Schofield Residence

Based on record review and staff interview, the facility did not ensure use of the assessment to develop, review and revise the resident's comprehensive plan of care which must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under .25. One (Resident #48) of one resident randomly reviewed for hydration revealed the care plan which identified the resident at risk for dehydration, did not include plans to monitor the resident's fluid intake. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #48 has diagnoses of pneumonia, coronary artery disease and dementia. Review of the admission Minimum Data Set (MDS) dated 9/2/11 revealed the resident has severe cognitive impairment, is sometimes understood and sometimes understands.

Review of admission Physician's Orders dated 8/23/11 revealed the resident has an order for Duoneb (respiratory treatment to open bronchus in the lungs) 3 milliliters (ml) via inhalation every four hours as needed for shortness of breath, oral APAP (Tylenol) 650 milligrams (mg) every four hours as needed for pain and temperature greater than 100 and oral Vantin (antibiotic) 200 mg twice a day for two days.

Review of the Comprehensive Care Plan (CCP) dated 9/6/11 revealed the resident has a history of pneumonia with planned interventions to watch for signs of respiratory distress, provide and encourage fluids, vital signs as ordered, report to MD as ordered. Review of the CCP update of 9/11/11 revealed the resident was newly identified at risk for dehydration due to insufficient fluid intake for the last three days. Planned interventions included assess for signs and symptoms of dehydration, encourage resident to take fluids provided, and monitor electrolytes and laboratory tests as ordered. There is no provision in the CCP to monitor the resident's fluid intake.

415.11(c)(1)

Based on record review and staff interview, the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. One (Resident #148) of four residents reviewed for accidents had an issue with an incomplete and inaccurate investigation of a resident fall with complaints of left hip pain who was determined nine days later to have a left hip fracture. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #148 has diagnoses including osteoarthritis, vitamin D deficiency, and malnutrition. The resident was admitted to the nursing facility 6/3/11 for rehabilitation following hospitalization for ORIF (open reduction internal fixation) for a fractured right hip sustained at home. Review of the Minimum Data Set (MDS) dated 6/10/11 revealed the resident is cognitively intact, is understood, and understands.

Review of Progress Reports dated 8/15/11 at 11:53 PM and written by a Licensed Practical Nurse (LPN) revealed the following:

- the resident was found on the floor at 10:50 PM,
- denied hitting head,
- no acute injuries "at this time",
- range of motion within normal limits,
- resident complained of pain to the left hip area,
- APAP (Tylenol) given relief pending.

Review of an Incident/Accident Report (A&I) dated 8/15/11 revealed the resident was found on the floor in her room on 8/15/11 at 10:50 PM. The A&I documented the resident denied hitting her head and no injuries were noted. Documentation in the section, "Unit Coordinator's Statement", revealed the resident was seen by the physician on 8/17/11 for left knee pain with an x-ray of the left knee negative for acute process. The documentation included that with increased pain, an x-ray of the left hip and pelvis done 8/24/11 showed a fracture of the left hip femoral neck.

Review of an undated two page typed document entitled, "Resident Investigation" signed by the Assistant Director of Nursing (ADON) revealed an investigation of the fall on 8/15/11 and subsequent care through 8/24/11 when the resident was determined to have a fractured left hip. The documented investigatory conclusion included that "it was determined that the resident was evaluated and treated appropriately".

Further review of the "Resident Investigation", completed by the ADON and interview with the ADON on 9/22/11 at 1:00 PM revealed:

a). The Investigation documented the resident complained of left lower extremity pain following the incident without including that the pain was documented in the Progress Reports specifically as "pain to left hip area".
b). The Investigation documented the resident was medicated with Tylenol following the fall "per nurse's note" (Progress Reports) but did not address the lack of documentation in the nurse's notes of resident response to pain medication and the lack of documentation in the medication administration record that the Tylenol was given after the fall.
c). The lack of a documented RN assessment following the fall was not addressed. The ADON stated her expectation was that the LPN should have contacted the on duty evening or night shift supervisor.
d). The investigation did not address the lack of a documented evaluation and assessment of the resident by nursing staff from after the Evening Shift LPN note of 8/15/11 at 11:53 PM until an LPN note of 8/17/11 at 5:14 AM when the Night Shift LPN documented the resident was afraid to walk due to fall on 8/15/11.
e). The ADON stated she did not interview staff involved, including the LPN who evaluated the resident after the fall, the Night Shift Supervisor, the Night Shift LPN, and did not interview the resident.
f). The Investigation did not address why the ADON only became aware of the fall on 8/17/11. The ADON stated she didn't know the resident had fallen because it wasn't put on report. She learned of the fall from the RCC on 8/17/11, at which time the resident was put on report.

415.12(h)(2)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 9/22/10.

Based on record review and staff interview, the facility quality assessment and assurance (QAA) committee did not implement a plan of action to correct an identified quality deficiency. Resident #48 was identified at risk for dehydration on 9/12/11 and the resident's care plan did not include plans to monitor the resident's fluid intake. Facility staff did not identify that the resident had suboptimal fluid intake from 9/12/11 to 9/21/11. F327, cited during the current survey, is a repeat deficiency from the Recertification Survey dated 9/22/10. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #48 was admitted to the facility on 8/23/11 with diagnoses including pneumonia, coronary artery disease, and dementia. Review of the Minimum Data Set (MDS) dated 9/2/11 revealed the resident has severe cognitive impairment, is sometimes understood and sometimes understands.

Review of an Initial Dietary Progress Report completed by the Registered Dietetic Technician (DTR) dated 9/1/11 revealed the resident weighed 126.3 pounds and had an estimated daily fluid need of 1720 cubic centimeters (cc). The Dietitian documented that the resident was eating 40 to 60% at meals, her initial fluid intake at meals was 950 cc (55% of estimated needs) and 1980 cc of fluid was provided daily.

Review of a CCP update of 9/12/11 revealed the resident was identified at risk for dehydration due to insufficient fluid intake during the last three days. Planned interventions included:

- assessing for signs and symptoms of dehydration,
- encouraging the resident to consume fluids provided,
- monitor electrolytes
- laboratory tests as ordered.

Additional review of the CCP revealed no documented evidence of a plan to monitor the resident's fluid intake.

Review of computerized "All Measurements Detail Reports" dated 9/12/11 to 9/21/11 revealed the resident's total daily fluid intake at meals including the following:

- 9/12/11 - 520 cc
- 9/13/11 - 410 cc
- 9/14/11 - 720 cc
- 9/15/11 - 600 cc
- 9/16/11 - 330 cc
- 9/17/11 - 360 cc
- 9/18/11 - 500 cc
- 9/19/11 - 680 cc
- 9/20/11 - 720 cc
- 9/21/11 - 60 cc

Review of "Detailed Med (Medication) Pass Intake Reports" dated 9/13/11 to 9/15/11 revealed the resident consumed additional fluids with medication pass as follows:

- 9/13/11 - 120 cc
- 9/14/11 - 60 cc
- 9/15/11 - 120 cc

Interview with the Unit 2 RN RCC on 9/23/11 at 8:23 AM revealed Resident #48 was placed on the 24 Hour House Report to capture fluid intake for MDS I&O on 9/13/11. The RN RCC stated he reviews the 24 Hour House Reports daily, however dietary staff is responsible to monitor the resident's fluid intake. The RN RCC stated he was not aware of the resident's low fluid intake and he was not aware how staff would ensure adequate fluid intake for a resident with an elevated temperature. The RN RCC could not indicate how he ensures staff push fluids for resident's with a temperature.

Review of the Statement of Deficiencies (CMS - 2567) for the Recertification survey dated 9/22/10 revealed the facility was found out of compliance for F327. It was determined that t he facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health. Two of five residents reviewed for hydration during the 9/22/10 survey had issues involving the lack of accurate monitoring and evaluation of actual fluid intake to ensure daily fluid needs were met.

Review of the facility's accepted Plan of Correction (POC) with a completion date of 11/18/10 revealed the Dietitian is responsible for reviewing residents that require fluid intake monitoring due to potential for dehydration to ensure adequate fluid intake is consumed. The POC also documented that the Director of Nursing (DON), Assistant DON and Dietitian will be responsible for inservicing all staff who are required to evaluate fluid intake. In addition, the POC documented that the Dietitian was responsible to conduct fluid intake audits on 25 percent of all residents that require fluid intake once a month for three months and that the results would be reported to the QAA Committee for subsequent review base on findings. The DON was identified as responsible for the 2010 POC with respect to F327.

Interview with the DON on 9/23/11 at approximately 1:07 PM revealed there was no QAA Committee initiative regarding monitoring of residents' fluid status such as audits, etc. The DON stated that she verified with the Dietitian that the monthly fluid intake audits identified in the 2010 POC were not done.
none
415.27(c)(1)(3)(v)

Based on observation, record review and staff interview, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. One (Resident #108) of ten residents reviewed for unnecessary medications had an issue involving a medicated patch that was not applied according to the manufacturer's specifications to not apply the patch to the same spot for at least 14 days. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #108 was admitted on 11/12/10 with diagnoses including dementia, Alzheimer's disease, and cerebral vascular accident (CVA - stroke) with hemiplegia (paralysis on one side of body). Review of the Minimum Data Set (MDS) dated 7/26/11 revealed the resident has moderate cognitive impairment, usually understands and is usually understood.

Review of the Comprehensive Care Plan (CCP) dated 8/3/11 revealed the resident has cognitive loss as evidenced by a diagnosis of dementia and receives an Exelon (medication used to treat Alzheimer's) patch. CCP approaches include medicating the resident as ordered and pharmacy reviews of the resident's medication regime.

Review of Physician's Orders dated 7/26/11 and 9/20/11 revealed an order for Exelon patch 9.5 milligrams (mg) one patch topically and remove old patch every day for a diagnosis of dementia.

Review of the Exelon Patch manufacturer's patient information revealed instructional information to change the application site every day to avoid irritation and do not use the same spot for at least 14 days after the last application.

Review of the Medication Administration Records (MARs) dated 7/11, 8/11 and 9/11 revealed the nurses documented that the Exelon patch was applied to site #13 (upper left back) and site #14 (upper right back). There were no directions to avoid the same application area for at least 14 days after the last application of the patch.

Interview with the Licensed Practical Nurse (LPN #1) on 9/22/11 at approximately 11:00 AM revealed she is the full time nurse and she works 5 days a week. The MAR dated 9/11 was reviewed with LPN #1 regarding documentation of the Exelon the application sites. LPN #1 stated she only applied the Exelon patch to sites #13 (upper left back) and 14 (upper right back) because the resident has a hairy chest and she doesn't use these areas. LPN #1 stated she did not know that the patch was not to be applied to the same area and that an application site should not be repeated within 14 days according to the manufacturer's specifications.

Interview with the Registered Nurse (RN) Unit Coordinator (UC) on 9/22/11 at approximately 11:15 AM revealed he did not know about the application of the Exelon patch and would need to telephone the pharmacy who supplies the resident's medications.

Interview with the Pharmacist at the dispensing pharmacy on 9/22/11 at approximately 11:20 AM revealed the nurses are not to repeat application sites for at least 2 weeks because it can cause skin irritation and the resident's upper arms, back, or chest area can be used to apply the patch.

Interview with LPN #2 Medication Nurse on 9/22/11 at 3:30 PM revealed she was not aware that the Exelon patch is not to be placed on the same site for 14 days.

Interview with the Director of Nursing Services (DONS) on 9/22/11 at 4:30 PM revealed the facility does have a policy entitled Rotation of Injection Sites that the facility uses for injection site locations but there is no policy and procedure regarding the application of Exelon patches. The DONS stated the nurses were unaware that the application site of the Exelon patch cannot be repeated for at least 14 days. The DONS stated the facility prints their own MARs and the directions for the application of the Exelon patch can be added.

Review of a facility policy and procedure entitled Rotation of Injection Sites dated 4/10 revealed a diagram of a body and a number key to document the sites for injections and patches.

Observation on 9/23/11 at 8:30 AM revealed LPN #1 Medication Nurse removed the old Exelon patch from the resident's right upper back. LPN #1 was observed to place a new Exelon patch to the resident's left upper arm. LPN #1 stated a new diagram and instructions not to repeat the (application) site for 14 days was added to the MARs book.

415.18(a)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 9/22/10.

Based on observation, record review and staff interview, the facility did not ensure that each resident was provided with sufficient fluid intake to maintain proper hydration and health. One (Resident # 48) of one resident reviewed for hydration, who was identified at risk for dehydration, had issues involving the lack of monitoring and evaluation of actual fluid intake to ensure daily fluid needs are met. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #48 was admitted to the facility on 8/23/11 with diagnoses including pneumonia, coronary artery disease, and dementia. Review of the Minimum Data Set (MDS) dated 9/2/11 revealed the resident has severe cognitive impairment, is sometimes understood and sometimes understands.

Review of an Initial Dietary Progress Report completed by the Registered Dietetic Technician (DTR) dated 9/1/11 revealed the resident weighed 126.3 pounds and had an estimated daily fluid need of 1720 cubic centimeters (cc). The Dietitian documented that the resident was eating 40 to 60% at meals, her initial fluid intake at meals was 950 cc (55% of estimated needs) and 1980 cc of fluid was provided daily.

Review of the Comprehensive Care Plan (CCP) dated 9/6/11 revealed the resident had a history of pneumonia with planned interventions to watch for signs of respiratory distress; provide and encourage fluids; obtain vital signs as ordered; and report to the MD (Medical Doctor) as ordered.

Review of the CCP updated 9/12/11 revealed the resident was identified at risk for dehydration due to insufficient fluid intake during the last three days. Planned interventions included:

- assessing for signs and symptoms of dehydration,
- encouraging the resident to consume fluids provided,
- monitor electrolytes
- laboratory tests as ordered.

Additional review of the CCP revealed no documented evidence of a plan to monitor the resident's fluid intake.

Review of Nursing Progress Reports 9/19/11 through 9/21/11 revealed the resident's temperature ranged from 99.2 degrees (normal 98.6 degrees) to 102.6 degrees and Tylenol was administered as ordered. The Nursing Progress Reports documented that the resident had general malaise, congestion and a non-productive cough.

Review of a Nursing Progress Report dated 9/21/11 at 9:06 AM revealed new orders were obtained for a chest x-ray, ZPack (Azithromycin - antibiotic - multidose package) two tablets 9/21/11 and then one tablet daily and a Duoneb (medicated respiratory treatment) nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) one unit dose inhaled three times per day.

Review of computerized "All Measurements Detail Reports" dated 9/12/11 to 9/21/11 revealed the resident's total daily fluid intake at meals including the following:

- 9/12/11 - 520 cc
- 9/13/11 - 410 cc
- 9/14/11 - 720 cc
- 9/15/11 - 600 cc
- 9/16/11 - 330 cc
- 9/17/11 - 360 cc
- 9/18/11 - 500 cc
- 9/19/11 - 680 cc
- 9/20/11 - 720 cc
- 9/21/11 - 60 cc

Review of 24 Hour House Reports dated 9/13/11 to 9/15/11 revealed the resident was placed on a 3 day "MDS I&O" (Intake and Output). The House Reports documented that medication pass totals are to be entered into the Care Tracker System (computerized documentation system) at the end of every shift.

Review of "Detailed Med (Medication) Pass Intake Reports" dated 9/13/11 to 9/15/11 revealed the resident consumed additional fluids with medication pass as follows:

- 9/13/11 - 120 cc
- 9/14/11 - 60 cc
- 9/15/11 - 120 cc

Additional review of the facility's computerized documentation of fluid intake dated 9/12/11 to 9/21/11 revealed no evidence that Resident #48's daily total fluid intake was calculated and/or addressed by facility staff.

Intermittent observations on 9/21/11 from 6:30 AM to 5:00 PM revealed the resident remained in bed and did not eat breakfast or lunch. Interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) on 9/21/11 at approximately 3:40 PM revealed the resident refused breakfast and lunch and remained in bed all day due to illness.

Interview with the Unit 2 RN RCC on 9/23/11 at 8:23 AM revealed Resident #48 was placed on the 24 Hour House Report to capture fluid intake for MDS I&O on 9/13/11. The RN RCC stated he reviews the 24 Hour House Reports daily, however dietary staff is responsible to monitor the resident's fluid intake. The RN RCC stated he was not aware of the resident's low fluid intake and he was not aware how staff would ensure adequate fluid intake for a resident with an elevated temperature.

Interview with the DTR on 9/23/11 at approximately 8:40 AM revealed he did not review Resident #48's MDS I & O because he hasn't been diligent in reviewing all of them and he was not aware of the resident's low fluid intake

Interview with the MDS RN on 9/23/11 at approximately 8:45 AM revealed she did not review the resident's fluid intake from 9/13/11 to 9/15/11 for the MDS I &O and she was not aware of the resident's low fluid intake.

In summary, the resident's fluid intake from meals from 9/12/11 to 9/21/11 did not meet his estimated daily fluid need of 1720 cc. A three day I&O to monitor fluid intake during medication passes on 9/13/11, 9/14/11 and 9/15/11 was done. Staff interview revealed that neither Nursing or Dietary were aware of the resident's suboptimal fluid intake and did not evaluate the resident's fluid status.

415.12(j)

Based on record review and staff interview, the facility did not immediately consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly. Two (Residents #48, 148) of two residents were affected. Resident #48 had issues that involved a delay in notifying the physician and family of the resident's fever, congestion, and low oxygen saturation levels (amounts of oxygen in the blood - normal 90 to 100%). Resident #148 had issues that involved a delay in physician/family notification of the resident's fall and subsequent left hip pain and fracture. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #48 has diagnoses of pneumonia, coronary artery disease and, dementia. Review of the admission Minimum Data Set (MDS) dated 9/2/11 revealed the resident has severe cognitive impairment, is sometimes understood and sometimes understands.

Review of admission Physician's Orders dated 8/23/11 revealed the resident had an order for Duoneb (respiratory treatment to open bronchus in the lungs) 3 milliliters (ml) via inhalation every four hours as needed for shortness of breath, oral APAP (Tylenol) 650 milligrams (mg) every four hours as needed for pain and temperature greater than 100 and oral Vantin (antibiotic) 200 mg twice a day for two days.

Review of the Comprehensive Care Plan (CCP) dated 9/6/11 revealed the resident has a history of pneumonia with planned interventions to watch for signs of respiratory distress, provide and encourage fluids, vital signs as ordered, report to MD as ordered.

Review of Progress Reports between 9/19/11 and 9/21/11 revealed the following:

- 9/19/11 at 2:42 PM written by a Registered Nurse (RN) revealed the resident had a temperature of 101.1 (normal 98.6) and Tylenol was administered at 1:00 PM.
- 9/20/11 at 5:00 AM written by the Licensed practical Nurse (LPN) revealed the resident had a pulse ox (oxygen saturation level - amount of oxygen in the blood (normal 90 to 100%)) of 98% and oxygen was applied at 2 liters (L) via nasal cannula (plastic tubing used to deliver oxygen through the nose).
- 9/21/11 at 2:36 AM written by the same LPN noted a correction indicating the pulse ox was 89%.
- An RN Nurses Note dated 9/20/11 at 2:46 PM written by the Registered Nurse (RN) revealed the resident's temperature was 99.2 degrees at 7:30 AM.
Tylenol was administered due to slight temperature and general malaise, at 11:00 AM the resident's temperature was 100.2 and Tylenol was again administered. The resident continues with an infrequent nonproductive cough and chest congestion and a message was left on the physician board to update the physician.

Review of the Progress Report, dated 9/20/11 at 8:20 PM written by an RN indicated the physician was updated on the "nursing recommendations" and obtained new orders for oxygen as needed to keep the pulse (oxygen saturation level - amount of oxygen in the blood - normal 90 -100%) greater than 92%. A subsequent Progress Report dated 9/20/11 at 10:00 PM written by the LPN indicated the resident had a temperature of 100.2 at 5:00 PM and Tylenol was administered as ordered with results of a temperature of 98.6 at 7:00 PM . General malaise continued, non productive cough and congestion noted in the afternoon, not evident in the evening. The Progress Report dated 9/21/11 at 4:14 AM written by an LPN revealed the resident's pulse ox was 81% on room air, and oxygen was applied at 2L via n/c pulse ox 92% Temperature 102.6 and Tylenol was administered as ordered, the recheck temperature was 101.7 and a second dose of Tylenol was administered. "Congestion" in the lungs was heard, breathing through mouth, skin clammy, diaphoretic, cool compresses applied under arms.

Review of a Progress Report dated 9/21/11 at 9:06 AM written by an RN revealed the physician was called and informed of the residents elevated temperatures chest congestion and the use of Tylenol nearly every fours hours. New orders included a chest x-ray due to elevated temperatures and chest congestion and an order for ZPack (antibiotic) 2 tablets today, then daily until the pack is finished and Duoneb via nebulizer one unit dose inhaled three times per day. Further review of the Progress Report dated 9/21/11 at 12:49 PM, written by the LPN, revealed the resident had a temperature of 101.3 and Tylenol was administered, later the temperature was 100.6. The resident's pulse ox was 87% on 2 liters of oxygen via nasal cannula, nebulizer with some effect, resistive with nebulizer mask trying to remove. Review of the Progress Report, dated 9/21/11 at 3:19 PM written by an RN revealed the physician was updated on the chest x-ray results which showed pneumonia, the responsible party was notified of the new treatment orders and results of the x-ray and new order to send the resident to the hospital if he becomes SOB (short of breath).

Interview on 9/21/11 at approximately 4:00 PM with the RN Staff Nurse revealed she worked on 9/20/11 and when she came into work today (9/21/11) she realized the physician was not updated regarding the resident's elevated temperatures and use of Tylenol every four hours on the previous day (9/20/11). The RN stated that the resident was on oxygen and had rhonchi (abnormal lung sounds) in both lung bases and called the physician around 8:30 AM (9/21/11) to inform him regarding those facts. The RN stated a Duoneb treatment was not provided as ordered. The RN stated she should have informed the physician (of the resident's condition) the day before.

Interview on 9/21/11 at approximately 4:30 PM with the evening RN Staff Nurse revealed that on 9/20/11 she contacted the physician at 8:20 PM and asked for new orders for oxygen to keep the pulse ox greater than 92%. The RN stated she did not relay any other clinical information other than what was in the "doctor book" (a physician notification/request log).

Interview with the RN Resident Care Coordinator (RCC) on 9/23/11 at approximately 10:30 AM revealed he did not notify the physician on 9/20/11 when the resident had a change of condition specifically elevated temperatures, low oxygen saturations levels and the implementation of oxygen.

Review of the "Physician Message Form" ("doctor book") revealed the following message "may resident have an order for prn (as needed) O2 (oxygen) to keep) 2 greater than 92%" and the message was scribbled out which indicated okay.

2. Resident #148 has diagnoses including osteoarthritis, vitamin D deficiency, and malnutrition. The resident was admitted to the nursing facility 6/3/11 for rehabilitation following hospitalization for ORIF (open reduction internal fixation) for a fractured right hip sustained at home. Review of the Minimum Data Set (MDS) dated 6/10/11 revealed the resident is cognitively intact, is understood, and understands.

Review of Progress Reports dated 8/15/11 at 11:53 PM written by an LPN revealed a note the resident was found on the floor at 10:50 PM, denied hitting head, no acute injuries "at this time", range of motion within normal limits, resident complained of pain to the left hip area.

Review of an Incident/Accident Report (A&I) dated 8/15/11 revealed the resident was found on the floor in her room on 8/15/11 at 10:50 PM. The A&I documented no injuries and that the incident was noted in the "MD Book". The resident denied hitting her head and no injuries were noted.

Interview on 9/22/11 at 1:00 PM with the Assistant Director of Nursing (ADON) revealed the "MD book" is used to document resident issues and problems that the nurses need to discuss with the physicians when they visit.

During an interview on 9/22/11 at 12:15 PM, the Evening Shift LPN, who wrote the note on 8/15/11 at 11:53 PM, stated she did not call the physician, but put a note in the "MD Book" so that nursing staff would bring the fall to the physician's attention when he/she next visits. The LPN stated the resident had no complaints of pain at the time she evaluated her, but approximately 15 minutes later the certified nurse aide (CNA) informed her the resident was complaining of pain. The LPN stated she returned to the resident's room and the resident told her she was having left hip pain. The LPN stated she medicated the resident for pain with Tylenol and could not recall if the resident got relief. When asked why she did not call the physician when the resident complained of left hip pain 15 minutes after falling, the LPN stated, "She (the resident) had leg pain since admission. It wasn't unusual". When the surveyor told the LPN that the resident's complaints of pain had previously only involved her surgically repaired right hip, the LPN did not respond.

Review of the "MD Book" information on 9/22/11 at 1:30 PM by the surveyor and the Registered Nurse (RN) Resident Care Coordinator (RCC) revealed no documentation of the fall on 8/15/11. The RCC stated at this time he was unaware of whether the family was called.

Review of the A&I and Progress Reports following the fall revealed no documented evidence the family was notified. Interview with the ADON (Assistant Director of Nursing) on 9/23/11 at 1:30 PM revealed she was unable to determine that the family was called, but "was apparently not".

Review of a policy and procedure entitled "Emergency Policy" dated 4/02 and reviewed 6/11 revealed, "The resident's private physician is called if the resident's condition requires transfer to the hospital for further evaluation, or change in condition is evident or suspected". Review of a policy and procedure entitled "Nursing Documentation Policies", dated 5/99 and reviewed 6/11 revealed "In the event that the resident's physician must be contacted for an urgent or emergency need, the time and reason should be documented in the medical record for each attempt. The return call time should also be documented". This policy also documented, "Voice mail answering machines may be utilized to notify physicians of non-urgent information". The policy does not document use of an "MD Book" for communicating to physicians.

The "Emergency Policy" also directs that "The RN Charge Nurse or Supervisor is responsible for communicating with the resident's healthcare proxy or designated representative regarding change in condition, treatment, or need for transfer at the time it occurs. Accident notification should occur within 24 hours".

415.3(e)(2)(ii)(b)

Based on record review and staff interview, the facility did not inform each resident during the resident's stay, of charges for services not covered under Medicare. Two (Residents #101, 152) of three residents reviewed for notification of Medicare Non-Coverage and Liability did not receive Liability Notices when payment for skilled services ended and the residents remained in the facility. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #152 has diagnoses of anemia, hypertension, and pneumonia. Review of the Minimum Data Set (MDS) dated 8/4/11 revealed the resident is cognitively intact and PT and OT services began on 7/30/11.\i

Review of the "Notice of Medicare Provider Non-Coverage" dated 8/2/11 revealed coverage for SNF Medicare services will end on 8/4/11 and the resident has the right to appeal the decision.

Review of the Progress Reports revealed the resident continued to reside in the facility until discharge on 8/22/11.
\i
Additional review of the medical record revealed no evidence that a Liability Notice was provided to the resident/resident's representative when covered services ended on 8/4/11.
\i
Interview on 9/21/11 at approximately 3:30 PM with the Director of Social Services revealed she did not issue a liability notice to the resident/resident representative.

2. Resident #101 has diagnoses including coronary artery disease, heart failure and peripheral vascular disease (PVD - poor circulation of the lower extremities). Review of Admission Minimum Data Set (MDS) dated 7/11/11 revealed the resident has moderate cognitive impairment and Physical Therapy (PT) and Occupational Therapy (OT) services began on 4/8/11.
\i
Review of the "Notice of Medicare Provider Non-Coverage" SNF revealed SNF (Skilled Nursing Facility) Medicare Part A services will end 5/12/11 and the resident has the right to appeal.

Additional review of the medical record revealed no evidence a liability notice was provided to the resident/resident representative.

Review of the Progress Reports revealed the resident continued to reside in the facility until discharged on 9/1/11.

Interview on 9/21/11 at approximately 3:30 PM with the Director of Social Services revealed she did not issue a liability notice to the resident/resident representative.

415.3(g)(2)(iii)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 9/22/10.

Based on observation, record review and staff interview, the facility did not provide 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 #48, 148) of two residents reviewed for change in condition had issues. Issues regarding Resident #48 involved lack of administration of Duoneb (respiratory treatment to open bronchus in the lungs) medication when the resident experienced low oxygen levels and an inaccurate temperature and respiratory rate for a resident with newly diagnosed pneumonia. Issues involving Resident #148 involved the lack of documented evidence of a Registered Nurse (RN) assessment following a fall with complaints of left hip pain after the fall, lack of informing the night nurse coming on shift of the resident's fall just prior to shift change, lack of documented evidence the resident was medicated for pain following the fall, ambulation of the resident following the fall without consulting the physician, and lack of documented resident assessment and monitoring for over 24 hours following the fall. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #48 has diagnoses of pneumonia, coronary artery disease and, dementia. Review of the admission Minimum Data Set (MDS) dated 9/2/2011 revealed the resident has severe cognitive impairment, is sometimes understood and sometimes understands.

Review of admission Physician's Orders dated 8/23/11 revealed the resident had an order for Duoneb 3 milliliters (ml) via inhalation every four hours as needed for shortness of breath, oral APAP (Tylenol) 650 milligrams (mg) every four hours as needed for pain and temperature greater than 100 and oral Vantin (ABT) 200 mg twice a day for two days.

Review of the Comprehensive Care Plan (CCP) dated 9/6/11 revealed the resident has a history of pneumonia with planned interventions to watch for signs of respiratory distress, provide and encourage fluids, vital signs as ordered, report to MD as ordered.

Review of the Progress Reports dated 9/19/11 at 2:42 PM written by a Registered Nurse (RN) revealed the resident had a temperature of 101.1 and Tylenol was administered at 1:00 PM. Review of a Progress Report dated 9/20/11 at 5:00 AM written by a Licensed Practical Nurse (LPN) revealed the resident had a pulse ox (oxygen saturation level - amount of oxygen in the blood (normal 90 to 100%)) of 98%, oxygen was applied at 2 liters (L) via nasal cannula (plastic tubing used to deliver oxygen through the nose). A subsequent entry dated 9/21/11 at 2:36 AM written by the same LPN noted a correction indicating the pulse ox was 89%.

Review of Progress Reports dated 9/20/11 at 2:46 PM written by an RN revealed the resident's temperature was 99.2 degrees (normal 98.6 degrees) at 7:30 AM. Tylenol was administered due to slight temperature and general malaise, at 11:00 AM the resident's temperature was 100.2 and Tylenol was again administered. The resident continues with an infrequent nonproductive cough and chest congestion and a message was left on the physician board to update the physician. A note dated 9/20/11 at 8:20 PM written by the Evening Staff RN indicated the physician was updated on the "nursing recommendation" and obtained new orders for oxygen as needed to keep the pulse ox greater than 92%.

Review of the Progress Reports dated 9/20/11 at 10:00 PM written by the LPN indicated the resident had a temperature of 100.2 at 5:00 PM and Tylenol was administered as ordered with results of a 7:00 PM temperature of 98.6. General malaise continued, non productive cough and congestion noted in the afternoon, not evident in the evening. Review of Progress Reports dated 9/21/11 at 4:14 AM written by an LPN revealed the resident's pulse ox was 81% on room air, and oxygen was applied at 2L via nasal cannula, pulse ox 92% Temperature 102.6 and Tylenol was administered as ordered. The re-check temperature was 101.7 and a second dose of Tylenol was administered. "Congestion" in the lungs was heard, breathing through mouth, skin clammy, diaphoretic, cool compresses applied under arms.

Review of the medication administration record dated 9/1/11 to 9/20/11 revealed no documented evidence that the ordered Duoneb was administered as needed during this time including around 4:14 AM on 9/21/11.

Review of a Progress Report dated 9/21/11 at 9:06 AM written by an RN revealed the physician was informed of the resident's elevated temperatures and the use of Tylenol nearly every fours hours and chest congestion. New orders were obtained for a chest x-ray due to elevated temperatures and chest congestion and order for ZPack (antibiotic) 2 tablets today, then daily until the pack is finished and Duoneb via nebulizer one unit dose inhaled three times per day.

Review of Progress Reports dated 9/21/11 at 12:49 PM written by the LPN revealed the resident had a temperature of 101.3 and Tylenol was administered, later the temperature was 100.6. The resident's pulse ox was 87% on 2L, oxygen via nasal cannula, nebulizer with some effect, resistive with nebulizer mask trying to remove.

Observation of the resident on 9/21/11 at 3:00 PM and 4:00 PM revealed the resident was in bed with 2L oxygen on via nasal cannula with a respiratory rate of 32/minute with shallow abdominal breathing noted, mouth open.

Review of a note dated 9/21/11 at 3:19 PM written by the RN revealed the physician was updated on the chest x-ray results which showed pneumonia.

Interview on 9/21/11 at approximately 3:30 PM with the evening LPN revealed she was told the resident had pneumonia and LPN explained she had checked on him when she arrived for the evening shift. The resident had his oxygen on and his respirations appeared normal and easy.

Interview on 9/21/11 at approximately 3:40 PM with the RN RCC revealed the resident had an elevated temperature and was being treated for pneumonia and had no other clinical abnormalities.

Additional observation on 9/21/11 at approximately 4:15 PM and 4:30 PM revealed the resident's respirations were 40 (normal 12-20), and shallow with abdominal breathing. Further observation at 4:35 PM revealed, while the LPN was looking on, the CNA obtained the resident's temperature orally. A reading of 98.4 degrees was registered. The surveyor asked, "Were earlier temps oral"? and the LPN replied "I'm not sure. I took an axillary (under the arm) earlier". The surveyor asked the CNA to obtain a rectal temperature and the resident's temperature was 103 degrees. The surveyor informed the LPN that the resident's respirations were 40 and asked her if she would obtain a pulse ox. The LPN agreed and stated "his respirations were 16 earlier when his family left". At 4:40 PM the resident's pulse ox was 87% on 2L oxygen via nasal cannula with an elevated pulse of 111.

Review of the Progress Report dated 9/21/11 at 5:10 PM written by an RN revealed the resident had a respiratory rate of 20 and a temperature of 103 degrees rectally when addressed at 4:50 PM. Review of the medication administration record revealed the resident received a Duoneb treatment at 12:00 PM and 4:00 PM on 9/21/11.

2. Resident #148 has diagnoses including osteoarthritis, vitamin D deficiency, and malnutrition. The resident was admitted to the nursing facility on 6/3/11 for rehabilitation following hospitalization for ORIF (open reduction internal fixation) for a fractured right hip sustained at home. Review of the Minimum Data Set (MDS) dated 6/10/11 revealed the resident is cognitively intact, is understood, and understands.

Review of Progress Reports dated 8/15/11 at 11:53 PM and written by an LPN revealed the following:

- the resident was found on the floor at 10:50 PM,
- denied hitting head,
- no acute injuries "at this time",
- range of motion within normal limits,
- resident complained of pain to the left hip area,
- APAP (Tylenol) given relief pending.

Review of an Incident/Accident Report (A&I) dated 8/15/11 revealed the resident was found on the floor in her room on 8/15/11 at 10:50 PM. The A&I documented the resident denied hitting her head and no injuries were noted. Review of the A&I dated 8/15/11 revealed no documentation of an RN assessment. Further review of the Progress Reports revealed no RN documentation from the time of the fall on 8/15/11 through 8/17/11 at 4:02 PM.

During an interview on 9/22/11 at 12:15 PM, the Evening Shift LPN, who wrote the note on 8/15/11 at 11:53 PM, stated the resident had no complaints of pain at the time she evaluated her after the resident was found on the floor. The LPN stated she and the CNA helped the resident up and to bed after the initial evaluation. The LPN stated that approximately 15 minutes later the CNA informed her the resident was complaining of left hip pain. The Evening Shift LPN stated she returned to the resident's room and the resident told her she was having left hip pain. The Evening LPN stated she medicated the resident for pain with Tylenol, but could not recall if the resident got relief. When asked why she did not call an RN to assess the resident, the LPN stated that she thought as long as a nurse, LPN or RN, evaluated the resident that was adequate. The LPN stated she did not inform the Evening Supervisor or Night Supervisor of the fall, but told the Night Shift LPN when she came on duty and also put the resident on "report" (24-hour house report).

Review of the medication administration record (MAR) for 8/11 revealed no documented evidence that Tylenol was administered after the resident's fall on 8/15/11 as stated by the evening Shift LPN. Review of the 24 hour House Reports for 8/15/11 and 8/16/11 revealed the resident was not on the report.

When interviewed on 9/22/11 at 1:05 PM, the surveyor showed the Evening Shift LPN the MAR for 8/11 that did not include documentation that Acetaminophen was given after the resident's fall on 8/15/11. The LPN stated, "Maybe I was going to give it and didn't give it. I don't remember". Regarding the lack of the resident's fall with complaints of left hip pain not being on report, the LPN stated, "I thought I had put it on report. I guess I didn't".

Review of the Progress Reports revealed that following the documentation on 8/15/11 at 11:53 PM of the fall, the next Progress Report was dated 8/17/11 at 5:14 AM when the Night Shift LPN documented "Resident calling for bedpan, states she is afraid to walk due to fall on 8/15/11".

During a telephone interview on 9/22/11 at 7:00 PM with the Night Shift LPN who came on duty just after the fall, it was learned that the Evening Shift LPN did not inform her of the fall and the resident had not been put on report. The Night Shift LPN stated she first learned of the fall on 8/17/11 at approximately 3:00 AM or 4:00 AM when the resident requested the bedpan during the night. The Night Shift LPN stated the resident had been ambulating to the bathroom in the past and she asked the resident why she needed to use the bedpan. The LPN stated the resident informed her of the fall and stated that her left hip and knee were hurting. The LPN stated she medicated the resident for pain at that time and informed either the Day Shift LPN or RN Nurse Manager that morning about the pain in the resident's left leg.

During an interview on 9/22/11 at 5:35 PM, the RN Evening Supervisor revealed she worked the evening shift 8/15/11 and "probably" left at 11:00 PM and was not informed and had not heard at that time of the resident's fall.

Interview on 9/23/11 at 7:00 AM with the RN Night Supervisor revealed she worked the night shift starting on 8/15/11. The RN stated that at approximately 11:00 PM she got off the elevator to deliver the CNA (certified nurse aide) assignment list and the Evening Shift LPN was walking by and told her Resident #148 had fallen. The RN Night Supervisor stated she decided to go see the resident and assessed her with full range and body check. The RN stated the resident was in bed and told her she did not hit her head and had no pain at that time. The RN stated she has been a Registered Nurse since 9/9/11 when she received her license and was a General Nurse (GN) at the time of the resident's fall on 8/15/11. The RN Night Supervisor stated she did not document her assessment, was "unaware I needed to", and was "under the impression the resident was put on report". The RN stated that later during the night shift 8/15/11 to 8/16/11 she saw the Evening Shift LPN, who had stayed over until about 4:00 AM and learned the resident was ambulating to the toilet, and that the resident's complaints of pain "were no more than usual".

Review of the Progress Reports dated 8/17/11 at 9:30 AM revealed an entry written by an LPN that the resident was complaining of "pain to left lower leg, specifically below the knee", the physician was updated and x-rays of the left lower extremity were ordered.

Review of a physician note dated 8/17/11 revealed documentation that the resident "was complaining of pain in and around her left knee. Apparently the patient suffered a fall about a week ago (actually 2 days earlier) and she had been complaining of pain". The physician documented he assessed the resident and there was no pain on range of motion.

Review of the x-ray report of the left knee dated 8/17/11 revealed no acute abnormalities. Review of Progress Reports dated 8/17/11 to 8/24/11 and the medication administration record (MAR) for 8/11 revealed continued complaints of lower extremity pain, left knee pain, and/or left hip pain.

Review of an RN Resident Care Coordinator (RCC) note dated 8/24/11 at 12:55 PM revealed resident complaints of anterior left leg pain from knee down, with little relief from Percocet (narcotic used to treat pain). "Resident had a fall on 8/15/11 ...(physician) concerned that perhaps pain is radiating to lower leg. New order given to x-ray left hip and pelvis due to pain".

Review of the x-ray report dated 8/24/11 revealed an "acute left hip fracture with varus angulation" (turned inward toward the midline of the body to an abnormal degree).

415.12

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 9/22/10.

Based on record review and staff interview, the facility did not ensure that the Pharmacy Consultant identified and reported drug irregularities regarding the application of a medicated patch. One (Resident #108) of ten residents reviewed for monthly drug regimen reviews was affected. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #108 was admitted on 11/12/10 with diagnoses including dementia, Alzheimer's disease, and cerebral vascular accident (CVA - stroke) with hemiplegia (paralysis on one side of body). Review of the Minimum Data Set (MDS) dated 7/26/11 revealed the resident has moderate cognitive impairment, usually understands and is usually understood.

Review of the Comprehensive Care Plan (CCP) dated 8/3/11 revealed the resident has cognitive loss as evidenced by a diagnosis of dementia and receives an Exelon (medication used to treat Alzheimer's) patch. CCP approaches include medicating the resident as ordered and pharmacy reviews of the resident's medication regime.

Review of Physician's Orders dated 7/26/11 and 9/20/11 revealed an order for Exelon patch 9.5 milligrams (mg) one patch topically and remove old patch every day for a diagnosis of dementia.

Review of the Exelon Patch manufacturer's patient information revealed instructional information to change the application site every day to avoid irritation and do not use the same spot for at least 14 days after the last application.

Review of the Medication Administration Records (MARs) dated 7/11, 8/11 and 9/11 revealed the nurses documented that the Exelon patch was applied to site #13 (upper left back) and site #14 (upper right back). There were no directions to avoid the same application area for at least 14 days after the last application of the patch.

Interview with the Licensed Practical Nurse (LPN #1) on 9/22/11 at approximately 11:00 AM revealed she is the full time nurse and she works 5 days a week. The MAR dated 9/11 was reviewed with LPN #1 regarding documentation of the Exelon the application sites. LPN #1 stated she only applied the Exelon patch to sites #13 (upper left back) and 14 (upper right back) because the resident has a hairy chest and she doesn't use these areas. LPN #1 stated she did not know that the patch was not to be applied to the same area and that an application site should not be repeated within 14 days according to the manufacturer's specifications.

Interview with the Pharmacist at the dispensing pharmacy on 9/22/11 at approximately 11:20 AM revealed the nurses are not to repeat application sites for at least 2 weeks because it can cause skin irritation and the resident's upper arms, back, or chest area can be used to apply the patch.

Review of the Pharmacist Consultant Report dated 8/18/11 and 9/22/11 revealed a lack of documented evidence that the Pharmacist Consultant identified and reported the irregularity of the continued application of the Exelon patch to sites #13 and #14 which is not in accordance with the manufacturer's specification.

Interview with the Pharmacist Consultant on 9/22/11 at 5:00 PM revealed he was unaware of the manufacturer's specification to not repeat the application site of the Exelon patch within a 2 week period. The Pharmacist Consultant stated he would complete a Pharmacy Consultant Memo to add these instructions to the MARs.

Review of a Pharmacy Consultant Memo dated 9/23/11 revealed the Pharmacist Consultant recommended the following for the Exelon patch: "do not repeat site for 14 days".

415.18(c)(2)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 9/22/10.

none 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. Observations on 9/19/11 from approximately 8:49 AM until approximately 2:35 PM revealed the ceiling assembly located throughout the facility was comprised of lay-in ceiling tiles. Observations above the ceiling tiles on 9/20/11 from approximately 9:40 AM until 10:15 AM revealed unprotected structural roof truss supports were observed throughout two of two resident units and that the ceiling tiles were not clipped in place.

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 9/19/11 and 9/20/11, 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.

Interview with the facility's Director of Environmental Services and Security on 9/20/11 at approximately 10:18 AM revealed the Director of Environmental Services and Security believed the facility did 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 Director of Environmental Services and Security 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 9/19/11, the facility was 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 9/20/11 did not identify the architect's interpretation of the building construction type classification.

In keeping with new guidance from the Centers for Medicare & Medicaid Services (CMS), a revised time limited waiver must be requested. Please include in your Plan of Correction, a request for a Time Limited waiver and include the following:

- Justification for the waiver.
- Timetable with milestones of major activities leading to correction.
- All interim life safety measures that will be undertaken.

10 NYCRR 415.29(a)(2), 711.2(a)(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