Island Nursing and Rehab Center

Based on record review, observations, and staff and resident interviews conducted during the standard survey, it was determined for 1 of 24 sampled residents (Resident #14) reviewed for activities of daily living (ADL), that the facility did not ensure a resident's abilities in activities of daily living did not diminish. Specifically, Resident #14 had a decline in ambulation and transfer status without documentation of clinical condition that they were unavoidable. This resulted in actual harm that is not immediate jeopardy.

The finding is:

Resident #14 has diagnoses that include Depression and Diabetes Mellitus.

The Minimum Data Set (MDS) Assessment dated 11/10/09 documented that the resident had modified independence with decision making and required limited assistance for ambulation and transfers.

The Certified Nursing Assistant (CNA) Accountability Records dated 10/2009 and 11/2009 documented that the resident was ambulating 100 feet (no supervision of staff was identified).

A Rehabilitation Screening Form dated 11/10/09 documented that the resident ambulated 100 feet with a rolling walker with one assist of staff and 1 person following with the wheelchair. It also documented that the resident was able to transfer out of bed/wheelchair/toilet with 1 assist of staff and may use the bar in the bathroom. The screen also documented that the resident had no significant changes since last evaluation.

The Rehabilitation Screening Form dated 12/7/09 for Significant Change relating to "now requiring Sarita lift for transfer" stated that the significant change was noted in Functional Status. The change was that the resident now required increased assistance for transfers from 1 to 2 persons and with increasing effort. The resident transfers with less effort with increased safety using the Sarita lift. There was no documentation on this screening form in regard to the resident's ambulation status.

A Nurse's Progress Note dated 12/8/09 documented to discontinue ambulation with no explanation as to why the resident was discontinued from ambulation.

A physician telephone order dated 12/8/09 documented to discontinue ambulation.

There was no documentation that a medical assessment was completed for a decline in ambulatory and transfer status.

The Significant Change MDS Assessment was not completed until 2/4/10. This MDS documented that the resident was now non ambulatory for walking in room/corridor (score 8/8 indicating that this ADL did not occur) and her transfer status declined to extensive assist requiring 2 + persons physical assist (score 3/3).

The CNA accountability records dated 12/09 through 5/10 documented that the resident did not ambulate.

On 5/27/10 at 10:45 AM, the resident was observed in a wheel chair. The Director of Physical Therapy (PT) was observed evaluating the resident for upper and lower body strength. The PT asked the resident what year and month it was and the name of the facility. The resident answered all three questions appropriately. The PT then asked the resident if she was in pain and the resident stated "no". The PT asked did she want to walk and the resident stated "yes". It was observed that the resident walked five feet with a rolling walker and two staff members assistance. The resident was asked if she enjoyed the walk and the resident stated "yes, it felt good to walk".

A PT evaluation dated 5/27/10 documented that the resident ambulated five feet, had no pain and was orientated to person, place and time. The PT evaluation also documented that the resident is a good candidate for PT services to attempt to return to her prior level of functioning.

An interview was held on 5/26/10 at 11:30 AM with the Registered Nurse (RN) MDS Coordinator. The RN stated that she completed a significant change MDS for the resident on 2/4/10 because the resident had a decline and was non ambulatory. A significant change Comprehensive Care Plan (CCP) meeting was held on 2/9/10. The MDS coordinator stated that the PT was not present at the meeting.

An interview with the resident's day shift Certified Nurse Aide (CNA) on 5/26/10 at 1:45 PM revealed that she has been caring for the resident for about one year and that the resident had been walking 100 feet in the hallway everyday and that the resident would "like to walk". The CNA also stated that the resident did not complain of pain when she was walking. The CNA also stated that the resident was not walking now and that it has been a couple of months (sometime in December) since she walked.

An interview was held with the Director of PT on 5/26/10 at 1:00 PM. The PT stated that the resident was ambulating 100 feet according to the screen completed 11/10/09. The PT also stated that she completes the screen by asking the CNAs about the resident's status and that she was not aware that the resident was not ambulating now. She then stated that she would be the one to recommend to discontinue a residents ambulation. The PT stated that at times the resident refused to ambulate and that the resident has a wound on her ankle, but has ambulated in the past with the wound. The PT also stated that she would expect the nurse to inform her that the resident was not ambulating. The PT reviewed the medical record and stated that she did not complete a significant change assessment on 2/4/10 and could not explain why. The PT did not find any documented evidence that the resident refused ambulation.

An interview was held on 5/27/10 at 9:00 AM with Resident #14. The resident stated that she had a sore on her ankle but that she has had it for 3 years since she fractured her ankle at home. The resident stated that the nurses said that the sore was very small but had a little drainage. The resident also stated that she does not have any pain in her ankle. Additionally, the resident stated that she has not walked in a while because the nurse told her she could not walk because her legs were weak. The resident stated that she liked to walk and she had walked everyday when she was home.

An interview was held with the 7 AM-3 PM shift Registered Nurse (RN) Manager on 5/27/10 at 9:15 AM. The RN stated that she wrote the Physicians order to discontinue ambulation. The RN also stated that she did not remember why and that she must have been asked by PT to call the Physician for the order.

An interview was held on 5/27/10 at 10:15 AM with Resident #14's Physician. The Physician stated that the resident is not ambulating because of the resident's confusion. The Physician also stated that the resident is medically stable at this time and if she wants to ambulate she would order a PT evaluation.

415.12(a)(1)

Based on record reviews and staff interviews during the standard survey, the facility did not ensure that the attending physician was notified in a timely manner of a significant change. Specifically, the resident had two CAT ( Computed Tomography) scans (diagnostic X-rays of the cross section of a part of the body shown on a computer screen) completed on 5/10/10 and as of 5/25/10 the Physician was not aware of the results. This was evident for 1 of 24 sampled residents (Residents #4). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #4 has diagnoses including Osteoporosis and Diabetes Mellitus.

A Nurses Progress Note (NPN) dated 5/10/10 at 7:30 AM documented to send Resident #4 to the hospital for an evaluation after sustaining a fall.

A Physicians Interim Order Form dated 5/10/10 at 8:00 AM documented to send Resident #4 to the hospital emergency room for a CAT scan of the head.

A NPN dated 5/10/10 at 9:25 PM documented that the resident returned from the hospital and that the resident should follow up with her primary Physician in three to five days.

A CAT Scan report of the Cervical Spine dated 5/10/10 documented a left posterior nasopharynx (nose/throat) mass concerning squamous cell carcinoma (a fast growing cancer). The report also documented that additional CAT scan imaging was advised.

A CAT Scan report of Resident #4's Head dated 5/10/10 documented a left posterior nasopharynx mass and recommended a clinical examination of the nasopharynx and additional CAT scan imaging.

There was no documented evidence in the medical record that the Physician was notified of the CAT scan results or the request to follow up in three to five days with the resident after her return from the hospital 5/10/10.

An interview was held on 5/25/10 at 11:00 AM with the Director of Nursing Services (DNS). The DNS stated that she and the Unit Manager were not aware of the CAT Scan results and that the nurses should have documented the results and notified the Physician.

An interview was held with the Physician on 5/25/10 at 1:00 PM. The Physician stated that she was not aware of the CAT Scan results or that the hospital recommended that she evaluate the resident within three to five days of the resident's return from the hospital.

An interview was held on 5/27/10 at 11:00 AM with the Registered Nurse (RN) Unit Manager. The RN reviewed the medical record and stated there was no documented evidence that the Physician was notified of the CAT Scan results.

415.3

Based on record review and staff interviews during a standard survey, the facility did not ensure that accident/incidents were thoroughly investigated. This was observed for 2 out of 24 sampled residents. Specifically, the facility did not thoroughly investigate a fall for Resident #16 and the investigation of a traumatic injury of the left lower leg for Resident #2 did not contain sufficient detail to rule out resident abuse/and or neglect. This resulted in no actual harm with a potential for more than minimal harm which is not an immediate jeopardy.

This is a repeat deficiency.

The findings are:

1) Resident #16 has diagnoses including a history of fracture of the femoral neck (2/7/10), left hand ecchymoses (2/23/10), Dementia and Chronic Renal Failure.

An Accident/Incident Investigation (A/I) report dated 2/7/10 documented that the resident had sustained a fall resulting in a fractured right femoral condyle (rounded protuberance at the end of a bone) and a laceration to the occipital region of head.

A Minimum Data Set (MDS) Assessment dated 3/9/10 documented the resident's cognition to be moderately impaired. The MDS also documented the resident's memory to be impaired.

A Comprehensive Care Plan (CCP) dated 2/8/10 documented that a personal bed and chair alarm were implemented to prevent further falls.

A nurses note dated 2/24/10 documented that at 2:45 AM the resident rang the call bell and was found sitting on the floor next to her bed. It was documented that the resident stated that she fell coming back from the bathroom and then crawled to near the side of the bed. The note further documented that the resident sustained a 3.5 X 1.5 centimeter bump to the back of head and a 1.5 inch long skin tear below the right elbow and that the resident was transferred to the hospital.

The documentation of the fall dated 2/24/10 in the nurse's progress notes and in the A/I report dated 2/24/10 did not address whether the personal bed alarm, which was supposed to be in place at the time of the incident, was in place and if it was checked for proper functioning. The incident report did not include pertinent information describing whether the planned preventative measures were in place and working at the time of the fall.

In an interview with the Director of Nursing (DON) on 5/26/10 at 10:00 AM she stated she completes the A/I reports and that normally she reviews the preventative measures. The DON further stated that she may have investigated the alarm related information and may not have documented the same.

Surveyor: VINSON, VASTIE

2) Resident # 2 has diagnosis including Parkinson's disease, Dementia with Agitation and Depression.

The MDS dated 3/31/10 documented the resident's cognitive status as moderately impaired,decisions poor,cues/supervision required.

The Nurse's Note dated 4/22/10 4:30 PM documented that Resident #2 sustained a laceration measuring 6 centimeters (cm) x 6 cm with minimal bleeding noted. The skin around the site boggy.

The Accident/Incident Investigation dated 4/22/10 documented "laceration apparent right lower leg 6 cm x 6 cm with boggy skin around site." The investigation included statement from the Hospice Home Health Aide (HHA ) who at 3:30 PM on 4/22/10 placed Resident#2 at the Nurses Station and 2 CNAs who put the resident to bed at 4:00 PM on 4/22/10.

During interview on 5/27/10 at 1:30 PM with the (HHA), she stated that she removed Resident #2 from an activity program and placed her at the Nurses Station at 3:30 PM on 4/22/10 for toileting. She further stated that at that time there was no injury visible to Resident #2's leg.

During interview with the Director of Nursing (DON) on 5/27/10 at 11:30 AM, she stated that she did not interview the staff that had cared for Resident #2 on the previous shifts nor had she interviewed the activities staff to rule out the potential that the incident had occurred piror to being placed in the activity program.. She further stated that the injury to Resident #2 was unexplainable.

The two CNAs that put Resident #2 to bed at 4:00 PM on 4/22/10 stated that they discovered the injury to the resident's leg when they were using a mechanical lift to put her to bed.

During interview on 5/27/10 at 1:00PM with the (RN) Supervisor Registered Nurse, she stated that the injury to Resident #2 was noticed during a mechanical lift transfer from chair to bed. She further stated that blood was notice on the lift and the resident's sock. The resident was transferred to the hospital and subsequently required seven sutures to the injury of her right leg. Review of hospital discharge transcript dated 4/22/10 documented laceration of unknown origin, possible puncture wound.

During interview on 5/27/10 at 1:30 PM with the Assistant Director of Nursing she stated that she conducted a re-enactment of the mechanical lift transfer and it was correct. She further stated that the resident did not display any signs of discomfort during the transfer which lead her to believe that the laceration did not occur during the mechanical transfer.

The facility's Accident/Incident investigation did not determine how the traumatic injury to Resident #2 occurred nor did it rule out abuse/neglect.

415.4(b)(1)