Schofield Residence

Based on observation, record review and staff interview, the facility did not provide each resident the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Two (Residents #4, 72) of 21 residents reviewed for quality of care had issues. Resident #72 did not have a bowel movement for more than three days on multiple occasions. The facility bowel protocol was not implemented as planned and bowel medications were not administered as ordered by the physician. In addition, there was a lack of a comprehensive physical assessment by a registered professional nurse at the time of a change in the resident's condition. This resulted in actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #72 who developed a fecal impaction.

Resident #4 did not have timely implementation of the bowel regimen including medication administration, an abdominal assessment and physician notification. Resident #4 had no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #72 has diagnoses including chronic obstructive pulmonary disease, cardiomyopathy (disease of the heart muscle causing decreased function of the heart), and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 8/2/10 revealed the resident has moderately impaired cognitive skills for daily decision making, short and long term memory problems, sometimes understands, and is sometimes understood. Additional review of the MDS revealed the resident is incontinent of bowel and continent of bladder, has an indwelling Foley catheter and is dependent on staff for toilet use and requires extensive assistance for hygiene. The MDS also documented that the resident has chewing and swallowing problems and has had weight loss.

a). Review of the Comprehensive Care Plan (CCP) for constipation dated 5/19/10 revealed a goal for the resident to have a "bowel movement (BM)" at least every three days. CCP approaches included plans for staff to encourage adequate fluid intake, provide medications as ordered, monitor effects and monitor and record bowel movements.

The CCP dated 5/19/10 identified that the resident has the potential for alteration in hydration status due to consuming less than 75% (percent) of estimated fluid needs and diuretic (medications to promote the excretion of urine) therapy. CCP approaches include plans to monitor and record fluid intake, provide fluid preferences as noted, provide additional fluid between meals, monitor for signs and symptoms of dehydration and report any changes.

Review of a current facility policy and procedure (P&P) entitled "Bowel Function Monitoring" (subsection 07 - 09) dated 11/05, revealed "it is the responsibility of each medication nurse to review the bowel lists prepared daily by the 11:00 PM to 7:00 AM shift". "If there is no indication the resident has had a bowel movement, the following intervention should be utilized:"

- No BM in 9 shifts, give prune juice during the 8:00 AM medication pass
- No BM by 12:00 noon that day, give Milk of Magnesia (MOM) prn (as needed) during the 12:00 PM medication pass (if ordered)
- No BM by HS (bedtime), give Dulcolax (laxative) suppository (if ordered)
- If no BM by the next morning, consult the physician for further intervention
- Have a complete assessment done before calling the physician
- Residents who have completed the three steps of the bowel protocol without a bowel movement, may be given prune juice and/or MOM in the interim of the physician being notified.

Review of Physician's Orders dated 6/1/10 revealed orders for:

- Senna S (laxative) one po (by mouth) QD (every day)
- Colace (stool softener) 100 milligrams (mg) po BID (twice a day)
- Dulcolax 10 mg rectal suppository QD as needed for constipation
- MOM (laxative) 30 cubic centimeters (cc) QD as needed for constipation

Review of Routine Medications sheets dated 6/10 revealed the resident received Colace 100 mg orally twice a day and Senna S one tablet daily from 6/1/10 to 6/30/10.

Review of Caretracker (computerized documentation system) Bowel and Bladder Detail Reports revealed no documentation that the resident had a BM for 23 shifts from 6/22/10 to 6/30/10.

Review of a Daily Bowel Record worksheet dated 6/26/10 revealed the resident's last BM was 6/22/10 and documentation that prune juice was given at 8:00 AM, MOM was given at 12:00 noon and a Dulcolax suppository was given at HS (bedtime). Additional review revealed there were no results from the bowel interventions. Review of Routine and PRN (as needed) Medications Sheets dated 6/10/10 revealed no documentation that MOM and the Dulcolax suppository was administered on 6/26/10. Review of Nursing Progress Report notes and 24 Hour Reports both dated 6/27/10 revealed no documentation that a complete assessment of the resident was done by a registered nurse (RN) or that the Physician was contacted for further interventions.

Review of the Daily Bowel Record worksheet dated 6/27/10 revealed the resident's last BM was 6/22/10. There was no documentation that prune juice or MOM was given, however a Dulcolax suppository was administered at HS. The Dulcolax suppository was not documented on the 6/10 Medications Sheets. There was no documentation regarding Resident #72 in the Nursing Progress Report notes or the 24 Hour Report for 6/27/10.

Review of the Daily Bowel Record dated 6/28/10 revealed the resident's last BM was 6/22/10, prune juice was given at 8:00 AM, MOM was given at noon and results were "pending".

A Nursing Progress Note written by an RN dated 6/28/10 at 11:22 AM revealed no documentation regarding the resident's bowel status.

Review of a Nursing Progress Report note, written by a Licensed Practical Nurse (LPN), dated 6/28/10 at 10:45 PM revealed the Physician was called because the resident had not moved her bowels since 6/22/10 and new orders were obtained for a "Fleets enema tonight". Review of the Routine Medications Sheet dated 6/10 revealed the Fleets enema was given on 6/28/10 at HS. Additional review of the 6/10 Medications Sheets and Nursing Progress Notes dated 6/28/10 and 6/29/10 revealed no documentation regarding the results of the Fleets enema.

Review of the Daily Bowel Record dated 6/29/10 revealed the resident's last BM was 6/22/10, prune juice and MOM were given with no results. Review of a Nursing Progress Report note dated 6/29/10 at 5:13 PM revealed the Physician was in and new orders were obtained to start MOM 30 cc daily and discontinue Colace. Review of the Physician's Progress Notes dated 7/13/10 revealed there was no MD Progress Note written on 6/29/10 and no documented evidence that the Physician examined Resident #72 on 6/29/10. The Daily Bowel Record dated 6/29/10 documented that a Dulcolax suppository was given at HS with results pending.

Review of the Daily Bowel Record dated 6/30/10 revealed the last BM was 6/22/10 and prune juice and MOM were given with no results documented.

A Nursing Progress Report note written by a licensed practical nurse (LPN) dated 6/30/10 at 2:44 PM revealed the resident had no documented BM in 7 days. The LPN "digitally (physical exam of the rectum by using a lubricated, gloved finger) assessed" the resident and "no stool felt in the rectal vault". "Abdomen firm with slight distention" and the Physician was to be called for orders. A Nursing Progress note dated 6/30/10 at 7:09 PM revealed the physician was updated and new orders were obtained to administer a soap suds enema. At 11:19 PM, an LPN documented there was hard stool in the rectum and the soap suds enema was given. The Bowel and Bladder Detail Report documented that the resident had an extra large BM on 7/1/10 at 2:27 AM and a small BM on 7/1/10 at 9:00 PM.

Review of Routine Medications Sheets dated 7/10 revealed the resident received Senna S 1 tablet and MOM 30 cc daily from 7/1/10 to 7/13/10.

Review of Bowel and Bladder Detail Reports for 7/10 revealed no documented evidence the resident had a BM for 16 shifts from 7/2/10 to 7/7/10. Review of the PRN Medications Sheet dated 7/10 revealed a Dulcolax suppository was given on 7/5/10 at 10:00 PM.

Additional review of Nursing Progress Report notes and 24 Hour Reports, both dated 6/30/10 to 7/5/10 revealed no documented evidence an RN assessed the resident regarding her abdomen/bowel status.

Review of Nursing Progress Report notes written by an RN dated 7/6/10 at 10:43 AM revealed an abdominal assessment was done, the abdomen was slightly firm, positive bowel sounds in 4 quadrants, and the resident had complaints of tenderness upon abdominal palpation. The RN documented she left a message on the "MD board to update".

Additional review of Nursing Progress Report notes revealed the following:

- On 7/6/10 at 10:23 PM, an LPN documented that the physician was updated and "Fleets enema tonight per rectum times one". The Bowel and Bladder Detail Report documented the resident had a medium size BM on 7/7/10 at 4:39 PM.
- On 7/7/10 at 11:00 PM, an LPN documented "resident noted to be guarding abdomen. Slightly distended (more prominent to the right) tender to touch". "BS (bowel sounds) present in all four quadrants". "Medium BM this shift".
- On 7/8/10 at 6:22 AM, an LPN documented soft mass remains on right side of abdomen, area movable, no complaints of pain on palpation, bowels sound positive in four quadrants.
- On 7/8/10 at 11:22 PM, an LPN documented abdominal distention noted, left and right abdomen firm and tender to touch. The LPN documented that the resident requested MOM at HS and results pending.

Further review of the Bowel and Bladder Detail Reports revealed no documentation of a BM for 11 shifts from 7/8/10 to 7/12/10.

Review of Nursing Progress Report notes written by LPNs on 7/9/10 at 6:45 AM, 2:24 PM and 10:59 PM documented that abdominal distention continued, there was a "right mass in lower abdomen (at 2:24 PM)" and "tender to touch" at 10:59 PM.

Additional review of Nursing Progress Report notes revealed the following:

- On 7/10/10 at 2:05 PM, an LPN documented the right side mass remains in the abdomen. "Hard/firm to touch".
- On 7/12/10 at 2:07 PM, an LPN documented the right side of the abdomen was firm and distended, no BM since 7/7/10, prune juice given this morning with scheduled MOM. New order for Fleets enema tonight "if no BM of at least a medium by then".
- On 7/12/10 at 11:12 PM, an LPN documented the resident had a medium BM and the scheduled Fleets enema was held.
- On 7/13/10 at 3:38 AM, an LPN documented the resident had a firm, movable mass on the right side of the abdomen.
- On 7/13/10 at 1:52 PM, the resident was complaining of severe abdominal pain in the morning and scheduled Ultram (pain medication) was given, poor effect.

Review of Nursing Progress notes and 24 Hour Reports, both dated 7/7/10 to 7/13/10 revealed no documented evidence an RN assessed the resident's abdominal distention, abdominal mass, and complaints of discomfort.

A Nursing Progress Report note written by an LPN dated 7/13/10 at 6:58 PM revealed the Physician saw the resident at approximately 5:00 PM and the Physician ordered that the resident be sent to the hospital.

Review of a hospital Final Radiology Report for CT scans (computerized axial tomography - pictures taken by a specialized x-ray) of the abdomen and pelvis dated 7/13/10 revealed the resident had "advanced dilatation of the rectum with stool", representing a "prominent fecal impaction", with moderate dilatation in the remainder of the colon with stool.

Interview with the Attending Physician on 9/21/10 at approximately 4:00 PM revealed when she was called several times regarding the resident's bowel problems, she expected that the nurses had followed the facility bowel protocol and had administered the ordered "as needed" medications for constipation, prior to calling her for additional orders. The Physician stated she was unaware that the nursing staff had not routinely administered the ordered "as needed" medications for constipation. During the interview, the Physician referred to her Progress Notes. The Physician had no specific recollection of her involvement on 6/29/10.

During an interview on 9/22/10 at approximately 12:15 PM, the ADON confirmed there was no RN assessment from 7/1/10 to 7/5/10 and from 7/7/10 to 7/12/10. The ADON stated there was a problem with documentation regarding the bowel regimen.

b). Review of a Nursing Progress Report note dated 7/14/10 at 6:49 AM revealed the resident returned to the facility on 7/14/10 at 6:30 AM. Additional review of the CCPs for Constipation dated 5/19/10 and 9/15/10 revealed no documented evidence that approaches were revised following the resident's return from the hospital.

Review of current Physician's Orders dated 7/27/10 revealed orders to administer Senna S one po QD; MOM 30 cc daily; and "as needed" daily for constipation; a Fleets Enema daily "as needed"; and a Dulcolax 10 mg rectal suppository 1 per rectum "as needed" for constipation.

Review of the Routine Medications sheets dated 9/10 revealed the resident received scheduled medications including one tablet of Senna S and MOM 30 cc daily at 8:00 AM from 9/15/10 to 9/20/10.

Interview with the resident on 9/20/10 at approximately 8:30 AM revealed she had not moved her bowels in 5 days and her abdomen felt uncomfortable, even though she has received her bowel medications. The resident stated staff are aware because she reported it.

Review of Caretracker Bowel and Bladder Detail Reports, on 9/20/10 at approximately 9:00 AM, revealed no documented evidence that the resident had a BM for 13 shifts from 9/15/10 to 9/20/10.

Interview with LPN #1 on 9/20/10 at 1:50 PM revealed "per policy", the 11:00 PM to 7:00 AM staff generate the bowel reports from Care Tracker for any resident who has not had a bowel movement in 9 shifts. The LPN found the report for 9/19/10 and stated Resident #72 was on the list and received prune juice in the morning and scheduled MOM during the day shift. The LPN stated no other interventions were provided (MOM, Dulcolax, Fleets enema), although the resident should have received "something" per the bowel protocol, the night of 9/19/10. The LPN could not find a bowel report for 9/20/10, checked with the two Medication Nurses and found that they did not have bowel reports for 9/20/10. The LPN explained that the day shift LPN Medication Nurses are expected to have the bowel reports on their medication carts from the beginning of the shift. The LPN stated she would generate the bowel reports now and distribute them to the LPN Medication Nurses and make sure the resident's constipation issues were taken care of. Observation revealed LPN #1 generated the list and Resident #72 was still listed on the bowel report.

Interview with LPN #2 on 9/20/10 at approximately 2:00 PM revealed she only gave the resident the scheduled MOM at 8:00 AM on 9/19/10 and did not administer the PRN (as needed) MOM because the bowel protocol calls for MOM and the resident already has it ordered.

During an interview on 9/20/10 at 2:07 PM, the LPN (#3) Medication Nurse stated having the bowel sheets earlier would not have changed the resident's medication treatment. LPN #3 stated he did not believe any additional medications were required and that the CNA had not reported anything unusual today.

Interview with CNA #1 on 9/20/10 at 2:15 PM revealed the resident told her she was constipated when she put the resident to bed after lunch and asked for medication for constipation. CNA #1 stated she reported the resident's request to LPN #3 at approximately 1:20 PM. When asked what the nurse's response was, CNA #1 stated LPN #3 told her he "already gave her MOM today so she was okay".

Additional review of the PRN Medications sheet dated 9/10, on 9/21/10, revealed a Fleets enema was administered on 9/20/10 at 7:30 PM. A Nursing Progress Report note dated 9/21/10 at 12:15 AM documented the resident had a large BM after the Fleets enema was given.

Interview with the Physician on 9/21/10 at approximately 4:00 PM revealed she expects the nurses to follow the facility bowel protocol policy and administer "as needed" medications for constipation (when a resident has not moved their bowels for 9 shifts). The Physician also stated that this resident would require, and she would expect, the administration of the "as needed" MOM, in addition to the scheduled MOM when the bowel protocol was initiated. (as well as the administration of Fleets and/or Dulcolax).

2. Resident #4 has diagnoses of cerebrovascular accident (stroke) with left hemiplegia (paralysis on one side of the body), diabetes mellitus and constipation. Review of the Minimum Data Set (MDS) dated 8/3/10 revealed the resident has short term memory problems, moderately impaired cognitive skills for daily decision making, and is incontinent of bowel all (or almost all) of the time.

Review of Physician Orders dated 8/24/10 revealed the following orders for the following medications:

- Baclofen (muscle relaxant) 20 milligrams (mg) po (orally) four times a day
- HCTZ (Hydrochlorothiazide - diuretic/antihypertensive) 25 mg po daily
- Depakote (seizure medication) 500 mg every morning
- Depakote 750 mg every bedtime
- Cymbalta (antidepressant) 60 mg po daily

Review of the Nursing 2011 Drug Handbook revealed constipation is documented as a potential adverse effect of Baclofen, HCTZ, Depakote and Cymbalta.

Additional review of the 8/24/10 Physician Orders revealed the following orders for the management of constipation:

- Prune juice 120 cubic centimeters (cc) po every morning
- Senna (laxative) Tabs one tab po daily at 1:00 PM and 4:00 PM
- Dulcolax suppository 10 mg one rectally daily as needed
- Milk of Magnesia 30 cc po daily as needed
- Fleets enema one rectally daily as needed
- Dulcolax tabs 5 mg po daily as needed

Review of the Comprehensive Care Plan (CCP) dated 8/5/10 indicated the resident has a potential for constipation with a goal to have a bowel movement at least every 3 days. CCP approaches included plans for staff to:

- Monitor and record bowel movements, address with MD as needed
- Administer medications as ordered; monitor effects

Review of Caretracker Bowel and Bladder Detail Reports revealed no documented evidence that the resident had a bowel movement for 24 shifts from 9/12/10 until 9/20/10 at 1:57 PM. On 9/12/10 at 6:51 AM, the Bowel and Bladder Detail Report documented that the resident had an extra large BM. The next BM was on 9/20/10 at 1:57 PM.

Review of a Nursing Progress Report note written by a Graduate Nurse (GN) dated 9/20/10 at 9:13 AM revealed "Abdominal assessment performed by writer d/t (due to) no documented BM since 9/12/10". The GN documented that a Fleets enema was administered by the Medication Nurse per the prn (as needed) order.

Review of a Daily Bowel Record worksheet dated 9/16/10 revealed the resident's last BM was 9/12/10, prune juice was given at 8:00 AM with no results and the resident refused Milk of Magnesia at 12:00 noon. Notes documented on the back of the PRN Medications Sheet for 9/10 revealed that the resident refused Milk of Magnesia at 12:00 PM on 9/18/10. There was no documented evidence that the Licensed Practical Nurse (LPN #1) Medication Nurse attempted to administer another prn medication.

Review of the 9/10 MAR and the Daily Bowel Record dated 9/19/10 revealed LPN #1 Medication Nurse gave a Dulcolax 5 mg tablet to Resident #4 on 9/19/10 at 12:00 noon with results pending.

The Daily Bowel Records dated 9/17/10 through 9/19/10 revealed the facility bowel protocol was intermittently implemented with no results. Additional review of the Daily Bowel Records and Nursing Progress Report notes dated 9/13/10 through 9/20/10 revealed the resident had no BM, there was no documented evidence that an abdominal assessment was done until 9/20/10 and the Physician was not made aware.

Review of House Reports (24 Hour Reports) dated 9/17/10, 9/18/10, and 9/19/10 revealed no evidence the physician was notified regarding the resident's lack of BM from 9/13/10 to 9/19/10.

During an interview on 9/21/10 at 12:00 PM, the GN stated she was not aware that Resident #4 did not have a BM for 8 days until 9/20/10. The GN also stated she was not aware that the resident had received bowel medications that were ineffective.

Interview with the Registered Nurse (RN) Unit Coordinator (UC) at 12:15 PM on 9/21/10 revealed he was not informed until 9/20/10 that the resident did not have a BM for 8 days. The RN UC stated he would have expected it to be reported. The RN UC stated that an RN was the Staff Nurse for the past weekend and he expected that the RN would have assessed the resident if there were no results after the administration of bowel medications and contacted the Physician if appropriate.

415.12

Based on observation, record review, staff and resident interview, a comprehensive care plan was not periodically reviewed and revised by a team of qualified persons after each assessment. Four (Residents #60, 114, 160, 169) of 21 residents reviewed for Care Plan revision had issues involving the lack of dietary care plan revisions for a resident with a pressure ulcer and a resident with consistent medication refusals. In addition, the care plan was not revised to reflect the resident's use of a boot cast or AFO (ankle foot orthotic - orthopedic brace), a change in a resident's ambulatory status, or a resident's preference to go outside. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #169 has diagnoses including malnourishment, depression, and hypertension. Review of the Minimum Data Set (MDS) dated 8/7/10 revealed the resident is independent in cognitive skills for daily decision making, understands and is understood. Review of the MDS dated 8/4/10 revealed under "Activity Pursuit Patterns" that the resident's preferred activity settings are her own room, the day/activity room, and inside nursing home/off unit, while the resident's general activity preferences are music, reading/writing, spiritual/religious activities, watching TV and talking or conversing. Review of the MDS dated 8/7/10 revealed that the resident's preferred activity settings are her own room, inside nursing home/off unit, and outside facility, while the resident's general activity preferences are music, reading/writing, spiritual/religious activities, watching TV, talking or conversing, and walking/wheeling outdoors.

Review of a Social Services note dated 8/25/10 revealed that in addition to confirming with the Social Worker that she was "praying to die" and declined psychology consult, the resident told the Social Worker that she would like to go outside more. The Social Worker documented that activity staff was made aware.

Review of the Social Event Detail Report (activity attendance) revealed the resident went outdoors on 4 occasions: 8/22/10, 8/25/10, 8/28/10, and 8/31/10.

Interview on 9/21/10 at 10:30 AM with the Activities Director revealed the resident may have been asked at other times and refused. When asked how that could be determined, the Activities Director stated there would not be a way to determine that as "we don't document refusals because it wasn't being documented by activity staff consistently".

Review of the Comprehensive Care Plan (CCP) dated 8/10/10, last updated 8/26/10, on 9/21/10 at 10:30 AM with the Activity Director, the Activity Director revealed that there was no documentation of the resident's preference for going outside except for "music concerts". When told the resident had expressed a desire to go outside to this surveyor and to the Social Worker, and that the MDS of 8/7/10 identified this, the Activities Director stated, "We should be offering that to her", and, "I'll need to add that to the care plan".

On 9/21/10 at 10:55 AM, the Activities Director was observed to go in the resident's room and ask the resident, "Have we been asking you if you want to go outside?" The resident replied, "No". The Activities Director then asked, "Would you like to go outside?", and the resident replied, " Yes". The Activities Director then told the resident, "Well, from now on when we stop to visit you, we'll ask you if you want to go out. And please feel you can ask any time." The resident replied "OK".

2. Resident #160 has diagnoses which include coronary artery disease, hypertension and high cholesterol.

Review of an Acute Visit note dated 8/25/10 revealed the Physician documented the resident has capacity to make her own health care decisions.

Review of Physician Orders revealed the following:

- 6/10/10, Lopressor 25 milligrams (mg) 1 tablet by mouth two times a day for hypertension and Zocor 40 mg 1 tablet by mouth at bedtime for high cholesterol
- 7/9/10, continue the Zocor 40 mg at bedtime, decrease the Lopressor to 12.5 mg by mouth twice a day
- 7/29/10, Remeron 7.5 mg by mouth daily for appetite stimulation
- 9/1/10, renewal orders to continue the Lopressor, Zocor and Remeron.

Review of a form entitled Routine Medications dated 7/1/10 to 9/15/10 revealed that the resident has refused to take the 8:00 PM dose of Lopressor for hypertension, the 8:00 PM dose of Zocor for high cholesterol, and starting 7/30/10 the 8:00 PM dose of Remeron for appetite.

Review of Nursing Progress Reports dated 7/1/10 through 9/17/10 revealed occasional documentation that the resident was refusing her medications. Review of Weekly Psychotropic Drug Review notations dated 8/22/10 and 8/29/10 revealed the resident received Remeron 7.5 mg by mouth daily for appetite, and a notation 9/1/10 that the MD was also made aware of refusals of all evening medications. There is a lack of documented evidence that the physician was informed of the resident's refusal of evening medications in the Progress Reports.

Review of Dietary Progress Reports dated 7/7/10 through 9/13/10 revealed a notation dated 8/9/10 that Remeron was added to the plan of care on 8/2/10 with poor results noted and med refusals noted. Confer with MD and follow.

During an interview with the resident on 9/17/10 at 11:08 AM, the resident stated "I only take my medications once a day, and I feel pretty good. I don't need to take anymore." "I don't take the evening meds cause they make me feel shaky, or something, I don't know". She additionally stated "I can talk to the Doctor, but he's not the boss of me, I can watch my own body and decide what to take".

Interview with the Registered Nurse (RN)/Unit Coordinator (UC) on 9/17/10 at 10:40 AM revealed that: "The resident has been refusing to take her afternoon, evening medications. She says that she should have to take medications only once a day". "I've known about this problem since at least September, and told the Doctor about it on 9/1/10. I reminded the physician on 9/3/10 that the evening meds are being refused. I checked the orders on 9/1/10, that's why I brought it to the MD's attention." In addition the RN stated "For 7/10 and 8/10 I was unaware of the refusals. If I did know (about the refusals), I would have had the staff nurse call the MD or called the MD myself. My expectation is that the Nurse administering the medication would bring refusals to my attention. The Physician has made no changes to the medications, he did not explain to me what he wanted to do about the refusals. She is refusing Remeron for appetite, and she is losing weight, but she said she did not want to take anything for her appetite. She is refusing the evening dose of Lopressor, but her BP (blood pressure) is stable, and looks good. She is refusing Zocor for high cholesterol, She has not had a cholesterol level since July".

During an interview with the Graduate Nurse/Staff Nurse on 9/17/10 at 10:55 AM, the Graduate Nurse stated: "I talked to the Doctor on 9/14, and he said to encourage her to take her meds, and document the refusal and the resident's reason why and he will review it the next time he is in".

During an interview with the Diet Tech/Nutritional Manager on 9/17/10 at 11:56 AM, the Dietary Tech stated "I think the Remeron would be good, it works for some people, she should be re-approached regarding the Remeron. We would probably wait for the quarterly review in October to review the effectiveness of the Remeron, with all the meds. I would depend on nursing to address the medication refusals in the meantime".

Interview with the Director of Nursing (DON) on 9/17/10 at 2:55 PM revealed: "I would expect the RN/UC to report a significant drug administration omission to me so that I could do an investigation as to how it happened. I just found out about this today. Residents have a right to refuse medications, but after two days or so it should be reported."

During an interview with the DON on 9/19/10 at approximately 1:00 PM, it was learned that the facility does not have a policy regarding the notification of a physician when a medication is refused.

Review of the resident's current CCP dated 7/14/10 revealed there is no documented evidence of a revision to the care plan to address the resident's medication refusal.

During an interview with the Registered Nurse (RN) Unit Coordinator (UC) on 9/17/10 at 2:31 PM, the RN stated "There have been no care plan revisions to address the resident's refusals of medication. The resident takes her morning meds, we could consider giving the evening daily meds in the morning, or adjusting the dose of the twice a day meds. I should have pushed the MD more, probably. We did not do a medication error investigation because the dose omission was by resident choice, not an error in administration. I did not report this to the DON.

3. Resident #114 has diagnoses which include dementia, pressure ulcer Stage 4 left gluteal (buttocks) fold, atrial fibrillation (irregular heart beat), osteoarthritis, and obesity. Review of the initial Minimum Data Set (MDS) dated 8/5/10 revealed the resident has modified independence in daily decision making, always understood, and usually understands.

Review of Skin Tear Evaluation Sheets revealed the resident was admitted on 7/29/10 with Stage 4 area left gluteal fold measuring 4 centimeters (cm) x 2 cm x 3 cm depth. Review of the Comprehensive Care Plan (CCP) printed 8/13/10 valid through 11/30/10 revealed a nutrition plan for impaired skin integrity which included provide diet per MD order, monitor weights monthly or as needed, provide food preference as noted, monitor lab results, provide additional protein/vitamin C source foods as per meal plan, provide supplements per dietary discretion, provide nourishments per dietary discretion. Additional approaches include Occupational Therapy (OT) referral to determine need for adaptive equipment or determine need for changes in positioning during meals prn (as needed), speech referral as needed, intake studies prn (as needed), provide meal replacements as needed, medications as ordered, -Monitor effect on changes in nutritional status, and involve resident/family in meal plan decisions.

Review of the initial Dietary Progress Note dated 7/30/10 revealed the resident received a No Added Salt Diet with mechanical soft texture. Preferences noted. Resident is 60 inches tall and weighs 217.4# on admission. Open area is noted on left buttock with a 3 day intake study in place 7/31/10.

Review of the nutritional assessment dated 8/5/10 Ideal Body Weight (IBW)-100#,current weight 217#. appetite 60-100%. Assessed needs at 1465 to 1760 kcal, protein-76 to 87 gm fluids-2465 cubic centimeters (cc). Intake analysis completed 1508 kcal (meeting needs) 69 grams (gm) protein (84% of needs met) fluids 1543 cc (63% of needs met). The changes to the nutrition plan of care included:

- request prealbumin (blood test that can indicate severe nutritional deficiency) & BMP (basic metabolic panel - blood test including basic chemistry studies of the blood).
- Requested MOV (multivitamin) with minerals.
- Discontinued milk at meals as resident is lactose intolerant and replaced with Lactaid.
- 8/5/10, added 4 ounces (oz) C.I.B. (Carnation Instant Breakfast) at dinner and supper, 4 oz juice at 10:00 AM and 3:00 PM to encourage hydration.
- 8/8/10, Arginaid (nutritional supplement) added to medication regimen,
- 8/17/10, 8 oz cib at dinner and supper and additionally will add 8 oz C.I.B. at breakfast,
- 8/22/10, changed C.I.B. to 8 oz Boost Breeze (nutritional supplement) for better acceptance,
- 9/3/10, food preferences reviewed with resident and family.

In summary, there was a lack of documented nutrition care plan revisions to address ongoing changes, specific nutritional supplement changes, specific medication changes, and food allergies.

4. Resident #60 has a history of dementia and degenerative joint disease (DJD). Review of the Minimum Data Set (MDS) dated 6/2/10 revealed the resident has moderately impaired cognitive skills for daily decision making with long and short term memory impairment.

a). Review of the Comprehensive Care Plan (CCP) dated 8/31/10 is ambulation in room with rolling walker. The resident is one assist ambulation in corridor 5 x (times) week for 25 to 50 feet with gait belt and rolling walker. A 9/1/10 entry documents the resident is a two assist stand pivot with gait belt.

When observed on 9/15/10 at 2:30 PM, Certified Nurse Aide (CNA) #3 and CNA #4 stood the resident and ambulated the resident 4 to 5 steps to the sink. The resident's left foot rolled backwards, knees flexed and the resident started to sit down and yelled "oh oh ouch." The CNAs assisted the resident to ambulate backwards 4 to 5 steps and sit down on the toilet.

When interviewed on 9/15/10 at 6:40 PM, the Licensed Practical Nurse (LPN) #2 stated the resident can walk in the room with a rolling walker and assistance.

When interviewed on 9/15/10 at 6:41 PM, CNA #3 stated the resident can ambulate short distances.

When interviewed on 9/16/10 at 1:00 PM, the Registered Nurse (RN) Unit Coordinator stated the resident is non ambulatory.

When interviewed on 9/16/10 at 1:20 PM, the Physical Therapist (PT) Assistant Rehabilitation Director stated it is not recommended that the resident walk.

During an interview on 9/17/10 at 10:25 AM, the RN Unit Coordinator (UC) stated he does the CCPs and updates them. After reviewing the CCP dated 8/31/10 the RN UC stated he did not update the care plan that the resident should not have been ambulated and would update it now.

b). The CCP dated 8/31/10 documented a plan for the resident to wear an AFO (ankle/foot orthosis) when oob (out of bed) and when walking. The resident is to wear cast boot and AFO on her left foot for all transfers and ambulation.

When observed on 9/15/10 at 1:05 PM and 9/15/10 at 6:00 PM, the resident self propelled in a wheelchair in the hall using her right foot (sneaker on) to self propel. The footrest on the left side of the wheelchair was folded up and the resident was holding her left foot with a black velcro open toe orthopedic shoe up off floor in front of her as she self propelled. When observed again on 9/16/10 at 7:45 AM, the resident was sitting in the wheelchair wearing a black velcro orthopedic shoe on her left foot.

When interviewed on 9/17/10 at 10:30 AM, the RN Unit Coordinator stated the left AFO should not be on the resident. He further explained that it is his responsibility to update the care plan and he would do it now.

415.11(c)(2)(iii)

Based on observation, record review and staff and resident interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. Three (Residents #60, 61, 127) of four residents observed for potential accidents had issues involving staff ambulating a resident without the use of a foot brace, which was not in accordance with therapy recommendations and the care plan; an alarm that was not properly implemented as planned; and lack of interventions to address a resident's repetitive behavior of standing up from the wheelchair. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #60 has diagnoses including dementia and degenerative joint disease.

Review of the current Comprehensive Care Plan (CCP), last reviewed 9/1/10, revealed the resident has limited ambulation due to dementia and degenerative joint disease. The CCP documented that the resident has a seven year history of a deformity of the left ankle and keeps her ankle plantar (sole of the foot) flexed and inverted (turn upside down). The CCP also documented that the resident wears an AFO (ankle-foot orthosis - brace) when OOB (out of bed), for all transfers and ambulation. CCP approaches also include the use of a rolling walker for transfers and ambulation.

Review of a Physical Therapy (PT) Progress note dated 9/1/10 revealed the AFO was discontinued due to a sore on the resident's left leg. The PT also discontinued ambulation for Resident #60 and changed the transfer plan to SPS (stand - pivot - sit) with two assists using a gait belt (GB) and a rolling walker (RW). A CCP revision dated 9/1/10 and the Door Card (used by certified nurse aides (CNAs) to provide care) dated 9/6/10 documented the plan for 2 assist SPS with a GB and RW. The Door Card documented "ambulation - none".

When observed on 9/15/10 at 2:30 PM, CNAs #3 and #4 assisted the resident to a standing position and ambulated the resident 4 to 5 steps from the toilet to the sink in the resident's room. The resident was wearing open toe velcro orthopedic shoes and the resident's left ankle was inverted approximately 90 degrees. When the resident stepped on her left foot, it rolled backwards and the resident yelled "oh, oh ouch ouch". The resident's knees flexed and the resident started to sit down. The CNA stated to the resident "stand up" and both CNAs assisted the resident to stand. As the resident took 4 to 5 steps backwards, she continued to yell "oh oh ouch" and her left ankle inverted and rolled backwards.

When interviewed on 9/15/10 at 6:40 PM, Licensed Practical Nurse (LPN) #2 stated the resident can walk in her room with a rolling walker and assistance.

When interviewed on 9/15/10 at 6:41 PM, CNA #3 stated the resident has not had the brace and does not walk well without it.

During an interview on 9/16/10 at 1:00 PM, the Registered Nurse (RN) Unit Coordinator stated that the resident's care plan documents that the resident is non-ambulatory.

During an interview on 9/16/10 at 1:20 PM, the Physical Therapist (PT) Assistant Rehabilitation Director stated it is not recommended that the resident walk without the AFO on.

When interviewed on 9/17/10 at 10:25 AM, the RN Unit Coordinator (UC) stated he updates the Comprehensive Care Plans (CCPs). After reviewing the CCP dated 9/1/10, the RN UC stated he did not update the care plan to indicate that the resident should not have been ambulated and would do it now.

2. Resident #61 has a diagnosis of chronic renal failure and receives hemodialysis 3 times a week. Additional diagnoses include hypertension, congestive heart failure, dementia, constipation and coronary artery disease. Review of the Minimum Data Set (MDS) dated 9/2/10 revealed the resident has modified independence for decision making, has short and long term memory problems, is usually understood, and usually understands.

Review of a Comprehensive Fall Risk Assessment dated 5/6/10 revealed a total score of 4 indicating moderate risk. Factors included diagnoses - hypotension, agitation, visual deficits, behavior and confusion, and use of psychoactive meds (Zoloft).

Review of an Incident/Accident (A&I) Report dated 8/17/10 at 5:45 PM revealed the resident was found sitting on her buttocks on the floor, her head and back were resting on the wheelchair and both legs were straight out in front of her. The resident complained of pain on the left side of her head and stated "I was trying to go to the bathroom". No bruises or open areas were noted.

Review of an A&I report dated 8/26/10 at 9:00 AM revealed the resident had an ecchymotic (purplish patch caused by blood under the skin) area on the right upper buttock. The ecchymotic area measured 3 centimeters (cm) by 1 cm and was "firm to touch". The A&I documented that the resident did not know how it happened. The Care Plan was reviewed and a TAB's alarm was applied "while out of bed".

Review of the Comprehensive Care Plan (CCP) in effect through 9/30/10 revealed the CCP for Cognitive Loss documented that the resident has occasional forgetfulness and slightly impaired decision making abilities. CCP approaches included a plan to apply a TAB's alarm when the resident is out of bed. The CCP also documented that the resident may be left alone in her room when out of bed, but cannot be left on the toilet.

Review of the Door Card (Closet Care Plan) updated 9/16/10 revealed the resident is non-ambulatory with a plan for a TAB's alarm when out of bed.

On 9/20/10 at 12:45 PM, the resident was observed sitting in a wheelchair in her room. The TAB's alarm was in a cloth bag on the back of the wheelchair. A cord was hanging out of the bag and a clip at the end of the cord was not attached to the resident. The resident was observed again at approximately 1:30 PM, sitting in the wheelchair in her room and the TAB's alarm was still not attached. The clip from the alarm was hanging from the back of the chair.

During an interview on 9/20/10 at 2:15 PM, the resident stated "they have told me many times not to get up by myself".

On 9/20/10 at 2:20 PM the surveyor asked a certified nurse aide (CNA)/ Hospitality Aide to check the resident's alarm. The CNA/Hospitality Aide stated "yep the alarm is not attached to the resident" and stated to the resident "let me put your alarm back on". After the CNA clipped the tab alarm back on the resident, the resident asked "what did you just clip on me?" The CNA stated "a clip alarm so they know when you get up". The resident then stated "ohhhh they keep telling me I'm not suppose to get up".

3. Resident #127 has diagnoses which include dementia, hypertension and osteoarthritis. Review of the current Comprehensive Care Plan (CCP) with a print date of 9/1/10 revealed the resident is at risk for falls with a plan for a TAB's alarm (portable alarm device used to prevent falls) at all times.

Observation on 9/13/10 from 11:45 AM to 1:10 PM during lunch revealed the resident frequently stood up while sitting in a wheelchair. The resident did not stand completely up, was not unsteady, and then sat down again. Prior to standing up, the resident was observed to place her feet on the ground behind the footrests of the wheelchair.

Observation on 9/15/10 from 5:10 PM to 6:20 PM during supper revealed the resident stood up twice from her wheelchair, with her feet positioned on the floor behind the footrests.

The resident was observed to have a TAB's alarm in place during the meal observations on 9/13/10 and 9/15/10.

Intermittent observations of the resident from 9/14/10 through 9/17/10, between the hours of 8:00 AM and 5:00 PM, revealed that the resident was sitting in her wheelchair and was placed in the hallway opposite the nurses' station. The resident was observed to continue the repetitive standing behavior by placing her feet on the ground behind the footrests, which were left in place on the wheelchair.

Interview with a Licensed Practical Nurse (LPN) on Unit 2, on 9/15/10 at 5:20 PM, revealed that the resident's "alarm is supposed to go off if the resident steps away from the wheelchair. Let me clarify that, she doesn't live up here, just up for dinner".

During an interview on 9/15/10 at 5:21 PM, the Unit 2 Registered Nurse (RN) Unit Coordinator (UC) stated "I don't know too much about this resident, she lives downstairs. The alarm is supposed to alert the staff when she stands up. We can put a shorter string on the alarm".

At 5:25 PM, the RN UC was observed to change the string on the alarm. After the string was changed, the resident was observed to still be able to stand and sit without the alarm going off. An observation at 5:55 PM revealed the resident stood up and sat down, and the alarm did not go off.

Interview with the Unit 1 RN UC, on 9/16/10 at 11:30 AM, revealed that Resident #127's alarm is meant to go off when she steps away from the wheelchair. The RN UC explained that the alarm is not meant to restrict the resident's movement; she partially stands and sits down. The alarm is meant to go off when she attempts to transfer or ambulate. "Everyone's TAB's alarm is in a bag. No one is supposed to stand unassisted. The resident stands and sits, she does this all day long, she does not attempt to walk". The RN UC stated that the alarm does not prevent the resident from standing, but if she was to walk away the tab would pull and the alarm would go off. "That is what we want. But it is not written in the care plan that way. The care plan has been that way since I took over the unit". The RN UC explained that after a fall, it is the responsibility of the UC to make a decision regarding the initiation of a TAB's alarm. "If someone has frequent falls I would add a TAB's alarm, and add it to the care plan. In this case I think it could be worded differently in the care plan, the standing is a behavior issue, yes."

Further interview with the Unit 1 RN UC, on 9/17/10 at 8:45 AM, revealed that Resident #127 "has never fallen from her wheelchair, all her falls have been from bed. She stands, but does not step. However, she can walk, she walks with her daughter per the care plan, and she is on an ambulation program, 50 feet 5 times a week. I did not consider the footrests as a tripping hazard when we care planned for the TAB's alarm, allowing her to stand. The footrests would be a tripping hazard if she took a step. We should change the care plan to remove the footrests when she is sitting in place in her wheelchair."

Additional review of the CCP revealed an addition dated 9/16/10 documenting "TAB's to activate if ambulation attempted-may stand unassisted at wheelchair".

415.12(h)(2)

Based on observation, record review and staff interview, the facility did not ensure that it is free of medication error rates of five percent or greater. There were 11 errors for 58 observed medication opportunities involving Residents #50, 72 and 155. This resulted in a medication error rate of 18.9% (percent). Issues involved medications that were administered more than one hour after the scheduled administration time, a medication that was not diluted per physician order, administration of an incomplete medication dose, and "Do Not Crush" medications that were crushed. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #155 has diagnoses including weight loss and general weakness. Review of a Minimum Data Set (MDS) dated 7/7/10 revealed the resident has modified independence in cognitive skills for daily decision making, usually understands and is usually understood.

Review of Physician Orders dated 7/27/10 revealed an order for Miralax (laxative) powder 17 grams (gm) by mouth in 8 ounces (oz) of H2O (water) qd (daily).

During an observation of medication administration on 9/15/10 at 4:45 PM, the Registered Nurse (RN) Medication Nurse poured the Miralax powder into the Miralax bottle measuring cap to the line marked as 17 gm. The RN added the Miralax powder to a 120 cubic centimeter (cc) (4 oz) cup of water, stirred it, and gave the Miralax mixture to the resident. The resident drank approximately half the cup of Miralax/water and stated, "That's enough. I don't want any more". The RN stated, "That's ok. You drank most of it". The nurse documented the medication as administered as ordered.

During an interview on 9/20/10 at 2:20 PM, the RN stated that she "thought it would be all right" to mix the medication in the small cup and stated she knew the cup held 120 cc (4 oz). The RN recalled that she documented the medication as given though the resident took half the dose. The RN stated, "I probably should have written a note on the back of the MAR".

2. Resident #72 has diagnoses including COPD (chronic obstructive pulmonary disease), cardiomyopathy (disease of the heart muscle causing decreased function of the heart), and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 8/2/10 revealed the resident has moderately impaired cognitive skills for daily decision making, short and long term memory problems, sometimes understands, and is sometimes understood.

Review of current Physician's Orders dated 7/27/10 revealed the orders included the following medications:

- Ultram (Tramadol - narcotic like pain reliever) 50 milligrams (mg) po (by mouth) TID (three times per day) for pain.
- Lopressor (Metoprolol - cardiac medication) 12.5 mg BID (twice per day)
- Duoneb (combination medication used to prevent bronchospasm in COPD) one unit dose via nebulizer (a device used to administer inhaled medication in a mist) BID

Review of the Routine Medications sheet dated 9/10 revealed the Ultram, Lopressor and Duoneb were scheduled to be administered at 8:00 AM.

Observation on 9/20/10 at approximately 9:46 AM revealed the Licensed Practical Nurse (LPN) Medication Nurse administered 8:00 AM medications to Resident #72 including Tramadol 50 (mg), Metoprolol 12.5 mg, and the Duoneb nebulizer.

Interview with the LPN Medication Nurse on 9/20/10 immediately after he administered the resident's medications revealed he administered the 8:00 AM meds now because he "has too many people to do" and he "can't get to them fast enough".

3. Resident #50 has diagnoses including dementia, degenerative joint disease and history of surgical repair of a right hip fracture.

Review of Physician's Orders dated 8/10/10 revealed orders for the following medications:

- Lortab (narcotic pain medication) 7.5/500 po BID for pain
- Lasix (diuretic medication used to promote the excretion of urine) po QD (every day)
- Isosorbide (medication used to dilate the blood vessels) 30 micrograms (mcg) po QD for hypertension (high blood pressure)
- Aldactone (diuretic) 25 mg po QD for hypertension
- Lopressor (cardiac medication) 25 mg po Q 6 hours for hypertension
- Omeprazole (Prilosec - prevents the production of acid in the stomach) 25 mg po QD for GERD (gastroesophageal reflux disease - backflow of gastric fluids into the esophagus)

A Physician's Telephone Order dated 8/24/10 included an order for Buspar (anti-anxiety medication) 5 mg po BID for anxiety.

Review of the Routine Medications sheets dated 9/10 revealed the Lortab, Lasix, Isosorbide, Aldactone, Lopressor, Prilosec and Buspar were scheduled to be administered at 8:00 AM.

During observation of medication administration on 9/15/10 at 10:30 AM, Licensed Practical Nurse (LPN) #1 was observed preparing the following medications scheduled for 8:00 AM:

- Lortab 7.5/500 mg
- Lasix 20 mg
- Isosorbide 30 mcg. Observation of the medication label revealed directions for "Do Not Crush and the medication was labeled as Isosorbide 30 mg
- Aldactone 25 mg
- Lopressor 25 mg
- Prilosec 20 mg. The medication label directed "Do Not Crush
- Buspar 5 mg

LPN #1 poured the medications into a cup and crushed all of the medications.

When interviewed on 9/15/10 at 10:45 AM, LPN #1 stated the resident went to the "Golden Slipper Breakfast" and was gone when the LPN was passing 8:00 AM meds, so she did not give them until now. During an interview on 9/15/10 at 10:55 AM, LPN #1 stated "I missed the Do Not Crush on the packet label". LPN #1 stated "I get so used to just reading the medication that I forget to look at the other side of the package for instructions". LPN #1 stated "I crush this resident's medications because I know her. She gets so many of them at once that I was in there for a half an hour once so I crush her meds". The LPN stated "if the resident is supposed to have crushed meds, we get an order from the doctor".

When observed on 9/15/10 at 10:56 AM, LPN #1 repoured the Do Not Crush medications into one cup and the other medications into another cup and crushed the medications that could be crushed. At 11:02 AM, the resident was observed to swallow the medications without difficulty.

Additional review of the Physician's Orders dated 8/10/10 revealed there were no orders to crush the medications.

During an interview on 9/15/10 at 11:10 AM, LPN #1 stated the policy is to give medications one before or one hour after the scheduled time. LPN #1 explained "I should have given this resident the medications before she went down for breakfast because there are only a few resident's on this hall that went to the breakfast". LPN #1 further explained that when she gives meds (medications) late and they are to be given again on her shift, she will just give them a little later. The LPN stated she will give the Lopressor at 2:30 PM instead of 2:00 PM and the other meds are given on the other shift so they can be given at the time they are scheduled.

When interviewed on 9/15/10 at 12:05 PM, the Registered Nurse (RN) Unit Coordinator stated medications are to be given one hour before or one hour after the scheduled time. The RN Unit Coordinator stated his expectation is that the nurse tells him if medications are given late.

415.12(m)(1)

Based on record review and staff interview, the facility did not ensure that all alleged violations, including injuries of unknown source, are thoroughly investigated. One (Resident #60) of three residents reviewed for injuries of unknown origin had issues involving the lack of a complete investigation including staff interviews. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #60 has diagnoses of hypertension, peripheral vascular disease (PVD - poor circulation of the lower extremities), arthritis, Alzheimer's disease, and anemia. Review of the Minimum Data Set (MDS) annual dated 6/2/10 revealed the resident has moderately impaired cognitive skills for daily decision making and short and long term memory impairment. Review of the Comprehensive Care Plan (CCP) dated 8/31/10 does not indicate skin tears.

Review of Incident/Accident Reports (A&Is) between 3/29/10 and 8/31/10 revealed the following:

- A&I dated 3/29/10, skin tear of unknown origin on right shin measures 5 centimeters (cm) x 2 cm,
- A&I dated 5/18/10 - skin tear right wrist of unknown origin, contributing factors unpredictable behavior,
- A&I dated 6/8/10 - skin tear right lower shin taking resident's sock off,
- A&I dated 8/11/10 - ecchymotic area on right posterior wrist-injury of unknown origin,
- A&I dated 8/31/10 - skin tear left shin possibly caused by AFO (Ankle - Foot Orthotic - brace).

During an interview on 9/17/10 at 2:25 PM, the Registered Nurse (RN) Unit Coordinator (UC) stated he fills out the Unit Coordinator Statement (on the A&I) and is responsible for investigating how the skin tear occurred. After review of the A&Is between 3/29/10 and 8/31/10, the RN UC revealed the following:

- A&I dated 3/29/10 - no staff interview on how injury occurred. He further revealed that a certified nurse aide (CNA) reported the skin tear but he does not know who the CNA is.
- A&I dated 5/18/10 - there was no discussion with staff on how this occurred.
- A&I dated 6/8/10 - he did not talk with the CNA on how this actually occurred. The RN stated "I just thought it was an accident".
- A&I dated 8/11/10 - it was reported by a Graduate Nurse (GN) and there was no investigation on how it occurred.
- A&I dated 8/31/10 - was reported to RN by CNA and he did not interview staff.

In addition, the RN stated after he completes the A&I it goes to the Assistant Director of Nursing (ADON) or Director of Nursing (DON) for review.

Further interview with the RN UC on 9/17/10 at 2:25 PM, the RN explained injury of unknown origin should be investigated and stated he did not interview staff to determine how skin tears occurred.

When interviewed on 9/17/10 at 2:45 PM the ADON stated whoever finds a skin tear reports it to the nurse, the A&I is made out, the RN UC Coordinator evaluates how the skin tear occurred and what needs to be put in to place to prevent recurrence. The A&Is are then sent to her for review and if she has any questions, she discusses it with the RN UC. The ADON stated she did not see anything inappropriate with the A&I and did not discuss them with the RN UC. She further stated that she would expect the Unit Coordinator to talk to staff and to determine what caused the injury.

After review of the A&Is, the ADON stated there are no staff interviews. The ADON further stated "I did not talk to staff" and explained she probably should have talked to staff to see if they knew anything.

415.4(b)(3)

Based on record review and resident and staff interview, the pharmacist did not report drug regimen irregularities to the attending physician, and the director of nursing. Three (Residents #3, 130, 160) of 12 residents reviewed for monthly drug regimen reviews had issues involving the lack of Pharmacist identification and reporting of residents' ongoing refusals of medications; an incomplete physician order for Tylenol; and the need to identify a maximum daily dose for Tylenol. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #3 has diagnoses including Alzheimer's dementia, Parkinson's disease, and weight loss. Review of the Minimum Data Set (MDS) dated 8/24/10 revealed the resident has short and long term memory impairment, is severely impaired in cognitive skills for daily decision making, is rarely or never understood, and sometimes understands.

a). Review of Physician Orders revealed orders dated 6/7/10 and 8/5/10 to administer DOK Plus 50/86 (Docusate/ Senna - combination medication to treat constipation) 3 tabs orally twice per day at 8:00 AM and 8:00 PM, Sorbitol (laxative) 45 cubic centimeters (cc) orally twice per day at 8:00 AM and 8:00 PM, Septra (sulfa medication used to treat infection) Single Strength 1 tab orally everyday at 8:00 PM, Vitamin B-12 500 milligrams (mg) orally once per day at 4:00 PM, Megace (appetite stimulant) 400 mg (10 milliliters (ml)) orally twice per day at 8:00 AM and 4:00 PM, Tylenol liquid 20 ml orally four times per day at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM, and Multivitamin liquid 10 cc orally once per day at 4:00 PM.

Review of Routine Medication sheets dated 6/10 through 9/10 revealed documentation that the resident consistently refused the 4:00 PM and 8:00 PM doses of scheduled medications, 60 percent (%) to 100% of the time.

Review of Pharmacy Consultant Report notes dated 6/23/10, 7/27/10, and 8/29/20 revealed no documentation regarding the medication refusals for approximately 4 months.

Interview with the Pharmacy Consultant on 9/21/10 at 9:15 AM revealed he was not aware of the medication refusals. The Pharmacy Consultant stated he "thought the physician had made a note of that", and, "the resident has a right to refuse". The Pharmacy Consultant stated that he had made no recommendations for rescheduling or discontinuing medications for the resident.

b). Review of Physician Orders revealed a telephone order dated 2/26/10 for "Tylenol Supp (suppository) 650 mg PR (per rectum) q4h (every four hours) prn (as needed) pain/temp". The 2/26/10 order did not identify an actual temperature. Review of monthly Physician Orders dated 4/8/10, 6/7/10, and 8/5/10 revealed an order for "Tylenol Suppository 1 rectally for Pain/Temp >___Deg. (degrees) every 4 hours as needed". The orders did not include a temperature parameter for nurses to determine when to administer the Tylenol. Additional review of the Physician Orders dated 6/7/10 revealed a "sticky note" with a handwritten notation, "Tylenol Suppos. order...what parameter do you want for fever?", was attached to the sheet.

Review of the Pharmacy Consultant Report notes dated 3/23/10, 4/20/10, 5/14/10, 6/23/10, 7/27/10, and 8/29/10 revealed no documentation regarding the incomplete order for Tylenol suppository.

2. Resident #160 has diagnoses which include coronary artery disease, hypertension and high cholesterol.

Review of a Physician Acute Visit report dated 8/25/10 revealed the Physician documented the resident has the capacity to make her own health care decisions.

Review of Physician Orders revealed an order dated 6/10/10 for Lopressor 25 mg by mouth two times a day for hypertension and Zocor 40 mg 1 tablet by mouth at bedtime for high cholesterol. A Physician Order dated 7/9/10 directed to continue the Zocor 40 mg at bedtime and decrease the Lopressor to 12.5 mg by mouth twice a day. A Physician Order dated 7/29/10 included an order for Remeron 7.5 mg by mouth daily for appetite stimulation. Review of Physician Orders dated 9/1/10 revealed renewal orders to continue Lopressor, Zocor and Remeron.

Review of Routine Medications sheets dated 7/1/10 to 9/15/10 revealed the resident consistently refused to take the 8:00 PM dose of Lopressor for hypertension; the daily 8:00 PM dose of Zocor for high cholesterol; and beginning 7/30/10, the daily 8:00 PM dose of Remeron for appetite.

Review of Nursing Progress Reports notes dated 7/1/10 through 9/17/10 revealed occasional documentation regarding the resident's refusal of the medications. Review of Weekly Psychotropic Drug Review notes dated 8/22/10 and 8/29/10 revealed that the resident received Remeron 7.5 mg by mouth daily for appetite. A Nursing Progress note dated 9/1/10 documented that the Physician was made aware of the resident's refusal of all evening medications.

Review of Dietary Progress Report notes dated 7/7/10 through 9/13/10, revealed a note written 8/9/10 documenting that Remeron was added to the plan of care on 8/2/10 with poor results and med refusals noted.

During an interview on 9/17/10 at 11:08 AM, the resident stated "I only take my medications once a day, and I feel pretty good. I don't need to take anymore." and "I don't take the evening meds cause they make me feel shaky, or something, I don't know". The resident also stated "I can talk to the Doctor, but he's not the boss of me, I can watch my own body and decide what to take".

Interview with the Registered Nurse (RN)/Unit Coordinator (UC) on 9/17/10 at 10:40 AM revealed "The resident has been refusing to take her afternoon, evening medications. She says that she should have to take medications only once a day". "I've known about this problem since at least September, and told the Doctor about it on 9/1/10.

When interviewed on 9/17/10 at 11:56 AM, the Dietary Tech/Nutritional Manager stated "I think the Remeron would be good, it works for some people, she should be re-approached regarding the Remeron. We would probably wait for the quarterly review in October to review the effectiveness of the Remeron, with all the meds. I would depend on nursing to address the medication refusals in the meantime".

Pharmacy Consultant Reports dated 7/27/10 and 8/29/10 documented "Meds are appropriate. No Irregularities". There was no documentation of the resident's refusal of evening medications.

When interviewed on 9/21/10 at 9:15 AM, the Consultant Pharmacist stated "I review the Medication Administration Record (MAR/Routine Medications sheets) in the resident's chart, not the current MAR on the Med Cart, unless I suspect a problem. I should look at the current MAR to determine what is happening now. I didn't catch that this resident was refusing her meds on either the 7/27 or 8/29 medication review".

3. Resident #130 has diagnoses of dementia, Parkinson's disease and a Stage 2 pressure sore. Review of the Minimum Data Set (MDS) dated 6/23/10 revealed the resident has moderate cognitive impairment for daily decision making, sometimes understands and is sometimes understood.

The Comprehensive Care Plan (CCP) dated 6/29/10 documented that the resident has potential for pain and includes approaches for "medication as ordered" and monitor effects.

Review of Physician Orders dated 9/8/10 revealed orders for the following pain medications:

- Oxycodone (narcotic pain medication) 5/325 BID (twice a day) (contains 325 milligrams (mg) of acetaminophen per dose)
- Oxycodone 5/325 po (by mouth) q4h (every 4 hours) prn (as needed) (325 mg of acetaminophen per dose)
- APAP (acetaminophen) 325 mg two tabs po q4h prn (contains 650 mg of acetaminophen per dose)

Review of the Nursing 2011 Drug Handbook revealed the maximum daily dose of Acetaminophen is 4 grams.

Additional review of the 9/8/10 Physician Orders revealed there was no documentation regarding the maximum recommended daily dose of acetaminophen.

Review of Pharmacy Consultant Reports dated 12/8/09 through 8/29/10 revealed there were no recommendations regarding the maximum amount of acetaminophen to be administered in a 24 hour period.

During an interview on 9/21/10 at 9:15 AM, the Consultant Pharmacist stated the maximum daily dose of acetaminophen is usually printed on the MAR. The Pharmacist explained that the facility prints their own MARs and the nurses should know that Oxycodone contains acetaminophen.

415.18(c)(2)

Based on observation, record review, staff and resident interview, the facility did not provide services to meet professional standards of quality. Five (Residents #3, 31, 60, 61, 160) of 31 residents reviewed for professional standards had issues involving lack of physician orders for a skin tear treatment or to discontinue an AFO (ankle-foot orthosis - brace), lack of medication refusals, incomplete physician orders and lack of clarification of physician orders. In addition, a medication was not administered daily per physician order due to unavailability. There was also a lack of a Registered Nurse (RN) assessment of a new skin tear and multiple ecchymotic areas. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Resident #3 has diagnoses including Alzheimer's dementia, Parkinson's disease, and weight loss. Review of the Minimum Data Set (MDS) dated 8/24/10 revealed the resident has short and long term memory impairment, is severely impaired in cognitive skills for daily decision making, is rarely or never understood, and sometimes understands.

a). Review of Physician Orders revealed orders s igned 6/7/10 and 8/5/10 for DOK Plus (combination medication to treat constipation) 50/8.6, 3 tabs orally twice per day (8:00 AM and 8:00 PM), Sorbitol (laxative) 45 cubic centimeters (cc) orally twice per day (8:00 AM and 8:00 PM), Septra (sulfa medication used to treat infection) Single Strength 1 tab orally everyday (8:00 PM), Vitamin B-12 500 milligrams (mg) orally once per day (4:00 PM), Megace (appetite stimulant) 400 mg (10 milliliters (ml)) orally twice per day (8:00 AM and 4:00 PM), Tylenol liquid 20 ml orally four times per day (8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM), Multivitamin liquid 10 cc orally once per day (4:00 PM).

Review of the Medication sheet for 6/10 through 9/10 revealed consistent refusals of 4:00 PM and 8:00 PM doses of medications from 60 percent (%) to 100% of the time.

Review of Physician and Nurse Practitioner notes from 6/7/10 through 9/16/10 (most current as of 9/21/10) revealed no documentation of the resident's medication refusals or consideration to discontinue or reschedule refused medications.

Interview on 9/21/10 at 10:10 AM with the Registered Nurse (RN) Unit Coordinator revealed he was unaware of the resident's refusals of 4:00 PM and 8:00 PM medications over the last four months, and stated, the resident "can be uncooperative in the late afternoon and evenings". The RN Unit Coordinator stated the evening nurses have not brought the resident's medication refusals to his attention and that would be the only way he would know.

Interview on 9/21/10 at 11:30 AM with the Attending Physician revealed she did not specifically remember if she had been made aware of the resident's medication refusals, but may have discussed this with the evening unit RN. The Attending Physician stated she would review the medications when she comes in and decide if some medications could be discontinued or rescheduled if the resident was not taking them as ordered.

Interview on 9/20/10 at 9:30 AM with the Director of Nursing (DON) revealed there were no policies and procedures regarding medication refusals.

Interview on 9/21/10 at 5:45 PM with the Unit Evening RN revealed she was unaware of the resident's medications refusals at 4:00 PM and 8:00 PM, and that she would not know unless the evening medication nurses brought this to her attention. The RN stated she would review the medications when the Attending Physician and the resident's Health Care Proxy (HCP) would be in on 9/23/10.

b). Review of Physician Orders revealed a telephone order dated 2/26/10 for "Tylenol Supp (suppository) 650 mg PR (per rectum) q4h (every four hours) prn (as needed) pain/temp". The 2/26/10 order did not identify the actual temperature. Review of monthly Physician Orders dated 4/8/10, 6/7/10, and 8/5/10 revealed an order for "Tylenol Suppository 1 rectally for Pain/Temp >___Deg. (degrees) every 4 hours as needed". The orders did not include a temperature parameter for nurses to determine when to administer the Tylenol. Additional review of the Physician Orders dated 6/7/10 revealed a "sticky note" with a handwritten notation, "Tylenol Suppos. order...what parameter do you want for fever?", was attached to the sheet.

Interview on 9/21/10 at 10:10 AM with the RN Unit Coordinator revealed the Physician must have missed the note and the RN would get the order clarified.

2. Resident #160 has diagnoses which include coronary artery disease, hypertension and high cholesterol.

Review of a Physician Acute Visit report dated 8/25/10 revealed the Physician documented the resident has capacity to make her own health care decisions.

Review of Physician Orders revealed an order dated 6/10/10 for the following medications:

- Lopressor 25 milligrams (mg) 1 tablet by mouth two times a day for hypertension
- Zocor 40 mg 1 tablet by mouth at bedtime for high cholesterol

Physician Orders dated 7/9/10 revealed the following orders:

- continue the Zocor 40 mg at bedtime,
- decrease the Lopressor to 12.5 mg by mouth twice a day

Physician Orders dated 7/29/10 revealed the following:

- Remeron 7.5 mg by mouth daily for appetite stimulation
- renewal orders to continue the Lopressor, Zocor and Remeron on 9/1/10.

Review of a facility form entitled Routine Medications revealed documentation for the period 7/1/10 to 9/15/10 revealed that the resident has refused to take the 8:00 PM dose of Lopressor for hypertension, the 8:00 PM dose of Zocor for high cholesterol, and starting 7/30/10 the 8:00 PM dose of Remeron for appetite.

Review of the Nursing Progress Reports, 7/1/10 through 9/17/10, revealed occasional notations of the resident's refusal of the medications.

Review of the Weekly Psychotropic Drug Review notations of 8/22/10 and 8/29/10 revealed that the resident received Remeron 7.5 mg by mouth daily for appetite, and a notation dated 9/1/10 that the MD was also made aware of refusals of all evening medications. There is no previous notation of the MD being informed of the resident refusal of evening medications in the Progress Reports.

Review of the Dietary Progress Reports, 7/7/10 through 9/13/10, revealed a notation dated 8/9/10 that Remeron was added to the plan of care on 8/2/10 with poor results noted and med refusals noted. Confer with MD and follow.

During an interview with the resident on 9/17/10 at 11:08 AM, the resident stated "I only take my medications once a day, and I feel pretty good. I don't need to take anymore" and that "I don't take the evening meds cause they make me feel shaky, or something, I don't know". In addition, the resident stated "I can talk to the Doctor, but he's not the boss of me, I can watch my own body and decide what to take".

During an interview with the Registered Nurse (RN)/Unit Coordinator (UC) on 9/17/10 at 10:40 AM, the RN stated "The resident has been refusing to take her afternoon, evening medications. She says that she should have to take medications only once a day". "I've known about this problem since at least September, and told the Doctor about it on 9/1/10. I reminded the physician on 9/3/10 that the evening meds are being refused. I checked the orders on 9/1/10, that's why I brought it to the MD's attention. For 7/10 and 8/10 I was unaware of the refusals. If I did know, I would have had the staff nurse call the MD or called the MD myself. My expectation is that the Nurse administering the medication would bring refusals to my attention. The Physician has made no changes to the medications, he did not explain to me what he wanted to do about the refusals. She is refusing Remeron for appetite, and she is losing weight, but she said she did not want to take anything for her appetite. She is refusing the evening dose of Lopressor, but her BP is stable, and looks good. She is refusing Zocor for High Cholesterol. She had not had a cholesterol level since July". Review of lab section of chart reveals no cholesterol test from 7/1/10 to present.

On interview with the Graduate Nurse (GN) Staff Nurse on 9/17/10 at 10:55 AM, the GN stated "I talked to Doctor stated on 9/14, and he said to encourage her to take her meds, and document the refusal and the resident's reason why and he will review it the next time he is in".

During an interview with the Diet Technician (Diet Tech)/Nutritional Manager on 9/17/10 at 11:56 AM, the Diet Tech stated "I think the Remeron would be good, it works for some people, she should be re-approached regarding the Remeron. We would probably wait for the quarterly review in October to review the effectiveness of the Remeron, with all the meds. I would depend on nursing to address the medication refusals in the meantime".

Interview with the Director of Nursing (DON) on 9/17/10 at 2:55 PM revealed "I would expect the RN/UC to report a significant drug administration omission to me so that I could do an investigation as to how it happened. I just found out about this today. Residents have a right to refuse medications, but after two days or so it should be reported."

On interview with the DON on 9/19/10 at approximately 1:00 PM revealed that the facility does not have a policy regarding the notification of a physician when a medication is refused.

3. Resident #31 has diagnoses which include cerebral embolism with infarct (obstruction of blood vessels in the brain with a blood clot resulting in localized tissue death), hypertension, atrial fibrillation (irregular heart rate) and dementia.

a). Review of the Physician's Orders dated 7/22/10 revealed an order for Plavix 75 milligrams (mg) by mouth daily for CVA (cerebral vascular accident - stroke) prophylaxis (prevention) and as an anticoagulant (blood thinner).

Review of a form entitled Routine Medication for 7/10 revealed that the resident refused to take the Plavix on 6 of 9 days during the period of 7/22/10 through 7/30/10 with the record for 7/23/10 left blank.

Review of the Progress Reports dated 7/22/10 through 7/30/10 revealed documentation on 7/30/10 "MD in on rounds; updated on residents refusal to take Zantac and Plavix as ordered. Order to discontinue Zantac and Plavix and increase Aspirin to 325 mg by mouth, stroke prevention". There is no other documentation in the progress reports of the Physician being contacted.

Interview with Registered Nurse (RN) Unit Coordinator (UC) on 9/16/10 at 1:30 PM revealed that:

- The resident was refusing the two medications, Plavix and Zantac, because she saw something on TV that said these meds were not good for you. The Physician spoke to her about the refusal, saying the TV was not talking about her in specific.
- We would inform the Physician of a resident refusal to take medications. It would depend on the drug. Something like Coumadin we would call right away. Drugs like Plavix and Zantac, after 2 days or so.
- According to the nurses notes, the MD was made aware of the situation on 7/30/10. The notes do document encouragement to take the meds.
- Either the administrating nurse can bring the refusal to the attention of the staff nurse or the UC to bring to the attention of the MD or they can call the MD themselves, but usually it goes through the staff nurse or the UC.
- I was not the UC at that time, the UC reviews the nurses notes, the resident refusals of the medications should have been questioned and brought to the attention of the MD, there is no documentation that the MD was contacted until after 7 days.

Interview with the Director of Nursing (DON) on 9/19/10 at approximately 1:00 PM revealed that the facility does not have a policy regarding the notification of a physician when a medication is refused.

b). Review of the Physician's Orders dated 7/22/20 revealed a handwritten order for Lisinopril 20 mg by mouth daily for hypertension..

Review of the current Physician's Orders dated 8/16/10 revealed a printed order for Lisinopril 20 micrograms (mcg) by mouth daily for hypertension. (NOTE: 1 mg = 1000 mcg).

Review of the resident's Routine Medications for 7/10 documented that the resident received Lisinopril 20 mg by mouth daily from 7/22/10 to 7/31/10.

Review of the resident's Routine Medications for 8/1/10 to 9/15/10 records that the resident received Lisinopril 20 mcg by mouth daily.

Review of the Pharmacy Label attached to the resident's medication revealed that the Pharmacy dispensed 20 mg Tablet to be taken 1 tablet by mouth once daily for hypertension.

Interview with the RN/UC on 9/15/10 revealed that the Lisinopril dose should be 20 mg, not mcg. Orders are typed by the medical Secretary, then the night before the Doctor comes in the nurse on the 11:00 PM to 7:00 AM shift checks the orders, she should check everything, including strength, the Doctor will review the orders and sign them. At the time the Doctor signs the order, the staff nurse on duty will again review the orders for correctness, including new orders. Then again on the 11:00 PM to 7:00 AM shift, the nurse will go through and check the orders. The orders are faxed to Pharmacy, the Pharmacy sent the correct 20 mg. The Pharmacy did not call us to clarify the strength.

Review of the facility policy entitled Physician Orders, Transcription of, dated 9/02 revealed the following:

- Review orders for completeness and clarity before transcribing.
- Clarify any discrepancies with the physician.
- All transcribed orders should be checked and/or bracketed, accompanied by the nurse's initials and date of transcription.

4. Resident #61 has diagnoses which include chronic renal failure and receives hemodialysis 3 times a week. Additional diagnoses include hypertension, cardiac heart failure, dementia, anemia, constipation and coronary artery disease. Review of the Minimum Data Set (MDS) dated 9/2/10 revealed the resident has modified independence for decision making, usually understood, and usually understands. The resident is noted to have memory problems with long and short term memory.

Review of a Physician Order dated 5/6/10 revealed an order for Renagel (medication used to prevent dangerous increases in the mineral phosphate used in patients with chronic kidney disease) 400 milligrams (mg) 1 po (by mouth) give with meals TID (three times a day) for CRF (chronic renal failure). Review of a facility form entitled Routine Medication dated 6/1/10 to 6/30/10 revealed medications ordered by the Physician (Renagel) had not been administered to the resident as ordered on 6/1/10, 6/2/10, 6/3/10, 6/4/10, 6/5/10, 6/10/10, 6/12/10, 6/15/10, 6/17/10, 6/18/10, 6/22/10, 6/24/10, and 6/29/10. Documentation on the back of the Routine Medication form documented the 1:00 PM medication was not given on 6/12/10, resident out on pass (OOP), 6/19/10 Renagel held resident at dialysis and 6/29/10, 1:00 PM Renagel held resident OOP dialysis. The Routine Medication form lacked description of why the Renagel was not given for the other days the Routine medication form was initialed and circled or left blank.

Review of the 7/10 Routine Medication form showed the Renagel was not given 8 times designated by the circled nurses' initials. The back of the facility form entitled Routine Medications revealed documentation dated 7/31/10 - 2:00 PM meds not given resident out on pass at dialysis. Additionally, on 6 occasions the Routine Medication form was blank indicating the medication was not given those 6 times during the month. Additionally, review of Physician Orders revealed a phone order dated 7/26/10 for Ampicillin (antibiotic) 500 mg TID (three times a day) for 7 days-PO (by mouth) and Lactinex (dietary supplement) 2 tabs TID-PO for 10 days. Review of the Routine Medication form showed the 8:00 AM and 2:00 PM dose of Ampicillin and Lactinex were not given on the 27th, and the 2:00 PM dose of Ampicillin was not given on the 29th and 31st.

Review of the back of the 7/10 Routine Medication form revealed documentation dated 7/27/10 the Lactinex and Ampicillin were not available and a notation on 7/26/10 the Ampicillin not available, and on 7/29/10 the 2:00 PM Lactinex and Ampicillin was not given -resident out on pass.

Review of a Physician's Order dated 5/6/10 revealed an order for Nephrovite (Vitamin B and C complex tablets used for renal patients) PO QD (every day) for renal impairment to be given at 8:00 AM. Review of the Routine Medication form dated 7/1/10 to 7/31/10 revealed the 8:00 AM Nephrovite was not given 7/10/10, 7/11/10, 7/16/10, and 7/19/10. All had nurses initials that were circled. Review of the back of the Routine Medication form revealed on 7/10/10 at 8:00 AM the Nephrovite was not available - order pharmacy. On 7/19/10 the Nephrovite not in from pharmacy. On 7/31/10 - 2:00 PM meds not given resident out for dialysis.

Interview with the Registered Nurse (RN) Medication Nurse on 9/21/10 at 3:30 PM verified she made those notations on 7/19/10 and 7/31/10 and stated she does not remember if she ordered them from the pharmacy. She couldn't find the Nephrovite on the medication cart and doesn't remember if she reported it to the Unit Coordinator.

Interview with Licensed Practical Nurse (LPN) Day Supervisor on 9/21/10 at 3:20 PM stated if the medications are not available the nurses are suppose to document they ordered it.

During an interview with the Pharmacist from the dispensing pharmacy on 9/22/10 at 1:35 PM, the Pharmacist stated there was a request for the Nephrovite to be refilled on 7/19/10.

Review of a Physician Order dated 7/29/10 revealed an order to extend the Ampicillin 500 mg, PO times 4 doses- TID on 8/2/10, 8/3/10 and 8:00 AM on 8/4/10 due to missed doses.

During an interview with the Registered Nurse (RN) per diem Staff Nurse, the RN stated the medication, especially Ampicillin, should have been given consecutively as ordered for maximum effectives. The timing of the antibiotic should have been adjusted to accommodate the resident's dialysis schedule.

Additionally review of the 8/10 Routine Medication form revealed the medication administration for 8/4/10 were left blank which included Imdur (medication used to prevent angina (type of chest pain)), Aspercin (analgesic), Metolazone (diuretic), Nephrovite, Ferrous Sulfate (medication used to treat anemia), Renagel 7:00 AM and 1:00 PM, Lasix (medication to promote urine excretion) 40 mg, Senna S (laxative) 1 Tab - 8:00 AM dose.

Review of the 8/10 Routine Medication form revealed the resident did not receive the 1:00 PM Renagel on 8/7/10, 8/17/10, 8/21/10, 8/24/10, 8/26/10, and 8/28/10. Review of the back of the Routine Medication form revealed the resident is unavailable to give Renagel on 8/5/10, 8/9/10, 8/14/10, and 8/28/10. No documented reason why the other times were omitted. Review of the back of the Routine Medication form documented the 2:00 PM Lactinex (dietary supplement for lactose intolerance) was not given as resident was out on pass.

Review of the Routine Medication form dated 9/1/10 to 9/19/10 revealed the 1:00 PM Renagel was not administered 9/4/10, 9/9/10, 9/11/10, 9/14/10, 9/16/10, and 9/18/10 wasn't given because the resident was out on pass to dialysis 9/11/10, 9/16/10, and 9/19/10. The Routine Medication form documentation showed the resident refused the medication on 9/15/10 and that it was not available from pharmacy 9/20/10.

During an interview with the Pharmacist on 9/21/10 at 9:30 AM, the Pharmacist stated he must have missed the fact they were not giving the 1:00 PM Renagel on dialysis days.

During an interview with the Director of Nursing (DON) on 9/21/10 at 11:50 AM, the DON explained they wouldn't give her the medication to take with her to dialysis. The medications would run right through her. They should give them to her later.

On interview with the RN per diem Staff Nurse on 9/21/10 at 12:10 PM, the RN stated we can't give residents medications to take with them to dialysis. The dialysis center won't take responsibility for giving the medications. If the resident self administers medication that would be acceptable. But many of the meds would not do her any good if they took them right before dialysis. They would just run through her. They should call the Physician and let them know she is not getting those medications because she is scheduled for dialysis at that time and is out of the building. They should call the Physician and get an order to give it later or at some other time.

When interviewed on 9/22/10 at 11:30 AM, the Physician stated he was not notified of the missed doses of Renagel and did not know of the conflict of medication administration on dialysis days (3 times a week).

5. Resident #60 has a history of skin tears, dementia and degenerative joint disease (DJD). Review of the Minimum Data Set (MDS) dated 6/2/10 revealed the resident has moderately impaired cognitive skills for daily decision making and long and short term memory is impaired.

a). Review of the Comprehensive Care Plan (CCP) dated 8/31/10 revealed the care plan does not address skin tears. Review of a Treatment Record dated 9/1/10 to 9/30/10 documents directions to cleanse left shin with Dermaklenz (wound cleanser), apply triple antibiotic ointment, wrap with kerlix.

When observed on 9/16/10 at 10:45 AM, the Licensed Practical Nurse (LPN) washed his/her hands, removed a dressing from left lower leg, cleansed the approximately 3 centimeter (cm) round superficial open area on the resident's anterior mid lower left leg with Dermaklenz, applied triple antibiotic ointment, 4x4 and kerlix (gauze bandage roll).

When interviewed at this time the LPN stated this is the treatment ordered for the resident. Review of the Physician Orders dated 8/26/10 does not reveal a treatment order for the resident's left lower shin.

When interviewed on 9/16/10 at 12:00 PM the Registered Nurse (RN) Unit Coordinator (UC) stated there is not a physician order for left lower shin treatment and he will call the Physician and get one.

b). Review of the CCP dated 8/31/10 is ankle foot orthosis (AFO) on left ankle when OOB (out of bed). Cast boot when OOB. The Physician Order dated 8/26/10 is Left Foot AFO when out of bed.

When observed on 9/15/10 at 1:05 PM, 9/15/10 at 6:00 PM and 9/16/10 at 7:45 AM the resident self propelled in a wheelchair in the hall with the right foot, the left foot had a black velcro open toe orthopedic shoe. There was a dressing on the resident's left lower leg and no AFO.

When interviewed on 9/17/10 at 10:25 AM, the RN Unit Coordinator stated the left AFO should not be on because the resident had a skin tear on the left lower leg and revealed he would get an order from physician to discontinue it.

When interviewed on 9/17/10 at 1:45 PM, the Rehabilitation Director stated he had removed the resident's left lower leg brace because of the sore on the resident leg. He stated he had informed the RN UC of this.

c). Review of the Skin Care Evaluation Sheet dated 8/31/10 revealed a 4.0 centimeter (cm) by 3.8 cm skin tear documented by the RN. The 9/7/10 and 9/14/10 Skin Care evaluation was done by the Licensed Practical Nurses (LPNs).

When observed on 9/16/10 at 10:45 AM, the LPN removed the dressing from the resident's left lower leg and a large ecchymotic (purplish patch caused by blood under the skin) area was noted directly above the outer aspect of the skin tear. The LPN stated the resident has always had ecchymotic areas on her lower legs.

When interviewed on 9/16/10 at 12:00 PM the RN UC stated no RN has assessed the left lower leg area since the initial assessment on 8/31/10. The RN UC stated he was not aware that the resident had ecchymotic areas on her left lower leg.

When observed on 9/16/10 at 1:20 PM, the RN UC removed the left lower leg dressing and measured a skin tear 2.8 cm by 3.1 cm. The RN stated the lateral side of the left leg wound (top to bottom) has ecchymotic areas measuring 1.5 cm by 0.7 cm, 3 cm by 1.6 cm, 2 cm by 3.8 cm, 2.4 cm by 2.8 cm, 1 cm by 0.9 cm, 0.6 by 0.7 cm. Front lower left leg ecchymotic area measured 0.8 cm by 1.8 cm. Above the wound on an ecchymotic area measured medial side 3.1 cm by 1.5 cm a. Directly above the wound an ecchymotic area measured 1.7 cm by 3.5 cm.

415.11(c)(3)(i)

Based on observation, record review, staff and resident interview, the facility did not provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. One (Resident #169) of four residents reviewed for activities had issues involving the lack of documented evidence of an ongoing activity program to address the resident's request to go outside. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #169 has diagnoses including malnourishment, depression, and hypertension. Review of the Minimum Data Set (MDS) dated 8/7/10 revealed the resident is independent in cognitive skills for daily decision making, understands and is understood. Review of the MDS dated 8/4/10 revealed under "Activity Pursuit Patterns" that the resident's preferred activity settings are her own room, the day/activity room, and inside nursing home/off unit, while the resident's general activity preferences are music, reading/writing, spiritual/religious activities, watching TV and talking or conversing. Review of the MDS dated 8/7/10 revealed that the resident's preferred activity settings are her own room, inside nursing home/off unit, and outside facility, while the resident's general activity preferences are music, reading/writing, spiritual/religious activities, watching TV, talking or conversing, and walking/wheeling outdoors.

Review of a Social Services note dated 8/25/10 revealed that in addition to confirming with the Social Worker that she was "praying to die" and declined psychology consult, the resident told the Social Worker that she would like to go outside more. The Social Worker documented that activity staff was made aware.

During an interview with the resident on 9/13/10 at 4:30 PM, the resident stated she likes to read and gets books off the book cart. She further explained that she would probably like group but is too sad to go to activities.

Review of the Social Event Detail Report (activity attendance) revealed the resident went outdoors on 4 occasions: 8/22/10, 8/25/10, 8/28/10, and 8/31/10. Interview on 9/21/10 at 10:30 AM with the Activities Director revealed the resident may have been asked at other times and refused. When asked how that could be determined, the Activities Director stated there would not be a way to determine that as "we don't document refusals because it wasn't being documented by activity staff consistently".

Review of the Comprehensive Care Plan (CCP) dated 8/10/10, last updated 8/26/10, on 9/21/10 at 10:30 AM with the Activity Director, the Activity Director revealed no documentation of a preference for going outside except for "music concerts". When told the resident had expressed a desire to go outside to this surveyor and to the Social Worker, and that the MDS of 8/7/10 identified this, the Activities Director stated, "We should be offering that to her".

On 9/21/10 at 10:55 AM, the Activities Director was observed to go in the resident's room and ask the resident, "Have we been asking you if you want to go outside?" The resident replied, "No". The Activities Director then asked, "Would you like to go outside?", and the resident replied, " Yes". The Activities Director then told the resident, "Well, from now on when we stop to visit you, we'll ask you if you want to go out. And please feel you can ask any time." The resident replied "OK".

415.5(f)(1)

Based on observation, record review and staff interview, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition. One (Resident #4) of six residents reviewed who required staff assistance for ADLs did not receive staff assistance for eating. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #4 has diagnoses of cerebrovascular accident (stroke) with left hemiplegia (weakness on one side of the body) and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 8/3/10 revealed the resident has moderately impaired cognitive skills for daily decision-making, short term memory problems, requires extensive assistance for bed mobility and is totally dependent on staff for transfers.

Review of the Comprehensive Care Plan (CCP) dated 8/6/10 revealed an approach for staff to provide assistance with meals prn (as needed) with a goal for the resident to consume > (more than) 75 percent (%) of meals.

During an observation of dining on 9/13/10, a lunch tray was delivered to the resident and setup by a Hospitality Aide at 12:05 PM. The resident was sitting in his wheelchair in his room and the tray was placed on the overbed table. At 12:10 PM and 12:20 PM the resident was observed to be sleeping.

At 12:22 PM, Licensed Practical Nurse (LPN) #1 entered the room, verbally encouraged the resident to eat and left the room. The resident went back to sleep and remained asleep when observed at 12:32 PM and at 12:43 PM.

When the second meal cart arrived on the unit at 12:44 PM, two certified nurse aides (CNAs) delivered trays from the cart in the resident's hallway. Neither CNA stopped to assist and /or encourage the resident.

A CNA was observed entering the room at 12:55 PM. The CNA asked the resident if he was going to eat, verbally encouraged him and left the room. The resident went back to sleep and remained sleeping in the wheelchair at 1:05 PM. At 1:10 PM, the resident was asleep in bed. The tray table was next to the bed and the meal was untouched.

A second dining observation was done on 9/15/10. Resident #4 was observed in bed sleeping at 5:20 PM.

During an interview on 9/15/10 at 5:25 PM, LPN #6 stated that the resident is boosted up and eats in bed per his preference.

At 5:30 PM the resident received his meal tray. The head of his bed was at a 45 degree angle and his head was leaning to his right side on a pillow. The resident was sleeping and the tray table was positioned over the bed. At 6:00 PM, the resident was sleeping in the same position. At 6:15 PM, the resident remained sleeping in same position and the meal was untouched. There were no attempts by staff to assist the resident to reposition or eat his meal from 5:30 to 6:15 PM.

Interview with the Registered Nurse (RN) Unit Manager (UM) on 9/21/10 at 10:30 AM revealed he expects that the resident is assisted with eating as needed.

415.12(a)(3)

Based on observation, record review and staff interview, the facility did not conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity, including dental status and fall risk. Two (Residents #72, 127) of 21 residents' care plans reviewed for comprehensive assessment had issues that involved a lack of a dental assessment and a lack of an assessment to identify a fall risk involving the resident's behavior. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #72 has diagnoses of cardiomyopathy (enlarged heart), chronic obstructive pulmonary disease (COPD), and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 8/2/10 revealed the resident is moderately impaired for cognitive skills for daily decision making, sometimes understands, is sometimes understood with impaired long and short term memory. ADL (activities of daily living) assistance is required as follows: supervision for eating/1 assist, and extensive assistance for hygiene/ 1 assist. The resident has chewing and swallowing problems, along with weight loss.

Review of the resident's Consultant Permission form revealed the resident's son did not give permission for a dental consult when he signed the form on 1/8/10.

Review of the Comprehensive Care Plan (CCP) dated 1/10/10, upon admission, revealed the resident has reduced independence for ADLs with goals to increase grooming assistance to supervision. There were no specific interventions regarding the resident's dentition.

Review of CCPs dated 1/26/10, 2/17/10, and 5/19/10 revealed no specific interventions regarding the resident's dentition.

Review of the CNA (certified nurse aide) Door Card/care plan updated on 9/2/10 revealed the resident has partial dentures and requires supervision to limited assist with self feeding abilities.

Review of the CCP printed on 9/15/10 revealed no care plan for potential ADL deficits and no documented evidence of care plan intervention/ information regarding the resident's dentition and altered nutritional status. Documentation dated 8/10/10 revealed the resident had significant weight loss in 6 months.

Interview with a 2nd Floor Secretary on 9/16/10 at approximately 11:50 AM revealed she coordinates all the dental consults for the facility. She checked the Dental consult book which indicated the resident had no permission to see the dentist upon admission of 1/8/10. The Secretary explained that upon admission the Admissions Coordinator obtains Consultant Permission information on the Consultant Permission form which probably indicated no dental care. The facility log indicated no permission for dental care.

Interview with the Medical Director on 9/16/10 at approximately 2:45 PM revealed the resident did not have a dental consult because the Consultant Permission form obtained on admission by the Admissions Coordinator did not give permission for dental care. The Medical Director indicated she did not know whose responsibility it is in the facility to ensure that a resident receives dental services if declined in the facility and not screened by the Physician.

Additional interview with the Medical Director on 9/16/10 at approximately 4:00 PM revealed she interviewed the resident, the Health Care Proxy (HCP) and Social Worker and determined the son wanted to take the resident to her own dentist because she needed extensive work done on her dentures, which had started prior to her admission to the facility. The Medical Director explained it was her understanding that there was a problem with handicap access in the dentist's private office because there were stairs leading into the building and additional stairs once inside the building which would pose a navigational problem. In addition, the Medical Director provided a copy of the Medical Staff Rules and Regulations and noted the physician has accountability for ensuring needed dental services are provided.

Interview with the Social Worker on 9/17/10 at approximately 11:12 AM revealed the resident's son recently approached the Social Worker requesting cheaper transportation for appointments. The Social Worker stated the resident's son did not specify dental appointments and she could not recall having any specific conversations with the resident or her son about dental services, the nurses would be the ones to have those conversations. The Social Worker stated the resident had declined dental services on admission. During the interview, the Social Worker recalled the resident's son comes in almost every afternoon and makes decisions because the resident's cognition, while improved, definitely fluctuates.

During an interview with the Attending Physician on 9/21/10 at approximately 4:00 PM, the Physician stated she thought those things (dental assessments) happened automatically. She doesn't look into them.

2. Resident #127 has diagnoses which include dementia, hypertension and osteoarthritis.

Review of the resident's CCP dated 9/1/10 revealed the resident is at risk for falls as per assessment. CCP approaches include TAB's alarm at all times dated 9/16/10. TAB's to activate if ambulation attempted-may stand unassisted at wheelchair.

On 9/13/10, from 11:45 AM to 1:10 PM, during observation of lunch, the resident was frequently observed to partially stand up in her wheelchair and then sit down again. The resident did not appear unsteady. The resident was observed to place her feet on the ground behind her footrests prior to standing.

On 9/15/10, from 5:10 PM to 6:20 PM, during observation of supper, the resident was observed to stand up twice in front of her wheelchair with her feet behind her footrests. The resident was observed to have a TAB's alarm (alarm system used to notify staff when a resident attempts to get out of bed or a chair) in place during the meal observations.

Intermittent observation of the resident from 9/14/10 through 9/17/10 between 9:00 AM and 5:00 PM revealed that the resident was placed in her wheelchair opposite the nurses station. The resident was observed to continue the repetitive standing behavior by placing her feet on the ground behind her foot rests which were left in place on the wheelchair.

Interview with the Licensed Practical Nurse (LPN) on Unit 2, on 9/15/10 at 5:20 PM, revealed that: the resident's "alarm is supposed to go off if the resident steps away from the wheelchair. "Let me clarify that, she doesn't live up here, just up for dinner".

Interview with the Unit 2 RN UC on 9/15/10 at 5:21 PM, the RN stated "I don't know to much about this resident, she lives downstairs. The alarm is supposed to alert the staff when she stands up. We can put a shorter string on the alarm".

At 5:25 PM the RN/UC was observed to changes the string on the alarm. The resident was observed to stand and sit after the string was changed without the alarm going off. Again, at 5:55 PM, the resident was observed to stand up and sit down, the alarm did not go off.

During an interview with the Unit 1 RN UC on 9/16/10 at 11:30 AM, the RN explained that the resident's alarm is meant to go off when she steps away from the wheelchair. It is not meant to restrict her movement, she partially stands and sits down. It is meant to go off when she attempts to transfer or ambulate. No one is supposed to stand unassisted. The resident stands and sits, she does this all day long, she does not attempt to walk. The alarm does not prevent her from standing, but if she was to walk away the TAB's alarm would pull and the alarm would go off, which is what we want, although it is not written in the care plan that way. The care plan has been that way since I took over the unit. After a fall, it is the responsibility of the Unit Coordinator to make the decision regarding the initiation of a TAB's alarm. If someone has frequent falls I would add a TAB's alarm, and add to the care plan. In this case I think it could be worded differently in the care plan, the standing is a behavior issue, yes."

Further interview of the Unit 1 RN/UC on 9/17/10 at 8:45 AM, revealed that: "The resident has never fallen from her wheelchair, all her falls have been from bed. I did not consider the footrests as a tripping hazard when we care planned for the TAB's alarm allowing her to stand. The footrests would be a tripping hazard if she took a step. We should change the care plan to remove the footrests when she is sitting in place in her wheelchair."

415.11(a)(2)

Based on record review, staff and resident interview, the facility did not assist residents in obtaining routine and 24-hour emergency dental care. Two (Residents #3, 72) of three residents reviewed for routine dental services had issues involving the lack of annual dental services and lack of dental services to address the resident's broken denture. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #3 has diagnoses including Alzheimer's dementia, Parkinson's disease, and weight loss. Review of the Minimum Data Set (MDS) dated 8/24/10 revealed the resident has short and long term memory impairment, is severely impaired in cognitive skills for daily decision making, is rarely or never understood, and sometimes understands. Review of the MDS dated 3/8/10 and 8/24/10 revealed the resident has chewing and swallowing problems.

Review of the Comprehensive Care Plan (CCP) dated 9/17/10 revealed under Dental Care, the problem of "some natural teeth missing, broken, loose or carious teeth", and included the approach of "dental visit as scheduled and prn" (as needed).

Review of the Dental Orders and Progress Notes revealed notes of annual dental exams completed on 9/3/07, 7/14/08, and 4/20/09. A note signed by the Dentist on 4/12/10 documented "Annual. Resident is on comfort care. Will not see. Will see as needed".

On interview 9/21/10 at 5:45 PM, the Registered Nurse (RN) Unit Coordinator stated, "The Medical Secretary would have gotten that note from dental and should have told me so I could reschedule. I did not see this note. Comfort care is not a reason not to see dentist". The RN Unit Coordinator stated the Dentist is in every Monday at 10:00 AM.

On interview 9/21/10 at 3:45 PM, the Director of Nursing (DON) stated, "Hospice or comfort care is not a reason not to provide dental services".

2. Resident #72 has diagnoses of cardiomyopathy (enlarged heart), chronic obstructive pulmonary disease (COPD), and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 8/2/10 revealed the resident is moderately impaired for cognitive skills for daily decision making, sometimes understands, is sometimes understood with impaired long and short term memory. ADL (activities of daily living) assistance is required as follows; supervision for eating/1 assist, transfer total dependence/2 assist, does not ambulate, total dependence for toilet use/1 assist, and extensive assistance for hygiene/ 1 assist. The resident has chewing and swallowing problems, has had weight loss.

Interview with the resident on 9/14/10 at approximately 9:00 AM revealed that she has not seen a dentist since 12/09. The resident stated she has partial dentures because 3 sections of her dentures are missing, and she was having dental work done in stages. The resident stated she went to her Dentist in 12/09 prior to hospitalization and came here for rehabilitation after hip surgery. Her molars are missing so she has to eat with her incisors and it's very frustrating.

Review of the Consultant Permission form revealed on 1/8/10 the resident's son signed for no dental consults for the resident. Review of the Comprehensive Care Plan (CCP) dated 1/10/10 upon admission revealed the resident has reduced independence for activities of daily living with goals to increase grooming assistance to supervision. There were no specific interventions regarding the resident's dentition.

Review of CCPs dated 1/26/10, 2/17/10, and 5/19/10 revealed no specific interventions regarding the resident's dentition.

Review of the CNA (certified nurse aide) Door Card/care plan (used by CNAs to provide care), updated on 9/2/10, revealed the resident has partial dentures and for feeding she requires supervision to limited assist with self feeding abilities.

Review of the CCP printed on 9/15/10 revealed no care plan for potential ADL deficits and no intervention/information regarding the resident's dentition and altered nutrition status with notes on 8/10/10 that the resident had a significant weight loss in 6 months.

Interview with a 2nd Floor Secretary on 9/16/10 at approximately 11:50 AM revealed she coordinates all the Dental Consults for the facility. She checked the Dental consult book which indicated the resident had no permission to see the dentist upon admission of 1/8/10. The Secretary revealed upon admission the Admissions Coordinator obtains Consultant Permission information on the Consultant Permission form which probably indicated no dental care. The facility log indicated no permission for dental care.

Interview with the Medical Director on 9/16/10 at approximately 2:45 PM revealed the resident did not have a dental consult because the Consultant Permission form obtained on admission by the Admissions Coordinator did not give permission for dental care. The Medical Director indicated she did not know whose responsibility it is in the facility to ensure that a resident receives dental services if declined upon admission, and not screened by the MD.

Additional interview with the Medical Director on 9/16/10 at approximately 4:00 PM revealed she interviewed the resident, the Health Care Proxy (HCP) and Social Worker and determined the resident's son wanted to take the resident to her own dentist because she needed extensive work done on her dentures, which had started prior to her admission to the facility. It was her understanding that there was a problem with handicap access in the dentist's private office because there were stairs leading into the building and additional stairs once inside the building which would pose a navigational problem. In addition, she provided a copy of the Medical Staff Rules and Regulations and noted the physician has accountability for ensuring needed dental services are provided.

Interview with the Social Worker on 9/17/10 at approximately 11:12 AM revealed the resident's son recently approached the Social Worker requesting cheaper transportation for appointments. The Social Worker stated the son did not specify dental appointments and she could not recall having any specific conversations with the resident or the son about dental services, the nurses would be the ones to have those conversations. The Social Worker stated the resident had declined dental services on admission. The Social Worker recalled the resident's son comes in almost every afternoon and makes decisions because the resident's cognition, while improved, definitely fluctuates.

During an interview with the Attending Physician on 9/21/10 at approximately 4:00 PM, the Attending Physician stated she thought those things (dental assessments) happened automatically. She doesn't look into them.

415.17(c)

Based on observation, record review, and staff and resident interview, the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Three (Residents #60, 72, 169) of 21 residents reviewed for development of a comprehensive care plan had issues involving lack of a comprehensive care plan to address skin tears, dental needs, depression, and resident choices. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #169 has diagnoses including malnourishment, depression, and hypertension. Review of the Minimum Data Set (MDS) dated 8/7/10 revealed the resident is independent in cognitive skills for daily decision making, understands and is understood.

a). Review of the Admission/ Readmission Nurses Note/Evaluation dated 7/28/10 revealed the resident's "preferred arise time" is 8:00 AM and "preferred bedtime" is 8:00 PM. Review of the Comprehensive Care Plan (CCP) dated 8/10/10, last updated 8/26/10, and the Door Card (used by certified nurse aides (CNAs) and nursing staff for directions for resident care), dated 9/6/10, revealed no documentation of the resident's preferred arise time and bedtime. The only documentation regarding "choices" is under the area of Cognitive Loss/Dementia: "Provide choices in daily life". There is no specific documentation of what those choices or preferences are.

On interview 9/13/10 at 4:45 PM, the resident stated that at home she got up in the morning between 7:00 AM and 7:30 AM, but here at the nursing home, the CNA "often" comes in and puts the light on between 6:00 AM and 6:30 AM and tells her it is time to get up. The resident stated she also preferred showers to baths.

On interview 9/16/10 at 11:30 AM, the Registered Nurse (RN) Unit Coordinator stated the information on resident preferences for get-up and bed times as documented in the Admission/ Readmission Nurses Note/Evaluation is not included in the CCP.

On interview 9/16/10 at 11:45 AM the RN Unit Coordinator stated he would change the Bath Schedule to reflect the resident is to get a shower.

b). Review of a DTR (Registered Diet Technician) note dated 8/24/10 revealed the resident "indicated she would "like to die" and has been "praying to die".

Review of a Social Services note dated 8/25/10 revealed the Social Worker was made aware by the DTR regarding wanting to die. The Social Worker met with the resident who acknowledged feeling this way. The Social Worker documented completion of a Geriatric Depression Scale, with a score of 11/15, "highly suggestive of depression".

Review of Physician Orders revealed an order dated 8/26/10 for Celexa (antidepressant) 10 milligrams (mg) orally every day for one week, then 20 mg every day for depression.

Review of the CCP dated 8/10/10, last updated 8/26/10, and the Door Card (used by CNA and nursing staff for directions for resident care), dated 9/6/10, revealed no documentation of depression or approaches to address the depression.

On interview 9/21/10 at 9:30 AM, the RN Unit Coordinator stated he would need to add the diagnosis of depression and approaches to the care plan.

2. Resident #72 has diagnoses of cardiomyopathy (enlarged heart), chronic obstructive pulmonary disease (COPD), and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 8/2/10 revealed the resident is moderately impaired for cognitive skills for daily decision making, sometimes understands, is sometimes understood with impaired long and short term memory. ADL (activities of daily living) assistance is required as follows: supervision for eating/1 assist, and extensive assistance for hygiene/ 1 assist. The resident has chewing and swallowing problems, has had weight loss.

Review of the Consultant Permission form revealed on 1/8/10 the resident's son did not sign for a dental consult.

Review of the Comprehensive Care Plan (CCP) dated 1/10/10 upon admission revealed the resident has reduced independence for activities of daily living with goals to increase grooming assistance to supervision. There were no specific interventions regarding the resident's dentition.

Review of CCP dated 1/26/10, 2/17/10, and 5/19/10 revealed no specific interventions regarding the resident's dentition.

Review of the CNA Door Card/care plan updated on 9/2/10 revealed the resident has partial dentures and requires supervision to limited assist with self feeding abilities.

Review of the CCP printed on 9/15/10 revealed no care plan for potential ADL deficits. In addition, the CCP did not address interventions or provide information regarding the resident's dentition or altered nutritional status including documentation on 8/10/10 that the resident had a significant weight loss in 6 months.

Interview with a 2nd Floor Secretary on 9/16/10 at approximately 11:50 AM revealed she coordinates all the Dental Consults for the facility. She checked the Dental consult book which indicated the resident had no permission to see the dentist upon admission of 1/8/10. The Secretary revealed upon admission the Admissions Coordinator obtains Consultant Permission information on the Consultant Permission form which probably indicated no dental care. The facility log indicated no permission for dental care.

Interview with the Medical Director on 9/16/10 at approximately 2:45 PM revealed the resident did not have a dental consult because the Consultant Permission form obtained on admission by the Admissions Coordinator did not give permission for dental care. The Medical Director indicated she did not know whose responsibility it is in the facility to ensure that a resident receives dental services if declined upon admission, and not screened by the MD.

Additional interview with the Medical Director on 9/16/10 at approximately 4:00 PM revealed she interviewed the resident, the Health Care Proxy (HCP) and Social Worker and determined the resident's son wanted to take the resident to her own dentist because she needed extensive work done on her dentures, which had started prior to her admission to the facility. It was her understanding that there was a problem with handicap access in the dentist's private office because there were stairs leading into the building and additional stairs once inside the building which would pose a navigational problem. In addition, the Medical Director provided a copy of the Medical Staff Rules and Regulations and noted the physician has accountability for ensuring needed dental services are provided.

Interview with the Social Worker on 9/17/10 at approximately 11:12 AM revealed the resident's son recently approached the Social Worker requesting cheaper transportation for appointments. The Social Worker stated the resident's son did not specify dental appointments and she could not recall having any specific conversations with the resident or her son about dental services and added the nurses would be the ones to have those conversations. The Social Worker stated the resident had declined dental services on admission. The Social Worker recalled the resident's son comes in almost every afternoon and makes decisions for the resident because her cognition, while improved, definitely fluctuates.

During an interview with the Attending Physician on 9/21/10 at approximately 4:00 PM, the Physician stated "I thought those things (dental assessments) happened automatically. I don't look into them".

3. Resident #60 has a history of dementia and degenerative joint disease (DJD). Review of the Minimum Data Set (MDS) dated 6/2/10 revealed the resident's cognitive skills for daily decision making are moderately impaired and she has long and short term memory impairment. Review of Incident and Accident (I/A) Reports dated 3/29/10, 5/18/10, 6/8/10, 8/11/10 and 8/31/10 revealed the resident had a history of skin tears. Review of the Comprehensive Care Plan (CCP) dated 8/31/10 revealed the CCP does not address approaches to prevent skin tears.

When observed 9/16/10 at 10:45 AM, the Licensed Practical Nurse (LPN) removed the dressing from the resident's left lower leg exposing an approximately 3 centimeter (cm) round skin tear.

When interviewed on 9/22/10 at 9:05 AM, the Registered Nurse (RN) Unit Coordinator (UC) stated he care plans skin tears under pressure ulcers. Review of the 8/31/10 care plan, the RN UC stated there is no care plan for prevention of skin tears. He stated "I would normally care plan this. I just missed it".

Review of a facility policy entitled MDS Assessments/ Care Planning dated 4/02 revealed the RN Unit Coordinators on each unit are responsible for care planning along with the interdisciplinary team to ensure each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being.

415.11(c)(1)

Based on record review and staff interview, the facility quality assessment and assurance (QAA) committee did not develop and implement an appropriate plan of action to correct an identified quality deficiency. Resident #72 was hospitalized in 7/10 with a fecal impaction. The QAA Committee met on 9/2/10 and did not review the occurrence of a fecal impaction and did not develop and implement a corrective plan of action. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #72 has diagnoses of chronic obstructive pulmonary disease (COPD), cardiomyopathy and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 8/2/10 revealed the resident has moderately impaired cognitive skills for daily decision making, sometimes understands, is sometimes understood and has long and short term memory problems. Additional review of the MDS revealed the resident is dependent on staff for activities of daily living (ADLs).

Review of Caretracker (computerized documentation system) Bowel and Bladder Detail Reports dated 6/22/10 through 7/13/10, Physician Orders dated 6/1/10 through 7/27/10, Routine and PRN (as needed) Medication sheets dated 6/10 and 7/10, and Nursing Progress Report notes dated 6/22/10 through 7/13/10 revealed Resident #72 did not have a bowel movement for more than three days on multiple occasions. The facility bowel protocol was not implemented as planned and bowel medications were not administered as ordered by the physician. In addition, there was a lack of a comprehensive physical assessment by a registered professional nurse at the time of a change in the resident's condition. Resident #72 was hospitalized with a "prominent fecal impaction" on 7/13/10 and was disimpacted.

Interview with the Registered Nurse (RN) Director of Nursing (DON) on 9/22/10 at approximately 12:30 PM revealed the DON is the QAA Committee Chair. The DON explained that the QAA Committee reviews all sentinel events (sentinel health events include any occurrence of a resident with fecal impaction, dehydration and pressure sores) including fecal impactions. Review of the Facility Survey Report, signed by the Administrator on 9/13/10, revealed the Quality Assessment and Assurance (QAA) Committee meets monthly and last met on 9/2/10.

During the interview on 9/22/10 at 12:30 PM, the DON stated the QAA Committee did not review Resident #72's fecal impaction that occurred 7/13/10 and took no further actions.

415.27(c)(1)(3)(v)

B ased on record review and staff interview, the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health. Two (Residents #61, 72) of five residents reviewed for hydration had issues involving lack of accurate monitoring and evaluation of actual fluid intake to ensure daily fluid needs are met and to ensure a daily fluid restriction is maintained per physician's order. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #72 has diagnoses including cardiomyopathy (disease of the heart muscle causing decreased function of the heart), and diabetes mellitus. Review of the Minimum Data Set (MDS) dated 8/2/10 revealed the resident has moderately impaired cognitive skills for daily decision making, short and long term memory problems, sometimes understands, and is sometimes understood. Additional review of the MDS revealed the resident requires supervision for eating.

Review of a Nursing Progress Report note dated 1/8/10 revealed the resident was admitted to the nursing home on 1/8/10 at 6:15 PM.

Review of Progress Report notes revealed the following:

- On 1/11/10 at 11:37 PM, the resident's appetite was poor. "Ate 25% (percent) and 180 cc (cubic centimeters) intake.
- On 1/12/10 at 2:45 PM, the resident ate 50% of breakfast with 180 cc intake and 25% of lunch with 100 cc intake.
- On 1/12/10 at 6:56 PM, the Attending MD (Medical Doctor) was in to see the resident and wrote new orders to administer Lasix (diuretic medication used to promote the excretion of urine) 20 mg (milligrams) daily and obtain a chest x-ray, a CBC (complete blood count - blood test) and a CMP (comprehensive metabolic profile - blood test to evaluate chemistry levels) in the morning.
- On 1/12/10 at 10:32 PM, the resident ate 25% with a fluid intake of 10 cc.

Review of a Dietary Progress Report note written by the DTR (Registered Dietary Technician) dated 1/14/10 revealed the newly admitted resident was receiving a mechanical soft diet with nectar thick liquids and a 3 days fluid study was in progress with results to follow. The DTR documented that the resident's estimated fluid need was calculated as 1665 cc daily and the daily meal plan provides approximately 1840 cc of fluid. The DTR documented pertinent medications included Lasix with a notation to monitor for serum potassium losses and dehydration. The resident was noted with poor po (oral) intake and lethargy. The DTR documented a plan to provide pudding cups between meals at 10:00 AM and 3:00 PM and 4 oz (ounces) of Boost Glucose (liquid nutritional supplement) with the dinner and supper meals.

Review of a Dietary Progress Report note dated 1/19/10 revealed the 3 day intake study was completed and showed the resident consumed 45% of her estimated fluid needs. The DTR documented a plan to increase the Boost Glucose shakes to 8 oz twice a day, confer with the physician and follow-up.

Review of a Dietary Progress Report note dated 1/20/10 revealed the resident triggered for RAP (resident assessment protocol) #12 related to meal acceptance < (below) 75%, mechanically altered and therapeutic diet and RAP # 14 for insufficient fluids and diuretic therapy with plans to proceed per care plan.

Review of the Comprehensive Care Plan (CCP) for Dehydration/Fluid Maintenance last reviewed 1/27/10 revealed the resident was identified with potential for alteration in hydration status due to the resident consuming less than 75% of fluid needs and diuretic therapy. CCP approaches include plans for staff to monitor and record fluid intake, monitor labs (laboratory results) as available, provide fluid preferences as noted, provide additional fluids between meals via nourishments, monitor for signs/symptoms of dehydration, and report any changes.

Review of a Dietary Progress Report note dated 1/29/10 revealed an additional 8 oz of Boost Glucose will be added at breakfast.

Review of a laboratory report dated 1/29/10 revealed the bloodwork was collected 1/28/10 and showed the sodium was 145 (normal 136 to 144), the BUN (blood urea nitrogen - blood test to determine kidney function and hydration status) was 28 (normal 8 to 31) and the creatinine (blood test to determine kidney function) was 0.6 (normal 0.5 to 1.6).

Review of Meal & Fluid Detail Reports From Caretracker (computerized documentation of fluid intake) revealed the resident's daily fluid intake, including meals and between meal nourishments, revealed the following intake totals:

- 1/26/10 - 595 cc,
- 1/27/10 - 870 cc,
- 1/28/10 - 665 cc.

Review of a Nursing Progress Report note dated 1/28/10 at 5:05 AM revealed the resident's mucous membranes were dry and fluids were encouraged but taken poorly. A Nursing Progress Report dated 1/28/10 at 7:03 PM documented the physician was called about the resident's dry heaves and dry oral mucosa, noted the Lasix therapy and a new order was obtained for a stat (immediate) BMP (basic metabolic profile - blood test to evaluate body chemistry) to better assess the resident's hydration status.

Review of Meal & Fluid Detail Reports From Caretracker revealed documentation of the following daily fluid intake totals:

- 1/29/10 - 470 cc,
- 1/30/10 - 430 cc,
- 1/31/10 - 715 cc,
- 2/1/10 - 520 cc,
- 2/2/10 - 500 cc.

Review of a Nursing Progress Report note dated 2/2/10 at 6:38 PM revealed the physician saw the resident due to increased confusion and new orders were obtained for a stat CBC, CMP, a chest x-ray due to lung congestion and a urine sample for culture and sensitivity. A Nursing Progress Report note dated 2/2/10 documented the urine sample was obtained and the urine was a dark amber color with a strong odor. Review of a laboratory report dated 2/2/10 revealed the sodium, BUN and creatinine were within normal limits.

Review of a Nursing Progress Report notes dated 2/3/10 at 9:01 AM revealed the LPN called the physician to report laboratory and x-ray results and a new order was obtained to administer a one time dose of Lasix 40 mg IM (intramuscular injection) for congestion.

Review of a current facility policy and procedure (P&P) entitled "Hydration" dated 10/04 revealed at the start of each 7:00 AM to 3:00 PM (7-3) shift, the Unit Coordinator, Unit Supervisor, or Staff Nurse will determine which residents need to have oral fluid intake assessed. "Fluid intake should be evaluated at least three days". The fluid intake monitoring need will be put on the House Report with an end date, start date, reason and fluid goal. Residents who are on fluid intake will be communicated to the Medication Nurse, who will communicate the information to the CNAs. The Medication Nurse will be responsible for all fluid totals given during medication pass for their assigned residents and enter the information in the Care Tracker. The Unit Coordinator, Unit Supervisor, or Staff Nurse on the 7-3 shift will be responsible for evaluating if each resident attained their fluid goal. If fluid goals are not attained by Day 1 and 2, staff are to push fluids and document attempts and resident response. On Day 3, staff are to notify the Nutrition Manager of the need for an assessment.

Review of a P&P entitled Fluid Intake dated 5/10 revealed reasons to initiate fluid intake assessment(s) include, but are not limited to: residents who have poor po intake, residents who are treated for or are suspected to have a UTI (urinary tract infection), URI (upper respiratory infection), or a febrile illness or have signs and symptoms of dehydration. Unit Coordinators, or Charge Nurses should initiate a Fluid Intake Assessment using the Fluid Intake Worksheet and an evaluation of whether the fluid goal is met should occur daily, by Nursing Nutrition Managers will review fluid intake totals at least weekly or more frequently as indicated via the Care Tracker System.

Review of a 24 hour House Report dated 2/3/10 revealed the Lasix administration was noted; however there was no evidence of "fluid intake monitoring" in accordance with facility policy.

Review of Meal & Fluid Detail Reports from Caretracker revealed documentation of the following daily fluid intake totals:

- 2/3/10 - 460 cc,
- 2/4/10 - 795 cc,
- 2/5/10 - 420 cc,
- 2/6/10 - 625 cc,
- 2/7/10 - 380 cc,
- 2/8/10 - 555 cc,
- 2/9/10 - 275 cc
- 2/10/10 - 630 cc,
- 2/11/10 - 445 cc,
- 2/12/10 - 375 cc.

Review of 24 hour House Reports dated 2/2/10 to 2/11/10 revealed there was no documentation to show that fluid intake monitoring was done by nursing. Review of the 24 hour House Report dated 2/11/10 through 2/12/10 revealed the resident was placed on MDS I/O (intake and output).

A Nursing Progress Report note dated 2/9/10 at 10:17 PM revealed the physician saw the resident in the afternoon, Lasix was increased from 20 mg daily to 40 mg daily with orders to obtain a BMP on 2/16/10.

Interview with the RN DON on 9/22/10 at approximately 12:15 PM revealed the resident was on MDS I/O, which was monitored by dietary, for 3 days from 2/10/10 to 2/12/10. When asked for evidence of the fluid intake monitoring by nurses, the DON stated "it is facility procedure for the dietary department to monitor the resident pretty much". The DON stated although not documented in Caretracker, the resident takes in an average of 60 cc of fluid at each medication pass for four medication passes daily and "most likely took in an additional 240 cc", however the DON could not provide specific totals. The DON also provided 24 hour House Reports dated 2/10/10 to 2/12/10 which documented some medication fluid intake totals which might not be in the Caretracker. The DON confirmed that it is facility policy for the medication nurses to place the medication pass fluid totals in Caretracker. The DON stated she believed that the resident's fluid intake in February did not veer from her normal/usual fluid intake, and her acute disease process (exacerbation of CHF) was the cause of her dehydration. The DON stated the facility had a plan, they were providing treatment and the disease process was more likely the cause of the increased BUN and Sodium levels. The DON stated the resident had normal BUN and creatinine levels on 2/2/10 which were obtained during her "low average" fluid intake.

Interview with the Physician on 9/21/10 at approximately 4:00 PM revealed she increased the dose of Lasix to 40 mg daily based on the chest x-ray done 2/2/10. The Physician stated she had last seen the resident on 2/2/10 and the CMP was good (BUN and creatinine). The Physician also stated she was aware of the resident's "intake status" (she normally reviews Caretracker with the nurses) and ordered a repeat BMP for 2/16/10 to monitor the resident's hydration. The surveyor reviewed the actual intake amounts from Caretracker for 2/10/10, 2/11/10, and 2/12/10 and the Physician stated in absence of diuretic therapy, they would be concerning; with recently increased diuretic therapy she definitely should have been informed by the nurses of the resident's poor fluid intake.

Interview with the Unit 1 7:00 AM to 3:00 PM Desk LPN on 9/20/10 at 11:00 AM revealed that the Medication LPNs are required to enter medication pass fluid totals in Caretracker when the resident is on MDS I/O. The LPN explained if a resident has a care plan to encourage fluids, the fluid totals are to be entered into Caretracker by the Medication LPN. The LPN stated the fluid intake is monitored by dietary. When the 24 hour House Report was reviewed with the Unit 1 7:00 AM to 3:00 PM Desk LPN, she could not think of another reason to place a resident on fluid intake monitoring unless dietary was doing a study.

In summary, there was a lack of accurate fluid intake monitoring for Resident #72, who was identified at risk for dehydration, in accordance with facility policy.

2. Resident #61 has diagnoses which include chronic renal failure, hypertension, congestive heart failure, dementia, and constipation. Review of the Minimum Data Set (MDS) dated 9/2/10 revealed the resident has modified independence for daily decision making, is usually understood, usually understands and has short and long term memory problems.

Review of a Quarterly Nutritional Assessment dated 9/10/10 revealed the resident's estimated daily needs included 1500 cc of fluid. The 9/10/10 Nutritional Assessment documented the resident's fluid intake at meals was 933 cc representing "62% of estimated fluid needs captured". Review of a Dietary Progress Report note dated 9/10/10 revealed "fluid provisions at meals and med (medication) passes" were reviewed with nursing. The DTR (Registered Dietary Technician) documented that the meal plan will be altered to allow 300 cc daily for med (medication) passes, 120 cc of fluid between meals and trays will now provide 1080 cc/day".

Review of Physician Orders dated 9/15/10 revealed orders to maintain a 1500 cc (cubic centimeter) fluid restriction daily.

Review of the current Comprehensive Care Plan (CCP) with a print date of 9/16/10 revealed the resident was identified with the potential for alteration in hydration status due to medications with a possible side effect of dehydration; insufficient fluids captured on the nutritional review of 9/10; and renal dialysis 3 times weekly due to chronic renal failure with a 1500 cc daily fluid restriction per the Physician. CCP approaches include plans to monitor and record fluid intake (nursing); provide fluid preferences as noted (dietary, nursing); provide additional fluids between meals via nourishments (dietary, nursing); monitor signs and symptoms of dehydration; report any changes (nursing); and encourage the resident to consume fluids provided (nursing). CCP goals include the resident will exhibit no signs or symptoms of dehydration and will consume > (over) 75% of estimated fluid needs through 12/30/10.

Interview with the Registered Nurse (RN) Unit Coordinator (UC) on 9/20/10 at 12:30 PM revealed documentation of fluid intake for the fluid restriction is in Caretracker. The RN UC explained that fluid information documented in the Caretracker system represents fluid intake from between meal nourishments and meals only. The RN UC stated that documentation on the Medication Administration Records (MARs) should indicate how much fluid the nurses are giving with the resident's med pass. Review of MARs dated 6/10 through 9/9/10 revealed no documentation of actual amounts of fluids provided with each medication pass. The RN UC stated the family gives the resident fluids and is not compliant with the fluid restriction despite education.

Review of Caretracker Fluid Intake Detail Reports dated 8/22/10 through 9/20/10 revealed the resident's daily fluid intake from meals and between meal nourishments ranged from 200 cc to 1201 cc. During the interview on 9/20/10 at 12:30 PM, the RN UC explained that the resident received an additional 300 cc daily during medication passes.

Interview with the Director of Nursing (DON) on 9/22/10 at approximately 11:15 AM revealed the facility does not have a policy regarding who monitors daily fluid intake to ensure fluid restrictions are maintained. Interview with the RN UC on 9/22/10 at 11:25 AM revealed no one totals fluid intake for the resident on a daily basis. Interview with the DTR on 9/22/10 at 12:10 PM revealed dietary does not have a policy for fluid restrictions.

In summary, the facility did not have a system to ensure that the physician ordered fluid restriction was maintained and that the resident consumed sufficient fluids to maintain adequate hydration.

415.12(j)

Based on observation, record review and staff and resident interview, the facility did not ensure that residents are free of any significant medication errors. One (Resident #169) of 13 residents observed for medication administration received the wrong dose of a medication. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #169 has diagnoses including depression, hypertension, and malnutrition. Review of the Minimum Data Set (MDS) dated 8/7/10 revealed the resident is independent in cognitive skills for daily decision making, understands and is understood.

Review of Physician Orders revealed an order dated 9/10/10 for Megace (appetite stimulant) 400 milligrams (mg) orally every day for decreased appetite. Review of the Medication Administration Record (MAR) for 9/10 revealed the order was transcribed as written by the physician.

During an interview with the resident in the resident's room on 9/13/10 at 5:00 PM, the Licensed Practical Nurse (LPN) Medication/ Treatment Nurse entered the room, stating, "I need you to take this before supper". The LPN explained to the resident that the medication was Megace, to help her appetite. The LPN then handed the resident a 30 milliliter (ml) medication cup filled with a white liquid. The resident attempted to drink the liquid from the medication cup, gagged and swallowed, and gagged again. The LPN slapped the resident on her back, the resident burped three times and the resident swallowed the remaining liquid and gagged. The LPN slapped the resident on the back multiple times and the resident burped three more times. The resident teared up, said "I'm ok" and within approximately one minute was observed to be as she was prior to swallowing the liquid medicine. The LPN left the room saying, "I don't know why they sent this as a liquid and not pills. I'll let the Charge Nurse know and see if we can get that changed".

Review of the 9/10 Medication Administration Record (MAR) and the 9/10/10 Physician's Order on 9/15/10 at 3:15 PM, revealed the Megace was ordered to be given orally, but did not specify a liquid or a pill.

Observation of the bottle of the white liquid medication for Resident #169 on 9/15/10 at 3:15 PM revealed it was labeled as Megestrol (Megace) 40 mg per ml. The LPN Medication/ Treatment Nurse verified that she had administered the liquid Megace from that bottle on 9/13/10 and it was determined the dose given on 9/13/10 was 1200 mg (30 ml) instead of 400 mg (10 ml) as ordered by the Physician. The LPN looked at the label and stated, "Oh my gosh, I don't know what I was thinking". The Registered Nurse (RN) Quality Surveillance Nurse who was present, stated that a medication error report would be completed.

415.12(m)(12)

Based on record review, staff and resident interview, the facility did not ensure that the resident has the right to choose activities consistent with his or her interests, assessments, and plans of care and make choices about aspects of his or her life in the facility that are significant to the resident. One (Resident #169) of two residents reviewed for the right to make choices was not given the opportunity after admission to voice her preferences for wake up time and bathing preference. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #169 has diagnoses including malnourishment, depression, and hypertension. Review of the Minimum Data Set (MDS) dated 8/7/10 revealed the resident is independent in cognitive skills for daily decision making, understands and is understood.

a). Review of the Admission/ Readmission Nurses Note/ Evaluation dated 7/28/10 revealed the resident's "preferred arise time" is 8:00 AM and "preferred bedtime" is 8:00 PM. Review of the Comprehensive Care Plan (CCP) dated 8/10/10, last updated 8/26/10, and the Door Card (used by certified nurse aide (CNA) and nursing staff for directions for resident care), dated 9/6/10, revealed no documentation of the resident's preferred arise time and bedtime.

On interview 9/13/10 at 4:45 PM, the resident stated that at home she got up in the morning between 7:00 AM and 7:30 AM, but here at the nursing home, the CNA "often" comes in and puts the light on between 6:00 AM and 6:30 AM and tells her it is time to get up.

On interview 9/16/10 at 10:18 AM, the assigned CNA stated she has usually been assigned to Resident #169 since the resident was admitted (on 7/28/10). The CNA stated she works from 6:00 AM to 2:00 PM and the resident usually puts her light on around 7:00 AM. The CNA stated that occasionally the resident wakes at 6:30 AM but usually calls for the CNA between 7:00 AM and 7:30 AM. The CNA stated she has never spoken with the resident regarding times she would prefer to get up in the morning.

On interview 9/16/10 at 11:10 AM, the Licensed Practical Nurse (LPN) Medication/ Treatment Nurse stated that when she comes on duty at 7:00 AM, Resident #169 is "usually still in bed".

On interview 9/16/10 at 11:30 AM, the Registered Nurse (RN) Unit Coordinator stated the information on resident preferences for get-up and bed times is documented in the Admission/ Readmission Nurses Note/Evaluation and not included in the CCP. The RN Unit Coordinator stated, "I know that doesn't make sense".

b). Review of the Admission/ Readmission Nurses Note/Evaluation dated 7/28/10 and nursing notes from 7/28/10 to 8/19/10 revealed no documentation regarding the resident's preferred bath or shower time of day or frequency, or whether the resident prefers a bath or shower. Review of the CCP dated 8/10/10, last updated 8/26/10, revealed no documentation regarding whether the resident receives a bath or shower or when or how often. Review of the Door Card (used by CNA and nursing staff for directions for resident care), dated 9/6/10, revealed the resident receives a bath every Monday on the 3:00 PM to 11:00 PM shift. Review on 9/15/10 of the Bath Schedule revealed the resident was scheduled for a bath on Mondays on the 3:00 PM to 11:00 PM shift.

On interview 9/13/10 at 4:45 PM, the resident stated that at home she took a shower every day, but at the nursing home she was told she would get a tub bath once a week on Monday on the evening shift. The resident stated she would prefer showers to baths, but no one asked her.

On interview 9/16/10 at 11:30 AM, the RN Unit Coordinator stated that if the resident had a preference for a shower instead of a bath, or for more frequent bathing/showering, "the resident would need to let us know. No residents are asked." The RN Unit Coordinator explained that baths/showers are scheduled for once a week on either the day or evening shift according to resident room location. The RN Unit Coordinator stated the bath/shower day and shift are "assigned to spread out the baths and showers" so each CNA would have no more than one bath or shower to do per shift." The RN stated that "if a resident objects to the bath or shower schedule, we'll change it".

On 9/16/10 at 11:40 AM, the RN Unit Coordinator went to the resident and asked for her preferences. The RN Unit Coordinator returned and stated the resident was satisfied with a once per week frequency at this time, but did prefer a shower. The RN Unit Coordinator stated he would change the Bath Schedule to reflect the resident is to get a shower.

On interview 9/21/10 at 11:00 AM, the Director of Nursing (DON) stated there were no policies and procedures for bath or shower assignments or scheduling.

451.5(b)(3)

Based on observation, record review and staff interview, the facility did not provide services by qualified persons in accordance with each resident's written plan of care. One (Resident #123) of 21 residents reviewed for care plans had issues involving TED stockings (thromboembolism deterrent stockings - elastic stockings to prevent blood clots) that were not applied as planned. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #123 has a history of cerebral vascular accident (stroke) and has a pace maker. Review of the Minimum Data Set (MDS) dated 1/13/10 revealed the resident has moderately impaired cognitive skills for daily decision making and short and long term memory problems.

The Comprehensive Care Plan (CCP) dated 7/16/10 and the Door Card (certified nurse aide (CNA) Care Plan) dated 9/13/10 revealed a plan for TED stockings (thromboembolism deterrent stockings - elastic stockings to prevent blood clots) " on in am, off at HS (bedtime)".

Observations on 9/14/10 at 9:00 AM and 9/15/10 at 1:15 PM revealed the resident was wearing slippers and did not have TED stockings on. When observed on 9/16/10 at 2:16 PM during resident care, a CNA bathed and dressed the resident and did not apply the resident's TED stockings.

When interviewed on 9/17/10 at 2:00 PM, the Registered Nurse (RN) Unit Coordinator (UC) stated the resident is not be able to put on his own TED hose. Review of the Adaptive Equipment and Special Needs sheet dated 9/10 revealed there were no signatures to indicate the resident's TED stockings were removed at HS from 9/1/10 to 9/16/10 and no signatures documenting that they were applied from 9/6/10 to 9/15/10. The RN UC stated the expectation is that when TED stocking are applied in the morning and removed at HS, the CNA would sign that this was done.

When interviewed on 9/20/10 at 10:55 AM, CNA #2 explained that on 9/17/10 she had the Licensed Practical Nurse (LPN) get her a new pair of TED stockings that she applied to the resident, before she left at the end of the day shift.

415.11(c)(3)(ii)

Based on observation, record review and staff interview, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. One (Resident #61) of 21 residents' clinical records had issues involving incomplete documentation of follow-up monitoring after dialysis and of the effectiveness of pain medication. This was a pattern with no actual harm with potential for minimal harm.

The findings are:

1. Resident #61 has a diagnosis of chronic renal failure and receives hemodialysis three times per week. Review of the Minimum Data Set (MDS) dated 9/2/10 revealed the resident has modified independence for daily decision making, short and long term memory problems, is usually understood, and usually understands.

a). Review of the current Comprehensive Care Plan (CCP) for Dialysis, printed 9/16/10, revealed approaches for staff to monitor and assess for signs and symptoms of infection of the right chest catheter, and "VS" (vital signs - blood pressure, pulse, respirations, temperature) and follow up monitoring per routine. Review of a facility policy and procedure (P&P) dated 9/10 entitled Dialysis Flow Sheet revealed the purpose of the policy is that "residents who receive dialysis outside the facility, will receive appropriate follow-up monitoring".

Review of a Physician's Order dated 5/6/10 revealed an order to complete a Dialysis Flow Sheet on dialysis days, and check vital signs (blood pressure, pulse, temperature, respiratory rate) upon return and 4 hours later.

The resident was observed leaving for dialysis on 9/16/10 at 10:40 AM and a bag lunch was taken with her. The observation revealed a transport van picked the resident up.

Review of a Dialysis Flow Sheet dated 6/10 revealed the following:

- The resident went to dialysis on 13 days in 6/10.
- One of the 13 days lacked documentation that vital signs were done 4 hours post return.
- Four of the 13 days lacked documentation that lung sounds were checked upon return to the facility.
- Twenty of 39 shifts lacked documentation the dressing was checked to ensure it was dry and intact
- Twenty-five of 39 shifts lacked documentation that the access site was monitored for redness, tenderness, drainage, or bleeding.
- Twenty-five of 39 shifts lacked documentation that the resident was monitored for peripheral edema.

Review of the Dialysis Flow Sheet dated 7/10 revealed the following:

- The resident went to dialysis on 14 days in 7/10.
- Three of 14 days lacked documentation that vital signs were obtained upon return from dialysis.
- Seven of 14 days lacked vital signs 4 hours post return.
- Five of 14 days lacked documentation lung sounds were checked upon return from the facility per the dialysis flow sheet.
- Twenty-three of 42 shifts lacked documentation that the dressing was checked to ensure it was dry and intact
- Twenty-five of 42 shifts lacked documentation that the access site was monitored for redness, tenderness, drainage, or bleeding.
- Twenty-four of 42 shifts lacked documentation that the resident was monitored for peripheral edema.

Review of the Dialysis Flow Sheet dated 8/10 revealed the following:

- The resident went to dialysis on 13 days in 8/10.
- Two of 13 days lacked documentation that vital signs were obtained 4 hours post return.
- Three of 13 days lacked documentation lung sounds were checked upon return from the facility.
- Twenty-five of 39 shifts lacked documentation that the dressing was checked to ensure it was dry and intact
- Twenty-five of 39 shifts lacked documentation that the access site was monitored for redness, tenderness, drainage, or bleeding.
- Twenty-five of 39 shifts lacked documentation regarding monitoring for peripheral edema

Review of the Dialysis Flow Sheets dated 9/1/10 through 9/18/10 revealed the following:

- The resident went to dialysis on 8 days.
- Three of 8 days lacked documentation that vital signs were completed upon the resident's return from dialysis.
- Three of 8 days lacked vital signs 4 hours post return from dialysis.
- Three of 5 days lacked documentation that lung sounds were checked upon return.
- Twelve of 24 shifts lacked documentation that the dressing was checked to ensure it was dry and intact.
- Fifteen of 24 shifts lacked documentation that the access site was monitored for redness, tenderness, drainage, or bleeding.
- Thirteen of 24 shifts lacked documentation that the nurses monitored for peripheral edema.

Interview with the Registered Nurse (RN) Per Diem Staff Nurse on 9/21/10 at 12:10 PM revealed she "would not expect staff to document the time the resident returned from dialysis on the flow sheet", that would be in the nurses notes. The rest of the information should be completed on the Dialysis Flow Sheet to assure the resident is adequately being monitored.

b). Review of the current CCP, printed 9/16/10, revealed Comfort Care (conservative, supportive measures to be provided at the end of life) was ordered 5/7/10 with a goal that the resident will remain comfortable and pain free.

Review of MARs dated 6/10 through 8/10 and Nursing Progress Report notes dated 6/22/10 through 8/15/10 revealed the "as needed" Lortab 5/500 was administered for pain on the following dated without documentation of its effectiveness:

- 6/22/10, 6/26/10
- 7/15/10, 7/16/10, 7/21/10
- 8/10/10, 8/12/10, 8/15/10

Interview with the Pharmacist on 9/21/10 at 9:30 AM revealed nurses are expected to document the effectiveness of pain medications on the back of the MAR.

415.22(a)(1,2)

1. Resident #125 has diagnoses which include dementia, chronic obstructive pulmonary disease and hypertension. Review of the Minimum Data Set (MDS) dated 9/13/10 revealed the resident is independent for eating with set-up help only.

During observations of lunch on 9/13/10 from 11:45 AM to 1:10 PM and supper on 9/15/10 from 5:15 PM to 6:20 PM, the resident was seated in her wheelchair at a table that was at face height.

Interview with a Licensed Practical Nurse (LPN), who was working as a floor aide, on 9/15/10 at 6:20 PM, revealed that the LPN came to the unit to help with dinner. The LPN stated the resident "usually eats by herself, with a little supervision. She usually does pretty good by herself, she can usually reach everything".

Interview with the Registered Nurse (RN)/Unit Manager on 9/16/10 at approximately 10:00 AM revealed "Whatever nurse is in the dining room would be in charge of the dining room at that time. Tables are adjustable. If the height is wrong, the table should be adjusted or a tray table should be used. The table should not be at that height for her face. Someone cannot properly eat at that height, it should not be like that for anybody".

415.29(c)(4)

Based on observation, staff interview and a review of facility blueprints and fire rating documentation during a Life Safety Code survey, structural components of the facility were not properly protected from fire. Issues include the structural support web truss systems located above the lay-in ceiling assembly that was not protected to meet minimum acceptable fire rated building construction classification. This affected the entire facility. This was widespread with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Per NFPA 101 Life Safety Code, 2000 edition, the minimum acceptable construction types for a two story building are I (443), I (332), II (222), II (111), II (000), III (211), IV (2HH), V (111). Based on general observations of the facility on 9/13/10 and 9/14 /10, the facility is not constructed of materials that meet building classification types III, IV and V.

Per NFPA 220 Standard on Types of Building Construction, 1999 Edition, Construction type I (443), I (332), II (222) and II (111) require that structural components [Exterior load bearing walls, Structural Framing (columns, girders, beams, trusses etc.) and Floor construction] are constructed of fire rated materials or are protected by a fire resistive barrier. Type II (111) buildings, with the exception of a single story building, must be fully protected by an automatic extinguishment system as well. Where the original construction material is not fire rated, providing a fire rated barrier can be accomplished by applying some type of physical fire rated protective covering on the structural steel components or by maintaining a fire rated ceiling assembly.

An interview with the facility's Director of Maintenance on 9/14/10 at approximately 2:25 PM revealed the Maintenance Director believes the facility does have a fire rated ceiling assembly. The only available documentation reviewed at this same time was the fire rating information label provided by the facility Maintenance Director from the Lay in ceiling tiles. This label did not include any information on a fire resistance rating (examples: one hour fire rated, two hour or otherwise).

Per NFPA 220 Standard on Types of Building Construction, 1999 Edition, Construction type II (000) and II (111) requires that buildings be fully protected by an automatic extinguishment system (Sprinkler System). Based on observations of the facility on 9/13/10, the facility is minimally protected by an automatic sprinkler system with protection identified in approximately nine rooms. (Holding Room, Laundry Room, Maintenance office, Mechanical Room, Employee Locker Room, Room #35a, Bath Suite Room #2, Nursing Supply Room, General Storage Room).

A review of facility blueprints on 9/14/10 did not identify the architect's interpretation of the building construction type classification.

Observations made on 9/14/10 from approximately 8:35 AM until approximately 10:40 AM revealed the ceiling assembly located throughout the facility is comprised of lay in ceiling tiles. Observations made above the lay in ceiling tiles at these same times revealed unprotected structural roof truss supports throughout two of two resident units.
10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-1.6.2, 13-3.5.1, 1-3.6, 13-1.1.4.1
2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1
none