Every finding on record at Wake Robin-Linden Nursing Home

Based on observation, interview and record review the facility failed to ensure one of fourteen sampled residents (Resident #6) medical record clearly communicated the resident's choice of code status to staff responsible for the resident's care. Findings include:Per record review, Resident #6 has a COLST (Clinician Orders for Life-Sustaining Treatment) dated [DATE] which states Resident #6 is a DNR (do not resuscitate) and that CPR (cardiopulmonary resuscitation, an emergency technique to restart breathing) should not be attempted, but that s/he might have a natural death. The Resident does not want to be intubated or ventilated, and s/he wishes treatment needed for comfort. Patient prefers no transfer to hospital for life-sustaining treatments. Transfer if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.Per record review, the Resident #6's code status choices not to have life sustaining treatment as specified in her/his COLST are not addressed by the facility in her/his care plan. Per record review, the resident's code status choices are not addressed in her/his Point Click Care (the facility's electronic medical record) physician's orders. Per record review, the resident's code status (desire for DNR status) is not indicated on the resident's face sheet (their medical record profile page in Point Click Care).Per interview at 9:30 AM on [DATE], the DON (Director of Nursing) was asked if Resident #6's code status was indicated on their Point Click Care profile page. The DON confirmed that Resident #6's code status was not listed on her/his medical record profile page in Point Click Care, and confirmed that it should have been listed there. Per interview, the DON confirmed that facility practice in a code situation is for a nurse to look at the resident's medical record profile page first, in order to determine their code status. The DON then updated Resident #6's code status on her/his Point Click Care profile page.Per interview at 11:38 AM on [DATE], a RN (Registered Nurse) #1 was asked to select a resident and confirm where they would go to identify a resident's code status. Per observation, s/he went first to a resident's medical record profile on Point Click Care and identified where the code status is indicated (the same spot that was blank in Resident #6's medical record).

Based on staff interview and record review, the facility failed to complete a performance review at least once every 12 months for every Licensed Nurse Assistant (LNA) and then must provide regular in-service education based on the outcome of these reviews for 5 of 5 LNA's in the sample. Findings include: During review of a random selection of 5 employee personnel files, 5 of 5 LNA files reviewed did not have evidence of annual performance review within the last 12 months. Per interview on 8/1/23 at 11:00AM, the Administrator confirmed that the facility had not conducted the required performance reviews for the LNA's.

Based on observation, record review, and staff interviews, the facility failed to have appropriate policies directing staff when to initiate basic life support by not ensuring documentation of a resident and their representative's choice to have emergency basic life support immediately when needed for one of twelve sampled residents (Resident #2). Findings include: Per review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy CPR (Cardiopulmonary Resuscitation) states: In the event of a cardiac or pulmonary arrest, Wake [NAME] provides CPR according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview on [DATE] at 12:46 PM, a registered nurse (RN) stated that Resident #2's code status was CPR according to his/her assignment sheet. When asked how s/he would know the code status of this resident if s/he couldn't find the assignment sheet s/he said s/he would look at the resident's face sheet, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This RN confirmed Resident #2 did not have this information in their electronic record or paper medical chart. A list of residents titled Full codes (residents to receive CPR when needed) dated [DATE], was discovered during this interview on the cabinet where residents' paper medical charts were located. Resident #2's name was not on this list. This nurse confirmed that s/he should be on this list. Per interview on [DATE] at 12:59 PM, the Director of Nursing (DON) stated that a resident's code status would always be in the resident's chart on the face sheet and on the COLST form. S/he confirmed that there was no documentation for Resident #2 addressing resuscitation status present on their face sheet and that the resident did not have a COLST form. The DON confirmed the Full code sheet was not up to date. Per interview on [DATE] at 2:25 PM with the Medical Director, s/he stated that Resident #2 has been at the facility over a year without a completed COLST form. Per interview on [DATE] at 2:52 PM with the Director of Social Services, s/he stated it would be the physician's responsibility to determine the code status if it wasn't decided by the family or resident. It would be social services responsibility to enter the information into the resident's medical record but would not do it until s/he had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on staff interview and record review the facility failed to ensure resident allergies were consistently identified throughout the resident's medical record for one of three residents sampled (Resident #6). Findings include: Per record review Resident #6's Physicians Orders lists allergies of raw apples, raw pitted fruit, and Aleve. These allergies are also listed in the resident's medication administration record. Per the Guidelines for Daily Care (tool used to inform Licensed Nursing Assistants (LNAs) of each resident's specific care needs) lists Allergies as Raw Apples, Raw Pitted Fruits, Aleve Review of Resident #6's care plan date 4/11/2022 reflects that she/he may need an epi [[MEDICATION(S)]] pen may have life threatening allergic reaction to peanuts and hazelnuts or pitted fruits. The care plan also states I need my nurses to know how to use my epi pen. I need my aides to make sure I am not fed any of the foods I am allergic to. and the care plan goal states My goal is to not have any exposure to the foods that I am allergic to, and avoid having life threatening allergic reaction. During interview on 6/22/2022 at approximately 1:15 PM when asked how staff would identify a residents allergies, she/he stated that they would review the Diet Sheets provided by the the dietary department. However, she/he did confirm that the peanut and hazelnut allergies were not listed consistently between the physicians orders, care plan, and Guidelines for Daily Care.

Based on staff interview and medical record and policy review, the facility failed to develop a care plan to meet the needs for 1 of 3 residents in the survey sample identified as being at high risk for falls (Resident #2). Findings include: Per record review on 12/17/14 Resident #2 had [DIAGNOSES REDACTED]. His/her 9/10/14 annual MDS (Minimum Data Set) assessment identified the resident as needing the assistance of 1 person for transfers, ambulation, dressing, toileting and personal hygiene. On 9/2/14 a Fall Risk Assessment identified Resident #2 as having a fall risk score of 17. The facility's Falls Protocol (revised 04/2013) states that "A score of ten (10) or greater is considered High Risk for potential falls". The facility's Fall Risk Assessment Policy (reviewed 4/2013) states a fall risk assessment provides a method to identify high risk residents and allow for staff to establish care planning to provide approaches to minimize falls. Per review of the nursing progress notes, on 10/12/14 Resident #2 had an unwitnessed fall when transferring from his/her wheelchair to his/her walker so that s/he could get into his/her chair. On 10/13/14, Resident #2 was transferred to the hospital for right hip pain related to the fall and was diagnosed with [REDACTED]. Per the nursing progress notes, on 10/16/14 the resident was readmitted to the facility. On this same date, another Fall Risk Assessment was done and Resident #2 had a fall risk score of 12 (12 = high risk for falls). On 11/12/14 the resident had a witnessed fall where s/he was slowly eased to the floor by a therapist when s/he felt the need to sit during a transfer. On 12/17/14, the DNS (Director of Nursing Service) confirmed that Resident #2 was identified as at high risk for falls and that the facility policy indicated that a care plan should be developed based on risk. The DNS reported that in the past, Resident #2 had a care plan for falls that was discontinued on 6/10/13 by a former staff member and this went unnoticed until the time of the survey.

Based upon observation, interviews and record review, the facility failed to revise the Care Plan for 2 of 2 residents (Resident #2, #3) of the sample group for non-pressure skin issues. Findings include: 1. Resident #2, whose [DIAGNOSES REDACTED]. Per review of the the care plan dated 02/23/14, it states skin integrity/risk, at risk related to incontinence and decreased mobility, assist with incontinence care, on toilet program to promote dryness, monitor skin every shift. There is no care plan noted for a dressing change or other wound protocols. Per the Nursing Assessment Note dated 04/23/14 states ''New area outer right lower arm...length 1...width 1...surface area 0.7-1.0 cm...depth 0.1 [MEDICATION NAME] tissue reddened...light drainage...surrounding tissue reddened...applied Versatel and non-adherent dressing on elbow." Per review of the TAR (Treatment Administration Record) nursing has changed the dressing to the elbow every day since 04/23/14. Per the Nursing Assessment Note, nearly three weeks later dated 05/14/14, it states that the resident has a healing skin tear on right outer lower arm, scab present no signs or symptoms of infection, surrounding skin WNL(Within Normal Limits), area scabbed over (continues with dressing change). Per interview on 5/20/14 at 1:49 PM the Clinical Coordinator confirmed there was no care plan revision for the dressing change to the elbow. 2. Resident #3 was admitted on [DATE] with [MEDICAL CONDITIONS], mobility issues and dementia with memory deficits. Although the care plan dated 03/07/13, is noted for dementia, mobility issues and general skin integrity/risks, the care plan was not revised to address any abrasions or wounds. The care plan for skin integrity risk states the resident will have no breakdown and to assess skin condition and apply lotion, inform MD/family of changes and monitor skin every shift. Per observation during interview on 05/19/14 at 1:32 PM, Resident#3 had a open red abrasion/sore on the chin. The Resident stated ''oh I had that for awhile" and noted that it will occasionally itch from time to time. Per review of the protocols and guidelines for wound care/skin care team, notes that the care plan will be updated and/or developed to address any skin concerns, wound or open area from any cause. Furthermore, it states weekly assessments and documentation. Per interview on 05/20/14 at 12:13 PM the DNS stated that the resident has a chronic lesion and although there is no documentation of the daily monitoring, s/he stated that ''I am sure they are monitoring it''. S/he confirmed that the care plan was not updated to reflect the lesion, its treatments or monitoring. ALSO SEE TAG F-278

Based on observation, staff interview and record review, the facility failed to assure that dietary staff stored and prepared foods under sanitary conditions and in accordance with accepted safe food handling practices. Findings include: Per observation in the kitchen during the initial tour on 3/21/11 at 9:45 AM, the following areas/practices were noted: a. The temperature of the first walk-in cooler was observed to be 42 degrees F (Fahrenheit). Per review of refrigerator temperature logs and refrigeration temperatures recorded on the daily Closing log for January - March 2011, there were multiple days when the temperatures exceeded the recommended maximum of 41 degrees F for storage of perishable foods. Per review of the facility's policy on Storage of Frozen and Refrigerated Foods, it stated "Keep refrigerator temperatures between 32 degrees and 45 degrees F." The ranges specified on the policy are not in accordance with accepted safe standard that refrigerator temperatures should be maintained at 41 degrees or below. This was confirmed with the Food Service Director (FSD) the same morning. b. Three raw beef steak packages were observed in a reach-in refrigerator on 3/21/11 at 10 AM, with a date of 3/1/11. There was also a wrapped piece of cooked steak in one of the walk-in refrigerators labeled from February, 2011. The cook said all of these meats were in the freezer and had not been relabeled when removed. Per interview with the FSD on 3/21/11 and 3/23/11, the facility's policies for dating of foods do not provide specific guidelines for staff in dating/labeling of perishable food items. c. Per observation of the 3 bay manual dishwashing sink on 3/21/11 at 9:45 AM, washed items were sitting in the drained middle sink. When staff were asked to describe the process for manual dishwashing, they confirmed they were not using a wash, rinse and final sanitizer or hot water final rinse in accordance with safe food handling practices. This was confirmed by the FSD who was also present. d. One trash container and the compost container were observed in the kitchen and were heavily soiled on the outside of the containers. This was confirmed with the cook and the FSD at the time.

Based on interviews and record reviews, the facility failed to develop a comprehensive care plan for 1 of 6 residents in the stage 2 sample (Resident #37). Findings include: 1. Per record review on 3/23/11, there was no care plan developed that addressed weight loss for Resident #37, who experienced a significant weight loss of 12 pounds during the period from 2/8/11 to 3/14/11. The weight logs for this resident show a re-weigh on 3/16/11 to confirm the weight loss, from 106 pounds on 2/8/11 to 94 pounds on 3/14/11 and 3/16/11 respectively. The lack of care plan to address the weight loss was confirmed during interviews with the Registered Dietician (RD) and the MDS (Minimum Data Set) Nurse during the morning of 3/23/11.

Based on observation, interview and record review, the facility failed to assure that care plans were revised to reflect the current identified needs for 2 of 7 applicable residents in the Stage 2 sample. (Residents #3 & #37) Findings include: 1. Per review of nursing notes, Resident # 3 sustained a fall in October 2010 and an unwitnessed fall on 02/27/11. The care plan for falls dated 4/27/09 states provide therapies, inform family/physician of changes, transfer according to ADL, keep area free of clutter, toilet schedule. The last updated care plan dated 1/4/11 states 'approaches ongoing'. Per observation on 03/22/11 the resident's room had a motion sensor detector. Per interview on 3/22/11 at 5:19 PM the primary nurse stated the motion detector is not on the working care plan. Per interview at 2:00 PM on 3/23/11, the MDS nurse confirmed the care plan was not updated to reflect the use of the sensor monitor, which was installed after the October fall. 2. Per record review on 3/23/11, Resident #37's care plan for falls risk/history was not revised to reflect the resident's most recent falls. Review of fall investigation documentation revealed the resident sustained [REDACTED]. A nursing progress note of 3/12/11 stated that the 'resident's room has a lot of furniture and other items and he/she is resistant to moving things around, but his/her son states he is visiting tomorrow and will try and work with him/her on some of the clutter'. As of 3/23/11, the care plan was not revised to reflect the most recent falls, nor was there evidence of follow up on the attempt to decrease clutter and environmental hazards in the room. The lack of care plan revision after the falls was confirmed during interview with the MDS nurse on the morning of 3/23/11.

Based on interview and record review, the facility failed to assure services are provided in accordance with the plan of care for 1 of 3 sampled residents (Resident #3). Findings include: 1. Per record review on 3/23/11 at 3:00 PM, Resident # 3's plan of care directed staff to provide AM/PM snacks as well as ROM (range of motion) daily . Per the care plan dated 01/04/11 and current LNA flow sheets, they direct staff to 'use walker or wheelchair and gentle ROM to bilateral lower extremities 2x every day'. ROM exercises remain ongoing. goals and approaches remain current. Per review of the LNA flow sheets for the months of January - March 2011, there was no documentation that staff offered the AM/PM snacks, nor the amount or type consumed. In addition, the LNA flow sheet for ROM was not consistently documented as being completed in February 2011, 7 missed opportunities out of 28 days, and in March 2011, 10 missed opportunities out of 22 days. Per interview on 3/23/11 at 9:30 AM, the DNS (Director of Nursing Services) stated that 'there is a glitch in the system in which the LNA flow sheet doesn't capture that snacks that were given, and also stated the nurses were 'assuming' that it was documented. The DNS also confirmed that there is no documentation that ROM was performed on the missed days noted above.

Based on staff interview and record review, the facility failed to ensure that 1 of 4 applicable residents in the sample at risk for weight loss maintained acceptable parameters of nutritional status. (Resident #37) Findings include: Per record review on 3/23/11, Resident #37 experienced a significant weight loss of 8.8% (12 pounds) during the period from 2/8/11 to 3/14/11 and staff failed to follow it's Weight Monitoring Policy regarding notification to the RD, assessment and care planning. Per review of the weight logs, the resident weighed 106 pounds on 2/8/11 and weighed 94 pounds on 3/14/11. The resident was reweighed on 3/16/11 and found to weigh 94 pounds again. During interview on 3/23/11 at 9:25 AM, the RD stated that she attends monthly Weight Wellness Meetings (last meeting was 2/16/11) and is at the facility to review residents weekly on Wednesdays. Although the resident was reweighed on Wednesday 3/16/11 to confirm the weight loss, the RD stated that she had not been notified of the weight loss. During interview with the Dietary Manager (who is also member of the Weight Wellness Team) at 10:15 AM the same day, he stated that he was not aware of the 12 pound weight loss. Per review of the facility's Weight Monitoring Policy/Procedure on 3/23/11, #4 states "Weight losses of 5% in 30 days or 10% in 180 days will be reported to the attending physician and the dietician. Contributing factors will be identified and the care plan updated with amended problem, goals and approaches." There was no care plan to address the nutritional needs and the weight loss and no evidence of an assessment to determine the possible cause(s). The failure to follow the facility's policy regarding weight monitoring and take timely action regarding assessment and care planning in response to the resident's weight loss was confirmed with the RD and the Nurse Manager on 3/23/11 at 9:25 AM and 11 AM, respectively.

Based on staff interview and record review, the facility failed to assure that each resident's drug regimen was free from unnecessary drugs for 1 of 10 residents in the targeted sample. (Resident #37) Findings include: Per record review on 3/23/11, Resident # 37, had routine MD (physician) orders for APAP ([MEDICATION NAME], an [MEDICATION NAME]) 650 mg. (milligrams) PO (by mouth) TID (3 times daily) at 0600, 1200 and 1800 and PRN at HS (hour of sleep). Additional routine orders for APAP included: 650 mg. twice a day for HA (headache). Another order included APAP 650 mg. every 3 hours times 3 days PRN pain/fever. There were no parameters for administering PRN doses and there was no maximum daily dose stated for APAP from all orders. The Nursing 2011 Drug Handbook states that the maximum dose of [MEDICATION NAME] should not exceed 4 grams daily. During interview with the DNS and the MDS nurse on 3/23/11 at 1:45 PM, it was confirmed that there was no daily maximum dose specified and there were 2 separate orders for routine APAP, although the resident was receiving the APAP per the TID order at present. The discrepancy had not been noted and clarified with the ordering provider. Resident #37 also had 2 separate orders for PRN (as needed) Risperdone. The orders included: Risperdone 0.25 mg PO BID (2 times daily) PRN dementia with agitation; and Risperdone 0.5 mg PO HS PRN agitation with dementia. The resident also received Risperdone 0.5 mg PO routinely at HS. Per review of the nursing behavior notes from 11/1/10 - 3/21/11, there were no behaviors documented. During interview with the Nurse Manager on 3/23/11 at 2 PM, she confirmed there should not be 2 orders for PRN Risperdone and that there were no specific parameters for administering the PRN doses.