Bethel Nursing & Rehabilitation Center

Based on observation, interview and record review, significant errors in the administration of pain medications occurred in that these medications were not administered in a timely manner to relieve severe pain experienced by a resident. This resulted in actual harm that is not immediate jeopardy for one Resident #220.

The findings are:

An agency LPN (Licensed Practical Nurse) was observed preparing to give medications to Resident #220 at 9:29AM on 2/17/11. At that time, the resident stated that she had "a lot of pain." The LPN asked the resident to rate her level of pain on a scale of 1 - 10 and the resident stated that she had a pain level of 8. The LPN looked in the medication cart for a tablet of Vicodin, a narcotic medication that was ordered for the resident to be given as needed for pain. The Vicodin was not available.

The LPN then told the RN Nurse Manager that the resident had generalized pain and that the Vicodin was not available. The LPN stated that the resident also had an order for Tylenol but her pain was rated as 8, too intense for Tylenol. The RN stated that she would contact the resident's physician to get an order to give the resident one tablet of Percocet (an alternate narcotic medication) at that time instead of the Vicodin because Percocet was available in the emergency box.

The LPN informed the resident, at 9:38AM, that the RN was arranging to get the medication and that she would have it soon. The resident stated, "Please get the medicine because it's a lot of pain."

The LPN then prepared medications and gave them to another resident. At 9:48AM, the RN informed the LPN that she had gotten an order form the Physician to give one tablet of Percocet from the emergency box now and that she would go to get the medication. The RN returned with one tablet of Percocet at 9:59AM and gave it to the LPN, 30 minutes after the resident had verbalized having a pain level of 8.

The LPN did not immediately go to the resident to administer her Percocet. The LPN began a lengthy procedure of preparing medications for another resident (Resident #219) at 10:02AM, including crushing numerous medications for administration via a feeding tube.

At 10:29AM, a CNA (Certified Nurse Aide) came and told the LPN that Resident #220 was unable to get up because she needed her pain medicine first. The LPN stated that she just got the resident's pain medicine and would give it to her soon so that she could get up (The LPN had the Percocet for 30 minutes as of that time). The LPN then finished preparing and administered medications to Resident #219 at 10:39AM, including giving him eye drops and a respiratory treatment.

The LPN then proceeded to the room of Resident #220 at 10:41AM. The LPN left the room to retrieve the blood pressure machine. At that time, the surveyor observed the resident in bed with slight facial grimacing and some generalized tension of her muscles. The surveyor asked the resident how would she rate her pain on a scale of 1 - 10? The resident stated, "Now, it's a 10. Today it has been bad, a 10 now."

The LPN returned with the blood pressure machine at 10:44AM and took the resident's vital signs. At that time the resident stated, "I'm in a lot of pain." The LPN prepared multiple medications and administered them along with the Percocet at 10:52AM, 83 minutes after the resident had stated that her pain level was 8 and 53 minutes after the pain medicine had been available for the LPN to give to the resident. The resident stated, "Was that the pain medicine? I'm in a lot of pain."

The LPN then stated that she needed to apply a Lidoderm patch to the resident's skin for local pain control in the affected area of the resident's body. The LPN stated that she did not know where to apply the patch because she did not know what was the resident's affected area. The LPN stated that there were no instructions in the medication book to indicate where to apply the patch and that she needed to find out where the resident's patch went.

The resident's current 2/17/11 Physician's Medication Orders and Medication Administration Records (MAR) were then reviewed and included instructions to apply a Lidoderm patch daily and to remove it after 12 hours, putting it on at 9:00AM and taking it off at 9:00PM. The resident's Physician's Admission/Readmission Evaluations, completed on 1/24/11 and 2/17/11 stated that the resident had neck and upper back pain.

The LPN was interviewed at 12:15PM on 2/17/11 regarding the delay in administering Percocet to the resident when she was experiencing severe pain. The LPN stated that she should have given the Percocet to the resident as soon as the RN obtained it. She stated that she felt badly that the resident was in pain and that she had apologized to the resident for not having the medication available right away. She stated that she did not give the medication to the resident right away because she is not familiar with the residents on this unit and she was overwhelmed.

The LPN was also interviewed at that time, 12:15PM, regarding application of the resident's Lidoderm patch that was scheduled to be applied at 9:00AM. The LPN stated that she had not yet applied the Lidoderm patch because she reviewed the resident's MARs and asked other nurses on the unit and she had still been unable to determine where the patch was intended to be applied. The LPN was further interviewed at 1:40PM on 2/17/11. She stated that, at 1:00PM, she asked the resident where was the location of her pain and the resident stated it was in her right shoulder and back area, so she applied the patch to that area.

The RN was interviewed at 1:50PM on 2/17/11. She stated that the resident's Lidoderm patch should be applied for pain in the upper right side of her back by her neck. She stated that the LPN had not asked her about the placement of the resident's patch and she had not been informed that there was a delay in administration of the Percocet or the Lidoderm patch.

415.12(m)(2)

Based on interview and record review, the facility did not promptly respond to concerns regarding quality of care and quality of life raised in the Resident Council group in order to resolve the issues or to provide a reasonable compromise or explanation as to why Resident Council members' concerns were not addressed. This resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Concerns that were identified in Resident Council Meeting Minutes for the six month period from 8/10 - 1/11 were reviewed. Responses by the facility to those resident concerns were also reviewed in the documentation designated by the facility for providing responses to Resident Council concerns.

There was no evidence in the facility designated documentation that the facility responded to many of the issues raised by the residents from 8/10 - 1/11 in order to resolve the issues or to provide a reasonable compromise or explanation as to why Resident Council members concerns were not addressed.

Specifically, there was no written response to various quality of care and quality of life concerns for the following months:

August, 2010
Short staffing related to Physicians; the Nurse Practitioner and the nursing staff; food availability on unit 1W including fresh fruit and roommate and dining room comparability issues.

September, 2010
Residents that requested more than two showers per week and were denied; too many nursing errors not being addressed and lack of response to call bells.

October, 2010
Minutes reflected that meeting was entirely devoted to introductions and greeting of new Administrator and CEO. No discussion of issues.

Further concerns included:

November, 2010
Long wait for toileting; intrusive behavior by visitors during med pass and inappropriate accessing of linens by visitors; dining room window coverings in disrepair and not opened at appropriate times; late medication deliveries and waiting long periods for new medications and staff treating residents disrespectfully when asking about meds.

December, 2010
Nurses not using sanitary methods when doing med passes and inappropriate responses by nurses to residents when asking about this; shower chairs not wheeling freely, in disrepair and not cleaned between uses on 3 units.

The December, 2010 minutes also included the following statements by the resident representative recording the minutes. "We would appreciate a timely response to the issues raised in these minutes." An e-mail address was given for response. "In addition, please give us printed copies of the minutes and responses to the November meeting, as well as December, so that we may complete our files. We would appreciate responses 1 week prior to the January 21 meeting."

The Directors of Food Service and Nursing provided responses to concerns raised in the 11/10 and 12/10 minutes. Those responses were submitted to the SW on 2/14/11, one month after the residents requested to be provided with responses.

Additional concerns were raised in the following meeting:

January, 2011
Long wait for call bell response, problems with prescriptions taken to outpatient tests, meals served late and food cold, servers leaving too soon to correct mistakes and provide seconds, trays removed too quickly forcing residents to eat too fast, unit 1W has fresh fruit daily and other units do not, family members on 1E and 2E intrusive in dining and TV areas, including displacing residents and accessing linens and supplies, CNAs do not identify themselves and residents do not know who is assigned to their care.

The 1/11 minutes reflected that the Administrator was present at the meeting and stated that she would investigate the fresh fruit issue, implement a rule per week to improve conditions for the residents and begin a customer service program in a week on 1W and roll out the program to another unit each week.

As of 2/23/11, there was no written response to the residents related to the 1/11 issues.

The Resident Council President was interviewed at 3:30PM on 2/18/11. The President stated that the facility has not responded to himself, the other group representative or the assembled group members about multiple concerns and grievances voiced by Resident Council members, including some persistent issues. He stated that he had not received responses verbally or in writing, including the responses to 11/10 and 12/10 concerns submitted to the SW on 2/14/11.

The President stated that some of these issues were related to meals served late, intrusiveness of families on 1E and 2E, shower chairs not rolling well and not being cleaned between uses, CNAs not identifying themselves, dining room blinds in disrepair and fresh fruit on 1W daily but not on the other units.

The Director of Social Services (SW) was interviewed at 8:30AM on 2/23/11 and stated that she receives the minutes from the Resident Council Secretary. She stated that she was responsible for reviewing the minutes and forwarding concerns via e-mail to the appropriate department heads or nurse manager to be addressed. The SW stated that she also e-mails all of the concerns to the Director of Nursing (DON) and Administrator. She stated that she expects responses from the involved parties related to the status or outcomes of the issues before the next meeting. The SW stated that the department heads did not always respond to the concerns. She notifies the Administrator when there is no response.

The SW stated that responses to the 8/10 meeting were provided to the Resident Council related to food concerns but not the other issues raised in that meeting. The SW stated that no responses have been provided to the residents since the 8/10 meeting. She stated that no staff members responded to issues raised in 9/10 meeting. No issues were discussed in the 10/10 meeting.

The SW stated that she received the Food Services and nursing responses to the 11/10 and 12/10 meetings on 2/14/11 after the SW elicited the assistance of the Administrator. During this interview, the SW reviewed "The Resident Council Response: December 2010 (from nursing)" document that included a notation that concerns regarding shower chairs would be forwarded to the Director of Maintenance. The SW further stated that she has not yet provided those responses to concerns raised in the 11/10, 12/10 meetings to the Resident Council representative(s).

The SW stated that she received the nursing responses to the 1/11 meeting on 2/22/11 and that she has not yet provided those responses to concerns raised in the 1/11 meeting to the Resident Council representative(s).

The Director of Maintenance and a maintenance worker were interviewed at 8:45AM on 2/23/11. They stated that they had not responded to the resident concerns related to the shower chairs. The Director of Maintenance and maintenance worker inspected the shower chairs at that time and stated that the wheels on some of the chairs were not operating properly because the mechanisms had become rusted and damaged. They stated that the wheels needed to be ordered and replaced.

The Director of Maintenance inspected the 2E window blinds in the dining room and stated that they are broken. He stated that he replaced some slats a few months ago but was not aware that there were concerns reported since then from the resident group. He stated that slats that are replaced sometimes remain in place for only a few days and then they fall out and are found on the floor. He stated that the the staff does not operate the mechanisms to open and close the blinds correctly so they break. They are broken now and need to be repaired or replaced.

The Administrator was interviewed at 11:15AM on 2/23/11. She stated that the SW had informed her that the staff members assigned responsibility for addressing residents' concerns had not been providing feedback to her. She stated that she was educating staff members and implementing measures to improve response rates in a timely manner. The Administrator produced documents that indicated that the Director of Nursing had responded to her regarding some of the residents' concerns but that responses had not yet been communicated to the residents verbally or in writing.

The Administrator further stated that she had investigated the residents' concern related to availability of fresh fruit but had not yet provided feedback to the residents. The customer service education planned to begin on unit 1 West at the end of January and then roll out to another unit each week had not yet begun.

415.5(c)(6)

Based on observation, interview and record review, medications were not given to residents with an error rate of less than 5%. This was evidenced by observation of 7 errors in the administration of 54 medications and resulted in an error rate of 12.96%. Errors included failure to provide two pain medications in a timely manner as needed, according to Physician's Orders that caused actual harm for Resident #220 (see F 333), as well as, errors that had the potential for more than minimal harm that is not immediate jeopardy including giving two additional medications outside of the ordered timeframes for Resident #220, omitting the administration of two ordered medications for Resident #219 and giving the wrong dose of one medication to Resident #221.

The findings are:

TIMELY ADMINISTRATION OF PAIN MEDICATIONS
An agency LPN (Licensed Practical Nurse) was observed preparing to give medications to Resident #220 at 9:29AM on 2/17/11. At that time, the resident stated that she had "a lot of pain," that she rated as an 8 on a scale of 1 - 10. The LPN looked in the medication cart for a tablet of Vicodin, a narcotic medication that was ordered for the resident to be given as needed for pain, and noted that Vicodin was not available.

The LPN informed the RN Nurse Manager that the resident needed Vicodin and that it was not available. The RN contacted the resident's physician and got an order to give the resident one tablet of Percocet (an alternate narcotic medication) at that time instead of the Vicodin because Percocet was available in the emergency box. The RN retrieved the Percocet and gave it to the LPN at 9:59AM, 30 minutes after the resident had verbalized having a pain level of 8.

The LPN did not immediately go to the resident to administer her Percocet. She prepared and administered medications to another resident. Then she proceeded to the resident's room and gave her the Percocet at 10:52AM, 83 minutes after the resident had stated that her pain level was 8 and 53 minutes after the pain medicine had been available for the LPN to give to the resident.

Additionally, at that time, the LPN stated that she needed to apply a Lidoderm patch to the resident's skin for local pain control in the affected area of the resident's body. The LPN stated that she did not know where to apply the patch because she did not know what was the resident's affected area. The LPN stated that there were no instructions in the medication book to indicate where to apply the patch and that she needed to find out where the resident's patch went.

The LPN was interviewed at 12:15PM on 2/17/11 regarding the delay in administering Percocet to the resident when she was experiencing severe pain. The LPN stated that she should have given the Percocet to the resident as soon as the RN obtained it. She stated that she did not give the medication to the resident right away because she is not familiar with the residents on this unit and she was overwhelmed.

The LPN was also interviewed at that time, 12:15PM, regarding application of the resident's Lidoderm patch that was scheduled to be applied at 9:00AM. The LPN stated that she had not yet applied the Lidoderm patch because she reviewed the resident's MARs and asked other nurses on the unit and she had still been unable to determine where the patch was meant to be applied. The LPN was further interviewed at 1:40PM on 2/17/11. She stated that, at 1:00PM, she asked the resident where was the location of her pain and the resident stated it was in her right shoulder and back area, so she applied the patch to that area, four hours after scheduled application.

The RN was interviewed at 1:50PM on 2/17/11. She stated that the resident's Lidoderm patch should be applied for pain in the upper right side of her back by her neck. She stated that the LPN had not asked her about the placement of the resident's patch and she had not been informed that there was a delay in administration of the Percocet or the Lidoderm patch.

The resident's current 2/17/11 Physician's Medication Orders and Medication Administration Records (MAR) were then reviewed and included instructions to apply a Lidoderm patch daily and to remove it after 12 hours, putting it on at 9:00AM and taking it off at 9:00PM. The resident's Physician's Admission/Readmission Evaluations, completed on 1/24/11 and 2/17/11 stated that the resident had neck and upper back pain.

TIMELY ADMINISTRATION OF OTHER MEDICATIONS
During the same observation of medication administration to Resident #220 noted above, the LPN gave the resident an 81mg tablet of enteric coated aspirin and a 40mg tablet of Lasix at 10:52AM.

The resident's current 2/17/11 Physician's Medication Orders and Medication Administration Records (MAR) included instructions to give those medications to the resident daily with breakfast and also indicated to give with food.

The LPN was interviewed at 1:40PM on 2/17/11. She stated that Aspirin and Lasix were ordered to be given with breakfast and that she gave them to the resident late. The LPN stated that she gave those medications to the resident in a spoonful of applesauce but should have given them with food because that is how they were ordered.

MEDICATION OMISSIONS
The same LPN observed above administered medications to Resident #219 at 10:39AM. The resident's Physician's Orders and MAR were then reviewed and revealed instructions to give him two medications every morning that the LPN did not give to the resident. There was a 1/20/11 Admission Physician's Medication Order for Pyridoxine (Vitamin B6) and a 1/24/11 Interim Physician's Order for him to be given one capsule of Acidophilus.

The LPN was interviewed at 11:50AM on 2/17/11 regarding why those medications had not been given to the resident that morning. The LPN flipped through the pages of the resident's MAR at that time and stated "Oh, there are more," when she saw a page with instructions to give Vitamin B6 and Acidophilus. The LPN stated that she had not checked the page with those medications during the medication pass.

WRONG DOSE
An LPN was observed giving medications to Resident #221 at 9:29AM on 2/18/11. Those medications included a chewable tablet containing a combination of 500 mg of calcium and 400 units of Vitamin D.

The resident's current Physician's Orders were reviewed following this observation. Those records included an order, dated 1/12/11, for the resident to be given a chewable supplement tablet containing a combination of 500 mg of calcium and 500 units of Vitamin D twice a day.

The LPN was interviewed at 9:50AM on 2/18/11. She stated that she knew that the Calcium with Vitamin D tablet ordered for the resident contained Calcium 500mg and Vitamin D 500 units. The LPN stated that she gave the resident the 500mg/400 unit combination because the wrong dosage was delivered for the resident. The LPN stated that she had a choice to give the resident two available dosages, 500mg/600 units or 500mg/400 units, and she chose to give the resident 500/400 because it was a chewable tablet and the resident had her medication ordered to be given in chewable form. The LPN stated that she knew the dosage she was giving was not the ordered dose and that she has been giving this dose to the resident. The LPN stated that she could not say how long the resident had been receiving the incorrect dosage.

415.12(m)(1)

Based on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less. Specifically, 1. A resident was administered two different inhalations using incorrect technique (Resident #2) 2. A resident did not receive medication as ordered by the physician (Resident #4) and 3. A resident was going to be administered the incorrect dosage of OS Cal until surveyor intervention (Resident #7).
This was evident for 3 of 8 residents on 4 units with 56 opportunities during observation of medication administration, Units 2 East and 2 West, resulting in a medication error rate of 7%.

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

The findings are:

1. During observation of medication administration on the 2 East Unit on 4/18/11 at 9:25AM, the Licensed Practical Nurse (LPN) was observed to administer medications to Resident #2. The LPN administered an inhalation of Flovent 110 Mcg without first shaking the inhaler as instructed on the label and also did not offer the resident any water with which to rinse his mouth, following this inhalation. The LPN immediately offered the resident the Spiriva w/handihaler and the resident took one puff. The instructions on the Medication Administration Record (MAR) and on the Physician's Orders were for two puffs to be administered.

The LPN was interviewed at 9:45AM and at this time she stated that she knew that she should have shaken the Flovent inhaler before administering the puff to the resident and that she should have offered the resident some water with which to rinse his mouth. The LPN further stated that she knew that she should have waited 3 to 5 minutes before administering the second inhaler (Spiriva) and that the resident should have taken two separate inhalations from the Spiriva via the handihaler device. The LPN stated that she became nervous and that she forgot.

2. During further observation of medication administration on the 2 East Unit at 10:05AM, the LPN was observed to observed to administer 9 medications to Resident #4. At this time the LPN stated that she would have to call the physician because she had not checked the resident's blood sugar at 7:30AM and also had not administered the Glipizide 5Mg (an antidiabetic medication) at 7:30AM as instructed on the MAR.

A call was placed to the physician and the resident had his blood sugar level checked and the resident received his medication at 10:30AM.

3. On 4/17/11 at 10:00AM, during the medication pass observation on 2 West Unit, the Licensed Practical Nurse (LPN) attempted to administer Os-Cal 500mg. (milligrams) w/600 IUs (international units) vitamin D to Resident #7. The physician's order read Os-Cal 500mg. w/500 IU Vitamin D by mouth twice a day. The LPN did not give this dosage of Os-Cal 500mg. w/Vitamin D 500 IU after surveyor intervention. She re-read the medication label and stated that the dosage was not as ordered. The LPN then called the Nurse Practitioner (NP) who renewed the order for this medication and the NP changed the order to Os-Cal 500mg. w/ 600 IU Vitamin D.

In an interview with the LPN immediately following this, the LPN stated that Os-Cal 500mg. w/Vitamin 600 IU was the medication routinely administered to this resident who had an order for Os-Cal 500mg. w/Vitamin D 500 IU. The LPN stated that she should have clarified/or had the order changed to ensure administering the correct dosage to the resident.

415.12 (m)(2)

Based on interview and record review, the facility did not ensure that parameters for assessing the need and monitoring for effectiveness of medications were consistently implemented when indicated. Specifically, 1) pain assessment and monitoring for effectiveness were not consistently implemented for a resident receiving pain medication and 2) monitoring for iron status was not implemented to justify the continued use for iron supplementation for a resident. This was evident for 2 of 10 residents review for unnecessary medications(#44,141).

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

The findings are:

1. Resident #141 was admitted to the facility with diagnoses including Peripheral Vascular Disease and Venus Stasis Ulcers with MRSA (methicillin resistant staphylococcus aureus) of both lower legs.

Review of the Physician's Order form dated 1/12/11 revealed two orders for Percocet (a narcotic pain medication). One order was for Percocet 5-325mg, 1 tablet every 4 hours as needed for pain. The second order was Percocet 5-325mg, 2 tablets every 4 hours as needed for severe pain. There was also an order for Tylenol 650mg every 4 hours as needed for pain.

In an interview with the Unit Manager RN on 2/17/11 at 10:00AM, she stated that the level of pain according to the pain scale should be documented prior to giving the medication. She further stated that mild pain = 0-3, moderate = 4-6 and severe = 7-10. She also stated that it depends on the physician. There were no parameters for pain indicated on the Physician Order sheet.

On 2/17/11 at 10:30 AM an LPN medication nurse was interviewed regarding the pain scale. She stated she would give Tylenol for pain less than 4, 1 tablet of Percocet for pain from 4-6 and for anything over 6 she would give 2 tablets of Percocet.

Review of the Medication Administration Record (MAR) for January revealed 20 instances where Percocet 2 tablets, indicated for severe pain, was given. However, pain scale ratings were not documented 12 out of 20 times and there was no monitoring for effectiveness documented 16 of the 20 times.

Review of the MAR for February 2011 revealed that Percocet 2 tablets was given 8 times between 2/1/11 and 2/15/11. Five of the 8 times the pain scale was not documented. Monitoring for effectiveness was not completed 6 of the 8 times the medication was administered.

2. Resident #44 was admitted on 6/18/10 and, according to her Physician Admission/Readmission Evaluation, she had a history of Gastrointestinal Bleeding and a diagnosis of Anemia.

The Physician ordered the use of an iron supplement, FeSO4, as part of the identified Treatment/Plan at the time of admission, and continuously, through the current 2/15/11 orders. The Physician also ordered Folic Acid to treat Anemia and a hemoglobin and hematocrit blood test (H/H) to be done initially on 6/22/10, and then monthly, to monitor for anemia.

The results of the 6/22/10 H/H were 11.9/36.1, within normal limits at the low end of the range.

The diagnosis of Anemia was noted repeatedly in the 8/27/10 Physician Admission/Readmission Evaluation, 10/4/10, 11/22/10 and 12/20/10 Monthly Physician/NP Assessment and Plan of Care.

Monthly H/H blood tests to monitor for Anemia were included in the Physician's Orders on 8/16/10, 11/22/10, 12/20/10, 1/19/11 and 2/15/11.

Except for the 6/22/10 H/H blood test results noted above, there was no evidence in the resident's clinical record that H/H test results were available to be evaluated or that H/H blood tests had been done as ordered.

The RN nurse manager was interviewed at 1:45PM on 2/22/11. She stated that the resident did not have blood drawn to monitor H/H as ordered monthly according to 8/16/10 and 11/10 - 2/11 orders. The RN stated that she checked the computer and there were no labs for H/H performed except for the 6/22/10 test.

The Physician documented in the 11/22/10, 12/20/10 and 2/15/11 Evaluation of Medication Orders that Ferrous Sulfate and Folic Acid were effective in progress towards therapeutic goals. The Physician did not indicate on which data or findings this evaluation was based.

The NP (Nurse Practitioner) was interviewed at 12:05PM on 2/23/11. She stated that she is familiar with the resident and her treatment plan. The NP stated that the resident has chronic anemia and is being treated with iron and folic acid.

The NP also stated that the resident should have had her H/H along with an iron panel checked after about six months to evaluate the status of her Anemia. The NP stated that the resident's H/H and iron panel should have also been checked after six months because she should not be treated with iron for chronic anemia for an indefinite period of time because it is so constipating.

The NP also checked the resident's clinical record and the computer and stated that there were no labs for H/H performed except for the 6/22/10 test. She stated that she would order an H/H and an iron panel now to correct the issue.

415.12(l)(1)

Based on observation, interview and record review, the facility did not ensure that infection control measures to minimize the spread of infection were put in place when there was a potential for a resident residing in a semiprivate room to have an infectious condition. This was evident for 1 of 36 residents reviewed (Resident #206). This had the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Review of the Interim Physician's Orders dated 2/3/11 for Resident #206 revealed an order for "stool for C-diff" (a bacterium that infects the lower intestines causing diarrhea). On 2/8/11 there was a second Interim Physician's Order that states, "was C-Diff done?"

In an interview with the Registered Nurse (RN) on the unit at 2:00PM on 2/16/11 regarding the lab work, she could find no evidence that the lab work had been done. She stated that she would have the stool collected and sent to the laboratory for testing.

Observation of the resident's room on 2/16/11 at 2:15PM revealed that he shared a room and the bathroom with another resident. There was no sign on the door indicating that precautions should be taken for suspected C-diff.

On 2/22/11 at 10:20AM the RN Unit Manager was interviewed regarding the results for C-diff. She stated that she could not find it. She then called the lab and they stated that they lost the sample. The RN also stated at that time that a new sample would be collected and sent out that day.

On 2/23/11 at 10:30AM in an interview with the RN unit manager she stated that the results came back and they are not conclusive. She further stated that she would wait until the final result before she would proceed with precautions. When asked what precautions would be taken she said that normally if a person has C-diff he/she would be put in a private room or in this case move the other resident out of the room. This is especially important when both residents are able to use the bathroom. She stated that both resident's in that room were able to use the bathroom.

The resident's roommate was discharged on 2/22/11 without knowing if he had been exposed to the C-diff. organism.

The nursing staff did not ensure that precautionary infection control measures were taken, such as educating the roommate and alerting the public and staff of the necessary precautions to take to avoid coming in contact with a possible infectious organism.

415.19(a)(1-3)

Based on observation, interview and record review, the facility did not ensure that medications were promptly acquired and available to meet resident needs. This was evident for 2 of 36 sampled residents (Resident #80 and #223) and resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #80 is a cognitively intact resident. She was assessed by the Nurse Practitioner (NP) on 2/17/11 and diagnosed with sinus congestion. According to the Interim Physician's Orders, the NP ordered Tylenol Cold and Sinus medication on that date to be administered every 4 hours as needed for 5 days. A subsequent order was written by the NP on 2/21/11 to give the resident Robitussin Cold and Flu medicine every 4 hours as needed for sinus congestion for 5 days.

According to the resident's Medication Administration Records (MAR), reviewed at 3:30PM on 2/23/11, the Tylenol Cold and Sinus medication and the Robitussin Cold and Flu medicine had not been given to the resident since they were ordered on 2/17/11 and 2/21/11 respectively.

Two unit LPN and one unit RN medication nurses who had worked on day, evening and night shifts since the medications were ordered were interviewed at 3:30PM on 2/23/11 to determine whether the resident did not need the medicines since they were ordered or did not have them available to her. The nurses each stated that they were not aware that the resident had these medications ordered and that they were unavailable.

The nurses checked the medication cart and stated that Tylenol Cold and Sinus medication was not there. They stated that they had not contacted the pharmacy to investigate why it had not been made available from 2/17/11 - 2/21/11 because they were not aware the medication had been ordered for the resident. Additionally, the nurses stated that they had not checked to see if the resident needed the medication since they did not know she had been having sinus congestion.

The nurses further checked the medication cart and discovered that Robitussin had been delivered for the resident on 2/21/11. They stated that they did not know why it had been delivered because it was not ordered for the resident. As noted above, Robitussin was ordered for the resident on 2/21/11.

The resident was observed at 3:45PM on 2/23/11. She stated that she continued to have sinus congestion and has been asking the nurses when she could get her medication. The resident stated that she had been told repeatedly that the medication was not delivered yet.

The NP was interviewed at 4:00PM on 2/23/11. She stated that the medications were still indicated for the resident. The NP stated that the pharmacy had notified her on 2/21/11 that the Tylenol Cold and Sinus medication was not available and she then ordered the Robitussin instead.ne

2. Resident #223 was admitted to the facility with diagnoses including Anemia and Renal Failure . Review of the Medication Administration Record (MAR) for February 2011 revealed and order for Vitamin B (B-50) complex 1 tablet daily.

Review of the Nursing Care Progress notes dated 2/19/11 revealed that Vitamin B complex was called in to the pharmacy to be filled. The pharmacy stated that Vitamin B complex was a stock medication. The nursing supervisor was notified but was unable to locate the medication. On 2/20/11 the B complex was ordered again. It was still not available. It was due to be delivered on 2/21/11.

In an interview with the RN medication nurse on 2/21/11 at 2:30PM she stated that Vitamin B6 that was the stock medication and the Vitamin B complex had not been available for the resident.

The medication cart was observed at 2:45PM and at that point the Vitamin B Complex was available to be given to the resident.

415.18(a)

Based on interviews, the facility did not ensure that necessary efforts were taken to resolve a resident's complaint regarding inappropriate staff interactions on the night shift. This was evident for 1 of 36 sampled residents (Resident #23). This had the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #23 is a 73 year old female who is alert and oriented and has the diagnosis of Depression.

Interviews with the resident on 2/17/11 at 11:00 AM and 2/18/11 at 1:20 PM revealed that the nursing staff on the 11-7 shift are "nasty" to her in terms of the manner in which they speak to her. Specifically, the resident stated, "They [aides] say all I do is eat and ring the bell and why do I have to use the bed pan at 2:00 AM or 3:00 AM. Why can't you remember what you want so that you don't have to keep ringing the bell all the time? The nurse yells at me for ringing the bell." The resident stated that she reported the way the staff communicates with her to the Social worker (SW). The resident also stated that things only got better for a little while after she spoke to the SW.

An interview with the SW on 2/17/11 at 11:20 AM revealed that the resident had complained to her about "toileting on the night shift, which she reported to the Nurse Manager. A follow-up interview with SW at 11:50 AM on 2/17/11 revealed that there was no further follow-up by her regarding the issue.

On 2/17/11 at 11:33 AM and on 2/18/11 at 2:35 PM the Nurse Manager was interviewed. She stated that she recalled being informed about the resident's concerns with the night shift, but that was months ago. She specifically recalled that the resident's concerns included waiting for staff assistance after she rang the call bell. The Nurse Manager stated that she addressed the problem by speaking to the specific nurse aide mostly assigned to the resident and that she had received no further complaint about this matter. The Nurse Manager offered no explanation why she did not address the resident's concerns with the nurse(s) and other nurse aides assigned to the night shift.

415.3(c)(1)(ii)

Based on observation, interview and record review, the facility did not ensure maintenance services were provided when indicated to maintain resident care equipment (shower chairs) and window treatment (blinds) for residents comfort. This had the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

The review of the Resident Council minutes for the months of November 2010 and December 2010 revealed that the residents complained about dining room window coverings in disrepair and shower chairs not wheeling freely, in disrepair and not cleaned between uses on 3 units.

The Director of Maintenance and a maintenance worker were interviewed at 8:45AM on 2/23/11 about the above mentioned complaints. They stated that they had not responded to the resident concerns related to the shower chairs. The Director of Maintenance and maintenance worker then proceeded to inspected the shower chairs and stated that the wheels on some of the chairs were not operating properly because the mechanisms had become rusted and damaged. They stated that the wheels needed to be ordered and replaced.

The Director of Maintenance observed the 2E window blinds in the dining room and stated that they are broken. He stated that he replaced some slats a few months ago but was not aware that there were concerns reported since then from the resident group. He stated that slats that are replaced sometimes remain in place for only a few days and then they fall out and are found on the floor. He stated that the the staff does not operate the mechanisms to open and close the blinds correctly so they break. They are broken now and need to be repaired or replaced.

415.5(h)(2)]

Based on interview and record review, the facility did not ensure that the pharmacist identified and reported irregularities when indicated. Specifically, the pharmacy report did not identify 1) irregularities related to the use of pain medciation for a resident and 2) the lack of monitoring for iron status to justify the continued use for iron supplementation. Additionally, there is no evidence that these irregularities were reported. This was evident for 2 of 10 residents reviewed for unnecessary medications (Residents #141 and 44).

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

1. Resident #141 was admitted to the facility with diagnoses including Peripheral Vascular Disease and Venus Stasis Ulcers with MRSA (methicillin resistant staphylococcus aureus) of both lower legs.

Review of the Physician's Order form dated 1/12/11 revealed two orders for Percocet (a narcotic pain medication). One order was for Percocet 5-325mg, 1 tablet every 4 hours as needed for pain. The second order was Percocet 5-325mg, 2 tablets every 4 hours as needed for severe pain. There was also an order for Tylenol 650mg every 4 hours as needed for pain.

In an interview with the Unit Manager RN on 2/17/11 at 10:00AM, she stated that the level of pain according to the pain scale should be documented prior to giving the medication as. She further stated that mild pain = 0-3, moderate = 4-6 and severe = 7-10. She also stated that it depends on the physician. There were no parameters for pain indicated on the Physician Order.

On 2/17/11 at 10:30 AM an LPN medication nurse was interviewed regarding the pain scale. She stated she would give Tylenol for pain less than 4, 1 tablet of Percocet for pain from 4-6 and for anything over 6 she would give 2 tablets of Percocet.

Review of the Medication Administration Record (MAR) for January revealed 20 instances where Percocet 2 tablets, indicated for severe pain, was given. However, pain scale ratings were not documented 12 out of 20 times and there was no monitoring for effectiveness documented 16 of the 20 times.

Review of the MAR for February 2011 revealed that Percocet 2 tablets was given 8 times between 2/1/11 and 2/15/11. 3 of the 8 times the pain scale was documented. Monitoring for effectiveness was completed 2 of the 8 times the medication was administered.

Review of the Consultant Pharmacist Plan Of Care dated 1/13/11 did not identify the lack of pain scale ratings or monitoring for effectiveness for Percocet for this resident.

2. Resident #44 was admitted on 6/18/10 and, according to her Physician Admission/Readmission Evaluation, she had a history of Gastrointestinal Bleeding and a diagnosis of Anemia.

The Physician ordered the use of an iron supplement, FeSO4, as part of the identified Treatment/Plan at the time of admission, and continuously, through the current 2/15/11 orders. The Physician also ordered Folic Acid to treat Anemia and a hemoglobin and hematocrit blood test (H/H) to be done initially on 6/22/10, and then monthly, to monitor for anemia.

The results of the 6/22/10 H/H were 11.9/36.1, within normal limits at the low end of the range.

The diagnosis of Anemia was noted repeatedly in the 8/27/10 Physician Admission/Readmission Evaluation, 10/4/10, 11/22/10 and 12/20/10 Monthly Physician/NP Assessment and Plan of Care.

Monthly H/H blood tests to monitor for Anemia were included in the Physician's Orders on 8/16/10, 11/22/10, 12/20/10, 1/19/11 and 2/15/11.

Except for the 6/22/10 H/H blood test results noted above, there was no evidence in the resident's clinical record that H/H test results were available to be evaluated or that H/H blood tests had been done as ordered.

11/22/10, 12/20/10 and 2/15/11 Physician Evaluation of Medication Orders documents had check marks to indicate that Ferrous Sulfate and Folic Acid were effective in progress towards therapeutic goals.

The RN nurse manager was interviewed at 1:45PM on 2/22/11. She stated that the resident did not have blood drawn to monitor H/H as ordered monthly according to 8/16/10 and 11/10 - 2/11 orders. The RN stated that she checked the computer and there were no labs for H/H performed except for the 6/22/10 test.

The NP (Nurse Practitioner) was interviewed at 12:05PM on 2/23/11. She stated that she is familiar with the resident and her treatment plan. The NP stated that the resident has chronic anemia and is being treated with iron and folic acid.

The NP stated that she believed the resident had normal blood test results in 6/10 and that the Physician did not intend to continue monthly monitoring of her H/H after that. The NP stated that the resident should have had her H/H along with an iron panel checked after about six months (during 12/10) to evaluate the status of her Anemia. The NP stated that the resident's H/H and iron panel should have also been checked after six months because she should not be treated with iron for chronic anemia for an indefinite period of time because it is so constipating.

The NP also checked the resident's clinical record and the computer and stated that there were no labs for H/H performed except for the 6/22/10 test. She stated that she would order an H/H and an iron panel now to correct the issue.

The Consultant Pharmacist Plan of Care documents, including the sections designated for evaluation of lab test results, were reviewed from 6/23/10 - 1/13/11. There was no evidence that the Consultant Pharmacist identified, or notified the Physician of, the lack of H/H monitoring for the last eight months for this resident receiving Ferrous Sulfate and Folic Acid for the treatment of Anemia.

415.18(c)(1)

Based on observation, interview and record review, the facility did not ensure that the decline in food intake of a resident with an unplanned weight loss of 11.8% in 5 months was addressed in that-

1) Attempts were not made by the interdisciplinary team to determine the reason (s) for the decline in the resident's intake;
2) The clinical staff (nursing and dietary) did not determine the resident's current preferences as a means of improving the resident's intake in accordance with the resident's plan of care;
3) An analysis of the adequacy of the resident's intake was not done to determine the need for supplementation or how best to address the decline in the resident's intake in order to maintain acceptable parameters of nutritional status such as weight, protein, blood sugar levels and iron levels.

This was evident for 1 of 3 residents (Resident #85) reviewed for weight loss, which had the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident # 85 is a 53 year old female with diagnoses to include Diabetes Mellitus, Hypothyroidism, Osteoporosis and Schizophrenia.

The annual comprehensive assessment dated 9/24/10 noted that the resident is 63 inches tall, weighed 169 lbs and left 25% or more of her food not eaten. The quarterly assessment completed 12/6/10 showed that the resident's weight had declined to 153 lbs, which reflected a 9.4% weight loss in the past 3 months.

The comprehensive nutritional plan of care dated 9/23/10 noted that the resident was at nutritional risk related to the above mentioned diagnoses and anemia. The nutritional goals established for the resident at that time were to consume at least 75% of food and fluids, have glycemic control as evidenced by HgbA1C in the range of 6 - 8 and to maintain weight in the range of 165 - 175 lbs. (The care plan noted that the resident's ideal body weight range was 105 - 134 lbs.) The interventions to achieve the nutritional goals for the resident included but not limited to the following: provide a No Concentrated Sweet diet, update food preferences and intolerance as needed, monitor lab work and assess need for nutritional support, monitor resident's daily intake and encourage good food /fluid intake.

On 12/16/10 the nutritional care plan was revised to reflect that the resident's weight loss to 153 lbs was secondary to a recent hospitalization (for sepsis). The resident's goal weight was changed at that time to "maintaining weight between 140 and 160 lbs." The intervention added was to monitor the resident's weight weekly for 4 weeks. The evaluation section of the care plan also dated 12/16/10 noted that the resident's appetite was fair to good; that her weight was still above her ideal weight range; and that the need for supplement would be monitored. No interventions to improve the resident's intake and determine the adequacy of her intake were addressed

A review of the resident's interim dietary notes showed that the resident continued to experience additional weight loss and no assessment done to determine the reason(s) for the loss and the nutritional adequacy of the resident's food intake.
These notes by the dietitian reflected the following:

1/11/11 - weight 148 lbs, a loss of 7 lbs in one week. Seems unrealistic.
1/19/11 - weight 151 lbs; appetite usually good.
2/03/11 - weight stabilization. Appetite fair to good.
2/06/11 - weight 149 lbs. Appetite fair to good. Continue to monitor weight and encourage good intake.

A review of the Meal & Weight records completed by certified nurse aides were reviewed by the surveyor to determine the percentage of daily intake in August 2010, December 2010 and February 2011. The data recorded showed the resident's intake to be as follows; 72% in August 2010, 63% in December 2010 and 61% in February 2011 (2/1/11 - 2/21/11), a decline of 11% since the resident's weight began to decline in October 2010.

According to the Meals & Weight record for February 2011, the resident's weight was noted to be 147.4 lbs on 2/22/1, an additional loss of 1.6 lbs since the last note written by the dietitian on 2/6/11.

A review of the resident's clinical record (to include physician notes, nursing notes and dietary notes) currently revealed 1)no reason(s) for the change in the resident's intake, 2) no assessment of the nutritional adequacy of the resident's food intake, and 3) the resident's current food preferences based on observation and interview with family (who visits the resident almost daily and is present during the noon and evening meals) and direct care staff was addressed by the nursing and/or dietary staff.

There were no current blood count levels which are used to assess for anemia and no albumin levels that are used to determine protein status. (The blood test for glucose levels was obtained on 2/16/11 which showed HgbA1C to be below 6, indicated low blood sugar levels for a diabetic during a 3 month period. Blood sugar levels are affected by a decline in caloric intake.)

On 2/18/11 the resident was observed during the lunch meal. She was served grilled cheese sandwich (using white bread), rice, juice, cake and 4 oz milk. The resident consumed the milk and refused the all the solids. (The family member visiting at that time saved the juice to be consumed later.) According to the family member, the resident does not eat white bread.

The dietitian was interviewed on 2/22/11 in the afternoon about the resident's weight loss and decline in food intake. The dietitian stated that the family is aware of the resident's weight loss and is not concerned. The resident is still overweight and, therefore, there is no need for any supplement at the current time.

Breakfast observation on 2/23/11 at 8:40 AM revealed the following amount served and consumed:

2 pancakes - ate all
1 sausage patty - ate all
8 oz milk - drank 4 oz
4 oz prune juice - refused
hot beverage - not served
1 banana - refused

On 2/23/11 at 8:50 AM an interview with the day shift CNA revealed that the resident does not like/eat toast; eats about 25% of the cereal served and that she likes pancakes. The CNA also stated that the resident usually eats 50% of fish and chicken when served and does not like/eat beef.

On 2/22/11 at 3:20 PM and interview with the CNA on the 3-11 revealed that the resident usually drinks well but has varied food intake. She does not know why resident refuses to eat when she does. The resident will not increase her intake when encouraged to do so and she will not allow staff to assist her to complete meal.

The resident's plan of care does not reflect the above information provided by the CNAs.

415.12(i)(1)

Based on interview and record review, interventions included in the plan of care to prevent falls were not implemented for Resident #201. This was evident for one of three residents reviewed for falls (#201) which resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #201 was admitted to the facility with diagnoses including a Fracture of the Forearm and Subarachnoid Hemorrhage. Review of the MDS (Minimum Data Set) dated 1/29/11 indicated that the resident has poor balance during transfers and a history of falls.

Review of the Nursing Progress Notes revealed that the resident had 2 falls since admission. On 1/26/11 she slid out of her wheelchair and on 2/5/11 she fell out of bed while trying to transfer to her wheelchair. She stated that she forgot to put the brakes on her wheelchair and she turned off her bed alarm. Neither fall resulted in injury.

Review of the care plan revealed that on 1/26/11 a chair alarm and a bed alarm were put in place and on 2/5/11 there was a recommendation that the resident be evaluated by Occupational Therapy (OT) for safe transferring techniques following falls
.
In an Interview with the resident's Occupational Therapist on 2/22/11 at 1:45PM she stated that she reinforces safe transferring every time the resident comes to OT. This review revealed that an evaluation was not done in accordance with the resident's written plan of care specific to the 1/26/11 and 2/5/11 falls.

In an interview with the RN unit manager on 2/22/11 at 2:00PM regarding the effectiveness of the care plan intervention of safe transferring techniques, she stated that her understanding was that since the resident is already on an OT program that the care plan intervention is intended for OT to focus in on the fall; why she fell, what she was doing wrong and how to correct the problem.

In an interview with the Director of Rehabilitation on 2/22/11 at 2:30PM, she also stated that when a resident who is on an OT program has a fall, the therapist working with the resident should focus on the fall and address the specifics around why the resident had a fall and how to prevent further falls. This should be included in the therapists weekly notes. She also stated that she could not be sure that this was done for this resident.

Review of the OT notes dated 2/3/11-2/15/11 revealed no evidence that safe transfer techniques were evaluated or that anything specific to the fall was reviewed.

415.11(c)(3)(ii)

Based on observation, interview and record review, the facility did not ensure that administration of medication and collection of lab specimens to test for infection and anemia was performed according to nursing standards of practice for carrying out Physician's orders in a timely manner and according to Physician and Pharmacist standards for monitoring clinical condition and response to drug therapy. This was evident for 4 of 36 sampled residents. Specifically, a delay in providing medication to treat sinus congestion for Resident #80, a delay to obtain stool specimens to test for infection for Residents #141 and #206, and failure to obtain blood tests to monitor for anemia for Resident #44 resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #80 is a cognitively intact resident. She was assessed by the Nurse Practitioner (NP) on 2/17/11 and diagnosed with sinus congestion. According to the Interim Physician's Orders, the NP ordered Tylenol Cold and Sinus medication on that date to be administered every 4 hours as needed for 5 days. A subsequent order was written by the NP on 2/21/11 to give the resident Robitussin Cold and Flu medicine every 4 hours as needed for sinus congestion for 5 days.

According to the resident's Medication Administration Records (MAR), reviewed at 3:30PM on 2/23/11, the Tylenol Cold and Sinus medication and the Robitussin Cold and Flu medicine had not been given to the resident since they were ordered on 2/17/11 and 2/21/11 respectively.

A unit RN and two unit LPN medication nurses who had worked on the day, evening and night shifts since the medication was ordered were interviewed at 3:30PM on 2/23/11. They each stated that they were not aware that the resident had these medications ordered so they had not been checking with the resident to see if she needed sinus medication. The nurses checked the medication cart and stated that Tylenol Cold and Sinus medication was not there but that they discovered that Robitussin had been delivered for the resident on 2/21/11.

The nurses stated that they were not aware that the Tylenol Cold and Sinus medication had been ordered and therefore did not contact the pharmacy to investigate why it had not been made available from 2/17/11 - 2/21/11. The nurses stated that they were not aware of an order for Robitussin and did not know why it had been delivered for the resident.

The resident was observed at 3:45PM on 2/23/11. She stated that she continued to have sinus congestion and has been asking the nurses when she could get her medication. The resident stated that she had been told repeatedly that the medication was not delivered yet.

The NP was interviewed at 4:00PM on 2/23/11. She stated that the medications were still indicated for the resident. The NP stated that the pharmacy had notified her on 2/21/11 that the Tylenol Cold and Sinus medication was not available and she then ordered the Robitussin instead.

2. Resident #44 was admitted on 6/18/10 and, according to her Physician Admission/Readmission Evaluation, she had a history of Gastrointestinal Bleeding and a diagnosis of Anemia.

The Physician ordered the use of an iron supplement, FeSO4, as part of the identified Treatment/Plan at the time of admission, and continuously, through the current 2/15/11 orders. The Physician also ordered Folic Acid to treat Anemia and a hemoglobin and hematocrit blood test (H/H) to be done initially on 6/22/10, and then monthly, to monitor for anemia.

The results of the 6/22/10 H/H were 11.9/36.1, within normal limits at the low end of the range.

The diagnosis of Anemia was noted repeatedly in the 8/27/10 Physician Admission/Readmission Evaluation, 10/4/10, 11/22/10 and 12/20/10 Monthly Physician/NP Assessment and Plan of Care.

Monthly H/H blood tests to monitor for Anemia were included in the Physician's Orders on 8/16/10, 11/22/10, 12/20/10, 1/19/11 and 2/15/11.

Except for the 6/22/10 H/H blood test results noted above, there was no evidence in the resident's clinical record that H/H test results were available to be evaluated or that H/H blood tests had been done as ordered.

The RN nurse manager was interviewed at 1:45PM on 2/22/11. She stated that the resident did not have blood drawn to monitor H/H as ordered monthly according to 8/16/10 and 11/10 - 2/11 orders. The RN stated that she checked the computer and there were no labs for H/H performed except for the 6/22/10 test.

The Physician documented in the 11/22/10, 12/20/10 and 2/15/11 Evaluation of Medication Orders that Ferrous Sulfate and Folic Acid were effective in progress towards therapeutic goals.

The NP (Nurse Practitioner) was interviewed at 12:05PM on 2/23/11. She stated that she is familiar with the resident and her treatment plan. The NP stated that the resident has chronic anemia and is being treated with iron and folic acid.

The NP stated that she believed the resident had normal blood test results in 6/10 and that the Physician did not intend to continue monthly monitoring of her H/H after that. The NP stated that the Physician could have evaluated the effectiveness of therapy to treat Anemia by noting that the resident had no acute clinical signs of Anemia like shortness of breath. The NP stated that the resident should have had her H/H along with an iron panel checked after about six months though (during 12/10) to evaluate the status of her Anemia. The NP stated that the resident's H/H and iron panel should have also been checked after six months because she should not be treated with iron for chronic anemia for an indefinite period of time because it is so constipating.

The NP also checked the resident's clinical record and the computer and stated that there were no labs for H/H performed except for the 6/22/10 test. She stated that she would order an H/H and an iron panel now to correct the issue.

3a. Resident # 206 was admitted to the facility with diagnoses including a Fractured Humerous and Gout. Review of the Interim Physician's Orders dated 2/3/11 revealed an order "stool for C-diff" (a lab test to check a specimen for a bacterium that infects the lower intestines causing diarrhea). On 2/8/11 there was a second Interim Physician's Order that stated, "Was C-Diff done?"

In an interview with the RN on the unit at 2:00PM on 2/16/11 regarding the lab work, she could find no evidence that the lab work had been done. She stated that she would have the stool collected and send in the sample for testing.

On 2/22/11 at 10:20AM the the RN Unit Manager was interviewed regarding the results for C-diff. She could not find it. She then called the lab and they stated that they lost the sample; A new sample will be collected and sent out today.

On 2/23/11 at 10:30AM in an interview with the RN unit manager she stated that the results came back and they are inconclusive.

3b. Resident #141 was admitted to the facility with diagnoses including Peripheral Vascular Disease and Venus Stasis Ulcers with MRSA (methecillin resistant staphylococcus aureus).

Review of Interim Physician's Order Form dated 12/18/10 revealed an order to obtain stool for C-diff. dx. diarrhea. In ani Interview with the RN unit manager on 2/16/11 at 1:45PM she could find no evidence that the lab work was done.

Review of a Nursing Care Progress Note dated 1/26/11 revealed a note stating "d/c stool collection for C-diff." There was an interim MD order to d/c stool for C-diff.dated the same day.

415.11(c)(3)(i)

Based on observation, interview and record review it was determined that unprotected vertical openings exist in the building that were not separated by fire resistive construction. In the event of a fire, this could lead to the vertical spread of fire and or smoke.

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

Findings are:

A life safety tour of the facility was conducted on 2/11/11 and the following unprotected vertical penetrations were noted:
1 ) On 2/11/11 at approximately 11:15 AM the sprinkler closet on 1 West was inspected. A shaft enclosed with 1 layer core board, surrounded by 2 layers 5/8 inch sheetrock was noted at the far corner of this small room. A cutout, approximately 8 x 10 inches in size was noted in both the core board and the twin sheetrock layers of this shaft . This cutout provided access to a vertical heating, ventilation and air conditioning ( HVAC ) duct penetrating the floor slab. An access door was noted in this duct that provided access to a horizontally oriented fire damper within. The duct within this shaft was not sealed to the floor of the shaft and penetrations to the level below were noted. A fire rated access door is required to cover the cutout in the shaft wall. In addition, the walls of the shaft were not tight to the floor and walls of the room. Review of the blueprints for this area revealed the presence of a vertically oriented HVAC shaft.

2.) On 2/14/11 at approximately 12:00 PM the expansion joints on the East wing were inspected. When viewed from below, the metal underside of the joint cover plate on the floor above was noted. The joint cavity (approximately 2 inches wide) lacked any visible filling or sealant material constituting a fire resistive assembly. The height to the cover plate above was roughly measured at 8 inches (the concrete slab thickness). Maintenance staff stated at this time that some of the joint cover plates were original, but also indicated that the sections in the corridor had been replaced when new carpeting was installed. Inspection of the expansion joint of the concrete slab of the attic revealed it to be open to the 2nd floor below. The top of the suspended ceiling tiles below were visible when viewed from the attic above. When viewed from below, light from the attic above was visible through this expansion joint.

The Director of Maintenance stated at the time that a fire rated access door would b e installed and the shaft would be separated by appropriate fire resistive construction.

10NYCRR 711.2(a)(1)
2000 NFPA 101: 8.2.5.6, 19.3.1.1