Island Nursing and Rehab Center

Based on record review and staff interviews during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was periodically reviewed and revised by a team of qualified persons after each assessment. This was evident for one resident in a total sample of fifteen residents reviewed for care planning. Specifically, Resident #177's Fall Prevention CCP was not revised to reflect the new interventions to be implemented after two fall incidents. A plan initiated on 5/6/11 to implement a low profile antithrust cushion on the resident's wheelchair at all times and a plan dated 5/18/11 for placement of an alarm box (unreachable by the resident) on their wheelchair was not updated on the Fall Prevention CCP. This resulted in no actual harm with the potential for more than minimal harm which is not immediate jeopardy.

The finding is:

Resident #177 was admitted on 2/23/11 with diagnoses including Hypertension and Psychosis with Dementia and was placed on Hospice (end of life) care.

The Minimum Data Set (MDS) Assessment dated 2/7/11 documented that the resident had impaired vision, memory, and cognition.

A CCP dated 3/21/11 for Fall Prevention documented a history of falls with a goal to remain free from falls.

An Accident /Incident (A/I) Report for a fall incident dated 5/5/11 documented that the resident slides off their wheelchair and the Physician ordered (on 5/7/11) a low profile antithrust cushion on wheelchair at all times. The low profile antithrust cushion was documented on the Certified Nursing Assistant Accountability Record (CNAAR) on 5/7/11, but was not transcribed to the Fall Prevention CCP.

An A/I Report for a fall incident dated 5/15/11 documented that the resident had removed her personal alarm clip from her clothing and destroyed the seat alarm box which was found on the floor. The report documented that the wheelchair alarm box would be placed so that it would be unreachable by the resident. This new intervention was not documented on the May 2011 CNAAR or the Fall Prevention CCP.

In an interview with the Unit Registered Nurse (RN) Charge Nurse on 5/26/11 at 11:00 AM she stated that the CCP should be updated by the two Nurses (one that obtains or picks up the Physician's Order and the second that co signs it). The RN was unable to explain why the Physician's Order for the antithrust cushion did not make it to the Fall Prevention CCP. The RN stated that she was unaware of the plan in the A/I Report dated 5/15/11 to reposition the chair alarm box in an unreachable location. The RN stated that new interventions are usually discussed in morning meetings and that she did not remember getting this information.

In an interview with the DON on 5/26/11 at 6:10PM she stated that she had completed the A/I Report dated 5/15/11 and decided that the alarm box would be placed somewhere in the back or underneath the resident's wheelchair seat. The DON stated that the A/I report was still pending the Physician's review. The DON also stated that she did not get to inform the Engineering Department to implement the change and the unit staff for documentation and follow-up.

415.11(c)(2)(i-iii)

Based on observation, staff interviews, and record review during the recertification survey, the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. This was noted for 1 of 3 residents reviewed for accidents. Specifically, for Resident #177's fall prevention interventions 1) to keep the resident under supervision at all times and 2) reposition the chair alarm box to make it unreachable for the resident were not implemented consistently and timely. This resulted in no actual harm with the potential for more than minimal harm which is not immediate jeopardy.

The finding is:

Resident #177 was admitted on 2/23/11 with diagnoses including Hypertension and Psychosis with Dementia and is on Hospice (end of life) care.

A Minimum Data Set Assessment (MDS) dated 2/2011 documented that the resident had impaired memory and cognition.

A Comprehensive Care Plan (CCP) dated 3/21/11 for Fall Prevention documented a high risk and a history of falls. he CCP included a goal that the resident will remain free from falls. The specific interventions included that the resident should not be left alone in their room and should be placed at desk/core area/TV area so staff could monitor behavior and activity.

An Accident Incident (A/I) Report documented a fall incident dated 5/15/11 at 3:03 PM in which the resident was found on floor in front of their wheelchair in the nursing core area. The A/I Report documented that the resident removed her personal alarm clip from her clothing and destroyed the seat alarm box, which was found on the floor. The Summary Investigation section documented that the resident was usually placed near the nursing station due to a high risk for falls and all her safety care plan was followed. The report documented that the wheelchair alarm box would now be placed so that it would be unreachable for the resident. The A/I Report did not include information regarding why the resident was not observed while she removed the personal alarm clip from her clothing and destroyed the seat alarm box, despite the plan for her to be always under staff observation.

The 7:00 AM-3:00 PM Licensed Practical Nurse (LPN) was interviewed on 5/27/11 at 8:00 AM and stated that on 5/15/11 at 3:03 PM, the resident was seated in a wheelchair in front of the TV in the nursing core area which is located in front of the nurse's station. The LPN stated that it was at the change of shift and she was sitting at the nurse's station with the 3:00 PM-11:00 PM LPN. The LPN stated that when she looked up, the resident was on the floor and the alarms were not ringing. The LPN stated further that the resident was sitting in the nursing core area, and was in constant view of the staff, and it happened at the change of the shift. The LPN stated that she did not observe the resident destroying the seat alarm and she left soon after the incident and was not involved in the investigation. The LPN stated that she did not even know that the resident had destroyed the alarm.

The resident was observed in their wheelchair on 5/27/11 at 8:00 AM, both alarm boxes (clip alarm and chair alarm) were attached to the right edge on the back of the wheelchair.

In an interview with the Director of Nursing (DON) on 5/26/11 at 6:10 PM she stated that she had completed the A/I Report dated 5/15/11 and determined that the alarm box should be placed somewhere in the middle back or underneath the seat of the resident's wheelchair. The DON stated that the A/I Report was still pending the Physician's review and that she did not get to inform the Engineering Department to reposition the boxes or unit staff for documentation and follow up.

The Unit Registered Nurse (RN) Charge Nurse was interviewed on 5/26/11 at 11:00 AM and stated that she was unaware of the plan documented in the A/I Report dated 5/15/11 for the chair alarm boxes to be repositioned to a location unreachable for the resident. The RN stated that the new interventions were usually discussed in morning meetings and that she did not remember getting this information and therefore the Certified Nursing Assistant Accountability Record and Fall Prevention Care Plan was not updated.

Therefore, the facility did not monitor the resident as per plan to prevent the resident from removing their clip alarm and breaking the wheelchair alarm box and slid to the floor on 5/15/11. Additionally' the facility did not complete the investigation and implement the plan for repositioning the safety alarms in a timely manner.

415.12(h)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that 1 of 3 residents reviewed for Pressure Ulcers in a total sample of 15 residents received nutrition care and services, consistent with the resident's comprehensive assessment. Specifically, Resident #226 was admitted to the facility with a reddened sacral area. Recommendations from the Chief Clinical Dietician were not noted on the resident's Physician's Orders for four days. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #226 has diagnoses that include Bacterial Endocarditis which required Intravenous Antibiotic therapy and a Reddened Sacral Area on admission to the facility.

The Admission Minimum Data Set dated 3/31/11 documented that the resident was cognitively intact with a score of 15/15 on the Brief History for Mental Status
(BIMS).

The Admission Nursing Note dated 3/30/11 documented that the resident's skin was intact with blanching and soreness on the sacral area.

The Plan of Care for Nutritional Status written by the Chief Clinical Dietician (CCD) dated 3/31/11 documented that the resident was at risk for altered nutritional status as evidenced by inadequate oral intake, particular eater, and altered nutritional related labs. Interventions included, but not limited to, were to recommend Prostat 101 30 cc (cubic centimeters) daily per med pass (start date 3/31/11) and to recommend Ensure Plus 120 cc twice a day with medication pass.

An evaluation written by the CCD dated 3/31/11 documented that the resident's Pre-Albumin level was 11.8 mg/dl (milligrams/deciliter) which was moderately depleted on admission to the facility. Nutritional support provided.

The CDD was interviewed on 5/26/11 at 10:30 AM and stated that the facility has 5 days after admission to complete an assessment for the resident. The CCD stated that she had made recommendations on 3/31/11 for the resident to have Prostat (a protein supplement) and Ensure (a liquid nutritional supplement). The CCD stated that she had placed her recommendations in the Nurse Practioner (NP) Book and they were not picked up by the NP until 4/04/11.

The Registered Nurse (RN) Unit Manager was interviewed on 5/26/11 at 10:45 AM and stated that the resident had been admitted with a reddened sacral area and she was not made aware of any recommendations by the CCD for any supplements until 4/04/11.

The Physician's Order dated 4/4/11 signed by the NP documented to give Ensure Plus 120 ml (milliliter) twice a day and Prostat 101 30 ml daily.

The Wound Care NP was interviewed on 5/27/11 at 11:00 AM and stated that recommendations from the CCD are placed in the NP book for review. The NP stated that she was unsure if the Dietary recommendations were placed in the NP book.

415.12(i)(1)

Based on resident and staff interview and record review during the recertification survey, the facility did not ensure that the Resident Council Representative knew who the ombudsman was and how to contact him/her. This lack of knowledge has the potential to affect all the residents in the facility. This resulted in no actual harm with the potential for no more than minimal harm.

The finding is:

On 5/26/11 at 8:40 am, the facility's Vice President of the Resident Council was interviewed and stated that no one has ever approached her and told her who the ombudsman was and how to contact them.

Resident Council Meeting Minutes dated 2/23/11, 3/21/11, and 4/25/11 were reviewed and no mention of the facility's ombudsman was made or how to contact them.

On 5/26/11 at 9:35 am, the Director of Recreation was interviewed and stated that she probably does not bring that up every month in resident council and that she needed to put that back into her monthly business to bring that up at Resident Council Meetings.

415.3(c)(2)(iv)

Based on observation, staff interviews, and record review during the recertification survey, the facility did not provide 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. Specifically, the facility did not honor residents' individual choice of whether or not to wear a clothing protector at meals. During a lunch meal, the staff was observed to don plastic bibs/clothing protectors on the residents in two of three unit dining rooms observed. This resulted in no actual harm with the potential for more than minimal harm which is not an immediate jeopardy.

The finding is:

During a lunch meal observation in the 2nd floor unit dining room on 5/23/11 at 12:00 PM, a 7:00 AM-3:00PM shift Certified Nursing Assistant (CNA) was observed to don plastic bibs on all 32 residents present in the dining room. The CNA was observed to don the bibs on residents without asking the residents for their preference for a bib.

On 5/23/11 at 12:35 pm the 2nd Floor 7:00 am-3:00 pm CNA was interviewed and stated that he had been instructed to give each resident a hand wipe, bib, and glass of water (if allowable) prior to them being served lunch. The CNA also stated that he does not ask each resident if they would like a bib because he knows the residents' preferences and none refuses a bib. The CNA further stated that plastic bibs were the only type of bibs that the facility offered.

During a lunch meal observation in the 3rd floor unit dining room on 5/23/11 at at 12:30 PM the following was observed: There were 25 residents in the dining room. A CNA was observed to ask five residents if they required the plastic bibs and they were observed to say "Yes" and given bibs. The remaining 20 residents were not asked if they wanted a bib before it was donned on them. In an interview with this 7:00 AM-3:00 PM CNA on 5/23/11 at 12:45 PM, she stated that a lot of time the residents do not respond and sometimes the residents are confused or too tired to answer.

The unit 3 Licensed Practical Nurse was interviewed on 5/23/11 at 12:50 PM and stated that "every resident should be asked if they want a bib or not. If they can refuse, then they should not receive the bib, if they cannot refuse then they should be given a bib for protection of clothing and safety."

In an interview with the Minimum Data Set (MDS) Assessment Registered Nurse (RN) on 5/23/11 at 2:00 PM, the RN stated that no Care Plan is developed for the use of plastic bibs for residents during meals.

The Director of Nursing (DON) was interviewed on 5/27/11 at 9:00 AM and stated that a trial of linen napkins was conducted in June/July 2009, on all the units. The DON stated that the residents did not like the linen napkins and it was discussed in the Resident Council Meeting and the use of plastic bibs was resumed.

The Recreation Director was interviewed on 5/27/11 at 10:00 AM and stated that after the residents refused to use the linen napkins in 2009, the facility did not revisit the issue and that there was no ongoing system to obtain the residents or their families preference regarding the use of a clothing protector.

415.5(a)