East Neck Nursing & Rehabilitation Center

Based on record review and staff interviews during the Recertification Survey, there was no documented evidence that the facility attempted to provide non-pharmacological interventions prior to giving Ativan and Haldol injections to one of twenty residents reviewed for psychoactive medications in a total sample of thirty residents. Specifically, Resident #6 received twenty-nine injections of Ativan and one injection of Haldol between 11/19/10 and 4/17/11, with no documented evidence that non-pharmacological interventions were attempted prior to the administration of the injections. This resulted in no actual harm with the potential for more than minimal harm, that was not immediate jeopardy.

The finding is:

Resident #6 has diagnoses including Dementia with Delusions.

Resident #6's Minimum Data Set (MDS) Assessments of 11/6/10, 2/5/11, and 4/30/11 documented his Cognitive Skills for Daily Decision Making as Moderately Impaired - decisions poor; cues/supervision required. The three MDS Assessments also documented that the resident had behavioral symptoms directed towards others.

Resident #6's Comprehensive Care Plan (CCP) dated 8/6/10 for Behavioral Symptoms, and in effect through 4/17/11, documented several non-pharmacological interventions that were to be utilized for his behavior disturbances, such as to provide emotional reassurance, inform resident of his inappropriate behavior and set limits, remove resident from area, approach him in a calm/gentle manner, etc.

The resident's Physician ordered Ativan injections of 0.5 milligrams (mg) every six hours as needed for extreme agitation on 11/9/10, and it had been ordered from that date though 4/17/11. Resident #6's Physician also ordered that a single injection of Haldol 0.5 mg be administered on 1/5/11.

A review of the resident's clinical record and Medication Administration Records (MARs), revealed that there was no documented evidence that non-pharmacological interventions were attempted by staff prior to the administration of twenty-nine Ativan prn (as needed) injections and one Haldol injection between 11/19/10 and 4/17/11. Examples include but are not limited to the dates of 11/19/10, 1/5/11, and 4/17/11.

The Nursing Supervisor (a Registered Nurse - RN) and Resident #6's Day Shift Unit Charge Nurse (a Licensed Practical Nurse - LPN) were interviewed on 5/4/11 at 10:05 AM. They stated that before a prn injection for behavioral disturbances was administered to a resident, staff must not only attempt non-pharmacological interventions first, possibly in lieu of the injection being given, but staff must also document the intervention(s) utilized, or why a non-pharmacological intervention was not or could not be attempted.

The Nursing Supervisor (RN) was interviewed again 5/4/11 at 11:50 AM and 1:20 PM, and on 5/5/11 at 8:50 AM. The Nursing Supervisor stated that she reviewed the resident's medical record and could not find any documentation that non-pharmacological interventions were attempted prior to the administration of the thirty injections. She stated that the facility once used a form specifically to document the non-pharmaceutical interventions attempted prior to administering a prn injection for behavior, that it had not been used for some time, and that the facility had just recently started utilizing it again. She further stated that if any additional pertinent documentation could be found regarding non-pharmaceutical interventions utilized before the injections were given to Resident #6, it would be provided prior to the Survey Exit Conference, which was held on 5/5/11 at 3:15 PM. No additional documentation with regard to this finding was provided by the facility.

The Facility Policy for the use of psychotropic medications in effect from 4/2010 to 3/1/11 was reviewed. It did not document that there was any responsibility on the part of staff to document non-pharmacological interventions for behavior attempted prior to a prn medication being administered. The facility's current policy for the use of prn medications for behavior dated 3/1/11 and now in effect, did document that nursing staff must document the interventions attempted. The Nursing Supervisor, interviewed on 5/5/11 at 8:50 AM stated that even though the new policy went into effect on 3/1/11, with staff inservices having to be conducted, not all units in the facility were following the new policy with regard to documentation and the use of the Behavior Log form until just the last few weeks.

415.12(1)(i)

Based on record review, and resident and staff interviews during the annual Recertification Survey, there was no documented evidence that one of thirty sampled residents had a documented Bowel Movement (BM) for four days and one shift (thirteen shifts). Specifically, the bowel records for Resident #18, documented by the facility Certified Nurse Aides (CNAs), revealed that from 5/2/11 through 5/5/11 Resident #18 had not had a bowel movement. This resulted in no actual harm but had the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #18 has diagnoses that include Osteoarthritis and is on Hospice Care.

On the morning of 5/5/11 at 9:30 AM, Resident #18 was interviewed and complained of pain all over her body.

A review of the bowel record revealed that Resident #18 had no documented BM's on 5/1, 5/2, 5/3, 5/4, and on the 11 PM -7 AM shift on 5/5/11.

The current comprehensive care plan goals dated 3/6/11 documented at least one soft formed stool every three days.

An interview was conducted with the facility 7 AM to 3 PM shift CNA on 5/5/11 at 10:00 AM. The CNA explained that Resident #18 is on Hospice Care and that she usually asks the Hospice Aide to find out whether or not the resident has had a BM. She also explained that she was not working the day before (5/4/11) and had not looked at the accountability book as of yet.

An interview with the district medication Licensed Practical Nurse (LPN) on 5/5/11 at 10:15 AM revealed that she was unaware that the resident had no documented bowel movements for the past four days. She also explained that she had done a treatment for that resident earlier this morning and that the resident had not complained of any pain at that time.

An interview with the Unit Charge Registered Nurse (RN) on 5/5/11 at 10:30 AM revealed that the resident is on Hospice care. She also stated that the resident was not put on report on 5/4/11 or 5/5/11 as not having a documented BM during the past four days.
In addition, the RN explained that it is the responsibility of the CNAs to report if there has not been a BM documented.

An interview was conducted with the Hospice Health Aide on 5/5/11 at 11:00 AM and revealed that she had cared for resident # 18 during the past week. The Aide also explained that she was sure that the resident had a BM yesterday (5/4/11) and may have had a BM this past Monday (5/2/11). She further explained that she had forgotten to tell facility staff about the resident having had a BM.

415.12

Based on staff interview and record review during the Recertification Survey, the facility did not ensure for one of thirty sampled residents (#15) with significant hearing loss who used a right hearing aid, that nursing staff documented necessary information to ensure weekly battery changes were being completed. Specifically, three months of hearing aid tracking sheets were incomplete of information to ensure that necessary battery replacement was completed timely as per facility policy.

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

The finding is:

Resident #15 has diagnoses including Severe Profound Bilateral Hearing Loss.

The comprehensive care plan dated 4/20/11 documented interventions as follows: Provide a right hearing aid as required and check hearing aid placement. Educate resident on the use of the hearing aid and speech evaluations as needed.

The evaluation of the comprehensive care pan dated 4/20/11 documented that the resident can be verbally disruptive constantly shouting for help despite continual assistance from staff.

A review of four months of hearing aid tracking sheets was completed. The following was noted: April 2011 documented that the battery was changed twice on the 3 PM to 11PM shift. March 2011 tracking sheet had no documented battery changes for the entire month. In addition, a third month of the tracking sheets which was undated and documented use of the hearing aid had no documentation that the battery was changed during that time period.

In addition, the current Certified Nurse Aide accountability record dated May 2011 did not document the use of the right hearing aid.

An interview with the hearing aid company staff on 5/4/11 at 2:00 PM revealed that usually the hearing aid batteries are good for one week.

An interview with the Charge Licensed Practical Nurse on 5/4/11 at 2:20 PM revealed that as per facility policy and confirmed with the Director of Nursing Services, the hearing aid battery should be changed weekly.

A facility policy and procedure for Hearing Aid Care and Accountability dated 6/2/08 documented that all residents with hearing aids need to have a tracking sheet. The forms are to be completed by the charge nurse every shift. Every Wednesday, the 7 AM to 3PM shift nurse puts in a new battery before giving the the hearing aid to the resident or the Certified Nurse Aide.

415.12(3)(b)

Based on observations, record reviews, and staff interviews the facility did not ensure that a physician's order was followed. Specifically, Resident #3 had a Physician's Order for a right multipodus boot to be worn at all times. On two occasions the resident was observed without the right multipodus boot in place. This was evident for 1 of 5 residents reviewed for assistive devices during an Off-Hour Recertification survey in a total sample of 30 residents .
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings is:

Resident #3 has diagnoses that include Cerebral Vascular Accident (CVA) and Dysphasia (difficulty speaking).

The Minimum Data Set 3.0 Assessment (MDS) dated 4/23/11 documented that the resident had severely impaired cognition with limitations to both lower extremities.

The Physician's Orders dated 4/27/11 documented that a Right Multipodus boot was to be worn at all times except for hygiene and range of motion.

On 5/03/11 at 8:00 AM and at 9:30 AM two observations were made of Resident #3 in bed without the Multipodus boot on.

During interview on 5/3/11 at 9:30 AM with the Certified Nursing Assistant (CNA) caring for Resident #3, she stated the Multipodus boot should have been on.

During interview with the Registered Nurse/Charge Nurse on 5/3/11 at 10:00AM, she stated that Resident #3 should have had the Multipodus boot on.

415.11(c)(3)(ii)

Based on record review and staff interview during the annual Recertification Survey, the facility did not ensure that two Licensed Nurses documented administration of a Physician ordered medication and or supplement as per the nursing standard of practice. Specifically, one Licensed Practical Nurse (LPN) did not document the administration of a weekly medication on the Medication Administration Record (MAR) and one medication Registered Nurse (RN) documented in error the administration of supplements several hours prior to the planned administration time.

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

The findings are:

1) Resident #4 has diagnoses including Dementia.

Current Monthly Physician orders dated April 2011 included an order for Fosamax. The order read: Take one tablet orally every week with an eight ounce glass of water... for a diagnosis of Osteoporosis.

The MAR dated April 2011 had boxed out 4/29/11 as one of the four dates in which the Fosamax medication should have been administered.

On 5/2/11 a review of the April/May 2011 MAR was completed. The boxed out date of 4/29/11 at 5:30 AM was unsigned by the LPN.

During an interview with the Director of Nursing Services on 5/3/11 at 11:00 AM she explained that the LPN was called and did remember giving the resident the Fosamax at 5:30 AM on 4/29/11. The LPN further explained that she had to sit the resident upright in her bed for thirty minutes following the administration of the Fosamax. In addition, the LPN stated that she must have forgotten to sign the MAR even though she gave the Fosamax to the resident.

2) Further review on 5/2/11 at 10:30 AM of Resident # 4's April 2011 MAR revealed that the following supplements were ordered by the Physician: Prostat 30 milliliters (ml) by mouth twice per day to be given at 9 AM and 1 PM and a hydration program of 240 ml to be given by mouth every shift.

Review of the April 2011 MAR revealed that both of the above mentioned supplements were documented by the RN as administered several hours prior to the planned administration time of 1 PM that was documented on the MAR. In addition to the nurses' signature, the quantity of the supplements taken at 1PM were also documented on the MAR.

An interview with the RN on 5/2/11 at 3:00 PM revealed that she was nervous and signed on 5/2/11 for the 1:00 PM administrations of Prostat and the 240 ml of fluid in error.

415.11(c)(3)(i)