Glengariff Health Care Center

Based on observation, record review, and staff interviews during the recertification survey, the facility did not insure that A) two of two residents wearing jumpsuits in a total sample of thirty where assessed for the use of these jumpsuits as a physical restraint. (Resident #22 and #3) Also, B) four of nine residents reviewed for physical restraints in a total sample of thirty were observed to not have their seatbelts released during meals as ordered by their Physician. (Resident #20, #21, #1, and #2) This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings include, but are not limited to:

A1) Resident #22 has diagnoses which include Alzheimer's Disease and Depression.

The Minimum Data Set (MDS) assessment dated 2/14/10 revealed that the resident had moderately impaired cognitive skills for daily decision-making with long and short-term memory problems. The MDS also documented that the resident used other types of side rails (e.g., half rail, one side) as a device or restraint.

The resident was observed wearing a jumpsuit in the 2nd floor dining room during lunch meal observation between 12:00 PM and 12:45 PM on all four days of survey (3/4, 3/5, 3/8, and 3/9/10).

Review of the Behavior Symptoms: Socially Inappropriate Behavior Comprehensive Care Plan (CCP) dated 12/21/09 revealed that the resident exhibited socially inappropriate behavior as evidenced by episodes of playing with feces. The CCP noted that on 1/8/10 the family provided jumpsuits which were effective in reducing episodes of inappropriate behavior. The Social Worker also spoke with the family on 1/7/10 at which time the Social Worker was authorized to purchase additional jumpsuits.

Review of the resident's medical record revealed no documented evidence that the resident's use of a jumpsuit was assessed as a physical restraint.

2) Resident #3 has diagnoses which include Dementia and Hypothyroidism.

The Minimum Data Set (MDS) assessment dated 12/29/09 revealed that the resident had moderately impaired cognitive skills for daily decision-making with long and short-term memory problems. The MDS also documented that the resident was free of any restraints.

The resident was observed wearing a jumpsuit in the 2nd floor dining room during lunch meal observation between 12:00 PM and 12:45 PM on all four days of survey (3/4, 3/5, 3/8, and 3/9/10).

Review of the Behavior Symptoms: Socially Inappropriate Behavior Comprehensive Care Plan (CCP) dated 3/9/09 revealed that the resident exhibited socially inappropriate behavior as evidenced by playing with feces. The CCP noted that on 5/6/09 the resident's daughter provided two one piece jumpsuits with improvement in episodes of inappropriate behavior. Social Worker will follow-up with family, requesting the purchase of additional outfits for day and night wear.

Review of the resident's medical record revealed no documented evidence that the resident's use of a jumpsuit was assessed as a physical restraint, nor was there evidence of a reassessment for the continued use of the jumpsuit.

The Registered Nurse (RN) Head Nurse was interviewed on 3/9/10 at 12:25 PM and stated that a jumpsuit had never been thought of as a restraint and that was also why no restraint reduction had ever been attempted on Resident #3 who had worn jumpsuits since 5/6/09.

The RN MDS Nurse was interviewed on 3/9/10 at 12:45 PM and stated that she has never captured a jumpsuit as a restraint when completing an MDS.

The unit Social Worker was interviewed on 3/9/10 at 12:50 PM and stated that a jumpsuit was not considered a restraint because it was not restricting any movement and it was provided to prevent an A-typical or abnormal behavior.

The RN Nurse Supervisor was interviewed on 3/9/10 at 12:55 PM and stated that a jumpsuit was not considered a restraint because the resident was still able to use their hands or scratch their leg.

The Director of Nursing (DON) was interviewed on 3/9/10 at 1:50 PM and stated that the facility never looked at a jumpsuit as a restraint before because the resident could still move their limbs and jumpsuits were provided to prevent a resident from doing a behavior that was not appropriate.

B1) Resident #20 has diagnoses which include Dementia and Chronic Obstructive Pulmonary Disease.

The Minimum Data Set (MDS) assessment dated 12/25/09 revealed that the resident had moderately impaired cognitive skills for daily decision-making with long and short-term memory problems. The MDS also documented that the resident used other types of side rails (e.g., half rail, one side) and a trunk restraint as a device or restraint.

The resident was observed in the 2nd floor dining room on 3/5/10 from 12:00 PM-1:00 PM and 3/8/10 from 12:00 PM-12:45 PM eating their lunch meal with her buckle belt buckled.

The monthly Physician's Order dated 3/1/10 revealed an order for the resident to have a buckle belt on their wheelchair due to decreased safety awareness, decreased strength and endurance, unsteady gait, and the inability to comprehend physical limits related to dementia. Release (the seatbelt) every 2 hours for skin care, exercise, toileting, and meals.

The Physical Restraint Comprehensive Care Plan (CCP) dated 2/1/08 documented that the resident had a buckle belt on their wheelchair due to decreased safety awareness, decreased strength and endurance, unsteady gait, and inability to comprehend physical limits related to dementia. Release buckle belt every 2 hours for skin care, exercise, toileting, and meals.

2) Resident #21 has diagnoses which include Alzheimer's Disease and Depression.

The Minimum Data Set (MDS) assessment dated 2/27/10 revealed that the resident had moderately impaired cognitive skills for daily decision-making with long and short-term memory problems. The MDS also documented that the resident used other types of side rails (e.g., half rail, one side) and a trunk restraint as a device or restraint.

The resident was observed in the 2nd floor dining room on 3/5/10 from 12:00 PM-1:00 PM and 3/8/10 from 12:00 PM-12:45 PM eating their lunch meal with her buckle belt buckled.

The monthly Physician's Order dated 3/2/10 revealed an order for the resident to have a buckle belt on their wheelchair due to decreased strength and endurance, non-ambulatory status, and inability to comprehend physical limits related to dementia. Release every 2 hours for skin care, exercise, toileting, and meals.

The Physical Restraint CCP dated 8/23/07 documented that the resident had a buckle seatbelt due to decreased strength and endurance, non-ambulatory status, and inability to comprehend physical limits related to dementia. Release buckle belt on wheelchair every 2 hours for 10 minutes for toileting, skin care, repositioning, exercise and meals.

The Registered Nurse (RN) Nurse Supervisor was interviewed on 3/8/10 at 12:45 PM and stated that all residents' seatbelts should be released during meals and the seatbelt should be released by whoever served them.

The Director of Nursing (DON) was interviewed on 3/9/10 at 2:30 PM and stated that she would expect the seatbelts to be taken off at meals and that anyone could take them off.

415.4(a)(2-7)

Based on observations, record review, and resident and staff interviews during the recertification survey, the facility did not ensure that one of thirty sampled residents received the necessary equipment to accommodate their physical needs. Specifically, Resident #6, who had no ability to use his hands, was not provided with an appropriate device to enable activation of the call bell system to obtain assistance. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #6 has diagnoses including Multiple Sclerosis, Quadriplegia, and Depression.

Resident #6 was observed on 3/04/10 at 12:50 PM sitting in his wheelchair in his private room. The resident had a call bell that was to be activated by pressing a small plastic ball with his chin. The resident was asked to activate the call bell, however was not capable of activating the call bell system because the small plastic ball was located below his chin.

Resident #6 was observed on 3/05/10 at 12:00 PM lying in bed with a different adaptive call bell placed under his chin. The Surveyor asked the resident to activate the call bell, however the resident was unable. When the resident was asked if he thought he activated the call bell, he stated that he thought he had, however neither the call bell light located in the wall at the head of the resident's bed nor the hallway light located outside the resident's door activated.

Resident #6 was observed on numerous occasions in his wheelchair and in his bed on 3/04/10 at 12:50 PM, 3/05/10 at 9:30 AM and 9:50 AM, 3/08/10 at 10:40 AM, and 3/09/10 at 9:50 AM. The resident attempted to activate the call bell, which was placed under the resident's chin at the Surveyor's request, however was not capable of activating the call bell. When asked if he thought the call bell was activated, the resident replied that he thought that he had activated the call bell system. The call bell system was not activated.

The Minimum Data Set (MDS) assessment dated 1/25/10 documented that the resident required total assist of two people for transfers, total assistance of two people for bed mobility, and exhibited limited Range of Motion of both arms and hands with full loss of volitional movement.

The Physical Therapy Evaluation dated 2/02/10 documented that Resident #6 exhibited trace shoulder and elbow strength bilaterally and no active movement of his wrist or fingers bilaterally.

The Comprehensive Care Plan (CCP) for Contractures dated 2/02/09 through 2/03/10 did not address the resident's inability to utilize a call bell. There was no CCP developed addressing the resident's physical limitations and need for a modified call bell to accommodate the resident's physical limitations.

An interview was held on 3/05/10 at 9:50 AM with the Certified Nursing Assistant (CNA) who was assigned to provide care to Resident #6 on the 7:00 AM-3:00 PM shift. The CNA stated that if the call bell fell below the resident's chin, then he could not utilize it. Additionally, the CNA stated that she did not have time to check on the resident until 9:50 AM.

An interview was held on 3/09/10 at 1:15 PM with the Director of Nursing (DON). The DON stated that they had a different type of call bell on order for the resident.

415.5(e)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that one resident in a total sample of thirty had current Physician's orders. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. (Resident #5)

The finding is:

Resident #5 has diagnoses which include Hypertension and Diabetes Mellitus.

The Minimum Data Set (MDS) assessment dated 12/18/09 revealed that the resident had moderately impaired cognitive skills for daily decision-making with long and short-term memory problems.

A review of the resident's computerized medical record revealed current monthly Physician's Orders dated 12/15/09. Requests for the renewal of monthly Physician's Orders dated 1/12/10 and 2/9/10 had expired.

The Director of Nursing (DON) was interviewed on 3/8/10 at 9:10 AM and confirmed that the current Physician's Orders for the resident were dated 12/15/09 and that the computer indicated in red letters that there were "New Orders Pending" and "Renewals Requested" for this resident. The DON stated that she would call the resident's Physician and ask him what had happened.

The facility's Medical Director was interviewed on 3/8/10 at 9:15 AM and stated that all resident's Physician's Orders had to be renewed on a monthly basis.

The Registered Nurse (RN) Head Nurse was interviewed on 3/8/10 at 9:25 AM and stated that she could not recall ever seeing the words "New Orders Pending" and "Renewals Requested" written in red when she had looked at Physician's Orders in the computer.

In a subsequent interview with the DON on 3/8/10 at 10:00 AM she stated that she had talked with the resident's Physician. The Physician told the DON that he had pressed the button (on the computer) when he had reviewed the resident's monthly Physician's Orders. The DON stated that the computer showed that he did not and that she would have the Physician come in to go over the computer process again. The DON stated that renewals are done on a monthly basis by a Nurse and she did not know why they did not see the outstanding Physician's Orders in the computer.

The Facility's Monthly Physician Renewal of Orders dated 9/09 revealed that all orders are ordered on a monthly basis.

415.22(a)(1-4)

Based on observations, staff interviews, and record review during the recertification survey, the facility did not ensure that one of six residents reviewed for pressure ulcers in a total sample of thirty received the necessary treatment and services to prevent deterioration to the periwound area (outside edges of the wound) of a pressure ulcer. Specifically, Resident #6 experienced deterioration of the edges of a Stage III pressure ulcer and there was no documented evidence that the Physician was notified of the change. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #6 has diagnoses that include Multiple Sclerosis, Stage III Pressure Ulcer to the Sacrum, and Stage II Pressure Ulcers to the Left Scapula and the Right Thigh.

The Minimum Data Set (MDS) Assessment dated 1/25/10 documented that the resident's cognitive skills for daily decision making were moderately impaired.

The Wound Assessment Sheet completed by the Wound Care Physician on 3/01/10 documented that the periwound area was intact.

The Physician's Order form for 3/01/10 documented that the resident was to receive collagenase (a debriding agent) 250 unit per gram ointment to the sacral decubitus after a normal saline cleanse and cover with a dry sterile dressing daily.

During observation of the wound care treatment, completed by the Registered Nurse (RN) Charge Nurse on 3/05/10 at 10:30 AM, the RN was observed to remove the sacral wound dressing. The Stage III Sacral pressure ulcer wound bed was observed with yellow and green patches of slough and three necrotic areas. The edges of the wound were noted to be beefy red.

A second wound observation was completed on 3/08/10 at 10:00 AM. The edges of the sacral wound were bleeding with blood tinged drainage noted.

A third observation of the wound was completed on 3/09/10 at 9:30 AM. The edges of the wound were beefy red with red and clear drainage present.

The RN Charge Nurse was interviewed on 3/09/10 at 10:00 AM and stated that she did not contact the Physician for treatment orders to the periwound area because the Wound Care Physician had seen the resident on 3/01/10.

The Wound Care RN was interviewed on 3/09/10 at 10:00 AM. The RN stated that the RN Charge Nurse did not notify her of the resident's sacral periwound increased redness and drainage.

On 3/09/10 at 11:00 AM, the Physician's Order documented that the resident was to receive Vitamin A and D ointment to the periwound area every day and when necessary.

The Wound Care Physician was unavailable for comment.

The Attending Physician was interviewed on 3/09/10 at 3:00 PM and stated that he was not contacted about the change in condition of the resident's sacral periwound until 3/09/10.

415.12(c)(1)(2)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that one of eighteen residents reviewed for assistive devices in a total sample of thirty wore hand rolls as prescribed by a Physician to prevent further contractures. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. (Resident #6)

The finding is:

Resident #6 has diagnoses including Multiple Sclerosis, Quadriplegia, and Bilateral Hand Contractures.

Resident #6 was observed on 3/04/10, 3/05/10, and 3/08/10 at different times during the 7:00 AM-3:00 PM shift lying in bed or sitting in his wheelchair without hand rolls in place.

The Minimum Data Set (MDS) assessment dated 1/25/10 documented that Resident #6 exhibited both short and long term memory problems, required total assist with all activities of daily living, required total assistance of two assist for bed mobility, and had limited range of motion (ROM) of both hands with full loss of voluntary movement.

The Physical Therapy Evaluation dated 2/02/10 documented that the Physical Therapist (PT) recommended hand rolls to both hands to prevent further contractures.

A Physician's Order dated 11/06/09 documented that the resident was to wear bilateral hand rolls at all times, to be released for hygiene and skin check.

The Resident Nursing Instructions, utilized by the Certified Nursing Assistants (CNAs), directed the CNAs to apply bilateral hand rolls at all times.

An interview was held on 3/08/10 at 9:50 AM with the CNA who was assigned to provide care for Resident #6. The CNA stated that she did not think the resident wore hand rolls.

An interview was held on 3/08/10 at 10:00 AM with the Registered Nurse (RN) Charge Nurse. The RN stated that the resident was supposed to wear hand rolls at all times except during skin checks and skin care.

An interview was held on 3/09/10 at 9:00 AM with the PT who recommended the use of the bilateral hand rolls. The PT stated the reason the bilateral hand rolls were ordered was to maintain the resident's available ROM and to prevent further contractures.

An interview was held on 3/09/10 at 10:00 AM with the Director of Nursing (DON) who stated that the resident's Physician's Orders should have been followed.

415.12(e)(2)

2000 NFPA 101- 19.3.6.4 Transfer Grilles.
Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Based on observation and staff interview, transfer grilles were noted in doors protecting corridor openings. Examples were doors to oxygen storage rooms on six of six nursing units in both the Glengariff building and the Poplar Hill building and a door to an electrical closet on Unit 2 in the Poplar Hill building.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 3/4/10 between 9:30am- 3:00pm during the recertification survey, transfer grilles were noted in doors protecting corridor openings. Examples were doors to oxygen storage rooms on six of six nursing units in both the Glengariff building and the Poplar Hill building and a door to an electrical closet on Unit 2 in the Poplar Hill building.

In an interview on 3/4/10 at approximately 12:15pm, the Director of Maintenance stated that he will seal the doors immediately.

711.2(a)(1)

Based on observation and staff interview the facility did not ensure that ashtrays of a safe design were provided in the residents' smoking areas in two of two buildings.

This resulted in no actual harm with potential for minimal harm.

The findings are:

During life safety inspections on 3/04/10 between 8:45am and 3:00pm the following two designated resident smoking areas were not provided with ashtrays of a safe design with center rests.

1. The Popular building smoking area that is located adjacent to the entrance was observed with a metal container and an outpost that are used for disposing cigarette ashes and butts.

2. The Glengariff building smoking area that is located in the outdoor terrace was observed with one outpost that is used for disposing the cigarette ashes and butts.

During the survey, residents were observed utilizing both smoking areas.

In an interview on the same day at approximately 10:30am the Director of Maintenance stated that the ashtrays were removed and that they would be placed back in each location. He also stated that the replacement ashtrays would be of the safe design.

711.2(a)(1)