San Simeon By the Sound Center for Nursing & Rehabilitation

Based on record review, observation and staff interviews during the standard survey, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs for 1 of 12 residents, reviewed for Psychotropic drug use, in a total sample of 24 residents. Specifically, Resident #11 received a hypnotic medication (Ambien) without documented evidence that it was clinically indicated, that behavioral interventions or other non pharmacological interventions were attempted prior to the use of the hypnotic, or that an attempt was made to taper or discontinue the medication was documented. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #11, was admitted to the facility 10/2/09,with diagnoses that include Congestive Heart Failure, Spinal Stenosis and Insomnia.

The Minimum Data Set (MDS) Assessment dated 8/15/10 documented that the resident was independent with daily decision making. The MDS also documented that the resident received a hypnotic medication daily.

During an observation on 9/22/10 and 9/23/10 at 8:00 AM, the resident was observed sitting in a wheelchair in the dining room. The resident stated that she was still "very sleepy" and that she did sleep during the night. The resident also stated that "some mornings I am so sleepy and I don't know why."

The Physician's Order Form (POF) dated 10/2/09, 12/2009, and 1/2010 documented Ambien 5 Milligrams (mg) when necessary (PRN).

The Medication Administration Records (MAR) dated 10/2009,11/2009,12/2009 documented Ambien 5 mg at bedtime PRN. The MAR also documented that the resident did not receive the Ambien.

A review of the Integrated Progress Notes (IPN) dated 12/2/09, 12/16/09 and 1/5/10 documented that the resident had a PRN Ambien Physician Order and that the resident had not requested the medication. There was no documentation that the resident had difficulty sleeping.

A re- admission POF dated 2/25/10 and subsequent POF's dated 3/2010, 5/2010,6/2010,7/2010 and 9/2010 documented Ambien 5 mg every night at bedtime.

The MAR's dated 2/2010 through 9/2010 documented that the resident received Ambien 5 mg every night at bedtime. There was no documentation that non-pharmacological interventions were used to address insomnia (if present) prior to the use of a pharmacological agent.

The Comprehensive Care Plan (CCP) with the heading: Altered Sleep Pattern dated 1/6/10 through 8/25/10 had no documented evidence of any non- pharmacological interventions.

The Pharmacy Consultant made a recommendation in the monthly review completed on 4/19/10 and 8/14/10 that Ambien should be changed from daily use to an as needed basis and that this medication is not for long term use.

The Physician Desk Reference (PDR) documents that Ambien is to be used short term for 7 to days. The PDR also documented re evaluate if needed for more than 2 to 3 weeks.

There was no documented evidence in the medical record from 2/25/2010 through 9/22/10 as to why the Ambien was administered every night. There was no documented evidence that the Physician addressed the Pharmacy consultant's recommendations (to use Ambien as needed basis) or any evidence that the physician evaluated the continued use of the Ambien.

An interview was held on 9/23/10 at 12:00 PM with the Pharmacy Consultant. The Pharmacy Consultant stated that she recommended on 4/19/10 and 8/14/10 that the Physician change the Ambien from daily to PRN because the medication is not to be used on a long term basis.

An interview was held on 9/23/10 at 11:00 AM with the Registered Nurse (RN) Charge Nurse. The RN reviewed the medical record and stated that there was no documented evidence that the Physician addressed the Pharmacy Consultant recommendations. The RN also stated that there is no documented evidence for the clinical reason, alternate interventions, or evaluation of the Ambien.

An interview was held on 9/23/10 at 12:30 PM with the Director of Nursing Services (DNS).The DNS stated that there is no documented evidence that the Physician addressed the Pharmacy Consultants recommendation.

The Physician was not available for interview on 9/23/10 at 12:40 PM.

An interview was held on 9/23/10 at 12:45 PM with the DNS. The DNS stated that she just spoke with the resident's Physician. The Physician stated to her that he was not aware of the Pharmacy consultants recommendations to decrease the Ambien to PRN.

415.12 (l)(1)

Based on record reviews and staff interviews during the standard survey, the facility did not ensure that one of five sampled residents reviewed for immunizations was addressed timely. Specifically, Resident #11 had an admission Physician's Order to administer a Purified Protein Derivative (PPD) test for Tuberculosis (TB) that was not completed. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #11, was admitted on 10/2/09 with diagnoses that include Congestive Heart Failure, Spinal Stenosis and Hypertension.

The physician's order dated 10/2/09 documented to administer a PPD skin test.

There was no documented evidence in the resident's Immunization Record, Interdisciplinary Progress Notes or the Medication Administration Record (MAR) that a PPD was administered as ordered on admission 10/2/09.

A facility policy dated 8/24/08 documented that upon admission all residents are to receive a PPD.

An interview was held on 9/23/10 at approximately 11:00 AM with the Nurse Manager Registered Nurse who reviewed the medical record and stated that there was no documented evidence that the PPD was completed.

An interview was held on 9/23/10 at approximately 11:00 AM with the Director of Nursing Services (DNS)/Infection Control Coordinator. The DNS stated that the PPD should have been completed on admission.

415.19(a)(1-3)

Based on record review and staff interviews during the standard survey, the facility did not ensure that residents are seen by a physician at least once every 30 days for the first 90 days after admission. Specifically, one of 24 residents reviewed for Physicians visits did not have 30 day Physician's Orders completed for 11/2009. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #11 had Diagnoses including Congestive Heart Failure, Hypertension and Spinal Stenosis.

The Admission Physicians Order Form (POF) was dated 10/2/09. The next POF was dated 12/3/09 (60 day) then 1/2/10 (90 day).

There was no documented evidence that the Physicians's 30 day orders were completed for the month of November 2009.

An interview was held on 9/23/10 at 11:30 AM with the Registered Nurse (RN) Charge Nurse and the Director of Nursing Services (DNS). The RN and DNS reviewed the medical record and stated there was no documented evidence that 30 day Physicians Orders were completed. The DNS also stated that new admission residents are to be seen by the Physician once every 30 days, for the first 90 days and could not explain why this was not done.

415.15(b)(2)(ii)

Based on observation, record review, and staff interviews during the standard recertification survey, the facility did not attempt any recent restraint reduction for one of three residents reviewed for physical restraints in a total sample of twenty-four. Specifically, Resident #14 had a criss cross seatbelt in wheel chair when out of bed since 2/08 and no formal attempt was made by the facility to reduce this restraint to a less restrictive device. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #14 has diagnoses including Dementia, Schizophrenia and Hypothyroidism.

The Minimum Data Set (MDS) Assessment dated 8/21/10 documented the resident's behavior as repetitive and physically abusive. Her cognition was documented as moderately impaired. The MDS listed the use of a trunk restraint.

The resident was observed on 9/20/10 in the East dayroom throughout lunch service, sitting calmly, feeding her self with hardly any movement from 12:15 PM to 1:10 PM. Resident #14 was again observed on 9/21/10 at 12:00 PM seated calmly in her wheel chair in the day room.

The Restraint Comprehensive Care Plan dated 2/08 documented a Criss Cross Belt Trunk Restraint in chair.

The Monthly Restraint Assessments dated 8/09 through 9/10 all document the continued use of the Criss Cross Restraint in the chair. The Monthly Restraint Assessment also documented that the resident had a "history of raising from chair unassisted and attempts to ambulate/ cannot do so safely." There was no documented evidence that a least restrictive device was attempted.

During interview on 9/22/10 at 10:00 AM with the Registered Nurse/Nurse Manager, she stated that there had never been an attempt to reduced the restraint and Resident #14 does attempt on occasion to stand on her own.

During interview on 9/22/10 at 10:30 AM with the Certified Nursing Assistant, he stated that the resident is always placed in an area where she can be observed and she is generally quiet and sleeping.

415.4(a)(2-7)

Based on observation and staff interview, the facility did not ensure that the resident call bell system was fully functional in that when two or more call bells were activated in a semi-private resident room (from both beds and the bathroom), and the calling station serving both beds was reset, all call bells in the room were cancelled, including the bathroom. This was noted on two of four resident units.

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

The findings are:

On 9/20/10 between 9:00am- 1:00pm during the recertification survey, call bells were tested in resident rooms throughout the facility. When two or more call bells were activated in a semi-private resident room (from both beds and the bathroom) on the East and West units, and the calling station serving both beds was reset, all call bells in the room were cancelled, including the bathroom. (Staff members are required to respond in person to call bells originating in bathrooms prior to cancelling the call.) This configuration could be problematic if a resident were to activate the bedside call bell simultaneously with a roommate activating the call bell from the bathroom, since resetting the calling station serving the bed would reset both call bells and may result in a delay in getting assistance to the resident in the bathroom.

In an interview on 9/20/10 at approximately 10:51am, the Director of Plant Operations stated that he would call the nurse call company to reprogram the system immediately.

10NYCRR 415.29