18/13 the resident fell , add non-skid strips to the bathroom floor. 4/22/13 do not leave unattended in living room. 6/3/13 the resident fell out of the wheelchair, add a wheelchair alarm. Review of the Fall Screen dated 5/28/13 revealed the resident was high risk for falls. Review of the Fall Investigations revealed on 5/3/12 at unknown time the resident fell on the floor in bathroom, the resident may have slid off the toilet after he/she turned off his/her bed alarm. Staff educated the cognitively impaired resident with dementia to not turn off the alarm. On 5/7/12 at 12:30 with no documentation of A.M. or P.M. documented the resident fell during self transfer to the bathroom, but was not injured. The alarm on the bed did not sound when the resident transferred himself/herself. Staff did not add new interventions to the care plan and did not assess to see if the resident was incontinent or when the resident was last toileted. On 7/22/12 at 11:40 with no documentation of A.M. or P.M. staff left the resident alone on the toilet and the resident fell , but was not injured. Staff was educated to not leave the resident alone on the toilet. On 9/1/12 at 2:00 P.M. the resident ambulated without assistance to the bathroom and fell , but was not injured. Staff did an alarm audit, but did not add appropriate interventions to the care plan and did not assess to see if the resident was incontinent or obtain witness statements from staff to see when the resident was toileted last. On 9/14/12 at 2:15 A.M. the resident fell on the floor in the bathroom and sustained an abrasion to the right knee. Staff did an alarm audit, but did not add appropriate fall interventions and did not assess to see if the resident was incontinent, did not obtain witness statements from staff to determine when the resident toileted last. On 2/6/13 at unknown time the resident fell on the floor in the bathroom door way, but was not injured. Staff did an alarm audit, but did not assess if the resident was incontinent or determine what time the resident was toileted last and did not add additional interventions to the care plan. On 3/11/13 at unknown time the resident fell ambulating to the bathroom, but was not injured. Staff did not document when the resident was toileted last or if he/she was incontinent at the time of the fall. Staff did a medication evaluation, but did not add additional interventions to prevent further falls to the care plan. Observation on 6/26/13 from 7:16 to 7:35 A.M. direct care staff O and P assisted the resident from bed, placed shoes on the resident, handed him/her dentures and glasses. Staff transferred the resident from the bed to the wheelchair using a gait belt and extensive assistance of 2 staff during the pivot transfer. Staff did not offer to toilet the resident and did not check the resident's brief for incontinence. Observation on 6/26/13 at 9:30 A.M. direct care staff O pushed the resident in the wheelchair from the living room into the resident's bathroom. Staff transferred the resident from the wheelchair to the toilet using a gait belt and extensive assistance. Staff lowered the resident's pants and incontinence brief which was saturated with urine. Direct care staff P entered the room and assisted the resident to stand from the toilet using the gait belt and extensive assistance and assisted the resident to remain standing by holding the resident up using the gait belt while staff O used wet wipes to clean the resident's buttocks and then pulled up his/her pants. Both staff attempted to pivot transferred the resident back to the wheelchair while staff pushed the chair up to the resident legs due to the resident had difficulty pivoting his/her legs during the transfer. During interview on 6/26/13 at 12:31 P.M. administrative nursing staff D reported the resident did have frequent falls and was hospitalized due to dizziness, but the reason for the falls was not determined. The resident was mostly continent of urine, but staff should assess if the resident was incontinent prior to the fall and implementing changes in the toileting plan, would be one of the first interventions for staff to put in place. Many of the falls were when the resident attempted to self toilet. Staff educated the resident to not attempt to self toilet. Staff D acknowledged the resident had memory problems and dementia. He/she reported the nurse working at the time of the fall should put new interventions in place after each fall. The facility provided a policy entitled Fall Risk Assessment revised December 2007 which directed the staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors, that were not modifiable. If falling recurs despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant. The facility failed to thoroughly investigate the cause of falls, and failed to implement effective interventions following falls for this cognitively impaired, incontinent, dependent resident determined to be a high risk for falls. - The 30 day Minimum Data Set (MDS) 3.0 dated 2/18/13 for resident #45 revealed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). The resident required extensive assistance of two plus (2+) persons assistance with bed mobility, transfer, and bathing, required extensive assistance of one person with dressing, toilet use, and personal hygiene. The resident was not steady only able to stabilize with human assistance with moving from a seated to standing position, moving on/off a toilet, and surface to surface transfer, and had impairment on both sides of her/his lower extremities. The Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact).The resident required extensive assistance of one person for bed mobility, transfer, locomotion on/off the unit, dressing, toilet use, and bathing. She/he used a wheelchair (w/c) for mobility, did not have functional limitation in range of motion (ROM) to the upper/lower extremities, was not steady, only able to stabilize with human assistance when moving from a seated to standing position, moving on/off the toilet, and surface to surface transfer. The resident did not have a fall since admission/entry, reentry or prior assessment. The Initial Care Plan (ICP) dated 1/21/13 for falls revealed staff would orient the resident to her/his room, keep the call light within reach of the resident's bed, nursing staff would complete a side rail assessment, and educate the resident on calling for assistance. The ICP dated 1/21/12 for pressure ulcers revealed staff would assist the resident with transfers with the sit to stand lift. The Care Area Assessment (CAA) for falls dated 1/30/13 revealed the resident was not steady without human assistance with all transfers which placed her/him at risk for falls. The resident stated she/he had falls in the past. She/he was alert and oriented and did not get up on her/his own. The staff care planned to provide assistance with all transfers, and nursing staff would provide medication as ordered and monitor for changes. The revised care plan (CP) dated 6/17/13 for at risk for falls revealed: nursing staff would monitor for any change and notify the physician, keep the call light within the resident's reach, assured proper footwear, assist the resident with slow position changes, used a w/c for mobility, provided adequate lighting, would keep pathways free and clear of objects and monitor for wet/slippery floor. The resident was lowered to the floor during a transfer on 3/14/13. Staff would provide a two person transfer at all times with a stand up lift. The revised CP dated 6/25/13 for self care deficits revealed the resident required extensive assistance of two plus (2+) persons with bed mobility, transfers, and toileting/bedpan per her/his choice, and mechanical lift only. The Nursing Notes (NN) dated 3/14/13 at 1:30 P.M. revealed nursing staff telephoned the physician's office and requested orders for treatment of [REDACTED]. The resident's legs gave out and staff lowered the resident to the floor per nursing staff report. A message was left for the physician a possible X-ray of the right lower extremity, and staff applied an ice pack. Five staff assisted the resident back to bed. Nursing staff awaited return phone call. At 3:40 PM. orders were received for x-ray to the right knee, lower leg, and foot. At 8:30 P.M. the resident complained of uncontrollable pain to the right knee and received as needed (PRN) Percocet (an analgesic) at 6:00 P.M. with little relief. 8:45 P.M. orders received from on call physician to increase the PRN Percocet to 1 to 2 tablets every 4 hours PRN through the night and call the resident's physician in the morning. NN dated 3/15/13 at 3:50 P.M. revealed the resident requested to go to the emergency room for right lower extremity pain. The resident did not want to wait for the x-ray results or pain management deemed necessary by the physician. The resident spoke with the director of nursing and arrangements were made for transportation to the hospital. At 9:15 P.M. the resident returned to the facility with continued complaints of left knee pain. The left knee was wrapped with ace wrap and the resident was assisted back to bed without problems. The Nursing Aide Information sheet dated 4/11/13 revealed the resident required a wheelchair for locomotion, assisted with transfers with one person and at times two persons. The sit to stand lift would be used for all transfers until therapy released the resident to use a walker. The Fall Risk assessment dated [DATE] score 10, a total score of 10 or above represented a high risk for falls. Observation on 6/24/13 at 12:27 P.M. revealed the resident sat in a wheelchair in the dining room and wore nonskid slippers. Observation on 6/26/13 at 7:35 A.M. revealed direct care staff Q and staff T applied the sit to stand lift upper body strap around the resident and attached the strap to the lift and transferred the resident from her/his wheelchair to the bed. Interview on 6/26/13 at 8:35 A.M. with the resident stated she/he fell in her/his room in March 2nd while she/he was transferred from the bedside commode and was assisted by one CNA. Interview on 6/25/13 at 1:04 P.M. with direct care staff R stated she/he was not aware of the fall in March. Nursing staff used a sit to stand to lift assisted by two CNA with all transfers. Interview on 6/26/13 at 11:22 A.M. with direct care staff P stated she/he worked with the resident on 3/14/13 and had two CNAs assist her/him with the transfer on the bedside commode. The two CNAs left to answer call lights and direct care staff P felt comfortable transferring the resident with a gait belt by her/himself. The resident was in a standing position in front of the bedside commode and she/he leaned forward and was unable to straighten up during pericare. She/he was able to hold resident up with a gait belt and assisted her/him to the floor. Interview on 6/25/13 at 1:45 P.M. with licensed nursing staff I stated the resident was lowered to the floor after she/he could not stand and one CNA was used as the resident could take steps. Nursing staff should to use the sit to stand lift with transfers. Interview on 6/26/13 at 2:00 P.M. with administrative nursing staff D stated in March 2013 the resident was able to pivot and turn with therapy during transfers. The policy and procedure dated December 2007 titled Fall Risk Assessment failed to address fall interventions outlined in the care plan. The facility failed to provide interventions as planned for this resident that required extensive assistance with transfers.
The facility had a census of 49 residents. The sample included 13 residents. Based upon observation, record review and interviews the facility failed to provide supervision to prevent accidents for 1 (#57) of 3 sampled residents. Findings included: - Review of resident #57's quarterly Minimum Data Set (MDS) 3.0 dated 10/20/13 identified the resident scored 14 (cognition intact) on the Brief Interview for Mental Status and did not have behaviors. The MDS recorded the resident was independent with bed mobility, transfers, walking in the room/corridor, locomotion on/off the unit, dressing, eating, toilet use, and personal hygiene. The MDS identified the resident was steady at all times when moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfers. The resident's Cognitive Care Area Assessment (CAA) dated 7/24/13 included the resident had a [DIAGNOSES REDACTED]. The resident's Activity of Daily Living CAA dated 7/24/13 documented the resident ambulated independently with a walker, wandered throughout the building and wore a WanderGuard (a device to alert staff when a resident attempted to exit the building). The resident's elopement risk assessment dated [DATE] identified the resident scored 18. According to the legend a score of 11 or above represented the resident was at high risk for elopement. Documentation included the facility placed the WanderGuard on the resident's walker. The resident's fall risk assessment dated [DATE] revealed the resident score of 13. According to the legend a score of 10 or higher represented the resident was at high risk for falls. The resident's smoking assessment dated [DATE] included the resident did not require staff supervision when he/she smoked. A handwritten entry included the resident was confused at times. The resident's care plan dated 10/22/13 included the resident had short term memory loss, was confused at times, and was at risk for falls. The care plan documented the resident was an independent smoker, and smoked on the east patio. The care plan addressed the resident had a WanderGuard on his/her walker. According to the care plan the resident lost his/her balance and fell on [DATE]. On 10/23/13 at 3:45 P.M. the resident smoked outside on the east patio with 2 other residents. Observation revealed the area was enclosed, a pop machine was in the vicinity, and the area leading to the machine narrowed. On 10/23/13 at approximately 3:55 P.M. the resident pushed the button located next to patio door and entered the facility. On 10/24/13 at approximately 8:55 A.M. the resident was outside on the east patio. Observation revealed no staff or residents with the resident. The resident had a dollar bill in one hand, and walked with the walker toward the pop machine. Observation revealed the resident's gait unsteady as he/she maneuvered the walker toward the pop machine. On 10/24/13 at approximately 3:00 P.M. observation revealed the resident entered the code in the keypad and exited outside to the east patio. Staff did not assist or supervise the resident during the time he/she was outside on the east patio. During interview with the resident on 10/23/13 at 4:15 P.M. the resident stated he/she smoked independently on the patio. The resident stated he/she knew the code to the east patio door and he/she could smoke on the patio whenever he/she desired. Observation revealed the resident's walker adjacent to him/her and a WanderGuard on the right side of the walker. On 10/24/13 at approximately 4:30 PM licensed nurse H stated the resident went outside to smoke on the east patio and the resident knew the code to exit the door. Licensed nurse H stated the resident was confused at times, and had a history of [REDACTED]. On 10/24/13 at approximately 4:50 P.M. direct care staff O stated the resident knew the code to the east patio door and went outside by himself/herself to smoke. Direct care staff O stated staff did not periodically check on the resident when he/she was outside to ensure his/her safety. On 10/24/13 at approximately 4:55 P.M. administrative nursing staff D stated the resident smoked on the east patio and the resident knew the code to exit the door that led to the patio. Administrative nursing staff D stated he/she did not know if the facility had a system in place to check on the resident well-being when the resident smoked without staff on the east patio. The facility did not provide a policy regarding supervision to prevent accidents. The facility failed to ensure this resident with a history of falls and a [DIAGNOSES REDACTED].
The facility had a census of 52 residents. The sample included 22 residents. Based upon observation, record review and interviews the facility failed to provide services as planned to promote healing and prevent new pressure ulcers from developing for 1 (#33) of 2 residents sampled for pressure ulcers. Findings included: - Resident #33's 5 day Prospective Payment System MDS dated [DATE] recorded the resident did not have unhealed pressure ulcers. The resident's quarterly Minimum Data Set (MDS) 3.0 dated 3/27/12 identified the resident scored 8 (moderately impaired cognition) on the Brief Interview for Mental Status, did not exhibit behaviors, was totally dependent upon staff for bed mobility, transfers, walking in the room, locomotion on/off unit, dressing, toilet use, and hygiene, and required staff supervision with eating. The MDS recorded the resident had an indwelling catheter and a [DIAGNOSES REDACTED]. The MDS recorded the resident had (1) Stage 3 pressure ulcer that was not present upon admission/reentry, and the Stage 3 pressure ulcer measured 5 centimeters (cm) by 3.5 cm and without depth. The MDS included the resident had a pressure relieving device for his/her chair and bed, and was not on a turning/repositioning program. The resident's annual MDS dated [DATE] identified the resident had short term memory problems, modified independence in cognitive skills for daily decision making, no behaviors, required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, dressing, eating, toilet use, personal hygiene, and did not walk in the room/corridor. The MDS recorded the resident was always incontinent of urine, weighed 117 pounds, had not experienced a weight loss, and was at risk for the development of pressure ulcers. The MDS included the resident had (1) Stage 4 pressure ulcer that was present upon admission/reentry, that measured 1.8 cm by 3.3 cm with a depth of 0.3 cm. The MDS coded the resident had a pressure relieving device for his/her bed and chair and was not on a turning/repositioning program. The resident's Pressure Ulcer Care Area Assessment (CAA) dated 5/7/13 documented the resident had a Stage 4 pressure ulcer that was present upon readmission, the resident was at risk for the development of pressure ulcers due to being incontinent of urine and required extensive staff assistance with bed mobility. The resident's Nutritional Status CAA dated 5/7/13 included the resident was on a mechanical soft diet, at times the resident chose not to get up for the breakfast meal, he/she required staff assistance with set-up of his/her meals, required limited staff assistance with fluids at night, and was on multiple supplements to maintain his/her weight. The resident's care plan dated 3/28/12 included the resident had an open area on his/her coccyx and right heel, staff turned and repositioned the resident at least every 2 hours, the resident had a low air loss mattress (implemented on 3/19/13) on his/her bed and a Roho pressure relieving device in his/her wheelchair (implemented on 3/27/12). Staff observed the wounds daily and recorded the measurements weekly on the wound condition report. The care plan included staff used pillows to float the resident's heels off the bed as the resident allowed, and staff checked and changed the resident according to his/her targeted toileting times. The resident's care plan dated 5/8/13 included the resident received nutritional supplements (Ensure plus and ice cream three times a day (TID) with meals and protein shakes between meals). The facility followed the facility guidelines for wound care prevention/treatment, staff provided peri-care and moisture barrier after each incontinent episode and as needed, staff monitored the resident frequently at least every 2 hours for pressure redistribution and assisted the resident with repositioning/transfers as indicated, staff observed the resident's skin on a daily basis, measured and recorded the resident's pressure ulcers on a weekly basis, the resident had a low air loss mattress on his/her bed, the resident was non-complaint with repositioning, staff educated this cognitively impaired resident on the importance of repositioning and staff continued to assist the resident with repositioning every 2 hours. Review of the local's hospital's wound care documentation dated 3/29/12 documented the resident had an unstageable pressure ulcer on his/her sacrum that measured 9.8 cm by 3.5 cm with no depth. The documentation included the pressure ulcer had a scant amount of serosanguineous (blood tinged) drainage, and the wound bed contained granulation tissue, slough (non-viable tissue), and black/brown eschar (dead tissue). On 6/21/13 the resident continued with the pressure ulcer on his/her coccyx, the pressure ulcer was a Stage 4 that measured 2.3 cm by 0.6 cm with a depth of .3 cm. Review of the resident's 6/2013 physician's orders [REDACTED]. A progress note dated and signed by a Registered Dietitian on 6/21/13 documented the resident weighed 117 pounds, the resident continued with the pressure ulcer on his/her coccyx that measured 2.5 cm by 0.6 cm, the resident received a mechanical soft diet, Ensure and ice cream TID with meals, and HPS TID between meals for improved protein and skin integrity. On 6/20/13 at approximately 8:00 A.M., direct care staff Q entered the resident's room with the resident's breakfast tray. A few minutes later, direct care staff Q exited the resident's room with the resident's breakfast tray. Observation revealed the breakfast tray contained ice cream, a glass of chocolate type milk, a glass of milk, and juice and a dome cover over the plate of food. Upon entering the resident's room at approximately 8:05 A.M. observation revealed the resident in bed and the resident's roommate stated the resident was not a morning person and did not eat breakfast. On 6/24/13 at approximately 7:50 A.M., direct care staff Q passed the room trays. Observation revealed the resident's breakfast tray on the cart. Observation revealed direct care staff Q did not offer the breakfast tray to the resident. At 8:00 A.M., and 8:15 A.M., observation revealed the resident's breakfast tray remained on the room tray cart. The resident's breakfast tray included the nutritional supplement, ice cream, milk and juice. On 6/24/13 at 12:10 P.M. the resident sat in his/her wheelchair in the assisted dining room and the resident's lunch meal consisted of fish, french fries, cold slaw, fruit cocktail, the nutritional supplement, juice, milk, and chocolate ice cream. Observation revealed staff did not encourage the resident to eat. At 12:24 A.M., the resident had consumed a couple of bites of fish, and ice cream, all of the nutritional supplement and the resident propelled him/herself from the dining room table. On 6/24/13 the resident sat in his/her wheelchair at 12:10 P.M. and at 12:24 P.M. in the dining room. At 12:25 P.M., 12:40 P.M., 12:55 P.M., 1:05 P.M., 1:15 P.M. the resident sat in the wheelchair in his/her room. At 1:25 P.M. the resident propelled his/her wheelchair in the hall way and at 1:45 P.M. the resident sat outside smoking in his/her wheelchair. On 6/24/13 at 4:55 P.M. the resident sat in the assisted dining room and ate his/her dinner meal which consisted of ground chopped steak with gravy, rice, mixed vegetable, bread with butter, slice of chocolate cake, juice, and milk. The resident did not receive the physician ordered Ensure or ice cream with the dinner meal. At 5:20 P.M. the resident propelled himself/herself from the dining room and observation revealed the resident consumed a couple of bites of food, and a couple bites of chocolate cake. During interview with direct care staff Q at that time, he/she stated the resident only ate a couple of bites of food at each meal, and usually consumed all of the chocolate shakes. On 6/25/13 at 8:00 A.M. the resident's breakfast tray sat on the meal room tray cart. Observation revealed the resident's breakfast meal included ice cream, orange juice, cranberry juice, ground sausage, scrambled eggs and toast. At 8:15 A.M. the resident's breakfast tray remained on the cart and during interview with direct care staff P at that time, he/she stated the resident never ate breakfast. On 6/25/13 at approximately 1:55 P.M. observation revealed the resident had a Stage 3 pressure ulcer on his/her coccyx that measured approximately 3 cm by 0.5 cm with a depth of approximately 0.3 cm. On 6/26/13 the resident sat in the wheelchair at 10:30 A.M., 10:45 A.M., 11:00 A.M., 11:30 A.M., 11:50 A.M., 12:05 P.M.,12:15 P.M., 12:30 P.M., 1:30 P.M., 2:00 P.M., and 3:15 P.M. On 6/25/13 at 1:28 P.M., licensed nurse I stated staff should offer the Ensure and ice cream to the resident at each meal and if the resident did not consume it at that time, staff should offer the supplements when the resident woke up. Licensed nurse I stated the resident received health shakes TID between meals per physician orders, and staff repositioned and toileted the resident every 2 hours. On 6/26/13 at approximately 7:35 A.M., nursing administrative staff D confirmed the resident acquired an unstageable pressure ulcer on his/her sacrum between 3/21/12 and 3/29/12 and the pressure ulcer was still unhealed. On 6/26/13 at 8:15 A.M. nursing administrative staff D confirmed the resident's breakfast tray sat on the cart and the resident's ice cream, nutritional supplement, milk and juice remained on the tray. Nursing administrative staff D stated staff should take the tray to the resident's room and offer the tray to the resident. Review of the resident's clinical record lacked evidence to support the facility offered the resident the Ensure supplement and ice cream when the resident woke up. According to the Pressure Ulcer Prevention & Treatment clinical Practice Guideline developed by the National Pressure Ulcer Advisory Panel and the European Pressure Advisory Panel: If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx, limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the ulcer. The facility failed to provide timely interventions as planned and failed to ensure the resident received the nutritional supplements per physician orders [REDACTED].
The facility identified a census of 51 residents, with a sample of 16 residents. Based on observation, interview and record review, the facility failed to provide necessary services to maintain skin integrity for one of 5 residents sampled (#42). Findings included: - The Minimum Data Set (MDS) 3.0 dated 12/17/12 an annual review listed the resident was totally dependent on staff for all activities of daily living, and required the assist of 2 staff. The resident had no pressure ulcers. The care area assessment (CAA) dated 12/17/12 for pressure ulcers revealed the resident had no pressure ulcers at this time, he/she was at risk for pressure ulcers, due to needing total assist with bed mobility,and incontinence care, staff would care plan to provide incontinent care, assist with bed mobility, and perform a weekly skin assessment. The Quarterly Minimum Data Set (MDS) 3.0 dated 6/15/13 listed the resident was totally dependent on staff for all activities of daily living, and required the assist of 2 staff. The resident had no pressure ulcers. The CAA for cognition dated 12/17/12 documented the resident had a [DIAGNOSES REDACTED]. He/she was mute and only laughs or moans out. The resident had a communication computer and at times was able to answer yes/no questions with staff assistance. The resident required total assistance with all areas of cares,and had short and long term memory deficits. Staff will care plan his/her cognition and anticipate his/her needs. The careplan for self care deficit dated 6/17/13 listed the resident as totally dependent on staff for all activities of daily living (ADLs) Use 2 staff members for incontinent care and transfers. Provide incontinent brief for protection/dignity. Provide peri-care when incontinent, apply moisture barrier when incontinent and as needed. Updated care plan dated 7/5/13 identified an area on the resident's back from a tube feeding cap, which healed 7/11/13. Review of the nurse's notes (nn) dated 7/2/13 at 6:22 A.M. revealed during first rounds on the 10 P.M. to 6 A.M. shift the staff found the resident lying in bed crying. Staff found the top of a container under the resident's back. The area was red, raised, and blanched when touched, there were no open areas, and the area measured approximately 1 and 3/4 inches in diameter. NN dated 7/3/13 at 2:30 P.M. revealed the resident with 2 open areas on his/her middle left back, the upper stage 2 wound, measured 1.5 cm (centimeters) x 3.0 cm x 0 cm. The left lower stage 2 wound measured 1.2 cm x 0.5 cm x 0 cm. The areas were cleaned and dressings were applied. Staff left a message for the DPOA (durable power of attorney) and the physician. Review of treatment sheet dated 7/3/13 listed the treatment of [REDACTED]. Review of the treatment sheet dated 7/5/13 listed the treatment for 2 wounds to the left mid back: wash/dry apply triple antibiotic ointment (TAO) and foam dressing twice daily till healed. Documented as healed on 7/9/13. The care plan dated 7/5/13 listed the interventions of mid back wounds, wash, dry apply triple antibiotic ointment and foam dressing twice daily. The resident was dependent on staff for mobility and repositioning did not have control over bowel or bladder, and required total assistance with toileting. The resident would be free of skin breakdown through the next review date. Turn and reposition at least every 2 hours and as needed, provide adequate nutrition thru tube feeding, pressure relieving mattress and wheelchair cushion,use pillows to keep the resident's heels off the bed, provide weekly skin assessments,preventative skin care per protocol. Check and change per routine, ensure he/she is clean and dry and perineal care after each incontinent episode. Dated 7/5/13 feeding cap left in the bed, nurse to inspect bed after each feeding. Observation on 8/28/13 revealed the following: 10:00 A.M. the resident laid in bed on his/her back looking at the television. Observation of the resident on 8/29/13 revealed the following: 8:30 A.M. staff took the resident to the shower room.Observation revealed skin check was performed by licensed nursing staff J on the resident's back, an area on the left mid-shoulder area that had a circle outline, approximately 1 and 3/4 inches in diameter, the skin in the circle outline remained red, approximately 6 weeks after the resident developed the 2 stage 2 pressure ulcers. On 8/29/13 at 8:16 AM licensed staff H stated the resident was lying on a cap from a perineal wash container, not a tube feeding cap. Licensed staff H referred to the charting he/she did, and produced a cap from a container of perineal wash same type as what he/she found under the resident. Staff stated there was no need to inspect for a tube feeding cap, they were much smaller than the cap he/she found. On 8/29/13 at 1:30 P.M. direct care staff Q stated we provide all cares for resident #42 if there were hair in his/her eyes, he/she was dependent on us to remove it. I heard about the incident a month ago. First rounds reported they found the resident crying and found a cap from the perineal wash under his/her back. Staff Q left and returned with a can of Soothe and Cool perineal wash to demonstrate the size of the cap that was under the resident. The facility failed to provide care and services for this cognitively impaired dependent resident to prevent the development of 2 stage 2 pressure ulcers.
Inspection of March 14, 2012
1 findingThe facility identified a census of 51 residents. The sample included 21 residents with 4 reviewed for weight loss. Based on observation, record review, and interviews, the facility failed to implement effective interventions to prevent weight loss for 2 of 3 residents sampled for weight loss (#13, and #4). Findings included: - The physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) with an assessment reference date of 1/30/12 reported the resident with short and long term memory problems. The resident displayed no swallowing disorder, ate a mechanically altered diet, and had a weight loss of 5 percent (%) or more in the last month or 10% or more in last 6 months. The Care Area Assessment for nutrition dated 2/7/12 noted the resident had a gradual weight loss but recently came off Hospice due to no significant change. His/her weight loss was not greater than 5% in 30 days. He/she was on a mechanical soft diet and needed total assist at meals. The quarterly Minimum Data Set ((MDS) dated [DATE] reported the resident had short and long term memory problems. The resident was totally dependent on staff for bed mobility, transfer, locomotion on/off unit, dressing, eating, toilet use, personal hygiene, and was always incontinent of bowel and bladder. The 1/4/11 care plan for nutritional status reported a problem of weight loss. The resident was to receive small frequent meals, and the resident was to eat as desired. The 2/17/11 care plan noted the resident continued to have gradual weight loss, and that staff were to assist/encourage him/her to eat. The care plan dated 6/30/11 noted an alteration in nutrition. The care plan directed staff to monitor labs as ordered and notify the physician, monitor weights, record percentage of meal intake and offer an alternative if the resident consumed less than or equal to 50%, monitor skin condition, provide pureed diet as ordered, monitor for medications that may have an adverse effect on weight and report to physician, and resident needed total assistance with feeding. The care plan dated 7/18/11 noted a weight loss of 7 pounds and staff notified the resident's physician and durable power of attorney. The care plan dated 2/3/12 and physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's telephone order dated 2/3/12 reported the resident was to receive a HPS three times daily with meals however, this order was not transferred to the 2/12/12 or 3/12/12 physician's orders [REDACTED]. Review of monthly weights reported: 1/20/11 130 pounds 2/11 123 pounds 3/11 118 pounds 4/11 117 pounds 5/11 102 pounds 6/11 100 pounds 7/11 95 pounds 8/11 97 pounds 9/11 99 pounds 10/11 104 pounds 11/11 99 pounds 12/11 105 pounds 1/20/12 99 pounds 2/12/12 97 pounds Review of the Food Acceptance Record for 1/11 through 3/12 recorded the following times when a high protein shake was not recorded as given as the physician ordered: January 2011 Breakfast 28 Dinner 30 March 2011 Breakfast 25 Dinner 30 April 2011 Breakfast 11 Dinner 10 May 2011 Breakfast 9 Dinner 12 June 2011 Breakfast 11 Dinner 18 July 2011 Breakfast 21 Dinner 28 August 2011 Breakfast 17 Dinner 31 September 2011 Breakfast 19 Dinner 30 The registered dietician progress notes included: 5/27/11 receives HPS twice daily with meals. Pureed diet. In decline. Continue to offer food/fluids as tolerated. Do not force to eat. 5/27/11 down 35 pounds in 6 months. Significant decline. Resident on hospice. Poor dentition, clamps mouth shut if he/she does not want to eat. Can verbalize but very difficult to understand. Receives HPS twice daily with meals. Resident in decline. Do not force to eat. 11/29/11 weight fairly stable for 6 months but well below usual weight by history. At times eats well. At times clamps mouth shut. Will have dietary send shake with all meals if resident will take. At times refuses shake as well. 2/10/12 weight 95 pounds appeared very cachectic (wasting syndrome from weight loss) especially when compared to former weights. Cries out severe dementia/decline. Total assist with feeding. Accepts only small amounts. Staff just started HPS with meals three times daily. On pain medications. Decline expected. Certified dietary manager notes included: 7/19/11 weight 99 pounds. Puree diet. HPS twice daily with meals. Clamps mouth shut and will not eat a lot of the time. 10/11 weight 98 pounds. Current diet was puree. Resident was brought to dining room in chair, total assist by staff. Continued to clamp mouth and will not consume any food or fluids, several attempts are made by staff. Resident at times yelled out continually and staff removed the resident from the dining room tried to feed resident in room in quiet atmosphere. 1/10/12 weight 99 pounds. Puree diet. HPS three times daily with meals. Continued to yell out at times during meals and refused to eat at times. Usually consumed 25 to 50%of most meals and fluids. The advanced registered nurse practitioner notes dated 10/4/11 Showed evidence of continual decline with continual weight loss which was down 9.5% in last 6 months. His/her appetite remained poor and he/she had dysphagia which increased his/her risk for aspiration. He/she remained hospice appropriate to provide support to patient and family to ensure the best quality of life and a peaceful dying process. Observation on 3/7/12 at 5:25 P.M. revealed staff served the resident pureed chicken, 3 bean salad, mighty shake, and ice cream in the dining room. The resident consumed approximately 75% of the meal with staff assistance. Observation on 3/8/12 at 8:00 A.M. revealed staff served the resident pureed eggs, oatmeal, meat, milk, cranberry juice, protein shake, banana in the dining room and the resident consumed everything except milk and half of cranberry juice with staff assistance. Observation on 3/8/12 at 12:45 P.M. revealed the resident in the dining room with staff attempting to feed the resident who clamped his/her mouth shut, and refused to eat. The resident consumed less that 10% of all meal and fluids served, and staff did not offer an alternate meal. Interview of direct care staff M on 3/8/12 at 8:00 A.M. indicated that the resident had his/her days and would consume everything offered, other days ate less or refused to eat by clamping his/her mouth closed. Interview of dietary staff T on 3/12/12 at 9:30 A.M. indicated that administrative staff A was responsible for reviewing dietary consumption logs for discrepancies, and reported to staff as necessary. Interview of administrative nursing staff D on 3/12/12 at 1:00 P.M. indicated that administrative staff A completed review of consumption logs and should bring to nursing's attention if he/she identified a problem. Additionally he/she reported that risk management discussed this resident's weight loss and staff attempted different approaches snacks, etc. Staff did not provide any documentation of these attempts. At 1:30 P.M., administrative nursing staff D stated that staff documented all interventions attempted under the dietary notes. He/she further stated that they would check on the medication administration sheet as the physicians order on 2/12/12 to give HPS increased from twice daily to three times daily was not reflected on the medication record for 2/12/12 or 3/12/12. The facility policy Nutrition (Impaired) Unplanned Weight Loss Clinical Protocol dated April 2007 stated that the nursing staff would monitor and document the weight and nutritional status of residents in a format which permitted readily available month-to-month comparisons. The facility failed to reassess, accurately record dietary intake and provide and implement timely interventions as planned to prevent further weight loss for this cognitively impaired, and dependent resident. - Review of resident #4's physician order [REDACTED]. The resident's significant change Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 2/15/12 identified the resident scored a 15 (no cognitive impairment) on the Brief Interview for Mental Status, did not exhibit any behaviors, did not walk in the room/corridor, required limited staff assistance from staff for eating, and was totally dependent upon staff for all other activities of daily living. The MDS identified the resident weighed 135 pounds, had experienced a weight loss of 5 percent (%) or more in the last month or 10% or more in the last 6 months, and was not on a physician prescribed weight loss program. The resident's cognitive loss/dementia care area assessment (CAA) dated 2/16/12 documented the resident had a [DIAGNOSES REDACTED]. The resident's nutritional status CAA dated 2/16/12 documented the resident experienced a recent weight loss and the facility would care plan for staff to encourage and assist the resident with oral intake, the facility monitored the resident's weight per protocol and referred the resident to the registered dietician as needed. The resident's care plan dated 2/14/12 documented the resident received a regular diet, the facility recorded the percentage of intake consumed, and dietary staff assessed the resident's diet for vitamins and supplements as needed. The care plan included the resident experienced a weight loss, received renal supplements three times a day (TID), the facility offered the resident an alternate if the resident consumed 50% or less of meals, received 2 hard boiled eggs at breakfast, a protein cookie and meat sandwich at night. A physician's progress note dated 2/2/12 included the resident was not eating and staff were to encourage the resident to eat and go to [MEDICAL TREATMENT]. A physician's progress note dated 2/16/12 included an abdominal ultrasound revealed the resident had 1800 cubic centimeters of urine in his/her bladder. A physician's progress note dated 3/1/12 included the resident was not eating, had lost some weight, had 1800 cubic centimeters of urine in his/her bladder, elevated [MEDICAL CONDITION] level, and no percutaneous endoscopic gastrostomy (PEG) tube was indicated at that time. The facility received a physician's orders [REDACTED]. The order also included for the resident to receive a protein cookie and sandwich at night. On 2/28/12 the facility received a physician's orders [REDACTED]. The resident's weekly weight log recorded the following weights: December of 2011(week 1): 150 pounds (#) December of 2011(week 4): 143# January of 2012 (week 3): 140 # (10 # weight loss in 1 month) February 2012 (week 1): 140# February of 2012 (week 2): 135# February of 2012 (week 4): 130# March of 2012 (3/7/12): 129# (21 # weight loss in 3 months) A registered dietician's note dated 2/10/12 (time unknown) documented the resident weighed 135 #, the resident's weight was down 8# in one month, the resident was hospitalized during the month of January 2012, the resident's December weight was 150#, a decline in the resident's weight. The note documented the resident refused most solids/liquids, did not always consume the Nepro (nutritional supplement) and staff would have to work to see if the resident would consume more. A registered dietician note dated 3/9/12 timed 7:52 A.M. documented the resident weighed 129 pounds, had a Stage 2 wound on his/her coccyx, the resident liked frosty wheats and coffee, and the resident started receiving [MEDICATION NAME] for appetite stimulant, continued to receive the Nepro-Vitamin, the 57 grams of pro-Nepro TID, pro cookie and sandwich, and hard boiled eggs. A registered dietician note date d 3/9/12 timed 9:30 A.M. documented the [MEDICAL TREATMENT] center would not allow the resident to eat when receiving [MEDICAL TREATMENT], the facility might consider sending a pro cookie or Nepro, and the facility provided food to the resident upon returning from [MEDICAL TREATMENT]. Review of the resident's meal acceptance record for January 2012 through March 11, 2012, revealed the facility did not always record the amount of the Nepro the resident consumed, the resident's food intake, or if the facility offered the resident an alternate if the resident consumed 50% or less of the meal: Dates of examples were as follows: 1/4/12, 1/11/12, 1/15/12, 2/11/12, 2/16/12, 2/29/12, and 3/1/12. The resident's food acceptance record recorded the resident was out of the facility on several days during the lunch meals (days the resident received [MEDICAL TREATMENT]). The resident's clinical record lacked evidence the facility offered the resident food upon return from [MEDICAL TREATMENT]. During interview with dietary staff T on 3/8/12 at 3:03 P.M. the staff stated the facility use to provide a sack lunch for the resident to consume while at the [MEDICAL TREATMENT] center, but [MEDICAL TREATMENT] staff requested the facility not to send the sack lunch, and the facility offered the resident a snack upon return from [MEDICAL TREATMENT]. Dietary staff T confirmed the clinical record lacked evidence the facility recorded the amount of the snack the resident consumed upon return from [MEDICAL TREATMENT] and also confirmed the facility did not consistently document the resident's intake. Review of the resident's snack log lacked evidence the facility provided the sandwich at night per physician's orders [REDACTED]. On 3/7/12 at 3:10 P.M. the resident returned from [MEDICAL TREATMENT], staff wheeled the resident to the dining room and gave the resident a glass of water and a cup of coffee. The resident remained at the dining room table and at approximately 5:00 P.M. staff provided the resident the dinner meal which included vegetable soup, tuna sandwich, and jello with whipped topping. At 5:10 P.M. the resident had finished eating the meal and consumed 1/2 of the vegetable soup, 3/4 of the sandwich and 25% of the 8 ounces of milk. On 3/8/12 at 7:56 A.M. staff delivered the resident's breakfast meal to the resident who remained in bed. At 8:05 A.M., the resident was in bed, a cover was on the plate, plastic wrap was on the glasses of milk, and juice, and no staff assisted the resident with the meal. Observation revealed the same at 8:10 A.M., 8:20 A.M., and 8:30 A.M. At 8:50 A.M. the cover was off of the plate, and the meal included corn flakes (no milk on the cereal), sausage gravy and biscuit, and (2) boiled eggs. The resident consumed 3/4 of the 8 ounces of the milk, a couple of sips of the Nepro, and none of the food. At 9:25 A.M. the resident had finished with the breakfast meal and had consumed 1 of the boiled eggs, and none of the other foods. At 9:30 A.M., direct care staff O removed the tray from the resident's room, confirmed the resident only consumed the boiled egg, and sips of the Nepro. Direct care staff O stated the resident required set-up at meals, and sometimes required staff assistance with meals. On 3/8/12 at 12:25 P.M. the resident was in bed eating the lunch meal which consisted of pork loin, bread with butter, squash, and potatoes. At 12:30 P.M. the resident attempted to eat the meal, asked the location of the fork, and no staff assisted the resident with the meal. At 12:40 P.M., the resident had consumed 25% of the pork loin, 100% of the potatoes, 50% of the squash, was reaching for the desert, could not reach it, and asked for help. At 12:50 P.M. the resident had consumed 100% of the desert. On 3/12/12 at 8:00 A.M. the resident was in bed eating the breakfast meal (no staff assistance), consumed a couple of bites of the boiled egg, and a couple of bites of the biscuit. Observation revealed no milk on the cornflakes, some of the Nepro had spilled, and the resident asked for a straw. At 8:45 A.M. the resident stated he/she was finished eating the breakfast meal, the resident had consumed 25% of the 8 ounces of milk, couple of bites of the biscuits, and 25% of the boiled egg. During interview with direct care staff P on 3/12/12 at 1:20 P.M. the staff stated the resident did not consume much food, and required staff assistance with eating since the resident's decline. During interview with licensed staff H on 3/12/12 at 1:30 P.M. the staff stated the resident's appetite had decreased, the resident experienced a weight loss, received snacks between meals, received Nepro, and staff cued the resident during meals. During interview with administrative nursing staff D on 3/12/12 at approximately 2:00 P.M. the staff reported the resident started receiving [MEDICATION NAME] the end of February, the resident received snacks that included the protein cookie, and Nepro, and the staff was unsure if the resident received a sandwich at night. Administrative nursing staff D stated the resident needed set up at meals, was very independent, cognitively intact at times, and had some periods of confusion. During interview with dietary staff T on 3/12/12 at 3:14 P.M. the staff stated the resident received the sandwich, protein cookie and Nepro at night since at least December of 2011, the facility continued to offer the resident the Nepro and protein cookie each night but not the sandwich. Dietary staff T confirmed the facility did not offer the sandwich since 2/10/12 and confirmed the facility received a physician's orders [REDACTED]. The facility's nutrition (impaired)/unplanned weight loss protocol revised April 2007 did not include documentation of meals, staff cueing residents at meal times, and providing nutritional supplements as physician ordered. The facility failed to provide the sandwich at night as physician ordered, failed to consistently document all food intake, failed to offer the resident a snack upon return from [MEDICAL TREATMENT], and failed to offer staff assistance during meals as care planned.
Inspection of January 11, 2012
2 findingsThe facility had a census of 56 residents. Based upon observation, record review and staff interview the facility failed to ensure that 1 (#5) of 3 residents sampled with pressure ulcers or at risk for the development of pressure ulcers received appropriate care and servies to promote healing and prevent the development of multiple pressure ulcers. Findings included: - Review of resident #5's Physician order [REDACTED]. The resident's annual Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 9/8/11 identified the resident scored an 8 on the Brief Interview for Mental Status (BIMS) (moderately impairment cognition), required total staff assistance for bed mobility, transferring, locomotion on and off of the unit, hygiene and toilet use, and required staff supervision with eating. The MDS coded the resident always incontinent of bowel and bladder, at risk for the development of pressure ulcers, did not have any unhealed pressure ulcers, had a pressure relieving device for the chair and bed, not on a turning/repositioning program, weighed 181 pounds and had not experienced a weight loss. The resident's pressure ulcer Care Area Assessment (CAA) dated 9/9/11 documented the resident was at risk for the development of pressure ulcers due to incontinence and bed mobility, the resident was totally dependent upon staff for bed mobility, the facility would develop a care plan to provide incontinent care, and the facility would monitor the resident's skin per facility protocol. The resident's significant change Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 1/9/12 identified the resident had short and long term memory problems, moderately impaired cognition, did not exhibit any behaviors, and was totally dependent upon staff for all activities of daily living (ADL's). The MDS coded the resident weighed 163 pounds, had experienced a 5 percent (%) weight loss in the last 30 days, was not on a physician prescribed weight loss regimen, and did not receive nutritional approaches and had (1) Stage 2 pressure ulcer and (1) Stage 3 pressure ulcer. The resident's Pressure Ulcer CAA dated 1/9/12 documented the resident had a pressure ulcers to his/her coccyx, incontinent of bowel and bladder, had experienced a weight loss, had a pressure relieving cushion in his/her chair and a low air loss mattress on his/her bed. The CAA included the facility would develop a care plan to monitor the resident's skin per facility protocol, skin treatment per physician orders, and weights per facility protocol. The resident's Nutritional Status Care Area assessment dated [DATE] documented the resident had experienced a 5% weight loss, and had a Stage 2 and Stage 3 pressure ulcer on his/her coccyx, and the facility weighed the resident per facility protocol. The resident's care plan which had been in effect since 8/9/11 (last reviewed and revised on 1/9/12) addressed the resident had short and long term memory problems, dietary assessed the resident's diet to ensure appropriate vitamins and supplements, staff assisted the resident to turn and reposition frequently, the resident had a low loss air mattress, staff used pillows to keep the resident's heels off of the bed as the resident allowed, staff performed weekly skin assessment per facility protocol. A handwritten entry dated 10/15/11 documented staff would apply [MEDICATION NAME] to the resident's coccyx until healed. A handwritten entry dated 12/9/11 documented the resident had coccyx wounds, and the facility would obtain a dietary consultation as needed. A handwritten entry dated 1/7/11 documented the resident had experienced a decline, and needed cueing/supervision with meals. A handwritten entry added on 1/9/12 documented the resident received Therm M (vitamin supplement) daily for wound healing, 220 milligrams of Zinc each day, 500 milligrams of Vitamin C daily for wound healing, and sugar free health shakes (SFHS) three times a day (TID), regular diet as ordered, and the resident had a Stage 2 and Stage 3 pressure ulcer. Review of the resident's wound evaluation flow sheet dated 10/18/11 (date first observed) documented the resident had a facility acquired pressure ulcer on his/her coccyx that measured 2.5 centimeters (cm) by .5 cm, and the facility received a physician's orders [REDACTED]. On 11/11/11 the pressure ulcer on the resident's coccyx measured .1 cm by .3 cm. On 11/25/11 documentation included the area was healed and the facility discontinued the treatment. The wound evaluation flow sheet did not identify the Stage of the pressure ulcer. Review of the resident's wound evaluation flow sheet dated 12/9/11 documented the resident had a facility acquired Stage 2 pressure ulcer that measured .7 cm by .3 cm, and staff received a physician's orders [REDACTED]. On 12/15/11 the pressure ulcer was a Stage 3 and measured 1 cm by .5 cm (worsening of the pressure ulcer in Stage and size). On 12/30/11 the Stage 3 pressure measured .5 cm by .1 cm. Review of the resident's other wound evaluation flow sheet dated 12/30/11 (did not identify type of wound) documented the resident had an area on his/her coccyx that measured .3 cm by .3 cm and the current treatment included cleanse the wound, cover with [MEDICATION NAME] and change every 3 days and as needed. A Registered Dietician's note dated 11/8/11 timed 10:25 A.M. documented the resident had open areas, weighed 176 pounds, the resident weight was slowly decreasing, recommended the resident get up to 2 health shakes per day, and the goal was wound healing and stabilizing the resident's weight. A Registered Dietician note dated 12/28/11 timed 10:15 A.M. documented the resident had (2) wounds on his/her upper and lower coccyx that had not improved, the resident weighed 172 pounds which was down 4 pounds from last month weight, the resident received a regular diet, and if the resident continued to lose weight the dietician would recommend the resident received more prompting, cueing, and staff assistance in the dining room. On 1/9/12 the facility received a physician's orders [REDACTED]. (25 days after the pressure ulcer on the resident's gluteal crease/coccyx had worsened from a Stage 2 to a Stage 3 pressure ulcer and 10 days after the pressure ulcer reopened on the resident's coccyx, and 19 days after the resident had experienced a significant weight loss). On 1/9/12 at 9:00 A.M. observation revealed the resident incontinent of bowel, the [MEDICATION NAME] not fully intact, and the resident had a pressure ulcer in the gluteal fold that measured approximately 2 centimeters (cm) by .5 cm and a pressure ulcer on the coccyx that measured .5 cm by 1 cm with eschar. After performing incontinent care, direct care G and H repositioned the resident's on his/her right side. The resident had on Ted hose bilaterally and the resident's heels were not floated. On 1/9/12 at 1:30 P.M. direct care H stated he/she and another direct care staff had just placed the resident in bed. Observation at 1:30 P.M. revealed the resident in bed on his/her right side. Observation at 1:40 P.M. , 1:50 P.M., 2:05 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M., 2:55 P.M., 3:05 P.M., 3:15 P.M., 3:30 P.M., 3:40 P.M., 3:45 P.M., 3:50 P.M., and 4:00 P.M. revealed the resident in bed on his/her right side, the resident had on Ted hose bilaterally, the resident's heel in direct contact with the sheet (a duration of 2 hours and 45 minutes without a change in position). Observation at 4:15 P.M. revealed the resident on his/her back and the resident's heels in direct contact with the sheet. During interview with licensed nurse B on 1/9/12 at approximately 4:45 P.M. the nurse stated the resident should be turned at least every 2 hours. Licensed nurse B also stated the area on the resident's coccyx reopened on 12/30/11. During interview with direct care staff I on 1/9/12 at approximately 5:10 P.M. the staff stated the resident was on a turning/repositioning program, and staff turned/repositioned the resident at least every 2 hours. The facility failed to float the resident's heels, failed to reposition the resident every 2 hours, failed to timely implement measures to promote wound healing, failed to prevent worsening of a pressure ulcer, and failed to prevent new pressure ulcer from developing.
The facility had a census of 54 residents. The sample included 6 residents. Based upon observation, record review and staff interview the facility failed to ensure 1 (#5) of 3 residents maintained acceptable parameters of nutritional status. Findings included: - Review of resident #5's Physician order [REDACTED]. The resident's annual Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 9/8/11 identified the resident scored an 8 on the Brief Interview for Mental Status (BIMS) (moderately impairment cognition), required total staff assistance for bed mobility, transferring, locomotion on and off of the unit, hygiene and toilet use, required staff supervision with eating. The MDS coded the resident weighed 181 pounds and had not experienced a weight loss. The resident's nutritional status Care Area Assessment (CAA) dated 9/9/11 documented the resident was on a regular diet, and the facility would develop a care plan to monitor the residents weights and encourage healthy food choices. The resident's quarterly Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 12/7/11 identified the resident scored a 12 on the BIMS (moderately impairment cognition), required total staff assistance for bed mobility, transferring, locomotion on and off of the unit, hygiene and toilet use, and required staff supervision with eating. The MDS coded the resident weighed 173 pounds and had not experienced a weight loss. The resident's significant change Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 1/9/12 identified the resident had short and long term memory problems, moderately impaired cognition, did not exhibit any behaviors, and was totally dependent upon staff for all activities of daily living (ADL's). The MDS coded the resident weighed 163 pounds, had experienced a 5 percent (%) weight loss in the last 30 days, was not on a physician prescribed weight loss regimen, and did not receive nutritional approaches and had (1) Stage 2 pressure ulcer and (1) Stage 3 pressure ulcer. The resident's Nutritional Status Care Area assessment dated [DATE] documented the resident had experienced a 5% weight loss, received a regular diet, needed cueing, supervision and at times required total staff assistance at meals. The facility had moved the resident to a table to ensure the resident received more staff assistance during meals, the resident had a Stage 2 and Stage 3 pressure ulcer on his/her coccyx, and the facility weighed the resident per facility protocol. The resident's care plan which had been in effect since 8/9/11 (last reviewed and revised on 1/9/12) addressed the resident had short and long term memory problems, and dietary assessed the resident's diet to ensure appropriate vitamins and supplements. A handwritten entry dated 1/7/11 documented the resident had experienced a decline, and needed cueing/supervision with meals. A handwritten entry added on 1/9/12 documented the resident received Therm M (vitamin supplement) daily for wound healing, 220 milligrams of Zinc each day, 500 milligrams of Vitamin C daily for wound healing, and sugar free health shakes (SFHS) three times a day (TID), regular diet as ordered, and the resident had a Stage 2 and Stage 3 pressure ulcer. A Registered Dietician's note dated 11/8/11 timed 10:25 A.M. documented the resident had open areas, weighed 176 pounds, the resident's weight was slowly decreasing, and the resident consumed less than 75% of meals. The note documented the dietician recommended the resident get up to 2 health shakes per day, and the goal was wound healing and stabilizing the resident's weight. A Registered Dietician note dated 12/28/11 timed 10:15 A.M. documented the resident had (2) wounds on his/her upper and lower coccyx that had not improved, the resident weighed 172 pounds which was down 4 pounds from last month's weight, the resident received a regular diet, and if the resident continued to lose weight the dietician would ask what supplements had been implemented, and recommended the resident received more prompting, cueing, and staff assistance in the dining room. Review of the resident's weekly weights recorded the following weights: 1st week of 12/11: 175 pounds 12/14/11: 172 pounds (a decrease of 3 pounds) 12/21/11: 164 pounds ( a decrease of 8 pounds or a 4.65% weight loss in one week; a significant weight loss of 6.29% in less than a month) 1/4/12: 163 pounds ( a significant weight loss of 6.86% in one month, or a decrease of 12 pounds in 1 month) Review of the facility's 12/11 snack log identified the resident should receive SFHS at 2:30 P.M. and each night. Further review revealed there was no documentation to support the facility offered SFHS to the resident on 12/12/11, 12/15/11, 12/16/11, 12/17/11, 12/18/11, 12/21/11, 12/23/11, 12/24/11 12/25/11 12/26/11, and on 12/28/11. On 1/9/12 the facility received a physician's orders [REDACTED]. On 1/9/12 at 8:10 A.M. staff assisted the resident with the breakfast meal which consisted of pancakes, bacon, and oatmeal. At 8:45 A.M. the resident had finished the breakfast meal and ate 100% of the meal. On 1/9/12 at 9:00 A.M. observation revealed the resident had a pressure ulcer in the gluteal fold that measured approximately 2 centimeters (cm) by .5 cm and a pressure ulcer on the coccyx that measured .5 cm by 1 cm with eschar. On 1/9/12 at 12:15 P.M. staff assisted the resident with the lunch meal which consisted of ham and macaroni and cheese casserole, carrots, and a cinnamon roll. At 12:30 P.M. the resident had finished the lunch meal and consumed 50% of the meal. The facility did not offer the resident additional food. During interview with dietary staff M on 1/9/12 at 5:17 P.M. the staff reported the facility started the resident on the SFHS twice a day on 11/8/11. Dietary staff M stated the dietician last evaluated the resident's nutritional status on 12/28/11 and the facility had not recorded the resident's weight from 12/21/11 of 164 pounds, and the dietician completed the assessment of the resident's nutritional status using the weight of 172 pounds. Dietary staff M confirmed the resident's care plan documented the staff moved the resident to a different table (table to provide more staff assistance) on 1/7/12 (10 days after the dietician's recommendation and 17 days after the resident had experienced a significant weight loss of 6.29% in less than one month). Dietary staff M confirmed the facility did not implement any other interventions to minimize the resident's weight loss or wound healing until 1/9/12 (19 days after the resident had experienced a significant weight loss of 6.29% in less than one month). Dietary staff M confirmed the facility's snack log did not support the facility had offered the resident the SFHS twice a day during the month of 12/11. The facility failed to reassess and provide timely interventions to prevent a significant weight loss in this dependent resident with pressure ulcers.
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