Cuba Memorial Hospital Inc SNF

Based on record review and staff interview, the facility did not provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident. One (Resident #51) of 10 residents reviewed for pharmacy services had issues that involved the lack of pharmacy identification that physician orders did not include the frequency of administration of an as needed medication. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #51 has diagnoses that include paranoid schizophrenia, depression and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated 6/1/11 revealed the resident is understood and understands, with a BIMS (Brief interview for Mental status-a brief screen that aids in detecting cognitive impairment) of 15 (cognitively intact). The resident is independent with activities of daily living (ADLs).

Review of Physician Orders dated 6/3/10, 1/1/11, and 5/1/11 revealed a Physician Order for Lorazepam (Ativan) 1 milligram (mg) tablet for Ativan, one tab by mouth (po) as needed for anxiety. Review of Physician Orders dated 3/13/11, 4/21/11, 5/22/11 and 6/24/11 revealed orders to renew Ativan 1 mg. by mouth as needed for anxiety times 30 days. The orders do not contain a frequency of administration (ie: every 4 hours, every 6 hours or daily). Review of the Medication Administration Records (MARs) for 3/11, 4/11, 5/11, 6/11 and 7/11 revealed a transcribed Physician Order for Lorazepam 1 mg. tablet for Ativan, one tablet by mouth as needed for anxiety. The transcribed order did not contain the frequency of administration.

During an interview on 7/15/11 at approximately 10:00 AM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) stated she had reviewed the Physician Orders and MARs and the Lorazepam as needed (PRN) order does not have a frequency for administration.

When interviewed on 7/19/11 at 9:30 AM, the LPN Medication Nurse stated he was not sure if he had ever noticed there was no time frame for administration documented on the MAR and stated he knows there should have been times transcribed.

During an interview on 7/19/11 at 8:15 AM the Director of Nursing (DON) stated the Physician writes the order or gives the order verbally as a telephone order. The orders are then transcribed to the MAR by the Unit Secretary or a nurse. The orders are then checked by a second nurse. All MARs are double checked by 2 nurses as signed. Both written, verbal and printed orders are checked by 2 nurses. For this extended period of time the nurses checking the orders for accuracy should have found the error. In addition the DON stated the Pharmacy Consultant should have caught the omission as well.

Review of the facility Policy and Procedure (P&P) entitled: Medications-Administering, last revised 3/08, revealed the licensed staff administering medication must ensure that the right resident, right medication, right dosage, right time and right method of administration are verified before the medication is administered.

415.18(a)

Based on observation, record review and staff interview, the facility did not ensure that only authorized personnel had access to the narcotic keys. Two (Second Floor, Third Floor) of two resident units had an issue involving the exchange of narcotic keys between two nurses without counting the controlled substances. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #67 has diagnoses of congestive heart failure, chronic kidney disease, and is on palliative care. Review of the Minimum Data Set dated 7/1/11 revealed the resident's cognition is severely impaired.

Review of Physician's Orders dated 7/11/11 revealed orders for Roxanol (a controlled substance used to treat pain) 5 milligram (mg) by mouth (po) or sublingual (under the tongue) (20 mg/ml) every hour as needed for pain, restless, anxiety or respiratory distress times 30 days.

When observed on 7/12/11 at 12:35 PM the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) opened the double locked narcotic cabinet on the Second Floor unit, removed Roxanol 20 mg per 1 milliliter (ml), drew up .25 ml in a syringe and administered it to Resident #67 at 12:55 PM.

Review of the skilled nursing facility (SNF) 2 (Second Floor) Narcotic Count Sheet dated 7/12/11 with the day LPN Medication Nurse #1 revealed the day LPN Medication Nurse #2 had counted the narcotics with the night Medication Nurse (nurse leaving) and the again with the evening Medication Nurse (nurse coming on). There are no initials that the LPN RCC counted the narcotics on 7/12/11.

When interviewed on 7/13/11 at 9:30 AM, the day LPN Medication Nurse #2 on 7/12/11 stated there are two sets of keys to the narcotic cupboard. (She has one and pharmacist has one). The Medication LPN stated she counts the narcotic when she comes on with the off going nurse and counts them again with the oncoming nurse. The LPN Medication Nurse #2 stated on 7/12/11 she gave the narcotic cupboard keys the LPN RCC so she could give Morphine to Resident #67. The Medication LPN further revealed she gave the narcotic keys to the LPN RCC because she is her boss and further explained it does not happen very often.

When interviewed again on 7/13/11 at 1:45 PM the Medication LPN #2 stated she counted the narcotics with the off going nurse at the beginning of the shift and the oncoming nurse at the end of the shift to make sure the narcotics were all there and none were missing. The LPN said she did not count with anyone else.

When interviewed on 7/14/11 11:05 AM the LPN RCC stated the Medication Nurses count the narcotics at the beginning and end of their shift to make sure there are no narcotics missing The LPN RCC stated there is one set narcotic keys and the med nurse keeps the keys at all times. The LPN RCC further explained she went to the dining room on 7/13/11 and obtained the narcotic cupboard keys from the Medication LPN to administer Roxinal to Resident #67 for pain then returned the keys to the LPN Medication Nurse. The LPN RCC stated she should have counted the narcotics before she took the keys.

2 . During the medication storage review on the Third Floor at 8:00 AM on 7/14/11, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) was questioned if she had keys to the door of the medication room. She stated that she could get them from the medication nurse, left and returned with the keys at approximately 8:03 AM.

An interview with the LPN RCC at that time revealed she was in possession of the narcotic keys.

An interview with the LPN Medication Nurse at 8:05 AM revealed he counted the narcotics at 6:00 AM and would be counting them with the second shift at 2:00 PM. He further stated that all the keys are on the same key ring.

415.18(e)(1)

Based on observation, record review and staff interview, a resident who is unable to carry out activities of daily living did not receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Two (Residents #8, 30) of 15 residents observed for activities of daily living care provided by staff had issues involving improper cleansing technique during peri care (washing the genitals and the rectal area) and a resident wearing inappropriate footwear. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #30 has diagnoses including chronic obstructive pulmonary disease, hypertension and is extremely hard of hearing. Review of the Minimum Data Set (MDS) dated 6/29/11 revealed the resident is cognitively intact.

Review of the Interdisciplinary Plan of Care dated 7/6/11 revealed the resident requires the extensive assistance of one for hygiene.

Observation on 7/14/11 at 5:05 AM revealed the resident was sitting on the toilet and a night Certified Nurse Aide (CNA) put on gloves and washed the resident's female genitalia (the area including the genitalia and rectum). The CNA washed the resident using a repeated back to front motion and did not change the position of the washcloth. The CNA then cleansed the rectal area.

During an interview on 7/14/11 at 5:20 AM, the CNA stated she usually cleanses the resident's peri area by washing from back to front and the rectal area from front to back.

When interviewed on 7/14/11 at 5:45 AM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) stated that when washing female genitalia, the CNA should have washed one side from front to back, turn the washcloth, wash the other side from front to back, turn the washcloth, and then wash down the middle using a clean area of the cloth for each stroke. The CNA should then remove their gloves, wash their hands, apply new gloves and then cleanse the rectal area with a new washcloth. After completing care, the CNA should then remove the gloves and wash their hands.

2. Resident #8 has a diagnosis of Alzheimer's dementia. Review of the Minimum Data Set (MDS) dated 6/15/11 revealed the resident has moderate cognitive impairment.

Review of the Interdisciplinary Plan of Care dated 7/5/11 revealed Resident #8 has a self care deficit and is unable to reach her lower extremities.

Intermittent observations from 7/12/11 to 7/15/11 and 7/18/11 from between the hours of 9:00 AM and 3:00 PM revealed the resident was wearing sneakers while sitting in a chair in front of the nurses' station. There were no laces in the sneakers

Interview with a Certified Nurse Aide (CNA) on 7/15/11 at 10:15 AM revealed that the resident wears the sneakers without laces because her feet get swollen.

Interview with the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) on 7/18/11 at 2:45 PM revealed the resident's feet swell "once in a blue moon". The LPN RCC further stated that the resident's family brought slippers in for the resident to wear, so she didn't know why the sneakers were still being put on the resident.

At 3:05 PM on 7/18/11, the LPN RCC stated that she checked Resident #8's room and found six pair of slippers with non skid soles belonging to the resident in her room. The LPN RCC was observed to put a pair of the slippers on the resident, walked her around and the resident ambulated without difficulty. The LPN RCC stated that the sneakers were tight because the resident had slipper socks on under the sneakers.

Review of Nursing Progress Notes dated 7/1/11 through 7/14/11 revealed no documented evidence that the resident experienced edema (swelling) in her feet and/or ankles.

415.12(a)(3)

STATE ONLY

The facility shall provide oral hygiene care and routine and 24-hour emergency dental care in accordance with the comprehensive resident care plan and which meets generally accepted standards of dental and dental hygiene care and services.

A complete oral examination of each resident shall be conducted by a licensed and currently registered dentist or dental hygienist within 7 days following completion of the initial comprehensive assessment in accordance with Section 415.11 of this Part and by a dentist at least annually thereafter.

This REQUIREMENT is not met as evidenced by:
Based on observation, record review and staff and resident interview, the facility did not provide or obtain routine dental services to meet the needs of each resident. One (Resident #15 ) of three residents reviewed for dental services had a delay in obtaining an initial dental consult following admission to the facility. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #15 has diagnoses including diabetes mellitus, hypertension, and dysphagia (difficulty swallowing). Review of the resident's face sheet revealed she was admitted to the nursing facility on 6/14/11. Review of the Minimum Data Set (MDS) dated 6/23/11 revealed the resident has a BIMS (Brief Interview for Mental Status - a brief screen that aids in detecting cognitive impairment) score of 15 indicating the resident is cognitively intact and able to make her own decisions.

Observation of the resident on 7/13/11 at 11:00 AM revealed the resident was edentulous (toothless). During the interview, the resident stated she did not have any dentures and would like to get fitted for dentures so she could chew her food and not have a pureed or ground diet. During the interview, the resident stated she was not fond of the food because she receives puree fruits and vegetable and ground meat. The resident stated when she first came in everything was pureed and she doesn't like pureed food.

Review of the Dental consult section of the medical record on 7/15/11 revealed no documentation the resident had been seen by the Dentist.

Interview with the Unit Secretary on 7/15/11 at approximately 11:00 AM revealed she is a fairly new staff member and was not aware Dental consults needed to be completed 30 days after admission. In an additional interview on 7/19/11 at 10:20 AM, the Unit Secretary stated she made an appointment for the resident to be seen by the dentist 2 weeks ago and the resident will have her initial consult with the dentist on 8/8/11.

415.17(b)(c)

Based on observation, record review, resident and staff interview, the nursing facility did not provide or obtain dental services to meet the needs of each resident. One (Resident #30) of three residents reviewed for routine/emergency dental services had an issue that involved a delay in referring a resident with loose dentures to the dentist. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #30 has a diagnosis of chronic obstructive pulmonary disease (COPD) and is extremely hard of hearing. Review of the Minimum Data Set (MDS) dated 1/19/11 revealed the resident is cognitively intact. The Interdisciplinary Plan of Care dated 7/6/11 documented a plan to monitor for loose or poor fitting dentures and arrange for a dental consult bi-yearly as needed.

When interviewed on 7/12/11 at 3:13 PM, the resident stated she has chewing problems. The resident explained she cannot chew anything that is not cooked enough or hard because her lower dentures are loose. The resident further explained she takes out her bottom dentures after she eats because they fall out and has not been back to the dentist about the loose dentures.

When observed on 7/14/11 at 5:05 AM, the night certified nurse aide (CNA) put on gloves, cleaned the resident's dentures, gave the dentures to the resident and she placed them in her mouth.

When interviewed on 7/14/11 at 8:45 AM, the resident pointed to her lower dentures and stated they are loose and move up and down sometimes when she eats. The resident also said the dentures sometimes fall out and she is not aware of it.

During an interview on 7/14/11 at 9:34 AM, the Unit Secretary stated the last time the resident was seen by the dentist was 11/18/10 and she is scheduled for an annual dental exam 11/11. The Unit Secretary reviewed the Dental list dated 8/8/11 and stated the resident is not on the list to be seen.

When interviewed on 7/14/11 at 11:55 AM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) stated the residents are seen by the dentist within 24 to 48 hours of admission, annually, and if there is an issue. The LPN RCC stated the resident has fallen asleep and dropped the dentures out of her mouth on two occasions that she is aware of and they broke. Today, the RCC explained, she saw the resident sleeping and the lower dentures were falling out. The RCC stated the resident's dentures "periodically" fall out when she falls asleep. The LPN RCC said she asked the resident if her lower dentures were loose but did not use the communication wipe board and she does not think the resident heard her.

On 7/15/11 at 8:46 AM, the LPN RCC informed the surveyor that the resident had an appointment to see the dentist today for her lower loose dentures. The RCC stated the resident informed her she would like new dentures but does not know if she can afford them.

When interviewed on 7/15/11 at 11:59 AM, the day CNA stated the resident's lower dentures have been loose for about two months. The CNA explained that the resident does not like Fixodent (denture adhesive). She further explained she had not told anyone that the resident's lower dentures were loose.

When interviewed on 7/15/11 at approximately 1:00 PM, the Dental Clinic Manager stated the resident was seen on 9/16/10 and it was recommended that the lower dentures be relined. The resident was told she had a poor lower ridge and explained that means she has had her dentures so long that the ridge is worn off flat and that would make an ill fitting denture. Further interview with the Dental Clinic Manager revealed that the relined lower denture was delivered and fitted to the resident on 9/24/10. The relined dentures were still loose and a recommendation was made to nursing to use Fixodent. The Manager explained she has not been notified of any problem with the resident's lower denture not fitting. She stated the resident could have new dentures but that would probably not correct the problem.

415.17(3)

Based on observation, record review and staff interview, a comprehensive care plan was not periodically reviewed and revised by a team of qualified persons after each assessment. Two (Residents #7, 30) of 19 residents reviewed for care plans had an issue involving the lack of documented care plan revisions to reflect Occupational and Physical Therapy recommendations for range of motion. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #7 has diagnoses of diabetes mellitus and peripheral vascular disease (poor circulation in the lower extremities). Review of the Minimum Data (MDS) dated 6/22/11 revealed the resident has moderate cognitive impairment.

a). Review of the Interdisciplinary Plan of Care dated 1/14/11 revealed an approach for nursing to provide AROM (Active Range of Motion - the range of joint movement that can be performed without assistance) to BLE (bilateral lower extremities). There was no plan to provide range of motion to the upper extremities.

Review of an Occupational Therapy (OT) Screen dated 6/16/11 revealed recommendations for nursing staff to provide PROM to bilateral upper extremities daily. A Physical Therapy (PT) Screen dated 6/17/11 documented recommendations for nursing staff to provide AROM to the bilateral lower extremities daily.

The untitled certified nurse aide (CNA) pocket care plan dated 7/11/11 documented a plan to provide AROM to the bilateral upper extremities and Passive Range of Motion (PROM) to the bilateral lower extremities.

The 1/11 Interdisciplinary Plan of Care did not include the ROM recommendations from the 6/16/11 OT Screen or the 6/17/11 PT Screen.

During an interview on 7/17/11 at 11:22 PM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) reviewed the CNA Pocket Care Plan dated 7/11/11 and the Interdisciplinary Care Plan dated 1/14/11 and confirmed the plans for range of motion were different. The LPN RCC stated that the OT recommendation was not on the Interdisciplinary Plan of Care, the Pocket Plan should document PROM to both upper extremities (not PROM to bilateral lower extremities) and AROM to bilateral upper extremities (not AROM to bilateral lower extremities). The LPN RCC explained that the Senior CNA updates the Pocket Care Plan and entered the range of motion recommendations into the Pocket Care Plan incorrectly. The LPN RCC stated that no one checks the Pocket Care Plan after the CNA makes changes. The LPN RCC explained she does the Interdisciplinary Care Plan and the Registered Nurse (RN) initials it, but it has not been initialed by the RN since 1/11. The LPN RCC stated the Interdisciplinary Care Plan and CNA care plan should match and they do not.

b). Additional review of Resident #7's Interdisciplinary Plan of Care dated 1/14/11 revealed an approach for regular heel booties AATs (at all times) except for transfer. Sneakers to be worn for transfers only.

Observation on 7/14/11 at 8:25 AM, 9:25 AM, and 12:52 PM revealed the resident was sitting in a recliner in her room and had sneakers on.

When interviewed on 7/14/11 at 1:30 PM, the CNA stated the resident is supposed to wear heel booties in bed and sneakers when out of bed. The CNA stated she did not know if the care plan had been changed. The CNA removed the Pocket Care Plan from her pocket and stated "It has been changed".

During an interview on 7/14/11 at 1:40 PM, the LPN RCC stated that the Interdisciplinary Care Plan is for booties at all times (AAT) and sneakers during transfer, but the booties were taken off at the resident's request and the Interdisciplinary Care Plan has not been updated.

After reviewing the SNF (Skilled Nursing Facility) Flow Sheet dated 7/11, the LPN RCC stated that the Senior CNA should have updated the SNF Flow Sheet, taken off the heel booties AAT and entered "sneakers when OOB" (out of bed).

2. Resident #30 has diagnoses including chronic obstructive pulmonary disease, osteoarthritis and is extremely hard of hearing. Review of the Minimum Data Set (MDS) dated 6/29/11 revealed the resident is cognitively intact.

Review of a Physician Order dated 6/24/11 revealed an order to provide PROM (passive range of motion) to bilateral lower extremities (BLE).

Review of a Physical Therapy Screen dated 6/24/11 and an Occupational Therapy (OT) Screen dated 6/27/11 revealed recommendations for nursing staff to provide daily PROM to bilateral lower and upper extremities to promote and maintain maximum joint integrity, mobility, and function.

Review of the Interdisciplinary Care Plan dated 7/6/11 revealed no documented evidence of a plan to provide range of motion. The untitled certified nurse aide (CNA) pocket care plan dated 7/11/11 documented a plan for PROM to the BUE (bilateral upper extremities) and did not include a plan for lower extremity ROM.

Review of a Physician Order dated 7/6/11 revealed an order for PROM to bilateral upper extremities (BUE) once a day (qd) to be provided by a certified nurse aide (CNA).

During an interview on 7/14/11 at 11:42 AM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) reviewed the Interdisciplinary Plan of Care dated 7/6/11 and stated "I do not see a care plan for range of motion (ROM)".

When interviewed on 7/15/11 at 8:47 AM, the LPN RCC stated the PT screen recommended PROM to the lower extremities, it was not on the care plans and it has now been added. The LPN RCC stated she found a care plan dated 12/09 with the ROM on it and it did not get carried over to the present care plan.

415.11(c)(2)(iii)

Based on record review and staff interview, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs. One (Resident #39) of three residents reviewed for psychotropic drugs had issues involving lack of justification for use of an antipsychotic medication. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #39 has a diagnosis of Alzheimer's dementia. Review of the Minimum Data Set (MDS) dated 4/20/11 revealed the resident has severe cognitive impairment, no psychosis or behavior issues.

Review of Physician Orders dated 5/6/10 revealed an order for Seroquel (antipsychotic) 50 milligram (mg) at bedtime (hs) for behavior. Review of the Physician's Progress Notes from 5/7/10 through 6/16/11 revealed no documented evidence that the Seroquel is being used to treat psychosis or behaviors or to support the use of Seroquel for relaxation and sleep.

Review of the Annual History and Physical (H&P) dated 6/16/11 documented the resident remains on the Seroquel to help her relax and sleep. Review of the Comprehensive Care Plan (CCP) dated 4/27/11 revealed no documented evidence the resident has had behaviors affecting her ability to sleep or relax.

Review of the Medication Regimen Review from 2/22/11 through 6/30/11 revealed no recommendations by the pharmacist regarding the use of the antipsychotic Seroquel for relaxation and sleep.

A telephone interview with the Pharmacy Consultant on 7/15/11 at 2:10 PM revealed the physician feels that the low dose of Seroquel works well for sleep in some patients so she did not make any recommendations about the justification for its use even though she noticed the Physician documented the resident remains on Seroquel to help her relax and sleep.

415.12(l)(1)

Based on observation, record review and staff interview, the facility did not maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. Two (Residents #7, 30) of two residents observed for infection control practices had issues involving lack of proper hand hygiene during direct resident care. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #7 has a diagnosis of diabetes mellitus and peripheral vascular disease (PVD-poor circulation of the lower extremities). Review of the Minimum Data Set (MDS) dated 6/22/11 revealed the resident's cognition is moderately impaired. Review of the Interdisciplinary Plan of Care (comprehensive care plan (CCP)) dated 1/14/11 revealed directions for the resident to wash upper extremities and requires limited/extensive/total assist of one/two staff.

When observed on 7/14/11 at 6:07 AM, a Certified Nurse Aide (CNA) applied gloves and asked the resident if he wanted to wash his face and the resident stated "yes" and washed his face. The CNA washed the resident's upper body, back then the peri rectal (area between the genitalia and anus) area. The CNA removed the resident's socks, applied clean socks and then did passive range of motion (PROM) to the resident's left upper and lower extremity. The CNA was then observed to put the soiled linen in a plastic bag, empty the resident's wash basin and pick up a foam cup of water with a straw from the stand and place it on the over bed table. The CNA opened the privacy curtain, pressed the electric button on the bed, opened the door with the right gloved hand and then took off her left glove and disposed of the linen in a soiled room and washed her hands for 15 seconds.

When interviewed on 7/14/11 at 1:13 PM the CNA stated she usually cleanses the peri area, changes gloves and sanitizes her hands and then cleanses the rectal area and removes gloves and sanitizes hands. The CNA stated she should have taken her gloves off after peri rectal care and then wash her hands 10 to 15 seconds.

2. Resident #30 has diagnoses of chronic obstructive pulmonary disease, hypertension and is extremely hard of hearing. Review of the Minimum Data Set (MDS) dated 6/29/11 revealed the resident is cognitively intact. Review of the Interdisciplinary Plan of Care dated 7/6/11 revealed the resident requires extensive assistance of one for hygiene.

When observed on 7/14/11 at 5:05 AM the resident was sitting on the toilet and the night Certified Nurse Aide (CNA) put on gloves and provided peri rectal care then applied lotion to the resident's buttock. She pulled up the brief and adjusted the resident's clothing before she removed her gloves and ambulated the resident from the bathroom to the chair in the hall. The CNA then went to the nurses' station, opened a drawer, and removed the resident's hearing aid and placed it in the resident's right ear. The CNA then returned to the resident's room and put the wash basin away, picked linen up off the bed, reapplied gloves and took the linen to the dirty utility room. The CNA then removed her gloves and washed her hands.

When interviewed on 7/14/11 at 5:20 AM the CNA stated she did not wash her hands after peri rectal care because she had gloves on.

When interviewed on 7/14/11 at 5:45 AM Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) stated after providing peri care you should remove the gloves, wash hands and reapply gloves, then cleanse the rectal area, remove gloves, and wash hands.

415.19(4)

Based on record review and staff and resident interview, the facility did not ensure that prompt efforts were made to resolve a resident's grievances. One (Resident #30) of three residents reviewed for personal property had an issue involving the lack of timely follow-up of the resident's concerns regarding missing money and personal property. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #30 has a diagnosis of chronic obstructive pulmonary disease (COPD) and is extremely hard of hearing. Review of the Minimum Data Set (MDS) dated 1/19/11 revealed the resident is cognitively intact.

When interviewed on 7/12/11 at 2:58 PM, the resident stated she had approximately one dollar in change and a red bird ornament missing. The resident stated the items have been missing about a month. The resident explained that she told one of the girls (certified nurse aide (CNA)) that they were missing and the items are still missing.

During an interview on 7/14/11 at 11:49 AM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) stated that the resident had not reported anything missing recently and if she had she would have filled out a Lost Items Form. The LPN explained that if the resident told the CNAs, they have not informed her.

When interviewed again on 7/14/11 at 3:59 PM, the LPN RCC stated she would look into the resident's missing property.

During an interview on 7/15/11 at 8:45 AM, the LPN RCC stated the resident informed her that she (the resident) had told the night CNA about the missing items. The LPN RCC stated she interviewed the night CNA, who stated the resident's red bird figurine was in another resident's room with the other resident's initials on the bottom of the figurine. The CNA also knew where the resident's money was. The LPN RCC stated both items have been found and the resident has been made aware of this. The LPN RCC stated she asked the CNA why she had not told her about the missing item and the CNA informed her she knew where the items were and did not think it was a problem.

Review of a Lost Items Report dated 7/14/11 revealed the lost items were recovered by the night CNA and returned to the owner by the LPN RCC.

415.3(c)(1)(ii)

Based on observation, record review and staff interview, the facility did not ensure that a resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Two (Residents #7, 30) of three residents observed for range of motion (ROM) had issues involving incomplete ROM and ROM that was not provided as planned in accordance with Occupational and Physical Therapy recommendations. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #30 has diagnoses including chronic obstructive pulmonary disease, osteoarthritis and is extremely hard of hearing. Review of the Minimum Data Set (MDS) dated 6/29/11 revealed the resident is cognitively intact.

Review of a Physician Order dated 6/24/11 revealed an order to provide PROM (passive range of motion) to bilateral lower extremities (BLE).

Review of a Physical Therapy Screen dated 6/24/11 and an Occupational Therapy (OT) Screen dated 6/27/11 revealed recommendations for nursing staff to provide daily PROM to bilateral lower and upper extremities to promote and maintain maximum joint integrity, mobility, and function.

Review of the Interdisciplinary Care Plan dated 7/6/11 revealed no documented evidence of a plan to provide range of motion. The untitled certified nurse aide (CNA) pocket care plan dated 7/11/11 documented a plan for PROM to the BUE (bilateral upper extremities) and did not include a plan for lower extremity ROM.

Review of a Physician Order dated 7/6/11 revealed an order for PROM to bilateral upper extremities (BUE) once a day (qd) to be provided by a certified nurse aide (CNA).

Observation on 7/14/11 at 5:05 AM revealed the resident was dressed and sitting on the toilet with a gait belt on. The CNA who was in the resident's room stated she got the resident up at 5:00 AM and provided morning care in the bathroom.

During an interview on 7/14/11 at 5:30 AM, the CNA stated that when she put the resident's shirt on, she had the resident bend her elbow back and forth; raise her arm; and "whirl the washcloth in the air" for range of motion.
When observed on 7/14/11 at 8:00 AM, the resident was sitting at a table in the hall, eating breakfast. The resident's meal tray was on a table that was chest high. The resident was observed to grasp the spoon with her right hand, and then lean forward to the food to feed herself instead of raising the spoon to her mouth. The resident was also observed eating toast. The resident kept her right elbow flexed and resting on the table, the resident scooped the jelly off the plate with the toast and leaning forward, placed the toast into her mouth.

During an interview on 7/14/11 at 8:45 AM, the surveyor explained PROM to the resident and the resident stated that the CNA did not do ROM with her morning care "today or any other day". The resident pointed to her right shoulder and stated "I fell and cannot raise my shoulder up because I hurt it".

When interviewed on 7/14/11 at 11:42 AM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) stated ROM is done with morning care and she expects the CNA to physically move the resident's arms for PROM to the bilateral upper extremities. The LPN RCC stated that PROM should take at least 15 minutes. The LPN RCC stated that the CNA pocket care plan directs for PROM to both upper extremities and the CNA carry cards with them so they know how to do ROM.

During an interview on 7/14/11 at 11:54 AM, the LPN RCC and Social Worker (SW) confirmed that Resident #30 is an accurate historian.

During an interview on 7/15/11 at 8:47 AM, the LPN RCC stated that the 6/24/11 PT screen recommended PROM to the lower extremities, it was not on the care plans and it has now been added.

When interviewed on 7/15/11 at 9:57 AM, the Occupational Therapist Rehabilitation Manager confirmed that the plan for Resident #30 is for nursing staff on the unit to provide PROM to all joints of the upper and lower extremities. The Occupational Therapist explained that the CNAs are provided ROM flip cards and they should do BUE ROM consisting of bilateral shoulder, elbow, wrist and finger flexion (bending of a joint) and extension; internal and external rotation of the shoulder, adduction (movement towards the body), abduction (movement away from the body) of the shoulder, horizontal adduction and abduction of the shoulders and supination (position of the forearm with the palm facing up)and pronation (rotational movement of the forearm) of the wrists.

The Occupational Therapist also explained that BLE ROM includes bilateral hip flexion, extension, abduction, abduction, and internal and external rotation; bilateral knee flexion, extension, dorsiflexion (upward movement) and plantarflexion (a toe-down motion of the foot at the ankle), foot inversion and eversion and toe flexion and extension.

The Occupational Therapist stated it should take the CNA 10 to 15 minutes to do 5 to 10 repetitions of ROM on a cooperative resident. The Occupational Therapist also stated that whirling a cloth in the air would not be part of ROM.

When observed on 7/15/11 at 10:35 AM, the OT Rehab Manager assessed Resident #30's upper and lower extremity ROM. The resident was heard to tell the Occupational Therapist that she is not getting ROM exercises and stated "No one has been moving my arms but me".

When interviewed on 7/15/11 at 11:28 AM, the OT Rehabilitation Manager stated the resident had declines in the following joints since the 6/27/11 OT Screen:

- Right hand extension - 10 degrees,
- Left shoulder extension - 15 degrees,
- Left hand flexion - 10 degrees,
- Right hip flexion - 10 degrees,
- Right hip extension - 9 degrees,
- Right knee flexion - 5 degrees,
- Left hip flexion - 3 degrees,
- Left hip extension - 10 degrees,
- Left hip abduction - 15 degrees.

2. Resident #7 has diagnoses including diabetes mellitus and peripheral vascular disease (PVD - poor circulation of the lower extremities). Review of the Minimum Data Set (MDS) dated 6/22/11 revealed the resident has moderate cognitive impairment.

Review of the Interdisciplinary Plan of Care dated 1/14/11 revealed an approach for nursing to provide AROM (Active Range of Motion - the range of joint movement that can be performed without assistance) to BLE (bilateral lower extremities). There was no plan to provide range of motion to the upper extremities.

Review of an Occupational Therapy (OT) Screen dated 6/16/11 revealed recommendations for nursing staff to provide PROM to bilateral upper extremities daily. A Physical Therapy (PT) Screen dated 6/17/11 documented recommendations for nursing staff to provide AROM to the bilateral lower extremities daily.

The untitled certified nurse aide (CNA) pocket care plan dated 7/11/11 documented a plan to provide AROM to the bilateral upper extremities and Passive Range of Motion (PROM) to the bilateral lower extremities.

The 1/11 Interdisciplinary Plan of Care did not include the ROM recommendations from the 6/16/11 OT Screen or the 6/17/11 PT Screen.

Review of Physician's Orders revealed an order dated 6/17/11 for nursing staff to provide AROM to BLEs daily and an order dated 6/23/11 for daily PROM to BLE by a CNA.

Observation on 7/14/11 at 6:07 AM revealed a CNA provided PROM to the resident's left upper and lower extremities. The CNA did not provide ROM to the right upper or lower extremity.

During an interview on 7/14/11 at 6:34 AM, the CNA stated that Resident #7 gets ROM to both sides. The CNA was observed to obtain a mechanical lift, asked another CNA to help her get the resident out of bed and did not complete PROM.

When interviewed on 7/17/11 at 11:22 AM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) stated that the CNAs follow the pocket care plan to do ROM.

During an interview on 7/14/11 at 1:10 PM, the CNA stated that Resident #7 is supposed to receive AROM to both upper extremities and PROM to both lower extremities. The CNA stated she did PROM on the upper and lower extremity on the left and should have done ROM to the right side but "I didn't".

415.12(e)(2)

Based on record review and staff and resident interview, the facility did not ensure a resident's right to choose activities, schedules, and health care consistent with his or her interests and make choices about aspects of his or her life in the facility that are significant to the resident. One (Resident #30) of 19 residents reviewed for choices was not given the opportunity to choose her preferred bedtime. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #30 has a diagnosis of chronic obstructive pulmonary disease (COPD) and is extremely hard of hearing. Review of the Minimum Data Set (MDS) dated 1/19/11 revealed the resident is cognitively intact and it is "somewhat important" to the resident that she choose her own bedtime. Additional review of the MDS revealed the resident requires extensive staff assistance for personal hygiene, toilet use and dressing.

When interviewed on 7/12/11 at 2:46 PM, the resident stated she does not participate in choosing her bedtime; the staff decides when she goes to bed; and this is not acceptable to her. The resident stated she would like to go to bed between 8:30 PM to 9:00 PM but that she is put to bed at 10:00 PM and "that is too late". She further stated "The staff is too busy and they do not get around to me".

Review of the Interdisciplinary Plan of Care dated 7/6/11 and the untitled certified nurse aide (CNA) pocket care plan dated 7/11/11 revealed there was no documentation regarding the resident's choice of when to go to bed.

During an interview on 7/14/11 at 3:37 PM, the evening shift CNA stated the resident prefers to go to bed between 8:00 PM and 9:00 PM "but the resident is not always getting to bed at that time". The CNA explained that there are a lot of "new staff", every resident has different "quirks" regarding when they want things done and the new staff will have to learn what they are. The CNA stated last week at 9:55 PM when she was ending her shift, another staff member was just getting ready to put the resident to bed. The evening CNA explained that she refers to the CNA pocket care plan to know what the resident wants and stated there is nothing on the pocket care plan indicating when the resident wants to go to bed.

During an interview on 7/14/11 at 3:52 PM, the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) stated choices about bedtime would be on the CNA pocket care plan. The LPN RCC stated that Resident #30 wants to go to bed at 9:00 PM and "I did not put it on the care plan". The LPN RCC explained there are "lots of new staff" and they would only know when the resident wanted to go to bed if she rang her bell or if it were on the pocket care plan.

415.5(b)(1)(3)

Based on observation, record review and staff and resident interview, the services provided or arranged by the facility did not meet professional standards of quality. One (Resident #7) of 19 residents reviewed for professional standards had an issue involving the lack of clarification/ discontinuation of a physician's order to provide booties at all times. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #7 has diagnoses of diabetes mellitus and peripheral vascular disease (poor circulation in the lower extremities). Review of the Minimum Data Set (MDS) dated 6/22/11 revealed the resident has moderate cognitive impairment.

Review of the current Interdisciplinary Plan of Care dated 1/14/11 revealed a plan for regular heel booties AATs (at all times) except for transfer, sneakers are to be worn for transfers only.

Review of a Physician's Order dated 6/4/11 revealed an order for regular heel booties AAT, except for transfer, sneakers to be worn for transfer only.

Observation on 7/14/11 at 6:07 AM following morning care, a certified nurse aide (CNA) put the resident's sneakers on and transferred the resident from bed to a recliner, using a sit to stand mechanical lift.

Observation on 7/14/11 at 8:25 AM, 9:25 AM, and 12:52 PM revealed the resident was sitting in the recliner in her room with the sneakers on.

During an interview on 7/14/11 at 1:21 PM, the Licensed Practical Nurse (LPN) Treatment Nurse stated the heel booties were discontinued. After reviewing the Physician Order dated 6/4/11, the LPN confirmed there was an order for the heel booties and stated there was no order to discontinue the heel booties.

When interviewed on 7/14/11 at 1:22 PM, the Unit Secretary (US) stated the resident's heel booties were not discontinued, they were taken off the treatment record and are now on the CNA flow sheet.

During an interview on 7/14/11 at 1:40 PM, the LPN Resident Care Coordinator (RCC) stated that the Interdisciplinary Plan of Care is for booties AAT and sneakers for transfer. The LPN RCC stated the booties were applied because the resident used the heel of his sneaker to itch his lower leg. She stated the booties were taken off at the resident's request and that she would call the doctor and get an order to discontinue the heel booties AAT.

When interviewed on 7/14/11 at 1:57 PM, the resident stated his lower leg itches once in awhile. The resident explained that he did not want to wear the blue booties anymore because they kept falling off. He would have to call someone to put them back on and he did not think the staff liked doing that.

415.11(c)(3)(i)

1. Resident #44 has diagnoses that include depression and chronic obstructive pulmonary disease.

Review of the Minimum Data Set (MDS) dated 5/11/11 revealed the resident has moderate cognitive impairment, is understood and understands and is dependent on staff for activities of daily living (ADLs).

During observation of medication administration on 7/15/11 at approximately 7:30 AM, a Licensed Practical Nurse (LPN) administered two medicated inhalers, Spiriva 30 and Advir Diskus to Resident #44 while he was in the Third Floor Dining Room. During the administration, two other residents were observed seated at the same table with the resident and there were approximately 25 other residents in the dining room.

During an interview on 7/15/11 at 7:30 AM, the LPN administering the inhalers stated he was told it was acceptable to administer inhalers in the dining room as long as the meal had not been served.

During an interview on 7/15/11 at 8:30 AM, the LPN Resident Care Coordinator (RCC) stated inhalers, eye drops or glucose monitoring are not to be done in public areas, "The resident should be taken to their room".

When interviewed on 7/19/11 at 8:30 AM, the resident stated he did not care if staff administered his breathing treatments in the dining room.

415.5(a)