Bayberry Nursing Home

Based on observation, record review and interview, the facility did not ensure that a resident's drug regimen was monitored through aprropriate laboratory testing. Specifically, a resident who was receiving a cholesterol lowering medication did not have Liver Function Tests done as ordered by the physician. (Resident #66).

This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.ne
The findings are:

Resident #66 has diagnoses including Parkinson's Disease, History of Falls, Cerebral Contusion, Chronic Obstructive Pulmonary Disease, Hypertension and Hyperlipidemia.

A review of the Physician's Order Form dated 7/20/11 revealed that the resident was receiving Crestor 5mg per day for high cholesterol. Included on the order form were monitoring orders that originated on 5/31/11, which included Basic Metabolic Profile (BMP), Liver Function Tests (LFT) and Lipid Profile for June and December. The Liver Function Tests and Lipid Profile are test used to monitor the Crestor.

A further review of the record revealed results from lab tests for June 2011 included the BMP and Lipid Profile. There were no LFT results.

The Daily Specimen Log dated 6/2/11 was reviewed and revealed that on that date a complete blood count, lipid profile and BMP were drawn. Liver function tests which were ordered by the physician had not been done.

In an interview with the Licensed Practical Nurse/Supervisor (LPN) on 8/23/11 at 11:15 AM, she stated that she thought the test had been ordered but was never sent from the lab. She then called the lab to have them send a copy of the results.

Review of the copy from the lab revealed that it was a duplicate and did not include the Liver Function Test.

Following surveyor intervention, the Liver Funtion Test for this resident was done and the results were available on 8/24/11.

415.12(I)(1)

Based on interview and record review, the facility did not ensure that an irregularity in a resident's drug regimen review was identified by the consultant pharmacist. This was evident for 1 of 8 residents who medication regimen was reviewed (Resident #66).

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

The findings are:

Resident #66 has diagnoses including Parkinson's Disease, History of Falls, Cerebral Contusion, Chronic Obstructive Pulmonary Disease, Hypertension and Hyperlipidemia.

A review of the Physician's Order Form dated 7/20/11 revealed that the resident was currently receiving Crestor 5mg once per day for high cholesterol. Included on the order form were monitoring orders that originated on 5/31/11, that included Basic Metabolic Profile (BMP), Liver Function Tests (LFT) and Lipid Profile for June and December. The LFTs and the Lipid Profile are tests used to monitor the Crestor.

A further review of the record revealed results from lab tests for the month of June 2011 including results for the BMP and Lipid Profile. There were no LFT results.

The Daily Specimen Log dated 6/2/11 was reviewed and revealed that on that date a complete blood count, lipid profile and BMP were drawn. The Liver FunctionTests that were ordered by the physician had not been ordered and therefore not done.

In an interview with the Licensed Practical Nurse/Supervisor (LPN) on 8/23/11 at 11:15 AM, she stated that she thought the test had been ordered but was never sent from the lab. She then called the lab to have them send a copy of the results.

Review of the copy from the lab revealed that it was a duplicate and did not include the Liver Function Test.

Review of the Consultant Pharmacist Plan of Care dated 6/8/11, 6/28/11 and 7/27/11 revealed that the Pharmacy Consultant did not identify the missing Liver Function Test.

The pharmacy consultant was interviewed on 8/23/11 at 11:20AM regarding the missing LFT. She reviewed the chart and stated that she had focused on the Lipid Profile and the BMP and had missed the LFT.

415.18(c)(2)

Based on observation, interview and record review, the facility did not ensure that recommendations by the Physical Therapist to improve ambulation for residents, who had been discharged from physical therapy, were implemented as required. This was evident for 2 of 3 residents reviewed for community discharge (Residents #17 and 66).

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

The findings are:

1. Resident #17 was admitted to the facility with diagnoses including Severe Aortic Stenosis, Alzheimer's Disease and Vertigo. Review of the admission MDS 3.0 (Minimum Data Set - an assessment tool) dated 4/11/11 revealed that the resident has no discharge plan. She was admitted for long term placement.

Review of the Physical Therapy Evaluation and Care Plan revealed that the resident could benefit from short term rehabilitation for improvement of range of motion, strengthening and gait. She received Physical Therapy from 4/6/11 - 4/15/11.

Review of the Physical Therapy Progress Note / Discharge Note dated 4/15/11 revealed that the resident was discharged from physical therapy due to improved strength, balance and endurance. The Physical Therapist discharged the resident with the following recommendations: Discontinue use of the wheelchair but continue to use a walker with 1 person assist for ambulation. Nursing rehabilitation was recommended 7x/week for transfers and hand held ambulation to improve safety in transfers and balance in ambulation.

Review of Restorative Nursing Program documentation for the month of August revealed that the resident was supposed to ambulate for at least 15 minutes or more each day as tolerated. This resident was ambulated an average of 9 minutes per day during August on the 8AM - 4PM shift.

On 8/24/11 at 12:00PM the CNA who cares for the resident and who is responsible for ambulating her was interviewed. The CNA stated that the resident wants to sit down before the 15 minutes is up due to hip pain.

In an interview with the LPN Charge Nurse on 8/24/11 at 12:15PM, she stated that this is the first she is hearing that this resident is not walking for the full 15 minutes. The CNA is supposed to report to her if there are any issues and she would report to the Physical Therapist for possible evaluation.

Observation of the resident on 8/24/11 at 12:20PM revealed she was sitting in a wheelchair in the day room.

Review of the Physician's Order Form dated 8/22/11 revealed under the orders for Mobility - "Transfer and ambulate with assist of one and walker." There was no order for the use of a wheelchair.

In an interview with the Physical Therapist she stated that she was unaware of the fact that this resident had not been walking for the recommended 15 minutes and she was also unaware that the resident was now using a wheelchair that she had discontinued in April.

2. Resident #66 was admitted to the facility with diagnoses including History of Falls, Chronic Obstructive Pulmonary Disease and Parkinson's Disease. Review of the admission MDS 3.0 dated 6/7/11revealed that there was no discharge plan in place. "Discharge to the community not feasible." Additionally the resident was receiving Physical Therapy 2 days per week.

Review of the care plan for ADL - Ambulation dated 6/1/11 revealed an intervention for the resident to participate in Physical Therapy 3x per week "focusing on gait training and resident education."

Review of the Physical Therapy Progress Note dated 6/14/11 revealed
the goal of therapy was to "improve safety in transfers and ambulation. Plan: continue with physical therapy 3x/wk for 2 wks."

The 7/1/11 Physical Therapy Progress Note / Discharge Note revealed the resident was to continue ambulation without a device with assist of one - nursing.

Review of the physician's order for Mobility dated 7/1/11 on the Physician's Order Form revealed an order to "ambulate with assist of one handheld."

In an interview with the Physical Therapist on 8/23/11 at 1:45PM, she stated that the resident was discharged from physical therapy because her gait was very unsteady and not improving and she has retropulsion (falling backwards) that continuing with physical therapy would not improve. She further stated that the resident was discharged from physical therapy with the recommendation that she was to be ambulated with an assist of one whenever possible. The reason the resident was not on a specific floor ambulation program was because she wanted her to be ambulated more than once per day.

Review of the Nursing Rehabilitation book revealed that there is no documentation for nonspecific ambulation, while there is a place for documentation when a Restorative Nursing Program for ambulation.

Review of the ambulation instructions on the CNA Assignement Record for Aug / Sept revealed, Ltd. (limited) assist of 1 - hand held." It does not specifiy how often or how far.

In an interview with the resident at 1:30PM on 8/23/11, she stated that she enjoyed walking during her Physical Therapy sessions. She further stated that her backside is getting sore from sitting in her wheelchair so much.

In an interview with the CNA who cares for the resident on 8/23/11at 2:00PM she stated that she is not the usual CNA that cares for the resident during the day. She is the 4PM-12AM CNA. She stated that she walks the resident from her wheelchair to the bathroom in her room.

In an interview with the Director of Nursing on 8/23/11at 2:30PM she stated that sometimes the resident is difficult to ambulate because she is insecure with the CNAs walking her. She further stated that she does better in physical therapy because she is more secure with the therapist. She stated that she thought that the nursing rehabilitation aides might be a better option for ambulating this resident.

There is no documented evidence that any of this information was ever communicated to the Physical Therapist.

415.12(a)(2)

Based on interview and record review, the facility did not ensure that food consumption data necessary to assess the adequacy of the protein caloric intake of a resident experiencing weight loss was obtained when requested. This was evident for 1 of 3 residents (Resident #77) reviewed for weight loss.

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

The findings are:

Resident #77 was admitted to the facility on 4/5/11 with diagnoses that include Anxiety and Depression. A review of the resident's weight chart showed that the residents admission weight obtained 4/5/11 was 160#. The admission nutritional assessment and nutritional care plan showed that the resident's appetite was poor.

A 3-day calorie count to determine the resident's actual protein and caloric intake was initiated by the Registered Dietitian (RD) on 4/15/11. (Adequate protein and calories is necessary to maintain acceptable parameters of one's nutritional status.) A review of the report of the resident's intake showed that 2 of the 3 days were incomplete. On 4/15/11 one meal was missing and on 4/17/11 two meals were missing. The RD used the data for one day to assess the adequacy of the resident's protein and caloric intake. There is no documented evidence that the RD requested that the 3-day calorie count be repeated.

Interview with the RD on 8/23/11 in the afternoon revealed that the nursing staff is responsible for documenting the resident's actual food/fluid intake for the calorie count. She offered no explanation why this was not done as requested.

415.12 (i)(1)