Highpointe on Michigan Health Care Facility

Based on observation, record review and staff and resident interview, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. One (Resident #137) of one resident reviewed for catheter use had issues involving the exposure of a urinary drainage bag. In addition, one (Second Floor) of four dining areas had issues involving disruptive staff activity and congestion in the unit Dining Room and delays in meal delivery to residents. Residents A, B, C and D were involved. 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 #137 was admitted to the facility on 12/4/11 with diagnoses including multiple sclerosis (MS), peripheral neuropathy (numbness and pain in the hands and feet caused by nerve damage) and had a neurogenic bladder (bladder with diminished sensation) with an indwelling suprapubic catheter (a urinary drainage catheter inserted into the bladder through the abdomen). Review of the Minimum Data Set (MDS) dated 12/9/11 revealed the resident is cognitively intact, has intact memory, and requires extensive to total care with bathing, hygiene and dressing. Additional review of the MDS revealed the resident requires transfers using a Hoyer (mechanical) lift with 2 staff to assist.

During an interview on 1/4/12 at approximately 10:30 AM, the resident was questioned about being treated with dignity by staff members. The resident explained that she had been having problems with staff not covering her urinary drainage bag. The resident stated she went about one month without having a drainage bag cover to use on a regular basis. The resident said she did get a bag cover of her own on 1/3/12, but the resident said she has also wanted a leg bag (smaller volume urine collection bag that is attached to the upper leg). The resident explained that without a leg bag there is a "bulge" and other people can tell she has a catheter bag. The resident said she does not want other people to know she has a catheter, and feels a loss of dignity when in public areas.

Observation of the resident at the time of the interview revealed she was sitting in a wheelchair and the drainage bag was attached to the right side of the outside of the wheelchair.

During the interview, the resident said that nursing staff have told her that they do not have enough catheter leg bags for all the residents needing them The resident said she had a continual feeling of loss of dignity, first not having a cover bag and now not having a leg bag. The resident said she did not like it when other people could see her urine, and she does not like the bulge without having a leg bag. The resident said this has been occurring regularly since her admission to the facility over one month ago. During the interview, it was learned that the resident was reluctant to leave her room and be in public areas due to the uncovered urinary drainage bag.

Observations of the resident in her room on 1/4/12 at approximately 11:00 AM and 11:30 AM revealed the resident's urine bag was uncovered.

Observation on 1/4/12 at approximately 12:30 PM revealed the resident was in the dining room. The urinary drainage bag was attached to the wheelchair and was covered with a dark colored bag.

Interview with the Registered Nurse (RN) Nurse Manager on 1/9/12 at 11:30 AM revealed she was aware that the resident was not satisfied with not having a leg bag. The RN Nurse Manager stated the leg bags were on order. The RN Nurse Manager stated she was also aware that Resident #137 had wanted a bag cover.

2. Observations of the Second Floor Dining Room lunch meal on 1/4/12 from approximately 12:00 PM to 1:00 PM and on 1/6/12 at 12:05 PM revealed the following:

- Approximately 12 residents who were sitting at tables near the Dining Room serving station appeared distracted by a large number of staff (up to 12 at a time) standing in line waiting for meals to deliver. The line of staff weaved through resident tables and the staff members were standing right next to the seated residents while some of the residents were eating their meal. Staff members (including certified nurse aides (CNAs) and nurses) were heard yelling out orders to kitchen staff. During the observation on 1/4/12 at approximately 12:45 PM, Resident A said "there's too many people around!" and "it disturbs my lunch!"
- Two staff members were assembling approximately 10 lunch trays on a cart directly next to a dining table where Resident B was eating her meal. One staff member passed a carton of milk directly over the head of Resident B to the other staff member. Resident B looked up at the surveyor and shook her head. When interviewed at this time, Resident B said that it was rude of staff to reach over her head to pass items and that when she worked in a restaurant she was taught that it was disrespectful to reach over customers.
- Residents who were seated at the same table were not all being served at same time. Resident C was seated at the table with two other residents, one of the two residents had their lunch and was almost finished eating. At this time, Resident C stated that his table mates are never served at the same time and that one may be finished before the others even get their food. The resident said that "if it were a restaurant it would be the grand opening and the grand closing in the same day" and "if a restaurant ever had this kind of service people would get up and leave - except we can't leave!" The resident said "you could be the first one in the dining room and the last one to be served".
- On 1/6/12 at 12:05 PM, Resident D was observed sitting across the table from another resident who was feeding himself, while a certified nurse aide (CNA) sat next to him. Resident D repeatedly looked at the resident eating, then the CNA sitting at the table and the surveyor and made a whimpering noise.

When interviewed on 1/6/12 at 12:09 PM, the CNA stated "I have to sit here because the resident (the other resident) is a total feed and I cannot leave". During the observation, the CNA did not ask anyone to get Resident D her meal. Other residents' meals were being served at tables around the resident.

On 1/6/12 at 12:10 PM, Resident D was asked if she wanted something to eat and she "whimpered" and shook her head "yes".

On 1/6/12 at 12:18 PM, the Dietitian was observed to approach Resident D. The resident looked at the Dietitian and "whimpered". The Dietitian stated "Oh you have your Pepsi, you're OK" and walked away. On 1/6/12 at 1:35 PM, the resident was observed to receive her meal.

During an interview on 1/6/12 at 1:30 PM, the RN Nurse Manager stated that she was well aware of the dining room issues and that staff members have "met many times to work out the kinks". The RN Nurse Manager stated that "things have improved and as each week goes by it gets a little better".

During an interview on 1/10/12 at 9:45 AM, the Registered Dietitian (RD) stated that she was aware that the dining service needs work and that the interdisciplinary team has been meeting to work on getting "a better flow". The RD stated "it has improved but still needs work".

When interviewed regarding the Second Floor meal service on 1/10/12 at 10:15 AM, the Food Service Director stated that Dietary has made suggestions to nursing but that "it's up to them to make it happen".

During an interview on 1/10/12 at 12:00 PM, the Assistant Administrator and the Director of Nursing (DON) said they were "well aware of the issues with meal service" and have allocated management team members to each floor to monitor and manage the meal service. They said they had been focusing on getting the meals served and need to also focus on the dining atmosphere.

415.5(a)

Based on observation, record review and resident and staff interview conducted during a complaint investigation (complaints #NY00109816, NY00109904) during the Standard survey completed 1/10/12, the facility did not ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Two (Residents #137, 177) of three residents who were dependent on staff for ADLs had issues involving incontinence care that was not provided in a timely manner and incontinence care that was provided while a resident laid on a urine soiled pad. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #137 has a diagnosis of multiple sclerosis (MS). Review of the Minimum Data Set (MDS) dated 12/9/11 revealed the resident is cognitively intact and requires total assistance of two persons for transfers and toileting.

Review of the current Care Guide, used by certified nurse aides (CNAs) to provide care dated 1/6/12 and the current Care Planning Report dated 1/6/12, the resident requires extensive staff assistance with clothing and hygiene management for toileting and is transferred using a mechanical lift with 2 person assist.

During an interview on 1/4/12 at 10:30 AM, the resident stated that staff is not always available to assist her when she becomes incontinent of bowel. The resident said she is having particular problems around meal times because staff are in the dining room and two staff members are not available to transfer her with the Hoyer lift (mechanical lift). The resident said this has been a frequent problem because so many staff are occupied in the dining room.

During the interview, the resident explained that she wants to get out of bed early in the morning, but staff come to get her out of bed usually after 10:30 AM. The resident stated she often becomes incontinent of bowel around the lunch meal time "when no one is around". Staff have told the resident they are short staffed to assist her during meal times, which includes getting her out of bed earlier around the breakfast meal time, and caring for her incontinence around lunch time.

Observation on 1/6/12 from 12:15 PM to 12:35 PM revealed the resident's call bell was ringing at the nurses' station. There were no staff members visible at the nurses' station. The surveyor went to the resident's room at 12:40 PM and the resident was observed sitting in her wheelchair by her bed. The resident stated she had been waiting for staff assistance because she needed to have a bowel movement.

Interview with the Unit Secretary on 1/6/12 at 12:45 PM revealed there is not enough staff to answer the residents' call bells during meal times.

During an interview on 1/6/12 at 1:30 PM, the resident was in her room and still waiting for assistance with incontinent care. The resident said staff had turned her call bell off twice during the past hour and still had not come to assist her with toileting. The resident said she has been waiting well over an hour for assistance and had become incontinent of feces. The resident said she was uncomfortable and stated this happens to her a lot.

The surveyor left the resident's room and did not observe any staff members on the nursing unit. Observation of the dining area on 1/6/12 at approximately 1:32 PM revealed 6 staff members (certified nurse aides (CNAs) and nurses) were waiting in line to get food trays from the servery. The surveyor asked a Registered Nurse (RN) in the dining room to get help for the resident. Staff were observed entering the resident's room at 1:35 PM.

Interview with the RN on 1/6/12 at approximately 2:30 PM revealed she was unaware that Resident #137 was asking for care.

2. Resident #177 has diagnoses including cancer and osteoarthritis. Review of the Minimum Data Set (MDS) dated 10/3/11 revealed the resident is cognitively intact.

Review of the Care Planning Report dated 10/5/11 and the Care Guide dated 12/16/11 revealed that the resident required total assistance for bathing and incontinence care.

When observed on 1/9/12 at 8:05 AM, the resident was awake and sitting up in bed. When interviewed at this time the resident stated "my bed is wet and cold".

During an observation of personal care on 1/9/12 at 8:18 AM in the presence of the Registered Nurse (RN) Nurse Manager, a certified nurse aide (CNA) applied gloves and washed the resident's upper body. The resident stated "I am wet". The CNA washed the resident's abdomen and then peri area. The resident stated "that's wet" and pointed to the top sheet. The CNA removed the top sheet, then turned the resident to her left side and washed her buttock and rectal area. The incontinence pad under the resident was observed to be wet with urine. The CNA removed her gloves and washed her hands. The CNA then removed the soiled incontinence pad from under the resident and applied the resident's brief. The CNA then removed her gloves, lowered the bed with the electric control and washed her hands.

During an interview on 1/9/12 at 8:47 AM, the CNA confirmed that the incontinence pad that was under the resident was wet from urine.

When interviewed on 1/9/12 at 9:14 AM, the CNA stated she was aware that the sheet she removed from the resident during bathing was wet with urine and that she should have put a dry pad under the resident prior to doing incontinence care.

During an interview on 1/9/12 at 9:26 AM, the RN Nurse Manager stated when a resident is incontinent of urine, the CNA should put a clean barrier under the resident before doing incontinent care.

415.12(a)(3)

Based on observation, record review, and staff and resident interview, the facility did not obtain and provide dental services to meet the needs of each resident. One (Resident #177) of three residents reviewed for dental services had an issue with dentures that had missing teeth and the lack of an annual dental exam. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #177 has diagnoses including cancer and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) dated 10/3/11 revealed the resident was admitted on 12/11/10, has moderately impaired cognition, requires supervision for eating and extensive assistance of one person for personal hygiene.

Review of an Oral Evaluation Form dated 12/20/10 revealed that the resident has full upper and lower dentures and that the dentures have several missing teeth. The treatment plan included an annual dental exam.

Review of the Care Planning Report for oral hygiene dated 9/13/11 and the Care Guide dated 12/16/11 revealed interventions for staff to provide denture care and to provide Dental Evaluations per Rehab admission schedule.

Review of the Dentist Visit Schedule dated 12/1/11 to 12/31/11 revealed the resident was scheduled to be seen by the dentist on 12/11/11.

Review of the entire medical record revealed no documented evidence that the resident had a dental visit since 12/10/10.

When interviewed on 1/4/12 at 4:23 PM, the resident stated she has problems chewing. At this time the resident removed her dentures to reveal teeth missing from the top and bottom dentures. She stated it was years ago that the dentist looked at her dentures and stated she thinks she could eat better if her dentures were fixed.

When interviewed on 1/9/12 at 8:49 AM and at 10:57 AM, the Registered Nurse (RN) Nurse Manager stated that she was not aware that the resident's dentures were missing teeth and confirmed that there was not a dental consult in the resident's medical record since 12/20/10.

When interviewed on 1/9/12 at 11:00 AM, the Unit Secretary stated that dental consults are done if the resident has a problem or annually. She explained that she would notify Medical Records and they would schedule the resident's dental appointment.

When interviewed on 1/9/12 at 11:27 AM, the RN Manager stated the resident should have been seen by the dentist on 12/20/11.

When interviewed on 1/9/12 at 1:11 PM, the Medical Records staff member in charge of making dental appointments stated that the resident was on the list to be seen by the dentist on 12/11/11. She further explained that the dentist comes every other week and was last at the facility on 1/2/12. She confirmed that the resident was supposed to be seen by the dentist on 12/11/11. She further explained that she forgot to print the Dentist Visit Schedule for 12/11/11 and 14 residents including this resident did not get seen. After surveyor intervention, the Medical Records staff member said that she called the dentist today and he is coming to see the residents.

When interviewed on 1/9/12 at 2:00 PM, the Dentist stated apparently the resident got missed for the annual dental exam and he will be in to examine the resident tomorrow. He stated that "absolutely teeth can be replaced on dentures".

When interviewed on 1/9/12 at 4:18 PM, the resident stated that she would like to have her dentures fixed and that no one had ever talked to her about having her dentures repaired.

415.17(c)

Based on observation, record review, staff, resident and family interview, the facility did not develop a comprehensive care plan for each resident to meet a resident's medical and psychosocial needs. Three (Residents #101, 177, 283) of three residents reviewed for comprehensive care plans did not have care plans for dental services. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #177 has a diagnosis of osteoarthritis. Review of the Minimum Data Set (MDS) dated 10/3/11 revealed the resident is cognitively intact.

Review of the Care Guide dated 12/16/11 and the Care Planning Report dated 10/5/11 revealed no documented evidence of a dental care plan.

Review of an Oral Evaluation Form dated 12/20/10 revealed the resident has full upper and lower dentures and the dentures have several missing teeth.

During an interview on 1/4/12 at 4:23 PM, Resident #177 stated she has a problem with her dentures. The resident removed her dentures and showed the surveyor there were teeth missing from the top and bottom denture.

Observation on 1/9/12 at 8:48 AM revealed the Registered Nurse (RN) Nurse Manager had the resident take out her upper denture which had several missing teeth.

During an interview on 1/9/12 at 8:49 AM, the RN Nurse Manager stated she didn't realize the resident had dentures because she could not see them due to the missing teeth.

When interviewed on 1/9/12 at 5:03 PM, the RN Nurse Manager stated she was not aware the dentures had broken teeth until this morning and has now added a dental care plan.

2. Resident #283 has swallowing problems and a history of a fractured femur (long thigh bone). Review of the Minimum Data Set (MDS) dated 3/21/11 revealed the resident is cognitively intact.

Review of the Care Guide dated 12/16/11 and the Care Planning Report dated 3/21/11 revealed no documented evidence of a care plan for dental care.

Review of an Admission Oral Evaluation Form dated 3/21/11 revealed the resident has multiple missing upper and lower teeth and has multiple caries (cavities).

Observation on 1/4/12 at 2:22 PM revealed the resident had missing upper and lower teeth.

During an interview on 1/4/12 at 2:13 PM, the resident stated she fell about a year ago and broke her partial upper and lower dentures. She stated she has some of her own upper and lower teeth. The resident stated she has 4 upper teeth and three lower teeth. The resident opened her mouth and showed the surveyor that she has missing teeth.

When interviewed on 1/10/12 at 11:56 AM, the RN Nurse Manager confirmed that the resident does not have a dental care plan and stated she was going to add this to the care plan.

3. Resident #101 was admitted to the facility on 12/4/11 with diagnoses which include dementia, coronary artery disease, and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) dated 12/9/11 revealed the resident has moderate cognitive impairment, and understands and is understood by others. Review of the current Care Guide (print date 12/16/11) used by certified nurse aides (CNAs) to provide care, revealed the resident receives a pureed diet.

Interview with the resident's son on 1/6/12 at 9:00 AM revealed the resident had a dental impression made several months ago for a new upper denture because the resident's upper denture was missing. The resident's son, who is the resident's responsible party and the Health Care Agent, stated he wondered what was happening with the dentures.

Interview with the Registered Nurse (RN) Nurse Manager on 1/6/12 at approximately 10:00 AM revealed she was not aware that the resident was being fitted for new dentures.

Interview with the Diet Technician on 1/6/12 at 10:05 AM revealed she had no knowledge of the resident receiving new dentures.

The RN Nurse Manager contacted the resident's Dentist via telephone at approximately 10:30 AM on 1/6/12, after the surveyor discussed the dentures with her. The RN Nurse Manager learned from the Dentist that the resident's dentures were ready, and the Dentist planned on inserting and adjusting both upper and lower dentures later today (1/6/12).

Interview with the RN Nurse Manager on 1/9/12 at 10:00 AM revealed the Dentist inserted and adjusted the resident's new dentures on 1/6/12. The RN Nurse Manager said there were dental notes from a previous facility, but these notes were deleted from the medical record when the resident was admitted. The previous facility's dental notes documented that the Dentist made full dental impressions on 11/17/11 with the resident's son present.

Review of the entire medical record revealed no documented evidence that the resident was waiting for new dentures. Review of the current Care Planning Report printed 12/19/11 revealed the care plan did not address the plan to replace the resident's missing dentures.

415.11(c)(1)

Based on observation, record review and staff interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #127) of three residents reviewed for accidents had an issue with the resident's feet dragging on the floor while a certified nurse aide (CNA) transported the resident in a wheelchair. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #127 has diagnoses including dementia, venous insufficiency, and osteoarthritis. Review of the Quarterly Minimum Data Set (MDS) dated 11/14/11 revealed the resident has severe cognitive impairment, is non-ambulatory, and requires total assistance of one person for locomotion.

Review of the Care Guide dated 1/9/12 revealed instructions for staff to propel the resident on and off the unit.

On 1/5/12 at 1:00 PM, the resident was observed being pushed in a wheelchair by a CNA. The foot rests were open and in the down position, the resident was wearing slippers with plastic soles on her feet. Her feet were not on the foot rests, dragging and could be heard scraping on the floor for a distance of approximately 75 feet. At no time during the transport did the CNA stop the transport to safely reposition the resident's feet or ask the resident to lift her feet.

When interviewed on 1/10/12 at 11:00 AM, the Registered Nurse (RN) Nurse Manager (NM) said that the resident can follow simple commands and was capable of lifting her feet. After surveyor intervention, the RN NM stated that the resident will be referred to Occupational Therapy (OT) to be evaluated for wheelchair calf rests to ensue the resident's feet stay safely placed during wheelchair transport.

415.12(h)(2)

Based on record review and staff and resident interview conducted during a complaint investigation (complaint #NY00109888) during the Standard survey completed on 1/10/12, the facility did not resolve a resident's grievance in a prompt manner. One (Resident #283) of five resident reviewed for personal property had unresolved complaints of missing personal property. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #283 has a diagnosis of hypertension and history of a hip fracture. Review of the Minimum Data Set (MDS) dated 3/21/11 revealed the resident is cognitively intact.

During an interview on 1/4/12 at 2:04 PM, the resident stated she was missing black pants, a cloth bag for her wheelchair, and an ivory colored throw blanket with flowers on one end. The resident stated she told "everybody" that she was missing property and "it is still missing".

During an interview on 1/9/12 at 10:51 AM, the Social Worker (#1) stated that Resident #283 had not reported any missing items. The Social Worker stated she would check and see if it was reported to another Social Worker.

When interviewed on 1/9/12 at 11:29 AM, Social Worker #1 stated there was no missing items report. The Social Worker explained that she called the resident's daughter, who confirmed that the items are missing. The resident's daughter stated she did not report the missing items to anyone because her mother told her that she reported it to a certified nurse aide (CNA). The resident's daughter stated the blanket and the cloth bag had been missing since the resident was transferred to the facility in 12/11 and the black pants since Christmas. The Social Worker stated she spoke to the resident who told her that she had reported the missing items to a CNA and many other people. The Social Worker stated when missing items are reported to a CNA, the CNA should know to make out a missing items report.

When interviewed on 1/9/12 at 11:43 AM, the CNA assigned to the resident stated that Resident #283 notified her that she was missing clothing items at Christmas time. The CNA explained it might have been the black pants and further revealed it had to be new clothes that she received for Christmas. The CNA stated she reported it to a nurse at that time. She explained she does not fill out a missing items report she just tells the nurses. The CNA also stated that she was not aware that the resident was missing a bag or a blanket.

During an interview on 1/9/12 at 12:47 PM, the Registered Nurse (RN) Nurse Manager stated Resident #283's missing personal property had not been reported to her. The RN stated when a resident informs a CNA of missing items, the CNA should tell a nurse about the missing item and the nurse should put it on the 24 Hour Report. The RN Nurse Manager stated that the nurses should make out a missing item report but thinks the Social Worker is notified and she does it. The RN Manager was observed to review 24 Hour Report sheets for 12/11 and stated there was nothing on the 24 Hour Report regarding the resident's missing property.

During an interview on 1/9/12 at 5:00 PM, the resident stated the Social Worker came and talked to her about her lost belonging and she would like her things replaced. The resident stated she has never been good with names and does not remember the name of the CNA that she told.

When interviewed on 1/9/12 at 5:46 PM, the RN Nurse Manager stated she talked with several different staff members and some think the Social Worker makes out the missing property form and some think the person who reports the missing item would make out the report.

Review of a facility policy entitled Property, Belongings, Storage dated 11/14/11 revealed if a resident and/or designated representative notices money/ valuables are missing, a Customer Relations Form is completed by the staff member who is made aware of the missing item and it is forwarded to the Director of Social Work for further investigation.

415.3(c)(1)(ii)

Based on record review and staff interview, the facility did not ensure that residents are free of any significant medication errors. One (Resident #22) of ten residents reviewed for unnecessary medications had an issue involving a medication for peripheral vascular disease that was not administered daily as ordered by the physician. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #22 has diagnoses which include peripheral vascular disease (PVD), diabetes mellitus and history of a cerebral vascular accident (CVA - stroke). Review of the Quarterly Minimum Data Set (MDS) dated 10/6/11 revealed that the resident is understood and understands and has moderately impaired cognition.

Review of the Follow-Up Geriatric Services History and Physical dated 11/8/11 revealed that the resident has a diagnosis of peripheral vascular disease and is to be on Plavix (blood thinner) 75 milligrams (mg) daily.

Review of the SNF (Skilled Nursing Facility) Physician Telephone Orders dated 12/23/11 revealed an order to discontinue Plavix.

Review of the hospital Transfer/Post Op Medication Orders dated 12/28/11 revealed a physician's order for Plavix 75 mg oral every day.

Review of the facility Medication Administration Record (MAR) dated 12/1/11 through 12/31/11 revealed that Plavix was discontinued on 12/23/11 and that the Plavix ordered on 12/28/11 was not transcribed back onto the MAR.

Review of the MAR dated 1/12 revealed that the Plavix order was crossed off and noted to be discontinued. There was no documented evidence that Plavix was administered between 12/28/11 and 1/9/12.

When interviewed on 1/9/12 at 11:45 AM, the Registered Nurse (RN) Nurse Manager (NM) said that when a resident comes back from the hospital, the nurse reviewing the orders is supposed to start with a blank admission sheet for the resident. She said that the nurse who was working that night, was from another facility and apparently used a different system. The RN NM said that the nurse wrote any changes on physician telephone orders and used the Transfer/Post Op Medication Orders Sheets as the physician's orders. The RN NM confirmed that the Plavix was discontinued on 12/23/11 in anticipation of the resident's surgery on 12/27/11 and was re-ordered on 12/28/11. She said that the resident was to have received the Plavix since 12/28/11 and has not. The RN NM said that the physician re-ordered the Plavix.

When interviewed on 1/9/12 at 12:05 PM, the Physician said that the resident was receiving the Plavix for PVD and that the medication was stopped prior to the surgery because of the risk of excess bleeding.

Review of the facility policy entitled LTC (Long Term Care) Medication Reconciliation with a revision date of 1/11, revealed that medication reconciliation must take place anytime a resident changes service/ provider/ level of care or setting whether or not there are new medications orders (anytime there is a handoff) and that there are three steps in this process: 1. Verification (collection of medication history), 2. Clarification (ensuring that the medications and doses are appropriate), 3. Reconciliation (documentation of changes in the order)".

415.12(m)(2)

Based on observation, record review, and staff and resident interview, the facility did not ensure that residents have the right to choose activities, schedules and health care consistent with his or her interests, and plans of care and make choices about aspects of his or her life in the facility that are significant to the resident. Three (Residents #137, 177, 283) of four residents reviewed for choices had issues involving the lack of resident involvement in the decision of when to get up in the morning (#137, 177) and when to go to bed at night (#283). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #137 was admitted to the facility on 12/4/11 from another facility where she had resided for approximately three years. The resident has diagnoses which include multiple sclerosis (MS), peripheral neuropathy (numbness and pain in the hands and feet caused by nerve damage) and a neurogenic bladder (bladder with diminished sensation) with indwelling catheter. Review of the Minimum Data Set (MDS) dated 12/9/11 revealed the resident is cognitively intact, understands others, is understood by others, and requires extensive to total care with activities of daily living. Additional review of the MDS revealed the resident is transferred using a Hoyer lift with 2 staff to assist.

During an interview on 1/5/12 at 10:15 AM, the resident stated she was having difficulty getting assistance with her care, getting out of bed in the morning and getting staff to help her get to the bathroom. The resident said she wants to get up earlier in the morning, but staff come to get her out of bed usually after 10:30 AM. The resident said she misses many morning activities. This morning she could not go to Catholic Mass at 10:30 AM, because she was still in bed. The resident also said, even when there is no formal activity to go to, she wants to get up early to do puzzles in her room. Staff were observed to come to the resident's room on 1/5/12 at 10:30 AM to get her out of bed.

On 1/6/12, the resident was observed sitting in a wheelchair in her room at 1:00 PM. The resident said she did not get out of bed until 10:45 AM and missed the coffee, chat and news activity scheduled at 10:00 AM. The resident stated she would have liked to participate in this activity. The resident stated that she had asked the certified nurse aides (CNAs) to follow the morning routine she had when residing at her previous facility.

During an interview on 1/9/12 at 1:45 PM, the Registered Nurse (RN) Nurse Manager stated she was not aware that the CNAs were refusing to do what the resident requested, and this is not acceptable.

2. Resident #177 has a diagnosis of osteoarthritis and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) dated 10/3/11 revealed the resident is cognitively intact.

Review of the Care Guide dated 12/16/11 and the Care Planning Report dated 10/5/11 revealed the care plans did not address the resident's choice for when she wants to get up in the morning.

During an interview on 1/4/12 at 4:08 PM, the resident stated she does not participate in choosing when to get up and explained that the staff gets her up at 6:00 AM. The resident stated this is not acceptable to her and she would like to get up at 11:00 AM. The resident stated "I am not a young woman and should not have to get up so early".

When observed on 1/6/12 at 8:45 AM, the resident was dressed and seated in a wheelchair in the main dining room eating breakfast.

During an interview on 1/6/12 at 3:59 PM, the RN Nurse Manager stated the resident is usually gotten up at 7:00 AM.

During an interview on 1/9/12 at 11:46 AM, the certified nurse aide (CNA) stated she was told that "everybody" is to be up and in the dining room by 8:00 AM. The CNA stated that she cared for the resident when she lived at another facility and the resident got up about 9:30 AM. The CNA stated she is not sure if there are any residents who get up late on this unit.

During an interview on 1/9/12 at 5:00 PM, the RN Nurse Manager stated the CNAs know when to get the residents up and if there was a special time the resident wanted to get up it would be under "other" on the care plan. The RN Nurse Manager stated the residents are gotten up for breakfast at 8:00 AM. After reviewing the care plan, the Nurse Manager stated there was nothing on Resident #177's care plan about her choice of when she wants to get up.

When interviewed on 1/10/12 at 9:56 AM, the RN Nurse Manager stated she revised Resident #177's care plan to include the resident's choice regarding when she wants to get up.

3. Resident #283 has a diagnosis of hypertension and history of a hip fracture. Review of the Minimum Data Set (MDS) dated 3/21/11 revealed the resident is cognitively intact.

Review of the Care Guide dated 12/16/11 and the Care Planning Report dated 3/21/11 revealed no documentation regarding the resident's choice for when she would like to go to bed.

During an interview on 1/4/12 at 1:52 PM, the resident stated the staff decides when she goes to bed; she does not participate in choosing her bedtime and this is not acceptable to her. The resident stated she would like to go to bed at 10:00 PM or after.

During an interview on 1/6/12 at 4:09 PM, an evening shift CNA stated that the resident usually goes to bed between 9:00 PM and 9:30 PM.

When interviewed on 1/9/12 at 4:47 PM, the resident stated a CNA comes in between 9:00 PM and 9:30 PM to put her to bed when she is in the middle of watching a TV program. The resident explained if she does not go to bed then, the CNA tells her that she will have to wait to go to bed at 11:00 PM when the next shift comes on. The resident stated she has talked to someone about going to bed at 10:00 PM, but does not remember who it was.

During an interview on 1/9/12 at 5:34 PM, the RN Nurse Manager stated there is no time on the care plan for when the resident wants to go to bed. The RN Nurse Manager stated she did not know what time the resident wants to go to bed, "but it is late".

When interviewed on 1/10/12 at 9:56 AM, the RN Nurse Manager stated she revised Resident #283's care plan to include the resident's choice of when she wanted to go to bed.

415.5(b)(1,3)

1. Resident #283 has diagnoses including dementia, malnutrition and hypertension. Review of the Minimum Data Set (MDS) dated 3/21/11 revealed the resident is cognitively intact. Review of the physician History and Physical and monthly physician orders dated 9/27/11 revealed that the resident is on comfort care. Review of the resident's entire medical record revealed no documented evidence of any further physician visits. Review of the Physician's Orders dated 11/1/11 through 11/30/11 revealed that the orders were not signed by the physician.

When interviewed on 1/9/12 at 12:14 PM, the Registered Nurse (RN) Manager confirmed the last medical and treatment orders and physician visit was on 9/27/11 and should have been seen in 11/11. She stated she does not know what happened or why the resident has not been seen by the Physician.

When interviewed on 1/9/12 at 12:36 PM, the Unit Secretary stated that the resident should have been seen by the Physician in 11/11. She stated that the 11/11 Physician Orders were misfiled in the resident's chart. She further explained she does not know how the orders got put in the medical record or how the resident physician visit was missed.

When interviewed on 1/9/12 at 5:45 PM, the RN Manager stated that the resident would be seen by the Physician Assistant in the morning.

Review of the facility policy entitled Attending Physician dated 12/13/10 revealed that the frequency of visits will be no less than once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. At the time of the scheduled visits, the Physician is required to review the resident's total program of care, including medications and treatments.

415.15(b)(2)(iii)