Elderwood Health Care at Birchwood

Based on observation, record review and staff interview conducted during the standard survey, the facility did not ensure there was proper storage of controlled substances. Specifically, the facility did not ensure the pharmacy refrigerator had a double lock system and used the refrigerator to store both current stock and outdated controlled substances (awaiting destruction); the facility allowed an unauthorized person access to the pharmacy; and did not ensure the pharmacist maintained an inventory for the controlled substances in the pharmacy refrigerator. In addition, 8 of the 8 controlled substance cabinets on the nursing units contained a substock of controlled substances that exceeded weekly usage amounts; 4 of 8 medication carts contained substock controlled substances; and inventory records from 5 of 8 controlled substance cabinets revealed nursing staff were splitting tablets to administer the residents' ordered dose. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) During an observation/interview in the pharmacy on December 16, 2010 at 1:45 PM, a refrigerator was observed locked (with a single lock on the door). The facility pharmacist stated the refrigerator (standard size) contained controlled substances that required refrigeration. The pharmacist stated he and the facility Administrator had keys to the pharmacy door, and he did not know if anyone else did. He stated the key to the refrigerator lock was kept in the double locked cabinet attached to the wall in the pharmacy. The refrigerator was not permanently affixed to the wall.

When requested on December 16, 2010 at 1:45 PM, the pharmacist unlocked the pharmacy refrigerator with a key. The surveyor observed the contents of the refrigerator included active (current stock) controlled substances that required refrigeration, and a large volume of outdated and surrendered controlled substances that required disposal/destruction.

When interviewed on December 16, 2010 at 2:05 PM, the facility Administrator stated she and the pharmacist had a key to the pharmacy hallway door, she kept the key on her work key ring, and her work keys were in her possession at all times. The Administrator stated she took her work key ring with her when she left the facility.

An inventory of the refrigerator contents was completed by the facility pharmacist and a surveyor on December 16, 2010 from 2:00 PM to 4 PM. The refrigerator's current controlled substances stock inventory included lorazepam (Ativan, anxiety) 30 milliliters (ml) multidose vial and 10 single dose lorazepam vials. The refrigerator contained outdated controlled substances requiring destruction; examples of this inventory included:
- 1190 tablets of hydrocodone/acetaminophen (Lortab, Vicodin, pain relief), different doses;
- 149 tablets of morphine (pain relief), (different doses and timed release);
- 60 ml of concentrated and 90 ml of standard morphine elixir;
- 5.5 ml multidose morphine (10 mg per ml) vial;
- 210 tablets of Methadone (pain relief) tablets;
- 301 tablets of diazepam (Valium, anxiety, muscle spasms), (different doses);
- 6 multidose diazepam vials (10 ml, 5 mg/ml concentration);
- 152 tablets of clonazepam (Klonopin, seizures, panic attacks), (different doses);
- 149 tablets of lorazepam (different doses);
- 78 ml (in 2 multidose vials, 2 milligrams/ml) lorazepam;
- 18 single dose (2 mg/ml) vials lorazepam;
- 123 tablets of Ritalin (for attention deficit disorder );
- 67 tablets of alprazolam (Xanax, anxiety, panic attacks), (different doses);
- 65 tablets of Ambien (for sleep).

When the surveyor interviewed the pharmacist on December 16, 2010 at 1:45 PM, the pharmacist stated he did not keep an inventory of the outdated controlled substances (stored in the refrigerator) that awaited destruction.

In summary, the facility did not ensure controlled substances were stored in conformance with accepted professional principles, as:
- controlled substances were not stored in a double locked/permanently affixed storage unit;
- there was no separate storage for active and outdated controlled substances;
- an inventory was not maintained for outdated controlled substances (awaiting destruction);
- the facility Administrator, not an authorized person, had access to the pharmacy room which stored controlled substances.

2) Resident #27 had diagnoses including hypertension, depression, and osteoarthritis.

On December 13, 2010, the physician renewed the resident's order for Lortab (narcotic pain relief medication) 5/325 milligrams (mg) 2 tablets, every 4 hours as needed, for reported pain of "5 to 10" on the pain scale.

The resident's comprehensive care plan (CCP), printed December 16, 2010, documented the resident was independent in decision making related to health care decisions and required pain management related to osteoarthritis of her left knee.

During a medication pass observation on December 14, 2010 at 3:30 PM, the surveyor heard the licensed practical nurse (LPN) ask the resident her pain level. The resident stated it was a "5". The surveyor observed the LPN open the locked controlled substance storage drawer on the medication cart, and retrieve 2 individually packaged/labeled Lortab 5/325 tablets. The packages were not labeled with a resident name. When the surveyor asked, the LPN stated they had non-resident specific stock of controlled substances in the medication room's controlled substance cabinets. The LPN opened 1 of 2 double locked cabinets in the medication room and showed the surveyor a stock package of Lortab 5/325 mg. There were no resident specific Lortab packages in the cabinet.

3) Resident #26 had diagnoses including pelvis fracture and osteoarthritis.

On December 9, 2010, the physician ordered Tylenol 325 milligrams (mg) every 4 hours as needed for general discomfort and oxycodone (narcotic pain relief medication) 5 mg, every 4 hours as needed, for pain rated "1 to 10" on the pain scale.

The current comprehensive care plan (CCP), printed December 16, 2010, documented the resident was independent in decision making related to health care decisions and required pain management related to her pelvic fracture.

During a medication pass on December 14, 2010 at 3:20 PM, the surveyor observed the licensed practical nurse (LPN) administer oxycodone 5 mg and Tylenol 325 mg (2 tablets) to the resident, who said her pain was "throbbing". The oxycodone tablet was individually packaged and labelled with the medication name and dosage; and was stored as a single tablet in the locked controlled substance drawer in the medication cart. When the surveyor asked, the LPN stated they had stock, non-resident specific, controlled substances in the medication room's controlled substance cabinets. The LPN opened 1 of 2 double locked cabinets in the medication room and showed the surveyor a stock package of oxycodone 5 mg. There were no resident specific oxycodone packages in the cabinet.

On December 16, 2010 at 4:50 PM, the surveyor observed the LPN assigned to the medication cart unlock the controlled substance storage drawer. The following substock of controlled substances were observed:
- 6 tablets of Percocet (narcotic pain relief medication);
- 8 tablets of oxycodone 5 mg;
- 1 tablet of OxyContin (pain relief) 10 mg;
- 1 tablet of OxyContin 20 mg;
- 10 tablets of Lortab 5/325 mg;
- 2 tablets of Lortab 5/500 mg;
- 1 tablet of Lortab 7.5/500 mg;
- 2 tablets of Nucynta (pain relief) 50 mg;
- 5 tablets of lorazepam (anxiety) 0.25 mg.

During an observation on December 16, 2010 at 4:55 PM, the LPN assigned to the medication cart, was observed to unlock 1 of the 2 controlled substance storage cabinets located in the unit's medication room. The surveyor observed the following substock of controlled substances:
- 100 tablets of Lortab 5/325 mg;
- 68 tablets of Lortab 10/325 mg;
- 80 tablets of Lortab 5/500 mg;
- 66 tablets of Lortab 7.5/500 mg;
- 23 tablets of lorazepam 0.5 mg;
- 80 tablets of Percocet;
- 38 tablets of OxyContin 10 mg;
- 100 tablets of oxycodone 5 mg;
- 37 tablets of Nucynta 50 mg.
During this observation, there were no resident-specific packages in the cupboard. When interviewed, the LPN told the surveyor that this stock was for the east wing residents (maximum number of east wing residents was 20). The LPN pointed to the other cabinet and said the north wing medication nurse used the other cabinet (maximum number of north wing residents was 20).

Review of the first floor east Controlled Substance Receipt Records (provided by the facility on December 16, 2010) revealed the following examples of substock controlled substances whose quantities exceeded the weekly resident needs for that unit:
- on November 4, 2010, alprazolam (Xanax, anxiety, panic attacks) 0.25 mg, 100 tablets supplied; last administered on November 17, 2010; and 74 tablets remained 6 weeks later.
- on November 4, 2010, clonazepam (seizures, panic attacks) 0.5 mg, 100 tablets supplied; last administered on December 8, 2010, 74 tablets remained 6 weeks later; for 8 doses, nursing staff documented the tablet was split and half was administered/ half was wasted.
- undated record, lorazepam 0.5 mg, unknown quantity supplied, first dose administered on September 27, 2010, with documented quantity remaining 44 tablets; 23 tablets remained 6 weeks later; and for 13 doses administered, nursing staff documented the tablet was split with half the tablet wasted.
- on November 11, 2010, Ambien (sleep) 5 mg, 100 supplied; and 60 tablets remained 5 weeks later.

During an observation on December 16, 2010 at 5 PM, the LPN assigned to the first floor north medication cart unlocked the controlled substance storage drawer. The following individually labelled substock of controlled substances were observed:
- 12 tablets of hydrocodone (Lortab, pain relief) 5/325 mg;
- 2 tablets of Lortab 5/500 mg;
- 8 tablets of oxycodone 5/325 mg;
- 2 tablets of oxycodone 5 mg;
- 2 tablets of OxyContin 10 mg;
- 1 tablets of OxyContin 20 mg;
- 2 tablets of Xanax 0.25 mg;
- 2 tablets of Ambien 5 mg.
The LPN stated she already administered 2 oxycodone 5/325 mg and 2 oxycodone 5 mg from this cart (substock).

During an observation on December 16, 2010 at 5:05 PM, the LPN assigned to the first floor north medication cart, was observed to unlock 1 of the 2 first floor controlled substance storage cabinets located in the medication room. The following substock of controlled substances were observed as part of the inventory:
- 98 tablets of Xanax 0.25 mg;
- 20 tablets of Ambien 5 mg;
- 90 tablets of hydrocodone 5/325 mg;
- 97 tablets of Lortab 5/500 mg;
- 41 tablets of Lortab 7.5/500;
- 65 tablets of OxyContin ER 10 mg;
- 22 tablets of OxyContin 20 mg;
- 190 tablets of Percocet 5/325 mg;
- 96 tablets of oxycodone 5 mg.

Review of the first floor north Controlled Substance Receipt Records (provided by the facility on December 16, 2010) revealed the following examples of substock controlled substances whose quantities exceeded the weekly resident needs for that wing:
- on November 11, 2010, Ambien 5 mg, 100 tablets supplied; and 22 tablets remained 5 weeks later.
- on December 9, 2010, clonazepam 0.5 mg, 100 tablets supplied; and 94 tablets remained 1 week later.
- on December 9, 2010, oxycodone 5 mg, 140 tablets supplied; and 108 tablets remained 1 week later.
- on December 9, 2010, Nucynta 50 mg, 100 tablets supplied; and 95 tablets remained 1 week later.
- on December 16, 2010, an addition of oxycodone 5 mg 100 tablets and Nucynta 50 mg, 100 tablets was supplied.

The registered nurse (RN) Unit Manager, when interviewed on December 16, 2010 at 10:35 AM, told the surveyor that controlled substances were "always stock", unless they were ordered from the off-site (emergency, local) pharmacy; and then they were labeled with a resident name. The RN stated the pharmacist was at the facility once a week, and the narcotic exchange was done then.

During an interview on December 16, 2010 at 1:45 PM with the pharmacist, he stated he was at the facility 4 hours a week (on Thursdays); reviewed the usage of each narcotic cabinet (8 cabinets) with the individual medication nurse; reconciled the narcotic cabinet's inventory sheets; and restocked the cabinet based on the current orders/usage. He stated this was done in the facility pharmacy and the medication nurses brought their controlled substance stock and the inventory sheets to the pharmacy. The pharmacist stated he did not use par levels when he stocked the 8 controlled substance cabinets on the nursing units. The pharmacist stated the nursing staff could access the outside vendor, if they ran out of a controlled substance.

In summary, the facility did not ensure medications that were "controlled substances" were stored in a secure manner, as:
- individually packaged controlled substance substock (from facility substock located in the unit's controlled substance cabinets) was stored on the first floor medication carts.
- tablets were split by nursing staff in an attempt to administer the ordered dosage.
- the quantity of substock on the nursing unit exceeded the weekly usage of the controlled substance.

10NYCRR 415.18(e)(1)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not maintain an infection control program to prevent the transmission of infection, for 1 (Resident #15) of 4 sampled residents reviewed for infection control concerns. Specifically, the facility did not use an effective disinfectant solution in Resident #15's room, when the resident was on contact precautions for Clostridium difficile (C. difficile, an intestinal infection with spores). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #15 was admitted to the facility with diagnoses of dementia, manic/depressive disorder, and coronary artery disease.

The Minimum Data Set (MDS), dated September 16, 2010, documented the resident had short term memory loss and moderate cognitive impairment. The resident was totally dependent for toileting assistance, was continent of bowel, and occasionally incontinent of bladder.

A nursing progress note, dated November 12, 2010 at 4:09 AM, documented the resident had a large, yellow colored, mucousy, foul smelling stool; a stool specimen was sent to the laboratory (lab) to rule out C. difficile. The resident was placed on contact precautions.

A lab report, dated November 12, 2010, documented the stool specimen was positive for C. difficile.

A nursing progress note, dated November 12, 2010 at 9:23 PM, documented the resident was placed on Flagyl (an antibiotic) 500 mg, with 1 tablet of Lactobacillus (used to reestablish the normal intestinal flora).

Nursing progress notes, dated November 14 through December 9, 2010, documented the resident continued to have intermittent loose stools, and continued on contact precautions.

A nurse practitioner (NP) progress note, dated December 8, 2010, documented the resident had C. difficile diarrhea the previous month, due to recurrent antibiotic use for cellulitis (soft tissue infection).

A nursing progress note, dated December 10, 2010 at 1:33 PM, documented the resident had a loose stool; a stool sample was sent to the lab; and contact precautions were maintained.

An NP progress note, dated December 10, 2010, documented the resident had diarrhea due to C. difficile, and was having stools checked again.

A lab report, dated December 10, 2010, documented the stool sample was positive for C. difficile.

The Resident Care Plan, dated December 11, 2010, documented the resident had a C. difficile infection and was on contact precautions.

A nursing progress note, dated December 11, 2010, documented a new order was given for the resident to be administered Flagyl 500 mg by mouth, every 8 hours for 14 days.

On December 16, 2010 at 12:35 PM, the surveyor interviewed the housekeeper working on the Resident #15's wing. The housekeeper was asked about the way to clean Resident's #15's room. The housekeeper stated she would look on the back of the precautions sign for instructions. For cleaning the bathroom, the housekeeper said she would spray the toilet and sink with the (Concentrate) "25 disinfectant", and then mop the floor with "3M" (neutral floor cleaner). She stated she went to training during orientation ("about 2 weeks ago"). She said it was very important to wash her hands and wear gloves when cleaning the room.

On December 16, 2010 at 12:40 PM, the surveyor read the sign on the door of Resident's #15 room. The sign documented "contact precautions", and specified to wear gown and gloves, and handwashing.

At 1:30 PM on December 16, 2010, the surveyor observed 2 certified nurse aides (CNAs) coming out of Resident's #15 room. They said they had just put Resident #15 to bed, using the mechanical lift. The CNAs were asked if Resident #15 used the bathroom. CNA #1 said "not in the past few days", as the resident had been incontinent. CNA #1 said if the resident was ambulatory, she would use the bathroom and her roommate would use a commode. When asked where the commode was, both CNAs said Resident #15's roommate was also incontinent, and did not use the bathroom. During the interview, the 2 CNAs were wiping the lift down with chlorine disinfectant wipes.

On December 16, 2010 at 2 PM, the surveyor asked the Housekeeping Supervisor for information relative to the solutions used in isolation rooms. The supervisor provided Material Safety Data Sheets (MSDS, documentation clarifying hazards to product users) for HB Quat Disinfectant Cleaner Concentrate #25 (a disinfectant cleaner for hard surfaces) and Neutral Floor Cleaner. Neither document specified the name of type of organisms these products were effective against.

The surveyor interviewed the Director of Administrative Services on December 16, 2010 at 5:45 PM, and was asked for information relative to technical data for the solutions used to clean isolation rooms. She provided the June 2010 Version 3 Technical Data for Concentrate 25. The Technical Data documented Concentrate 25 was an effective disinfectant against an array of bacteria, which did not include C. difficile. The document did not specify that this product killed spores.

There was no documented evidence the disinfectant/cleaning products, used during the survey in Resident #15's room, were effective disinfectants for C-difficile.

On December 16, 2010 at 6:45 PM, the Housekeeping Supervisor provided the surveyor with a copy of undated technical information about Lotus Pro (an ozone based spray disinfectant), which she said should have been used in the room. She said she inserviced the housekeeper that afternoon on this product, which was effective against spores. She said this product was relatively new, and the facility started using it because it was effective against spores. The technical information documented Lotus Pro was an effective sanitizer for C. difficile.

In summary, for this resident who required 2 courses of antibiotic treatment for C. difficile, the facility did not use an effective disinfectant solution in the resident's room for this type of bacteria.

10NYCRR 415.19

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure the resident environment was free of accident hazards in 1 of 13 (Residents' #7 and 25 room) sampled resident rooms on Unit 3. A small throw rug was present in Residents' #7 and 25 room during survey. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During a tour of Unit 3 on December 14, 2010 between 1:30 PM and 2:30 PM, the surveyor observed a small throw rug in front of the dresser in Residents' #7 and 25 semiprivate room. The rug did not have a non-slip backing or pad under it, to reduce the possibility of the rug sliding. During this observation, the corridor door was open and the rug was visible from the corridor.

The surveyor observed the throw rug in the same location on December 14, 2010 at 3:20 PM; on December 15, 2010 at 9:05 AM and 5:30 PM; and on December 16, 2010 at 9 AM and 1:10 PM. There was no non-slip pad or backing during these observations.

1) Resident #25 had diagnoses including dementia, hypertension, and atrial fibrillation.

An incident report, dated August 23, 2010, documented the resident fell in the lounge and sustained a skin tear on the left thigh. The incident report documented the resident stood up from her wheelchair independently and started walking.

The physical therapy discharge note dated September 29, 2010 documented the resident needed a contact guard with visual cueing for ambulation.

The MDS (Minimum Data Set) assessment, dated November 18, 2010, documented the resident was severely cognitively impaired, required extensive assistance of 1 person for ambulation, and had 1 fall since her admission.

The current comprehensive care plan (CCP), reviewed by the interdisciplinary team on December 1, 2010, documented the resident had moderate cognitive impairment related to dementia, was at high risk for falls related to poor safety awareness, had a history of falls, an abnormal gait, and other factors. Goals for safety included: "provide a safe environment".

A social work progress note, dated December 3, 2010, documented the resident had a bed alarm and chair alarm, and cognitive deficits.

The Profile of Care (instructions for direct caregivers), dated December 14, 2010, documented the resident was ambulatory with extensive assist of 1, was to have a bed alarm and chair alarm, and was in the fall prevention program.

2) Resident #7 had diagnoses including dementia, kyphosis (curvature of the spine), macular degeneration (visual impairment), and abnormal gait.

The Fall Risk Assessment, dated August 18, 2010, documented the resident was at high risk for falls due to multiple factors, including lack of understanding of safety precautions, poor vision, and confusion.

The MDS (Minimum Data Set) assessment, dated November 25, 2010, documented the resident's cognitive status was severely impaired, she required limited assistance of 1 for ambulation, and had 1 fall since the prior assessment.

The current comprehensive care plan (CCP), reviewed by the interdisciplinary team on December 8, 2010, documented the resident's cognition was severely impaired related to dementia; and she was at high risk for falls related to a history of falls, dementia, kyphosis (hunch back), and blindness.

The Profile of Care (instructions for direct caregivers), dated December 17, 2010, documented the resident ambulated with limited assistance of 1 staff, was to have a bed alarm and chair alarm, and was in the fall prevention program.

The registered nurse (RN) Unit Manager was interviewed on December 16, 2010 between 1:15 PM and 1:30 PM. She stated she understood throw rugs could be a safety issue. She thought the family may have recently brought in the throw rug for Residents' #7 and 25 room.

In summary, for Residents #25 and 7 who were at risk for falls, their room was not kept free of accident hazards, due to the throw rug without a non-slip backing or non-slip pad.

10NYCRR 415.12(h)(1)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure 1 (Resident #13) of 3 sampled residents discharged from the facility, was permitted to remain in the facility unless it was necessary for the resident's needs. Specifically, Resident #13 was transferred to another long term care facility after the resident's status changed from short term placement to long term placement. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #13 had diagnoses including coronary artery disease, neuropathy (nerve damage), and status post motor vehicle accident.

A Subacute Discharge Plan and Notice of Discharge, dated September 20, 2010, documented the resident was to be discharged home. It was signed by a representative for the resident.

The Minimum Data Set (MDS) assessment, dated September 27, 2010, documented the resident's cognitive status was independent, and the resident's stay was projected to be 30 days or less.

The comprehensive care plan (CCP), reviewed by the interdisciplinary team on September 20, 2010, documented the resident required short term rehabilitation placement, with a goal of discharge to an appropriate level of care, when the resident was medically stable and completed therapy.

A social work progress noted, dated October 8, 2010, documented the resident's progress in therapy was declining; he attempted to leave therapy; and the resident's daughter agreed he probably needed long term placement.

A social work progress note, dated October 13, 2010, documented the resident required total care on the unit, and would not be able to return home.

A social work progress note, dated October 20, 2010, documented the resident's daughter saw the resident's social worker, and the family wanted the resident moved to a "long term care bed" at this facility.

A social work note, dated October 21, 2010, documented the social worker was assisting with alternate placement, and 2 local long term care facilities received information regarding a "lateral transfer".

A nurse practitioner (NP) progress note, dated October 21, 2010, documented the resident would no longer participate in restorative therapy, and the family was interested in long term placement.

On November 2, 2010, a social work progress note documented the resident was accepted at another long term care facility, with an available bed on November 3, 2010.

The MDS assessment, dated November 3, 2010, documented the resident's cognitive status was moderately impaired, and the resident expected to be discharged to another facility.

An undated Physician Discharge Summary, completed by am NP, documented the resident was discharged to another skilled nursing facility on November 3, 2010.

A Notice of Transfer/Discharge, dated November 3, 2010, documented this form was mailed to the resident's Health Care Proxy November 5, 2010.

The surveyor attempted to interview the resident's Health Care Proxy by telephone on December 16, 2010, and was unsuccessful.

During an interview with the resident's social worker on December 16, 2010 between 1:45 PM and 2:05 PM, she stated the resident was unmotivated during his stay and seemed to give up. She said there were few long term care beds available for male residents at this facility, and it could take a long time for this kind of bed to become available.

In summary, there was:
- no documented evidence the resident was permitted to remain in the facility when restorative therapy was no longer provided.
- no documented evidence the resident's Health Care Proxy preferred the resident to be transferred from this facility.
- no documented evidence the transfer or discharge was necessary for the resident's welfare, or that his needs could not be met in the facility.

10NYCRR 415.3(h)(a)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not provide care that met professional standards of quality for 1 (Resident #2) of 24 sampled residents. Specifically, the facility did not follow the physician prescribed parameters for administration of medication, checking blood pressure and apical pulse prior to administration of antihypertensive medication to Resident #2. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #2 had diagnoses of hypertension, stroke, dementia, and depression.

The comprehensive care plan (CCP), dated November 12, 2010, documented the resident had alteration in cardiac status, due to hypertension and stroke.

The Minimum Data Set (MDS) assessment, dated November 24, 2010, documented the resident had severe cognitive impairment.

The physician order sheet, dated November 12, 2010, documented the resident was to receive Toprol XL 25 milligrams (antihypertension medication) once a day, with parameter of holding the medication, if the systolic blood pressure was below 100, or if the apical pulse was below 60.

A review of the Medication Administration Record (MAR) from November 12, 2010 to December 15, 2010 revealed the blood pressure or apical pulse readings were not documented on the MAR, for the 9 AM doses of the medication.

Facility Query Results, licensed practical nurse (LPN) progress notes, documented the blood pressure and apical pulse were recorded on 11 of the 33 days at 7:30 AM, 4 days at other times, and were not recorded on 18 days (from November 12, 2010 to December 15, 2010).

An interview with the registered nurse (RN) Unit Manager on December 15, 2010 at 9:30 AM revealed the medication nurse may have documented the blood pressure and apical pulse in a separate location of the electronic medical record. She stated the medication nurses usually documented the readings on the MAR, when associated with medication times.

On December 16, 2010 at 1:10 PM, during an interview with the LPN passing medications on Resident #2's unit, the surveyor asked why the resident's blood pressure and pulse were not documented on the December 2010 MAR. The LPN stated if the resident was on report, the blood pressure and pulse were checked and she would check the report. The LPN stated this resident was on report, but she could not guarantee the vital signs were checked every day.

In summary, the facility did not consistently follow the physician prescribed parameters for administration of medication.

10NYCRR 415.11(c)(3)(i)