Beechwood Homes

Based on observation, record review and staff interview, the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and ensure that each resident receives adequate supervision and assistance devices to prevent accidents. Four (Residents #111, 250, 401, 422) of seven residents observed for accidents had issues involving 25 feet of oxygen tubing laying on the floor of the dining room in the path of residents who were entering and exiting the dining room. Residents were observed to step on and roll over the oxygen tubing, which was in use by a resident. 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 #401 has diagnoses including chronic obstructive pulmonary disease, and dementia.

Review of the quarterly Minimum Data Set (MDS) dated 4/22/11 revealed that the resident has severe cognitive impairment and is sometimes understood and sometimes understands.

Review of Physician's Orders dated 4/20/11 revealed an order for oxygen 2 to 3 liters (l) via nasal cannula for shortness of breath.

Review of the Care Plan for medical conditions dated 2/8/11, revealed an intervention for "Oxygen as ordered".

During observation of the dinner meal on 4/29/11 from 11:45 AM to 12:45 PM the resident was seated at a table in the Unit 3B dining room. She was wearing a nasal cannula which was attached by oxygen tubing to an oxygen concentrator that was approximately 25 feet (') to 30' away from her. The connecting oxygen tubing stretched across the floor for approximately 25' and was looped in several spots. The oxygen tubing was laying in the direct path of residents and staff who were entering and leaving the dining room. The following was observed:

a). Resident #250 has diagnoses including osteoarthritis, osteoporosis and has a history of falls. Review of the Care Plan for activities of daily living (ADLs) revealed that the resident is non-ambulatory and includes an approach dated 1/1/09, for a power wheelchair for mobility.

On 4/29/11 at approximately 11:50 AM, the resident was observed to roll her power wheelchair over Resident #401's oxygen tubing as she entered the dining room. The tubing compressed as the wheels ran over it.

b). Resident #442 has diagnoses including dementia and a left above the knee amputation and a chronic right foot wound.

Review of the Care Plan for ADL revealed an approach dated 4/21/11 for a wheelchair for transport.

On 4/29/11 at approximately 12:00 PM, staff was observed to transport the resident in her wheelchair out of the dining room. During the transport, the resident's wheelchair rolled over Resident #401's oxygen tubing, which compressed as the wheels rolled over it.

c). Resident #111 has diagnoses including rheumatoid arthritis, hip and knee contractures and a history of falls with a left shoulder fracture. Review of the Care Plan for ADL dated 6/19/10 revealed an approach for independent transfers and ambulation with a quad cane.

On 4/29/11 at approximately 12:05 PM the resident was observed to ambulate independently with a quad cane into the dining room. During the observation, Resident #111's cane temporarily caught in a loop of Resident #401's oxygen tubing as she walked over the tubing. Resident #111 lifted her cane and crossed over the tubing without incident.

During the observation on 4/29/11 between 11:45 AM and 12:45 PM, 2 Certified Nurse Aides (CNAs) walked over the tubing without stopping to intervene.

When interviewed on 4/29/11 at approximately 12:50 PM, the Unit 3B Home Maker stated that the tubing was not normally stretched across the floor in the dining room. She further stated that the oxygen concentrator is usually placed along the windows with the tubing between the resident and the wall where no one is.

When observed on 5/2/11 at 12:30 PM Resident #401's oxygen concentrator and tubing were in the same position as observed on 4/29/11 between 11:45 AM and 12:45 PM. The tubing was looped and was stretched approximately 25' from the concentrator to the resident.

When interviewed on 5/2/11 at 12:45 PM the Registered Nurse (RN) Unit Manager (UM) said that she observed Resident #401's oxygen tubing on the dining room floor and said it could be an accident hazard. The RN UM said she would be moving the resident's dining room table to be closer to the electric outlet.

415.12(h)(1)(2)

Based on observation, record review, staff and family 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 psychological well-being of each resident. One (Resident #368 ) of three residents reviewed for activities had issues involving a lack of individualized assessments and care plans for activities. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #368 has diagnoses which include Cerebral Vascular Accident (CVA - stroke) with hemiplegia (paralysis on one side of body) and dementia. Review of the Minimum Data Set (MDS) dated 4/16/11 revealed the resident has severely impaired cognitive skills for daily decision making.

During an interview with the resident's responsible party (wife) on 4/28/11 at 9:55 AM the responsible party gave a negative response when asked if the staff provide encouragement and assistance to attend activities. During the interview, the responsible party stated the resident enjoys music and would like to see him go to more activities that involve music. Additionally she said that she had brought in a compact disc (CD) player for his room.

Review of the Initial Activity assessment dated 10/26/10 revealed the resident was oriented to place and time, preferred music and religious activities and attended activities 1/3 to 2/3 of the time.

Review of the Activity Care Plan, revised 4/28/11, revealed that the resident enjoyed bowling, golfing, model airplanes and is interested in catholic services. Additionally, the care plan documented that the resident's wife and daughter visit frequently and are involved in discussions of his care. Activity approaches included providing the resident with sports magazines, invite to music programs, socials, bowling, and catholic mass. The activity goals included to attend sing along and socials two times a month, catholic mass once a month and household activities, when offered.

The resident was observed on 4/27/11 at 10:12 AM watching TV with 3 other residents in the Buffalo Household. During intermittent observations of the unit household between 4/27/11 and 5/3/11, the resident was not observed to attend any other activities.

Interview with the Activity Director on 5/2/11 at 10:50 AM revealed that on each household, the homemakers, Nurses or Certified Nurse Aides (CNAs) are to initiate activities for the residents and document what activity was done and which residents attended the activity in a book kept on the household. Additionally, the Activity Director stated that the staff have not been recording what activities they have been doing throughout the day/night. The Activity Director also stated "if its not documented, it hasn't been done."

Additional interview with the Activity Director on 5/3/11 at 9:45 AM revealed that there is no policy for activity schedules. The Activity Director said that activity personnel complete an activity attendance log based on documentation in the household book.

Interview with the Registered Nurse (RN) Unit Manager (UM) on 5/3/11 at approximately 10:15 AM revealed that it was everybody's job to do activities with the residents.

Review of the Activity Attendance Calendar dated 2011 revealed that the resident enjoyed bowling, golfing, model air planes, taking naps and visits and walks with his wife. The attendance calendar did not include that the resident liked music or that there was a CD player in his room. Further review of the 2011 Activity Attendance Calendar revealed that the resident attended 4 religious/chat activities in February, 5 religious/chat activities and one chat activity in March and 3 chats, 1 religious/chat activity and one nap activity in April on the Buffalo household.

415.5(f)(1)

Based on record review and staff interview, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs and that residents who use antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. One (Resident #375) of ten residents reviewed for unnecessary medications had an issue with the use of an antipsychotic medication without adequate indications for its use. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #375 has diagnoses including Alzheimer's type dementia and depression. Review of the significant change Minimum Data Set (MDS) dated 3/22/11 revealed that the resident has short and long term memory loss, is rarely understood or understands, and has severely impaired cognitive skills for daily decision making. The MDS also revealed that the resident receives an antipsychotic medication.

Review of Physician Orders dated 2/28/11 revealed an order for Haldol (antipsychotic medication) 0.5 milligrams (mg) sub Q (subcutaneous - injection beneath the skin) BID (twice a day) prn (as needed) for increased agitation.

Review of Licensed Practical Nurse (LPN) Interdisciplinary Notes dated 2/28/11 through 3/14/11 revealed the resident had behaviors of either wandering, being resistive or combative with care and eating feces, all with which the staff was able to redirect the resident.

Review of the Medication Administration Record (MAR) for 2/11 and 3/11 revealed that the prn Haldol was not administered between 2/28/11 and 3/14/11.

Review of a Hospice Care Plan and Progress Note dated 3/14/11 revealed that the resident had an increase in insomnia and behaviors that elevate as the day wears on. The note included that the Unit Manager (UM) would bring this to the attention of the Physician.

Review of an LPN Interdisciplinary Note dated 3/15/11 revealed that on 3/14/11 the resident was seen by Hospice and that they recommended that "we give her something for agitation and restlessness". The note included that the LPN spoke with the Physician and received a new order for Haldol 0.25 mg po (by mouth) BID for agitation and restlessness. Review of Physician's Orders dated 3/14/11 revealed a telephone order for Haldol as noted above for "increased agitation".

Review of Physician's Orders and Interdisciplinary Notes dated 2/28/11 through 3/15/11 revealed no documented evidence of a qualifying diagnosis and behavior symptoms that meet the criteria required for antipsychotic medication use.

Review of Interdisciplinary Notes dated 3/15/11 through 3/25/11 revealed the resident had behaviors of wandering and one episode of crying for which redirection and "one to one" was effective.

Review of Physician's Orders dated 3/25/11 revealed a telephone order to discontinue Haldol 0.25 mg po BID and start Haldol .5 mg po BID for increased agitation.

Review of the Consultant Pharmacist Progress Notes and Medication Regimen Review (MRR) dated 3/28/11 revealed that a note was written to the MD that the resident is receiving the antipsychotic agent, but lacks an allowable diagnosis to support its use. Review of the MRR dated 4/26/11 revealed that the Consultant Pharmacist wrote a note to the MD that the orders need to be updated "Dementia with associated behavior symptoms".

Review of Physician's Orders and Interdisciplinary Notes dated 3/15/11 through 5/2/11 revealed no documented evidence of a qualifying diagnosis and behavioral symptoms that meet the criteria required for antipsychotic medication use.

Review of a Directive and Procedure entitled "Physical and Chemical Restraints" dated 8/14/02 revealed a procedure that residents receive an antipsychotic medication only if one of the following diagnoses is documented in the resident's medical record. The diagnoses included dementia with specific behaviors that cause the resident to be a danger to themselves or others or cause interference with the ability of the staff to provide care, or psychomotor symptoms that cause the resident distress. The procedure included that the specific behavior must be documented quantitatively and described objectively at the time the medication is started.

An interview on 5/3/11 at 10:58 AM with the Registered Nurse (RN) Unit Manager revealed that the Hospice nurse discussed issues about the resident's insomnia and wandering the halls at night. The RN Unit Manager stated that in her discussion with the resident's doctor about the insomnia there was no discussion of anti-insomnia or anxiety medications, or other non-pharmacological interventions to address the resident's difficulty with sleeping. She stated it was the doctor's idea to initiate, then increase the antipsychotic medication Haldol to address the resident's insomnia. The RN Unit Manager further stated that the resident was somewhat aggressive with hands on care but did not include hitting or kicking, just pulling away from staff with care. She stated the resident was easily redirected and approachable.

When interviewed on 5/4/11 at 11:40 AM, the Physician stated that in part she prescribed the Haldol because the resident couldn't sleep and that the resident was difficult with hands on care. The Physician stated she had to increase the Haldol for the resident to "become more manageable".

415.12(m)(1)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 3/4/10.

Based on observation and staff interview, the facility did not ensure that controlled drugs were stored in separately locked, permanently affixed compartments in accordance with State and Federal regulations. Two (Unit 5, Horizon Unit) of 14 nursing units reviewed for medication storage had issues involving controlled drugs that were stored in a cabinet that was not separately locked and in an unsecured cart. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation of the Horizon Unit Medication Room on 4/27/11 at 10:30 AM revealed that controlled drugs for the West Hall were stored in a metal double locked box that was affixed to the wall in the medication room. The same key that opened the outer cabinet door was observed to also open the inner cabinet door. The box contained one blister pack each of Hydrocodone (narcotic pain medication) 5/500, Hydrocodone 7.5/500, Lorazepam (sedative, anti-anxiety medication) 0.5 milligrams (mg), Hydrocodone 2.5/500, Lyrica (pain medication) 150 mg, Alprazolone (anti-anxiety medication) 0.25 mg and two blister packs of Oxycodone/APAP (pain medication) 10/325.

Interview on 4/27/11 at 10:30 AM with the Licensed Practical Nurse (LPN) assigned to West Hall revealed that there has been one key working for both locks for about 2 months and that maintenance was waiting for a part to fix it.

When interviewed about the key for the West Hall controlled drug box on 4/27/11 at 12:20 PM, the Registered Nurse (RN) Unit Manager (UM) revealed "It's been like that for 2 months".

Review of a work order revealed that on 2/7/11, the Director of Nursing (DON) requested to have the Horizon Unit narcotic cupboard locks fixed because "both cabinets have the same keys". The work order was closed on 3/3/11.

Interview with the Maintenance Department staff member who was responsible for the repair on 5/2/11 at 2:30 PM revealed that the outside lock of the two cabinets was changed, but there was no check to see if the new key for the new lock also opened the inside door of the larger cabinet. The Maintenance Department staff member stated he was unaware the two doors on the larger cabinet opened using the same key.

2. Observation on 4/28/11 at 10:45 AM revealed a medication cart was unattended in the hall on Unit 5. Approximately 6 inches of the cart was visible from the nursing station. The medication cart contained one blister pack each of Lyrica (pain medication) 50 milligram (mg) tabs, Oxycodone/apap (pain medication) 5/325 tabs, and Clonazepan (anti-convulsant) 1 mg tabs. Both the cart and the narcotic drawer were locked.

When interviewed on 4/28/11 at 10:50 AM, the Licensed Practical Nurse (LPN) responsible for the medication cart revealed she finished her morning medication pass at 9:30 AM and would be starting her next pass at 11:30 AM. The LPN stated she thought it was "OK" to leave the controlled substances in the cart as long as they were locked in the inner metal box and the cart itself was locked.

415.18(e)(2)

Based on observation, record review and staff interview, the facility did not ensure that services are provided by qualified persons in accordance with each resident's written plan of care. One (Resident #40) of 17 residents reviewed for care plan implementation did not have heels floated according to the plan of care. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #40 has diagnoses including diabetes mellitus, osteoporosis, and history of vertebral (backbone) fractures. Review of the Minimum Data Set (MDS) dated 4/22/11 revealed the resident has severely impaired cognition.

Review of the current Comprehensive Care Plan (CCP) dated 4/27/11, and two previous CCPs dated 12/8/10 and 9/8/10 revealed the resident was identified at high risk for skin breakdown. Care Plan approaches, in effect since 9/8/10 included a plan to "float the heels". Review of Certified Nurse Aide (CNA) Assignment Sheets, used by CNAs to provide care, dated 10/4/10 through 4/29/11 revealed the plan to "float heels" was not included on the Assignment Sheets.

The resident was observed lying in bed, without her heels floated (heels were observed directly on mattress) on the following dates:

- Wednesday, 4/27/11 from 11:30 AM to 12:00 PM
- Thursday, 4/28/11 at 11:30 AM and 3:45 PM
- Friday, 4/29/11 at 10:00 AM, 10:50 AM and from 1:00 PM to 1:30 PM
- Monday, 5/2/11 from 11:30 AM to 12:15 PM

Interview with the assigned CNA (#1) on 4/29/11 at 1:40 PM revealed she frequently checks the resident for incontinence, the resident "rarely gets up in the chair lately", and she has not floated the resident's heels. When asked if floating the resident's heels was part of the care plan, the CNA reviewed her copy of the CNA Assignment Sheet and stated, "No, floating the heels is not on here".

Interview with the assigned Licensed Practical Nurse (LPN) on 5/2/11 at 12:15 PM revealed the direction to float the resident's heels should have been part of the CNA Assignment, but she did not know why the direction was not included.

Interview with the Unit Secretary on 5/2/11 at 12:45 PM revealed she places information on the CNA Assignment Sheet as directed by the Unit Manager (UM) via e-mail or written note. The Unit Secretary stated that she did not get any notice to include "float heels" in the CNA Assignment Sheet.

Interview with the assigned CNA #2 on 5/3/11 at 1:40 PM revealed she was unaware of the plan to float the resident's heels, and review of the CNA Assignment Sheet revealed no plan to float the heels.

Interview with the LPN Interim Unit Manager on 5/3/11 at 1:45 PM revealed she communicated the need to add "float heels" to the CNA Assignment Sheet to the Unit Secretary, but the Secretary had yet to do this. The LPN Interim Unit Manager stated she herself had floated the resident's heels.

Observation with the LPN Interim Unit Manager on 5/3/11 at 1:48 PM revealed the resident was in bed with a pillow and small blanket positioned to allow the heels to float.

415.11(c)(3)(ii)

Based on observation, record review and staff interview, the facility did not ensure that services provided by the facility met professional standards of quality. One (Resident #40) of 17 residents reviewed for professional standards did not have their heels "floated" according to a physician's order. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #40 has diagnoses including diabetes mellitus, osteoporosis, and history of vertebral (backbone) fractures. Review of the Minimum Data Set (MDS) dated 4/22/11 revealed the resident has severely impaired cognition.

Review of a Readmission History and Physical (H&P) dated 3/7/11 for a physician visit on 3/2/11, revealed the resident "has some pinkness at both heels slightly more on the R (right) than the L (left) and the R heel is slightly boggy and tender. There is no blistering and no ulceration present.

Review of Physician's Orders dated 3/2/11 and 4/8/11 revealed orders to "float" heels while in bed.

Review of Treatment Administration Records (TARs) dated 12/10 through 5/11 revealed the Physician's Orders were transcribed to "float heels when in bed". Additional review of the TARs dated 12/10 through 5/11 revealed a handwritten notation for nursing staff to initial that the heels were floated at bedtime (hs), with no entry for days and evenings. The TARs documented that the heels were floated every hs as initialed by nursing staff.

Interview with the Licensed Practical Nurse (LPN) Unit Manager (UM) on 5/2/11 at 12:30 PM revealed the transcription to float heels prior to the 3/2/11 order may have occurred from an old order or maybe nursing staff added this to what pharmacy would include on the treatment administration record. The LPN explained that it "may have originally been appropriate" for only the evening staff to check for floating the heels because the resident used to be "up during the day", but over the last couple months has been mostly in bed.

The resident was observed lying in bed, without her heels floated (heels were observed directly on mattress) on the following dates:

- Wednesday, 4/27/11 from 11:30 AM to 12:00 PM
- Thursday, 4/28/11 at 11:30 AM and 3:45 PM
- Friday, 4/29/11 at 10:00 AM, 10:50 AM and from 1:00 PM to 1:30 PM
- Monday, 5/2/11 from 11:30 AM to 12:15 PM

Interview with the Attending Physician on 5/4/11 at 11:45 AM revealed she saw the resident on 3/2/11 and noted redness on her heels. The Attending Physician stated she recalled that the resident was in bed and did not have her heels floated at the time of her examination, and wrote an order to float the resident's heels when in bed.

415.11(c)(3)(i)